Every finding on record at Maplewood Healthcare Center

Based on observation, staff interview, resident interview, and record review, the facility failed to ensure residents received the portions specified on the facility's approved production sheets and failed to consistently provide menu items as planned. This deficient practice had the potential to affect all residents receiving meals from the facility's dietary department. Facility census: 76Findings include: During an observation of the lunch tray line on 06/10/26 beginning at approximately 12:30 p.m., [NAME] #94 was observed serving roasted squash. The facility's serving utensil was a four (4) ounce scoop; however, the scoop was not filled to capacity. The scoop was frequently less than half full and at times only approximately half full before being placed on resident trays. This practice continued for approximately 15 minutes while meal trays for multiple dining room carts were prepared and served.During the observation, [NAME] #94 was interviewed regarding the serving portions. [NAME] #94 stated, I'm doing the best I can, but I'm starting to run out and I have more halls left to serve.The surveyor continued to observe the tray line and noted [NAME] #94 continued to serve undersized portions of roasted squash after the concern was identified.A review of the facility's production records on 06/10/26 revealed roasted squash was to be served in a one-half (1/2) cup, four (4) ounce portion. Although the facility utilized the appropriate four-ounce serving scoop, the scoop was not filled to the required serving size.A review of the facility matrix revealed all residents received meals prepared by the dietary department. No residents were identified as nothing by mouth (NPO) or receiving nutrition exclusively through tube feedings.During an interview on 06/11/26 at approximately 10:00 a.m., Resident #66 stated the facility frequently runs out of menu items and residents sometimes receive food that differs from what is listed on the meal ticket. Resident #66 stated, The portions are small. My six-year-old granddaughter could eat four servings of what they serve. The resident further stated that on 06/10/26 the evening meal consisted of a turkey and cheese sandwich, a serving of lettuce, approximately five to seven cucumber slices with diced onions, a cookie, and pudding. Resident #66 stated concerns regarding food portions and meal service have been discussed during Resident Council meetings; however, We're told they will address it, but they don't follow up with our concerns.During an interview on 06/11/26 at approximately 10:30 a.m., Resident #74 stated, There were about three times I have not gotten any meat on my tray. When asked why, the resident stated, They told me they ran out. Resident #74 described meal portions as small, not fulfilling. The resident further stated experiencing weight loss during the past five months and reported that food was often not warm, stating, They said the machine that heats the plates was down. I can't eat cold food.During an interview with Nurse Aide (NA) #6 on 06/10/26 at approximately 1:45 p.m., while waiting for meal trays to arrive, NA #6 confirmed the dietary department occasionally runs out of menu items and substitutes foods not listed on resident meal tickets. During the interview, the Dietary Manager informed staff that residents would receive green beans instead of squash for the meal. When asked if residents were normally informed of menu substitutions, NA #6 stated, No, usually when we get the trays and see it's something different from what's posted or on the tickets, we all know then.

Based on record review, resident interview, and staff interview, the facility failed to ensure resident grievances were appropriately tracked, resolved, and reviewed by the designated grievance official/administrator. Additionally, the facility failed to ensure grievance documentation was completed, including administrator review and signature. This deficient practice affected Resident #74 and had the potential to affect more than a minimal number of residents residing in the facility. Facility census: 76.Findings include:a) Resident #74Record review completed on 06/11/26 of the facility's Resident Council meeting minutes revealed Resident #74 reported during the February 2026 meeting that a pair of green pajama pants was missing. Review of the facility's grievance log revealed no grievance had been initiated for this concern.Further review of the March 2026 Resident Council meeting minutes revealed Resident #74 again voiced concerns regarding the missing pajama pants. A grievance form dated 03/26/26 documented the resident was missing a pair of [NAME] green pajama pants.Review of the grievance form revealed a resolution date of 03/30/26. Under Specific Actions Taken to Resolve Grievance, the form stated, Laundry, residents' rooms checked - unable to be immediately located. The resident was informed that we will keep looking.Further review of the Resolution of Grievance section revealed the question, Was the grievance resolved? was marked Yes. The resolution description stated, No further complaints.Review of the grievance form revealed the line designated for the grievance official was signed by the Social Worker; however, the administrator signature line was blank. Review of two additional grievance forms revealed the administrator signature line was also not completed.During an interview on 06/11/26 at approximately 12:00 PM, Social Worker #14 stated, There have been a few administrators, and they are currently working out the process for notifying the administrator regarding the resolution of grievances.During an interview on 06/11/26 at approximately 1:00 PM, the Mobile Administrator stated the process at the facility he was at is that he signs some grievances when he reviews them or they are discussed during morning and evening meetings.During a follow-up interview with Resident #74 on 06/11/26 at approximately 1:30 PM, in the presence of Social Worker #14, Resident #74 stated the green pajama pants were still missing. Social Worker #14 confirmed, stating, That's right, we are still looking for those.The grievance form documented the grievance had been resolved despite the resident's concern remaining unresolved and the missing item not being located.During an interview on 06/11/26 at approximately 2:00 PM, the Mobile Administrator and Director of Nursing confirmed the grievance should have been resolved and appropriately completed.

Based on observation, medical record review, and staff interview the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections including Covid-19 in regard to, precaution signage on resident doors. This had the potential to affect all residents that reside in the facility. Resident identifiers: #60 and #62. Facility Census: 76. a) Observations on 01/06/26 at 1:13 PM revealed no signs near the door frames of room B2. Interview on 01/06/26 at 1:13 PM with Nurse Aid #38 she verified that both residents in room B2 were on isolation precautions. Continues review revealed Resident # 60's clinical record revealed that theresident was diagnosed with Covid-19 on 01/02/26 and was placed on precautions. Subsequent review revealed Resident # 62's clinical record revealed that theresident was diagnosed with Covid-19 on 01/06/26, was placed on precautions. During an interview on 01/06/26 at 1:25 PM Licensed Practical Nurse #46 verified there was no precautionary signage for Covid-19 on room B2 where resident's #60 and #62 were residing. She stated there should be precaution signs on the door. A sign was placed on the door at this time

Based on Interview and Record review the facility did not evidence of the required attendees being present or having them sign in to verify their presence at the Quality Assessment and Assurance (QAA) meeting. This was discovered during the regular survey process and has the ability to effect more then a limited number of residents. Census 76.During an interview with both the Director of Nursing (DON) and Regional Director Clinical Operations (RDCO) on 01/14/2026 at approximately 8:50 AM, both stated they have been looking for the Quality Assurance (QAPI/QAA) books or records since the survey team entered the facility. Unfortunately, they were unable to locate documentation to show their meetings and what was discussed. They provided the names of the active participants from the meetings, but only a few sign in sheets had been found. They stated the main focus of the facility has been wounds, falls and weights. They said If they located any documentation before exit they will bring it to surveyors. RDCO was able to locate sign in sheets for the last twelve (12) months. However, they were missing the necessary signatures from Medical director, Infection preventionist, and ADMIN/Executive director for each of the required quarterly meetings in Q1,Q2,Q3 and Q4. No other documentation was found/provided to the survey team prior to exiting the facility.

Based on facility documentation and staff interviews, the facility failed to have/keep the required documentation for Quality Assessment meetings (QAA). Additionally, the facility did not have required attendees present or sign in at the Quality Assessment and Assurance (QAA) meeting logs. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 76. Findings included: During an interview with both the Director Of Nursing and Regional Director Clinical Operations (RDCO) on 01/14/26 at approximately 8:50 AM, both stated they had been looking for the Quality Assurance (QAPI/QAA) books or records since the survey team entered the facility. Unfortunately, they were unable to locate documentation to show their meetings and what was discussed. They provided the names of the active participants from the meetings, but only a few sign in sheets had been found. They stated the main focus of the facility had been wounds, falls and weights. If they locate any documentation before exit they will bring it to surveyors. RDCO was able to locate sign in sheets for the last twelve (12) months. However, they were missing the necessary signatures from the Medical director, Infection preventionist, and ADMIN/Executive director for each of the required quarterly meetings in Q1,Q2,Q3 and Q4. No other documentation was found/provided to the survey team prior to exiting the facility.

Based on resident interview, staff interview, and operation policy, the facility failed to report the results of an investigation to the appropriate officials in accordance with State law, within five (5) working days of the incident. This has the potential to affect all residents in the facility. Resident identifier #9, #47 and #40. Facility census: 76 Findings include: Record review of the facility's policy titled, Abuse, Neglect & Misappropriation, showed: - In the event an allegation is made, the facility will take measures to protect residents from harm during an investigation. Accurate and timely reporting of incidents, both alleged and substantiated, will be sent to officials in accordance with the state law. If the alleged violation is verified, appropriate corrective action will be taken by the facility. - The Director of Nursing (DON) and Executive Director (ED) receives reports of resident incidences. - The Executive Director / designee will report appropriate incidents to OHFLAC, APS, the Regional Ombudsman, and other local authorities, including but not limited to local law enforcement (if appropriate), as required by State law. - If the events that cause the allegations involve abuse and / or serious bodily injury, the self-report must be made immediately, but not later than 2 hours after the allegation is made. - The results of the facility's investigation must be reported to the Executive Director / designee, OHFLAC, APS, Regional Ombudsman, and other officials as required by State law, within five working days of the incident. a) Resident #9 During an interview on 1/06/26 at 9:55 AM he then told this surveyor that he fell while being transferred by a Certified Nursing Assistant (CNA) on 01/12/25 and fractured his femur. On 01/08/26 at 9:35 AM this surveyor spoke with the Director of Nursing (DON) about Resident #9 two (2) falls. I asked for the reportable and the five (5) day follow ups for both incidents. She could not provide those because they were not completed. The care plan was not updated for either fall. Record review of the care plan verified that is was not updated. On 01/12/26 at 2:45 PM this surveyor spoke to the DON again about Resident #9 two (2) falls. She told me that the Social worker was terminated on 05/08/25 for not completing the reportable or the five day follow up. The Certified Nursing Assistant (CNA) had a teachable moment on 01/13/25 for her involvement with the fall on 01/12/25. b. Resident #47 During an observation on 01/05/26 at 10:25 AM Resident #47 screaming, she hit me. Resident #62 present in Resident 47's doorway. Staff redirected Resident #62 from the area. During an interview on 01/05/26 at 11:00 AM Resident #47 stated that Resident #62 hit her. She continued to say she comes in here all the time and takes things. A record review of grievances, concerns and reportables found no documented issues from Resident #47. Resident #47's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/25 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 14. A BIMS score of 14 indicates that the resident is cognitively intact and has capacity. Review of the Social Workers (SW) documentation found Resident #47 stated that she felt fearful during the incident with Resident #62, and does feel uneasy at times with the other resident who does wonder around. During an interview the Director of Nursing (DON) stated that the facility did not report the incident between Resident #47 and Resident #62 because the Social worker interviewed Resident #47 after the allegation, and Resident #47 stated that she felt safe in the facility. During the investigation of a Facility Reported Incident (FRI), the facility failed to complete the five (5) day report to the state agency. On 01/12/26 at 3:24 PM the Director of Nursing (DON) stated that the former Nursing Home Administrator (NHA) had been in charge of reporting FRI's. The DON stated there was no evidence that the five (5) day follow up was completed for Resident #40.

Based on observation, staff interview, and operation policy the facility failed to report alleged violations related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribe time frames. This was a random opportunity for discovery. Resident identifier: #9 and #47. Facility census: 76. Findings include: a) Resident #9 During an interview, on 01/06/26 at 9:55 AM, Resident #9 said he fell while being transferred by a Certified Nursing Assistant (CNA) on 01/12/25 and fractured his other femur. On 01/07/26 at 10:00 AM this surveyor spoke with the Director of Nursing (DON) about Resident #9's fall. The surveyor asked for the reportable and the five (5) day follow-ups for the incident. She said she could not provide it because it was not completed. On 01/12/26 at 2:45 PM this surveyor spoke to the DON again about Resident #9 two (2) falls. She told me that the social worker was terminated on 05/08/25 for not completing the reportable or the five-day follow-up. The Certified Nursing Assistant (CNA) had a teachable moment on 01/13/25 for her involvement with the fall on 01/12/25. b) Resident #47 During an observation on 01/05/26 at 10:25 AM Resident #47 screaming, she hit me. Resident #62 present in Resident 47's doorway. Staff redirected Resident #62 from the area. During an interview on 01/05/26 at 11:00 AM Resident #47 stated that Resident #62 hit her. She continued to say she comes in here all the time and takes things. A record review of grievances, concerns and reportables found no documented issues from Resident #47. Resident #47's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/25 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 14. A BIMS score of 14 indicates that the resident is cognitively intact and has capacity. Review of the Social Workers (SW) documentation found Resident #47 stated that she felt fearful during the incident with Resident #62, and does feel uneasy at times with the other resident who does wonder around. During an interview the Director of Nursing (DON) stated that the facility did not report the incident between Resident #47 and Resident #62 because the Social worker interviewed Resident #47 after the allegation, and Resident #47 stated that she felt safe in the facility.

Based on record review, resident interview, staff interview and Operation Policy review the facility failed to ensure they implemented the facility written abuse policy in regard to investigating and reporting to proper agencies an alleged allegation of abuse or neglect. This has potential to affect all residents that reside at the facility. Resident identifier: #47 and #9. Facility census: 76. Findings included: a) Resident #47 Record review of the facility's policy titled, [NAME] Virigina Abuse, Neglect, & Misappropriation, showed: Protection from AbuseIn the event the alleged abuse involves a resident to resident altercation, the resident will be separated by staff, and the appropriate physical assessment will be completed on each resident. All alleged violations involving abuse, neglect, exploitation or mistreatment, injury of unknown source, and misappropriation of property will be reported to the Executive Director immediately. The Executive Director / Designee will report incidents to OHFLAC, APS, The Regional Ombudsman, and other local authorities.If the event that caused the allegations involving abuse (physical, verbal, sexual, mental) the self-report must be made immediately, not later than 2 hours after the allegation is made. During an observation on 01/05/26 at 10:25 AM Resident #47 screaming, she hit me. Resident #62 present in Resident 47's doorway. Staff redirected Resident #62 from the area. During an interview on 01/05/26 at 11:00 AM Resident #47 stated that Resident #62 hit her. She continued to say she comes in here all the time and takes things. A record review of grievances, concerns and reportables found no documented issues from Resident #47. Resident #47's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/25 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 14. A BIMS score of 14 indicates that the resident is cognitively intact and has capacity. Review of the Social Workers (SW) documentation found Resident #47 stated that she felt fearful during the incident with Resident #62, and does feel uneasy at times with the other resident who does wonder around. During an interview the Director of Nursing (DON) stated that the facility did not report the incident between Resident #47 and Resident #62 because the Social worker interviewed Resident #47 after the allegation, and Resident #47 stated that she felt safe in the facility. b) Resident #9During an interview, on 01/06/26 at 9:55 AM, Resident #9 said he fell while being transferred by a Certified Nursing Assistant (CNA) on 01/12/25 and fractured his other femur.On 01/07/26 at 10:00 AM this surveyor spoke with the Director of Nursing (DON) about Resident #9's fall. The surveyor asked for the reportable and the five (5) day follow-up for the incident. She said she could not provide it because it was not completed. On 01/12/26 at 2:45 PM this surveyor spoke to the DON again about Resident #9 two (2) falls. She told me the social worker was terminated on 05/08/25 for not completing the reportable or the five-day follow-up. The Certified Nursing Assistant (CNA) had a teachable moment on 01/13/25 for her involvement with the fall on 01/12/25.

Based on record review and staff interview, the facility failed to maintain an accurate and complete record for Resident #56. This was true for one (1) of five (5) residents reviewed under the care area of falls. Resident identifier: #56. Facility census: 74. Findings Include: a) Resident #56 On 05/07/25 at 12:30 PM, a record review was completed for Resident #56. The review found the resident had been transferred to an acute care facility. The transfer forms were noted with errors as follows: --Transfer date 11/01/24; incorrect date of 09/06/24 --Transfer date 11/25/24; incorrect date of 11/01/24 --Transfer date 03/04/25; incorrect date of 11/25/24 On 05/07/25 at 1:30 PM, the Administrator was notified and confirmed the dates on the transfer forms were incorrect.

Based on record review and staff interview, the facility failed to post nurse staffing with accurate information reflecting the actual hours worked, and total hours worked by category for nursing. This was true for 14 (fourteen) of 15 (fifteen) calendar days reviewed. The facility also failed to accurately reflect Facility census:75 Findings included: A) Record review 11/02/24: Nurse Staffing Report recorded a total of 191.50 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 221.88 hours worked for RNs, LPNs, and Certified Nurse Aides. 11/03/24: Nurse Staffing Report recorded a total of 337 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 227.5 hours worked for RNs, LPNs, and Certified Nurse Aides. 11/07/24: Nurse Staffing Report recorded a total of 240.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 260.5 hours worked for RNs, LPNs, and Certified Nurse Aides. 11/09/24: Nurse Staffing Report recorded a total of 307 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 244.75 hours worked for RNs, LPNs, and Certified Nurse Aides. 11/10/24: Nurse Staffing Report recorded a total of 283.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 240 hours worked for RNs, LPNs, and Certified Nurse Aides. 12/25/24: Nurse Staffing Report recorded a total of 249.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 222.5 hours worked for RNs, LPNs, and Certified Nurse Aides. 12/31/24: Nurse Staffing Report recorded a total of 298 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 220 hours worked for RNs, LPNs, and Certified Nurse Aides. 02/26/25: Nurse Staffing Report recorded a total of 191 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 220.75 hours worked for RNs, LPNs, and Certified Nurse Aides. 03/08/25: Nurse Staffing Report recorded a total of 190.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 190.5 hours worked for RNs, LPNs, and Certified Nurse Aides. 03/09/25: Nurse Staffing Report recorded a total of 187.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 209.25 hours worked for RNs, LPNs, and Certified Nurse Aides. 03/25/25: Nurse Staffing Report recorded a total of 231 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 211.25 hours worked for RNs, LPNs, and Certified Nurse Aides. 03/26/25: Nurse Staffing Report recorded a total of 218 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 255 hours worked for RNs, LPNs, and Certified Nurse Aides. 03/27/25: Nurse Staffing Report recorded a total of 242 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 249.25 hours worked for RNs, LPNs, and Certified Nurse Aides. 04/02/25: Nurse Staffing Report recorded a total of 177.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 192.75 hours worked for RNs, LPNs, and Certified Nurse Aides. 04/05/25: Nurse Staffing Report recorded a total of 199.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 204.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Additionally, an observation of the posted nursing staffing report on 05/07/25 reported 12 Certified Nurse Aides were supposed to be working evening shift (3:00 PM - 11:00 PM). An on-site visit at the facility on 05/07/25 at approximately 9:45 PM, revealed that were in actuality only 5 Certified Nursing Aides working that shift. B) Staff interview Staffing information and time/attendance reports were reviewed with the NHA on 05/07/25 at 4:40 PM. The NHA indicated a lack of awareness on how the data was accumulated and the lack o accuracy of the data.

Based on record review, resident interviews, and staff interviews, the facility failed to adequately deploy nursing staff across all shifts to properly care for residents and their safety. This was found to be true for 15 (fifteen) of 15 calendar days. Facility census: 74. Findings included: Nurse staffing postings review revealed the following: 11/02/24: Facility census: 74 LPN on night shift: 3 CNA on night shift: 2 CNA/resident ratio: 1:37 (one CNA for every 37 residents) 11/03/24: Facility census: 74 LPN on night shift: 4 CNA on night shift: 3 CNA/resident ratio: 1:25 11/07/24: Facility census: 73 LPN on night shift:3 CNA on night shift: 5 CNA/resident ratio: 1:11 11/09/24: Facility census: 74 LPN on night shift:3 CNA on night shift: 4 CNA/resident ratio: 1:18 11/10/24: Facility census: 74 LPN on night shift:2 CNA on night shift: 5 CNA/resident ratio: 1:15 12/25/24: Facility census: 74 LPN on night shift:2 CNA on night shift: 3 CNA/resident ratio: 1:25 12/31/24: Facility census: 75 LPN on night shift:2 CNA on night shift: 5 CNA/resident ratio: 1:15 2/26/25: Facility census: 76 LPN on night shift:3 CNA on night shift: 5 CNA/resident ratio: 1:15 03/08/25: Facility census: 76 LPN on night shift:3 CNA on night shift: 3 CNA/resident ratio: 1:25 03/09/25: Facility census: 76 LPN on night shift:3 CNA on night shift: 3 CNA/resident ratio: 1:25 03/25/25: Facility census: 77 LPN on night shift: 2 CNA on night shift: 3 CNA/resident ratio: 1:25 03/26/25: Facility census: 77 LPN on night shift:2 CNA on night shift: 5 CNA/resident ratio: 1:15 03/27/25: Facility census: 77 LPN on night shift: 4 CNA on night shift: 4 CNA/resident ratio: 1:19 04/02/25: Facility census: 76 LPN on night shift: 2 CNA on night shift: 3 CNA/resident ratio: 1:25 04/05/25 Facility census: 77 LPN on night shift: 2 CNA on night shift: 3 CNA/resident ratio: 1:25 A review of the current facility assessment, under the Section of staffing, states according to their acuity, 4-6 nurse aides are needed on night shift, along with 2-3 licensed nurses. During the morning of 05/07/25 during interviews with Resident #4, #50, and #38 these three residents complained of staffing shortages on night shifts and the long waits for responding to their call lights. During an interview NA #37 on 05/07/25 at approximately 9:50 PM, when asked after if she felt there was sufficient staffing on nights to properly care for residents, she responded, No, most nights we have 3 aides for all these residents, one in each wing. When asked if she was able to get all her tasks done before the end of shift, she stated no, unfortunately. When asked if she had any concerns that she wanted to share, she stated, I just feel this place is going downhill, several staff have left over the last few months. During an interview with LPN #38 on 05/07/25 at approximately 10:12 PM, she stated, I do not feel there is sufficient staff on nights. I frequently have to help the aides, and it is difficult for me to get all my documentation completed. Staffing information and time/attendance reports were reviewed with the NHA on 05/07/25 at 4:40 PM.

Based on record review and staff interview the facility failed to report all allegations and five (5) day follow up reports of abuse and or neglect to required agencies within the required time frames. This was a random opportunity for discovery and was true for 13 residents for a total of 16 allegations. Resident identifiers: #4, #50, #54, #16, #60, #32, #33, #29, #73, #68, #76, #77, and #78 Facility census: 74. Findings include: a) A review of the facility's filed grievances for the previous 12 months on 05/07/25 found the following allegations of abuse and/or neglect contained on the grievance forms: -- 05/29/24 Resident # 4 grievance voiced during the resident council and read as follows: resident stated CNA (First Name of Nurse Aide (NA) #56) yelled at her for pushing her call bell resident states w/c is dirty. -- 06/24/24 Resident #76's family voiced this grievance to the DON , Hospice and Social Services and it read as follows: yesterday residents wife found him undressed from the waist down. His shirt had not been changed for several days. He had food from his tray and BM up his back. Also a staff member was going up the hall yesterday saying loudly quit ringing your bells and residents and families could hear this. would like to have range of motion provided. -- 06/28/24 Resident #77's family reported this grievance to social services, and it read as follows, Family came to see her Wednesday and she was dirty and in the dame hospital gown se had been in on Monday when she got here. Please be sure she has her cochlea implant in to talk with her. She is also known to lay it on bed and it could get lost, staff needs to make sure it is not in her bed if she isn't wearing it and it isn't in he charger. -- 07/06/24 Resident #54 grievance voiced by the resident's family unsure who the grievance was reported too and read as follows: I would like to see if my mom's depend can be checked more often I have came everywhere day Thursday and Saturday and she was soaked through. -- 07/16/24 Resident #16 grievance voiced to the social worker and read as follows: timeliness of call bell response. they took her whistle away from her. She stated that she needed to go to the bathroom at 6:00 am a few days ago and staff came in and told her that they couldn't do it right now because they were passing breakfast trays. -- 08/06/24 Resident #54 grievance voiced by the resident's family the concern was voiced to social services and read as follows, 'activities told social services followed up with the family who was visiting today. (First Name of Resident #54) daughter (First name of Resident #54's daughter) state (First Name of Resident #54) was so wet when she got here there was urine dripping down into her shoes. When Social service spoke with her she said she had already talked to the aide. -- 09/04/24 Resident #32 grievance voiced by family to social services which read as follows: Resident's daughter stated her mother told her that the CNA (First Name of NA #56) didn't change her sheet which was wet as the result of her using the bed pan. (First name of Nurse Aide #56) told her it wasn't wet and she didn't have time to change it. (First name of unidentified Staff) came in and said she would get someone to change her. She then stated (First name of two more staff members who no longer work at the facility) came in and put a thicker sheet over her wet sheet and that (First Name of Staff who no longer works at the facility) jerked her nightgown in the process. She said (First Name of Staff who no longer works at the facility) had told her mother a few days before she wasn't going to be caring for her anymore. She also said that (First Name of Staff) told her that no one liked her. -- 09/28/24 Resident #60's family member voiced a concern to social services which read as follows: Expressed concern over mothers knee being bruised. They documented on the concern is was unknown how the injury occurred and the resolution was the NP (nurse practitioner) looked at her knee and confirmed it was healing. -- 10/08/24 Resident #78's family reported to nursing/social services the following grievance, daughter feels the stage 2 on (First Name of Resident #78)'S bottom is related to the staff leaving her up in her wheelchair last night to sleep because her bed had not been made. -- 10/28/24 Resident #33 voiced this grievance to social services, and it read as follows: Resident came to social services and stated that another female resident was in her room and going through her belongings, when she told her to stop the other resident grabbed her neck and put her hand over (First Name of Resident #33) face. (First Name of Resident #33) said it did not cause her any pain or injury. -- 10/28/24 - Resident #29 reported the grievance to social services and it read as follows: Resident told the nurse, (First and Last Name of Registered Nurse #31) that there was a girl on night shift that came in and woke her up and startled her. She was tall with long blonde hair. She said she was husky not fat nor thin and tall like an amazon. She was rude and pulled her arm. -- 11/11/24 Resident #50 voiced to the social worker and read as follows: Resident does not like an evening CNA She would prefer not to have her care for her at night. Resident stated the CNA had previous lied about thing she said (First Name of Resident #50) had said to her. She stated the aide is loud and did not change her brief on several occasions. -- 01/21/25 Resident #73's family voiced this grievance to social services and it read as follows: Social Service was informed that the resident had a concern from over the weekend. When Social Service talked with her, (First name of Resident #73) expressed concern over how she felt an aide was rough with her when cleaning up a bowel movement midday on 01/19/25. She couldn't remember the staff members name. -- 04/01/25 Resident #68 reported the grievance to social services, and it read as follows: 'They were outside my door at about 1:30 last night and they were being very ;loud. They were talking loudly and singing loudly. Yesterday (first Name of NA #56) got (first name of Resident #68's roommate) up to sit in the hall and go to the dining room. They didn't get her back to bed until 12:30 last night. (First Name of Nurse Aide no longer working at facility) put her back to bed and there was a girl with her in training. They also didn't change me till 5:00 am (Name of day shift aide #56) changed me before she left. -- 04/03/25 Resident #16 voiced by the resident's family to social services an read as follows: stated that the other night around shift change her mother was put on the toilet and the bathroom door was closed as well as the room door. No one came back for a half hour (First Name of Resident #16) was banging on the wall for assistance. A friends came to visit and found her in this situation and notified staff. A review of the facility's reportable log for the same time frame found none of the allegations noted above were on the log. An interview with the Nursing Home Administrator (NHA) on 05/07/25 at 6:02 PM confirmed if they were not on the log they were not reported. She stated she would double check and provide them had they been reported. The allegations were reviewed with the NHA, and she agreed they needed to be reported. She assumed the social worker had done it.

Based on record review and staff interview the facility failed to implement their abuse prohibition policy in regards to identifying and reporting all allegations of abuse and/or neglect. The facility failed report all allegations of abuse and or neglect to required agencies within the required time frames. This was a random opportunity for discovery and was true for 13 residents for a total of 15 allegations. Resident Identifiers; Resident #4, #50, #54, #16, #60, ##32, #33, #29, #73, #68, #76, #77, and #78. Facility Census: 74. Findings Include: a) Policy Review A review of the facility;s policy Titled: [NAME] Virginia Abuse, neglect, and Misappropriation Policy with an effective date of 10/17/24 found the following: .Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, visitors, and staff or others but has not yet been investigated and, if verified, could be noncompliance with the federal requirements related to mistreatment, exploitation, neglect, or abuse including injuries of unknown source, and misappropriation of resident property VII. Reporting of incidents and Facility Response. 1. All alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported to the executive director immediately. 2. The executive director/designee will report appropriate incidents to OHFLAC< APS, The regional Ombudsman, and other local authorities including but not limited to local law enforcement iff appropriate, as required by state law. b) Grievance Forms review for the previous 12 months. A review of the facility's filed grievances for the previous 12 months on 05/07/25 found the following allegations of abuse and/or neglect contained on the grievance forms: -- 05/29/24 Resident # 4 grievance voiced during the resident council and read as follows:resident stated CNA (First Name of Nurse Aide (NA) #56) yelled at her for pushing her call bell resident states w/c is dirty. -- 06/24/24 Resident #76's family voiced this grievance to the DON , Hospice and Social Services and it read as follows: yesterday residents wife found him undressed from the waist down. His shirt had not been changed for several days. He had food from his tray and BM up his back. Also a staff member was going up the hall yesterday saying loudly quit ringing your bells. and residents and families could hear this. would like to have range of motion provided. -- 06/28/24 Resident #77's family reported this grievance to social services and it read as follows, Family came to see her Wednesday and she was dirty and in the dame hospital gown se had been in on Monday when she got here. Please be sure she has her cochlea implant in to talk with her. She is also known to lay it on bed and it could get lost, staff needs to make sure it is not in her bed if she isn't wearing it and it isn't in he charger. -- 07/06/24 Resident #54 grievance voiced by the residents family unsure who the grievance was reported too and read as follows: I would like to see if my mom's depend can be checked more often I have came everywhere day Thursday and Saturday and she was soaked through. -- 07/16/24 Resident #16 grievance voiced to the social worker and read as follows: timeliness of call bell response. they took her whistle away from her. She stated that she needed to go to the bathroom at 6:00 am a few days ago and staff came in and told her that they couldn't do it right now because they were passing breakfast trays. -- 08/06/24 Resident #54 grievance voiced by the residents family the concern was voiced to social services and read as follows, 'activities told social services followed up with the family who was visiting today. (First Name of Resident #54) daughter (First name of Resident #54's daughter) state (First Name of Resident #54) was so wet when she got here there was urine dripping down into her shoes. When Social service spoke with her she said she had already talked to the aide. -- 09/04/24 Resident #32 grievance voiced by family to social services which read as follows: Resident's daughter stated her mother told her that the CNA (First Name of NA #56) didn't change her sheet which was wet as the result of her using the bed pan. (First name of Nurse Aide #56) told her it wasn't wet and she didn't have time to change it. (First name of unidentified Staff) came in and said she would get someone to change her. She then stated (First name of two more staff members who no longer work at the facility) came in and put a thicker sheet over her wet sheet and that (First Name of Staff who no longer works at the facility) jerked her nightgown in the process. She said (First Name of Staff who no longer works at the facility) had told her mother a few das before she wasn't going to be caring for her anymore. She also said that (First Name of Staff) told her that [NAME] liked her. -- 09/28/24 Resident #60's family member voiced a concern to social services which read as follows: Expressed concern over mothers knee being bruised. They documented on the concern is was unknown how the injury occurred and the resolution was the NP (nurse practitioner) looked at her knee and confirmed it was healing. -- 10/08/24 Resident #78's family reported to nursing/social services the following grievance, daughter feels the stage 2 on (First Name of Resident #78)'S bottom is related to the staff leaving her up in her wheelchair last night to sleep because her bed had not been made. -- 10/28/24 Resident #33 voiced this grievance to social services and it read as follows: Resident came to social services and stated that another female resident was in her room and going through her belongings, when she told her to stop the other resident grabbed her neck and put her hand over (First Name of Resident #33) face. (First Name of Resident #33) said it did not cause her any pain or injury. -- 10/28/24 - Resident #29 reported the grievance to social services and it read as follows: Resident told the nurse, (First and Last Name of Registered Nurse #31) that there was a girl on night shift that came in and woke her up and startled her. She was tall with long blonde hair. She said she was husky not fat nor thin and tall like an amazon. She was rude and pulled her arm. -- 11/11/24 Resident #50 voiced to the social worker and read as follows: Resident does not like an evening CNA She would prefer not to have her care for her at night. Resident stated the CNA had previous lied about thing she said (First Name of Resident #50) had said to her. She stated the aide is loud and did not change her brief on several occasions. -- 01/21/25 Resident #73's family voiced this grievance to social services and it read as follows: Social Service was informed that the resident had a concern from over the weekend. When Social Service talked with her, (First name of Resident #73) expressed concern over how she felt an aide was rough with her when cleaning up a bowel movement midday on 01/19/25. She couldn't remember the staff members name. -- 04/01/25 Resident #68 reported the grievance to social services and it read as follows: 'They were outside my door at about 1:30 last night and they were being very ;loud. They were talking loudly and singing loudly. Yesterday (first Name of NA #56) got (first name of Resident #68's roommate) up to sit in the hall and go to the dining room. They didn't get her back to bed until 12:30 last night. (First Name of Nurse Aide no longer working at facility) put her back to bed and there was a girl with her in training. They also didn't change me till 5:00 am (Name of day shift aide #56) changed me before she left. -- 04/03/25 Resident #16 voiced by the residents family to to social services an read as follows: stated that the other night around shift change her mother was put on the toilet and the bathroom door was closed as well as the room door. No one came back for a half hour (First Name of Resident #16) was banging on the wall for assistance. A friends came to visit and found her in this situation and notified staff. A review of the facility's reportable log for the same time frame found none of the allegations noted above were on the log. An interview with the Nursing Home Administrator (NHA) on 05/07/25 at 6:02 PM confirmed if they were not on the log they were not reported. She stated she would double check and provide them had they been reported. The allegations were reviewed with the NHA and she agreed they needed to be reported. She assumed the social worker had done it.

Based on record review and staff interview the facility failed to ensure each resident received medically related social services. The facility failed to assist the residents in the assertion of their right related to being free from abuse and or neglect and comprehensive person-centered care planning. This was random opportunity for discovery and has the potential to affect more than a limited number of residents. Resident identifiers: #75, #6, #77, #4, #54, #16, #32, #60, #78, #33, #29, #50, #73, #68, and #16. Facility Census: 74. Findings include: a) A review of the SOM found medically related social services include Advocating for residents and assisting them in the assertion of their rights within the facility in accordance with §483.10, Resident Rights, §483.12, Freedom from Abuse, Neglect, and Exploitation, §483.15, Transitions of Care, §483.20, Resident Assessments (PASARR), and §483.21, Comprehensive Person-Centered Care Planning. b) Care Plan with Interdisciplinary Team 1) State Agency Complaint The state agency received a complaint on 11/18/24 which indicated the following: Complainant was contacted by the facility's Social Worker about a care plan meeting for her mom. She said that the social worker normally only contacts her the day before or the day of the meeting but on this occasion, she did contact her a few days prior. This was helpful because she wanted to review her mom's care plan prior to the meeting. The complainant stated the social worker was the only staff member present on the care plan meeting that was held on the phone. She said she knew there was no interdisciplinary team there when this was going on. 2) Facility's Process for Care Plan Meetings A review of the facility's process for Care Plan Meetings found the following: .5. The following team members will be present during the care plan meeting: A clinical representative, Dietary, Social Services, Activities, and therapy . 12. A care plan note must be created at the time of the meeting to include the brief discussion of the meeting, concerns, follow up etc. This note should include a list of all who attended the meeting, both from the resident/ representative and facility staff. The note can be found in PCC under progress notes. 3) Resident #75 A review of Resident #75's medical record found she had the following care plan meetings with the following attendees: -- 07/25/24 Attendees: Social Services and Activities -- 10/24/24 Attendees: Social Services, Activities and Responsible Party. -- 01/23/25 Attendees: Social services and Responsible party. 4) Resident #6 A review of Resident #6's medical record found the resident had the following care plan meetings with the following attendees: -- 05/16/24 Attendees Social Services and activities. -- 06/27/24 Attendees: Social Services and Activities -- 08/15/24 Attendees: Social Services and Activities. -- 11/14/24 Attendees Social Services and Responsible party. -- 02/13/25 Attendees: Social Services, Activities and Son -- 02/20/25 Attendees: Social Services and Activities 5) Staff Interviews An interview with the Nursing Home Administrator on the afternoon of 05/08/25 confirmed the IDT team was not participating in the care plan meetings. She indicated the social worker was in charge of scheduling and coordinating the meetings and she did not realize they were not participating like they should. The Director of Nursing (DON) also present during the interview stated she would send a floor nurse to the meetings to represent nursing because they would know the resident the best and have the best input. Both agreed the only participating members were social services and activities who shared an office. c) Abuse Reporting 1) Grievance Forms review for the previous 12 months. A review of the facility's filed grievances for the previous 12 months on 05/07/25 found the following allegations of abuse and/or neglect contained on the grievance forms: -- 05/29/24 Resident #4 grievance voiced during the resident council and read as follows: resident stated CNA (First Name of Nurse Aide (NA) #56) yelled at her for pushing her call bell resident states w/c is dirty. -- 06/24/24 Resident #76's family voiced this grievance to the DON , Hospice and Social Services and it read as follows: yesterday residents wife found him undressed from the waist down. His shirt had not been changed for several days. He had food from his tray and BM up his back. Also a staff member was going up the hall yesterday saying loudly quit ringing your bells. and residents and families could hear this. would like to have range of motion provided. -- 06/28/24 Resident #77's family reported this grievance to social services, and it read as follows, Family came to see her Wednesday and she was dirty and in the dame hospital gown se had been in on Monday when she got here. Please be sure she has her cochlea implant in to talk with her. She is also known to lay it on bed and it could get lost, staff needs to make sure it is not in her bed if she isn't wearing it, and it isn't in the charger. -- 07/06/24 Resident #54 grievance voiced by the resident's family unsure who the grievance was reported too and read as follows: I would like to see if my mom's depend can be checked more often I have came everywhere day Thursday and Saturday and she was soaked through. -- 07/16/24 Resident #16 grievance voiced to the social worker and read as follows: timeliness of call bell response. they took her whistle away from her. She stated that she needed to go to the bathroom at 6:00 am a few days ago and staff came in and told her that they couldn't do it right now because they were passing breakfast trays. -- 08/06/24 Resident #54 grievance voiced by the residents family the concern was voiced to social services and read as follows, 'activities told social services followed up with the family who was visiting today. (First Name of Resident #54) daughter (First name of Resident #54's daughter) state (First Name of Resident #54) was so wet when she got here there was urine dripping down into her shoes. When Social service spoke with her she said she had already talked to the aide. -- 09/04/24 Resident #32 grievance voiced by family to social services which read as follows: Resident's daughter stated her mother told her that the CNA (First Name of NA #56) didn't change her sheet which was wet as the result of her using the bed pan. (First name of Nurse Aide #56) told her it wasn't wet and she didn't have time to change it. (First name of unidentified Staff) came in and said she would get someone to change her. She then stated (First name of two more staff members who no longer work at the facility) came in and put a thicker sheet over her wet sheet and that (First Name of Staff who no longer works at the facility) jerked her nightgown in the process. She said (First Name of Staff who no longer works at the facility) had told her mother a few das before she wasn't going to be caring for her anymore. She also said that (First Name of Staff) told her that [NAME] liked her. -- 09/28/24 Resident #60's family member voiced a concern to social services which read as follows: Expressed concern over mothers knee being bruised. They documented on the concern is was unknown how the injury occurred and the resolution was the NP (nurse practitioner) looked at her knee and confirmed it was healing. -- 10/08/24 Resident #78's family reported to nursing/social services the following grievance, daughter feels the stage 2 on (First Name of Resident #78)'S bottom is related to the staff leaving her up in her wheelchair last night to sleep because her bed had not been made. -- 10/28/24 Resident #33 voiced this grievance to social services and it read as follows: Resident came to social services and stated that another female resident was in her room and going through her belongings, when she told her to stop the other resident grabbed her neck and put her hand over (First Name of Resident #33) face. (First Name of Resident #33) said it did not cause her any pain or injury. -- 10/28/24 - Resident #29 reported the grievance to social services and it read as follows: Resident told the nurse, (First and Last Name of Registered Nurse #31) that there was a girl on night shift that came in and woke her up and startled her. She was tall with long blonde hair. She said she was husky not fat nor thin and tall like an amazon. She was rude and pulled her arm. -- 11/11/24 Resident #50 voiced to the social worker and read as follows: Resident does not like an evening CNA She would prefer not to have her care for her at night. Resident stated the CNA had previous lied about thing she said (First Name of Resident #50) had said to her. She stated the aide is loud and did not change her brief on several occasions. -- 01/21/25 Resident #73's family voiced this grievance to social services and it read as follows: Social Service was informed that the resident had a concern from over the weekend. When Social Service talked with her, (First name of Resident #73) expressed concern over how she felt an aide was rough with her when cleaning up a bowel movement midday on 01/19/25. She couldn't remember the staff members name. -- 04/01/25 Resident #68 reported the grievance to social services and it read as follows: 'They were outside my door at about 1:30 last night and they were being very ;loud. They were talking loudly and singing loudly. Yesterday (first Name of NA #56) got (first name of Resident #68's roommate) up to sit in the hall and go to the dining room. They didn't get her back to bed until 12:30 last night. (First Name of Nurse Aide no longer working at facility) put her back to bed and there was a girl with her in training. They also didn't change me till 5:00 am (Name of day shift aide #56) changed me before she left. -- 04/03/25 Resident #16 voiced by the resident's family to social services an read as follows: stated that the other night around shift change her mother was put on the toilet and the bathroom door was closed as well as the room door. No one came back for a half hour (First Name of Resident #16) was banging on the wall for assistance. A friends came to visit and found her in this situation and notified staff. A review of the facility's reportable log for the same time frame found none of the allegations noted above were on the log. An interview with the Nursing Home Administrator (NHA) on 05/07/25 at 6:02 PM confirmed if they were not on the log they were not reported. She stated she would double check and provide them had they been reported. The allegations were reviewed with the NHA, and she agreed they needed to be reported. She assumed the social worker had done it.

Based on record review and staff interview the facility failed to ensure the resident and/or resident representative were afforded the right to participate in the care planning process with all required members of the interdisciplinary team. This was true for two (2) of two (2) sampled residents reviewed during a complaint survey. Resident Identifiers: #6 and #75. Facility Census: 74. Findings Include: a) State Agency Complaint The state agency received a complaint on 11/18/24 which indicated the following: The complainant was contacted by the facility's Social Worker about a care plan meeting for her mom. She said that the social worker normally only contacts her the day before or the day of the meeting but on this occasion, she did contact her a few days prior. This was helpful because she wanted to review her mom's care plan prior to the meeting. The complainant stated the social worker was the only staff member present on the care plan meeting that was held on the phone. She said she knew there was no interdisciplinary team there when this was going on. b) Facility's Process for Care Plan Meetings A review of the facility's process for Care Plan Meetings found the following: .5. The following team members will be present during the care plan meeting: A clinical representative, Dietary, Social Services, Activities, and therapy . 12. A care plan note must be created at the time of the meeting to include the brief discussion of the meeting, concerns, follow up etc. This note should include a list of all who attended the meeting, both from the resident/ representative and facility staff. The note can be found in PCC under progress notes. c) Resident #75 A review of Resident #75's medical record found she had the following care plan meetings with the following attendees: -- 07/25/24 Attendees: Social Services and Activities -- 10/24/24 Attendees: Social Services, Activities and Responsible Party. -- 01/23/25 Attendees: Social services and Responsible party. d) Resident #6 A review of Resident #6's medical record found the resident had the following care plan meetings with the following attendees: -- 05/16/24 Attendees Social Services and activities. -- 06/27/24 Attendees: Social Services and Activities -- 08/15/24 Attendees: Social Services and Activities. -- 11/14/24 Attendees Social Services and Responsible party. -- 02/13/25 Attendees: Social Services, Activities and Son -- 02/20/25 Attendees: Social Services and Activities e) Staff Interviews An interview with the Nursing Home Administrator on the afternoon of 05/08/25 confirmed the IDT team was not participating in the care plan meetings. She indicated the social worker was in charge of scheduling and coordinating the meetings and she did not realize they were not participating like they should. The Director of Nursing (DON) also present during the interview stated she would send a floor nurse to the meetings to represent nursing because they would know the resident the best and have the best input. Both agreed the only participating members were social services and activities who shared an office.

Based on observation, record review and staff interview, the facility failed to maintain infection control standards Resident #53's urinary catheter. This was a random opportunity for discovery. Resident identifier: #53. Facility Census: 74. Findings include: a) Resident #53 On 05/07/25 at 3:24 PM, Resident #53's urinary catheter drainage bag was touching the floor. On 05/07/25 at 3:28 PM, Licensed Practical Nurse (LPN) #55 raised the resident's bed up to keep the urinary catheter drainage bag from touching the floor. On 05/07/25 at 3:35 PM, the Administrator was notified of the infection control breach. The Administrator stated, it should not be touching the floor. On 05/07/25 at 4:20 PM, the facility policy entitled, Catheter Care was reviewed. Section V under the heading of procedure states, Check that collection bag is not on the floor and is draining properly and secured allowing for no reflux of urine back to the bladder. (Typed as written.)

Based on observation and staff interview, the facility failed to ensure the correct alternative menus were posted to be available if the primary menu or immediate selections for a particular meal are not to a resident's liking. This was a random opportunity for discovery, and currently no residents are receiving enteral tube feedings in the facility, therefore; this failed practice had the potential to affect all residents residing in the facility. Facility Census: 76 Findings include: On 03/05/24 at 10:00 AM an Always available menu was observed posted by the daily menus near the dining room showing the following substitutes. -Hot or cold cereal- maple brown sugar oatmeal or variety of cold cereal -Gelatin, pudding, yogurt - variety -fruit cup- Mandarin oranges or peaches -sandwiches Deli meat, meat salad of the day, PB&J, ad grilled cheese -soup- Chicken noodle, tomato, or vegetable -cottage cheese and fruit plate -chef salad (mixed greens with assorted meats, cheese, tomato, and boiled egg) -Tossed salad ( lettuce, cheese, tomato) - Pickled Beets On 03/06/24 at 9:45AM the Culinary Director (CD) confirmed the always available menu posted was not correct and the current alternative menus was: -Burgers -Hotdogs -Deli Sandwiches During an interview with the Administrator on 03/06/24 at 10:59 AM, she confirmed the incorrect always available menu was posted.

Based on staff interview and record review, the facility failed to ensure a qualified staff person assessed each resident's activity pursuits by not providing a qualified activity professional. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the facility. Facility census: 76. Findings included: a) During an interview, on 03/05/24 at 01:00 PM, with Activity Director (AD), she stated she was currently enrolled in the Modular Education Program for Activity Professionals (MEPAP) class and had been employed since May of 2023. On 03/05/24 at 01:30 PM, the Executive Director (ED) confirmed the Activity Director (AD) had been employed since May of 2023 and had worked for eight (8) months without a qualified activity professional overseeing the facility's activity department. A record review, on 03/05/24 at 2:45 PM, revealed the resident's activity assessments are being completed by the AD who is not a Qualified Activity Professional, and the facility did not have a qualified activity professional in the facility overseeing the AD.

Based on staff interview and record review, the facility failed to provide a qualified activity professional for recreational services. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the facility. Facility Census: 76 Findings included: During an interview, on 03/05/24 at 1:00 PM, with Activity Director (AD), she stated she was currently enrolled in the Modular Education Program for Activity Professionals (MEPAP) class and has been employed since May of 2023. On 03/05/24 at 01:30 PM, the Executive Director (ED) confirmed the Activity Director (AD) has been employed since May of 2023 without a Qualified Activity Professional overseeing the facility's AD.

Based on resident interview and staff interview, the facility failed to review resident rights during the residents stay. This was a random opportunity for discovery during the Long-Term Care Survey process and had the potential to affect more than a limited number of residents in the facility. Facility census: 76. Resident identifiers: #54, #3, #59, #22, #43, #25, #76. Findings included: a) During the Resident Council meeting on 03/05/24 at 1:20 PM, Residents #54, #3, #59, #22, #43, #25, #76 stated no one has gone over resident rights with them. On 03/05/24 at 2:54 PM, the Administrator confirmed resident rights had not been reviewed with residents regularly after admission to the facility.

Based on record review and staff interview, the facility failed to ensure medications were available for administration to residents. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for medications. This deficient practice caused harm to Resident #15. Resident #15 experienced seizures as a result of not receiving anticonvulsant medication as ordered and required an emergency room evaluation and medical testing. Resident identifiers: #15 and #24. Facility census: 76. Findings included: a) Resident #15 Resident #15 was admitted in August 2023. He had diagnoses of cerebral palsy, seizures, and moderate intellectual disabilities. His most recent Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 09/12/23 showed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Review of Resident #15's physician's orders showed an order for brivaracetam (Briviact) 100 mg, two (2) times a day for seizures. The resident had been receiving this medication since 08/05/22. Review of Resident #15's Medication Administration Record (MAR) for July 2023 showed the resident did not receive brivaracetam on 7/30/23 at 9:00 PM and on 07/31/23 at 9:00 AM. The code 9 was recorded on these dates and times, which according to the MAR chart code meant, Other/see nurses notes. A nurses' note written on 07/30/23 at 8:18 PM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. Medication on order. Unavailable in dispensary. A nurse's note written on 7/31/23 at 12:45 PM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. Will receive on 7/31/2023 from pharmacy. Resident #15's MAR for August 2023 showed the resident did not receive brivaracetam on 08/03/23 at 9:00 PM, 08/04/23 at 9:00 AM, and 08/04/23 at 9:00 PM. The code 9 was recorded on these dates and times, which according to the MAR chart code meant, Other/see nurses notes. A nurse's note written on 08/03/23 at 9:24 PM stated, Brivaracetam Oral Tablet 100 MG Give 1 tablet by mouth two times a day for Seizures. Medication on order. A nurse's note written on 8/04/23 at 8:43 AM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. Not received from pharmacy. A nurse's note written on 08/04/23 at 11:22 AM stated, Called pharmacy to order medication Brivaracetam 100mg for resident. It is to be delivered this evening. Pharmacist is going to possibly call in a dose to [pharmacy name] for today's dose. He will call later to confirm. A nurse's note written on 08/04/23 at 3:14 PM stated, NP [Nurse Practitioner] update on 2 missed doses of Brivaracetam no new orders at this time. Medication to arrive this day. A nurse's note written on 08/04/23 at 9:10 PM stated, During my evening med pass, this nurse heard screaming coming from dining area. When I arrived, pt [patient] was sitting in wheelchair, halfway slumped over shaking. Pt had dropped his water and snack on the floor. Pt involuntarily shook for approx [approximately] 2 mins. Was very disoriented with whole body weakness. Pt vitals 220/102, P [pulse] -112, O2 [oxygen saturation] -97%, R [respirations] -22, T [temperature] - 98.9. Provider notified. Received new orders to recheck BP [blood pressure] in 15 mins, if still elevated, send to ER [emergency room ] for eval. Pt recheck was still 200/110. Pt sent to ER [emergency room ], RN [registered nurse] supervisor on call notified. A nurse's note written on 08/04/23 at 9:54 PM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. not in cart, pharmacy on way with medication. A nurse's note written on 08/04/23 at 10:09 PM stated, Pt left with emergency transport via stretcher. Review of Resident #15's emergency department after visit summary showed the resident had been diagnosed with seizures. In the emergency department, the resident was subjected to having blood drawn for laboratory testing. He also had a chest x-ray, computerized tomography (CT scan) of the brain, and an electrocardiogram. The resident returned to the facility 08/05/23 at 3:27 AM. The admitting nurse's note stated, Pt arrived via stretcher with EMS [emergency medical services]. Pt very lethargic and sleepy, still experiencing weakness, and skin feels hot to touch. Pt did not have a fever upon exam. Pt was sent to [hospital name] and underwent labs, ECG [electrocardiogram], brain CT all unremarkable. Pt chest x-ray showing some vascular congestion per hospital RN staff. Frequent visual checks. Pt denies any complaints, call bell in reach. Further review of Resident #15's physician's orders showed at the time of his transfer to the emergency room , the resident was receiving two (2) anticonvulsant medications in addition to brivaracetam. The resident was receiving phenytoin sodium (Dilantin), 300 mg by mouth at bedtime and lacosamide (Vimpat) 200 mg, two times a day. Review of Resident #15's nurses notes since admission showed no evidence the resident had experienced seizures prior to 08/04/23. Resident #15 was not interviewable about the experience. However, the National Library of Health's article titled Postictal Seizure State, which was updated 07/10/23, and is available on-line, states, The postictal state is a period that begins when a seizure subsides and ends when the patient returns to baseline. It typically lasts between 5 and 30 minutes and is characterized by disorienting symptoms such as confusion, drowsiness, hypertension, headache, nausea, etc. This would be frightening to a reasonable person. During an interview on 11/07/23 at 10:05 AM, the Administrator and Director of Nursing confirmed Resident #15's brivaracetam was unavailable for administration on 07/30/23 at 9:00 PM, 07/31/23 at 9:00 AM, 08/03/23 at 9:00 PM, 08/04/23 at 9:00 AM, and 08/04/23 at 9:00 PM. The Administrator and Director of Nursing stated they did not know why the medication was unavailable. No further information was provided through the completion of the survey process. b) Resident #24 A record review, conducted on 11/06/23, for Resident #24, found a physician's order, written on 10/06/23, for Gabapentin oral tablet 600 mg, give one (1) tablet by mouth two (2) times a day for pain. Further review of the record showed staff had documented the medication, Gabapentin was not available on 10/06/2 starting at 8:33 pm, 10/07/23, 10/08/23, and 10/09/23 to be administered to the resident. An interview with the DON, on 11/07/23 at 11:06 AM, revealed the medication Gabapentin, had not been available to administer to Resident #24 from 10/06/23 through 10/09/23.