Every finding on record at Morgantown Healthcare Center

Based on record reviews, staff interviews, resident interviews, and observations, the facility failed to maintain an environment free from accidents and hazards by providing inadequate supervision. This deficient practice had resulted in actual physical harm to one (1) of 21 residents. Resident #65 sustained a subarachnoid hemorrhage after being knocked down by Resident #42. Resident #42 was known to the facility as having episodes of physical agression. Resident Identifiers: #65 and #42. Facility Census: 114. Findings included: a) Resident #42 The facility's policy and procedure for Incidents/Accidents stated, It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees by minimizing possible exposure to safety hazards to the extent applicable. A Facility Reported Incident received 03/03/26 was reviewed for alleged resident-to-resident abuse. Resident-to-resident physical abuse was substantiated by the facility. The Initial Reporting of Allegations summary included: Resident #42 was found in a resident room holding Resident #65's iPad. Staff felt Resident #42 was in the victim's room rummaging through her belongings; Resident #65 attempted to take it back and, during a struggle, Resident #65 lost her balance. The report stated that Resident #65 was lying flat on her back in the doorway to her room, and she was bleeding from a wound on her head. Resident #65 was transferred to the Emergency Department for further evaluation at 11:15 PM. Resident #42 was placed on one-on-one supervision. Resident #65's Trauma History and Physical report dated 03/03/26 stated, Impression: Acute medial right frontal lobe multifocal areas of subarachnoid hemorrhage, with parafalcine and right tentorium subdural hematoma measuring up to 5 mm. No midline shift. Resident #65 was capacitated with a Brief Mental Status Score (BIMS) of 14. Resident #42 was incapacitated and a BIMS was not completed secondary to the resident hardly/never understood.Resident #42's progress notes were reviewed and summarized: On 02/16/26, the nurse's note stated that redirection was not effective; the resident was agitated, combative, and exit-seeking. On 02/18/26, an Alert Note stated Resident #42 hit another resident in the face and pulled her hair. However, further investigation by the State Surveyor of the risk assessment determined Resident #42 had gone into another resident's room and was hit in the face and her hair was pulled. On 02/19/26, Clinical Psychological Services (CPS) recommended the following: continue consistent re-direction and frequent re-orientation strategies, Utilize structured environment and limited overstimulation. Monitor for further agitation or interpersonal conflicts. On 02/21/26, an Alert Note stated the resident entered another resident's room causing agitation with other residents; both were screaming and staff intervened by removing the resident. On 02/25/26, CPS's note had no change in recommendations. On 02/27/26, the Physician Monthly Visit note documented no change in cognition and no increased nervousness or depression. On 03/02/26 at 15:14, an Alert Note documented one-on-one supervision failed. On 03/03/26 at 00:46, an Alert Note documented a resident-to-resident altercation. On 03/03/26 at 10:41, a note documented the resident was deemed safe and removed from one-on-one supervision. On 03/03/26 at 23:05, an Alert Note documented the resident was agitating residents, taking belongings, and was verbally abusive to staff; one-on-one supervision had limited success. Frequent documentation of wandering throughout the facility was documented in the resident's progress notes. On 07/27/26 at 6:10 PM, the State Surveyor observed Resident #42 wandering in the hallways from E Hall, D Hall, and C Hall; she was redirected back to E Hall twice by staff. d) On 07/28/26, Registered Nurse/Minimum Data Set Coordinator (RN/MDS) #130 reported Resident #42's behavioral interventions were hit or miss and the resident can sometimes communicate. The social worker updates the care plan for resident-to-resident behaviors. The RN/MDS coordinator #130 confirmed the only update on the care plan for behaviors was for a wander guard on 03/06/26 and reported unit nurses update care plans for daily changes. No intervention had been edited/revised since 2024. On 07/28/26 at 1:30 PM, Social Worker #50 confirmed there were no resident-to-resident interventions on the care plan and stated, I know interventions are from 2024. The SW said the only interventions for behavior were Just the ones I showed you. Interventions included: Inform family of behaviors.Inform MD of behaviorsEducate about the potential for harm to other residents when pushing or attemptingto push them.Educate to request staff assist rather than pushing other residents. Social Worker #50 confirmed it would be difficult for the resident to be educated. Resident-to-resident behavior was not monitored for Resident #42 by nursing. On 07/28/26 at 8:47 AM, the DON reported there was no resident-to-resident behavior on the behavior monitoring chart and stated, It's not on there. b) Resident #65 On 07/28/26 at 9:50 AM, Resident #65 was interviewed concerning the reported abuse incident resulting in a major injury.The resident recalled the incident from March and reported that Resident #42 took her blanket and threw it. I fell down. My head bumped. I didn't wake up. When asked what staff does when Resident #42 comes into her room, Resident #65 stated, They take her away. She reported she was afraid she to have surgery if something happened. The resident reported she has angels watching over her. Again reported she was afraid, but Name (Resident #42) don't know what's going on. and They don't have no medicine for her. The resident reported she was afraid when Resident #42 comes in her room and stated, I was afraid. Big woman. You have to watch her. Even a man would. It's dangerous. The resident reported Resident #42 still comes into her room even with a stop sign and, two nights ago, slept in her roommate's bed all night. The resident reported she was afraid and she tried to stay up, but she fell asleep. She reported the stop sign works sometimes. Resident #65 stated, I'm praying hard, she don't know. The resident reported she still has residents coming into her room even with a 'Stop Sign' across the door. On 07/28/26 at 10:07 AM. Licensed Practical Nurse (LPN) #84 reported that she got report and Resident #42 was in Resident #112's bed all night. LPN #84 reported the resident was hard to re-direct and both resident's were currently sleeping in each other's beds. They (nursing staff) redirect Resident #42 by encouraging the resident to join activities that are going on, directing her to look out the window, and giving her a snack or coffee. The LPN reported it was really hard to hold the resident's attention to redirect. On 07/28/26 at 10:19 AM, LPN #131 reported Resident #42's behaviors depend on the day and some days are easier. The LPN reported the staff will re-direct the resident to the resident's room to wait for her husband. When the resident gets agitated, LPN #131 reported the staff offer books, snacks and drinks. LPN reported it just depends on her mood if the interventions work. LPN #131 stated, We have a lot .a lot of behaviors back there. referring to the E hallway. On 07/29/26 at 12:30 PM, the incident resulting in harm between Resident #65 and Resident #42 was reviewed with the Administrator and the Director of Nursing (DON), including interventions, resident supervision, progress notes, and care plans for Resident #42. The Administrator reported he thought there were no issues with the care plans and he would follow-up with the care plan nurse. The DON reported both residents were seen by psych services on this date. On 07/29/26 at 1:00PM, the State Surveyor reviewed the findings with the Regional Director of Operations including interventions, progress notes and care plans for Resident #42. On 07/29/26 at 1:30 PM, the DON reported there was no additional information concerning supervision and interventions for Resident #42. No further information was provided through the completion of the survey process.

Based on record reviews, staff interviews, resident interviews, and observations, the facility failed to ensure that adaptive equipment and utensils were provided for residents at mealtimes as ordered by the physician. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #5, #53, #62, and #69. Facility Census: 114.Findings included: a) The facility's policy and procedure for Assistive Devices stated, 1. Appropriate assistive devices/utensils will be provided as indicated in the physician's orders and individualized plan of care. b) Resident #5 On 07/27/26 at 12:12 PM, Resident #5 was observed with no Dycem under the lunch plate. The resident reported she gets Dycem sometimes. Speech-Language Pathologist #98 confirmed there was no Dycem under the resident's plate and stated, I can get some. The resident's tray card stated Dycem highlighted in blue. The resident's order stated, Dycem with meals. c) Resident #53 On 07/27/26 at 12:35 PM, Resident #53 was observed not to have a [NAME] Cup per the blue-printed [NAME] Cup on his tray card. The resident's order stated, Blue Kennedy cup. Licensed Practical Nurse #100 confirmed the resident did not have a [NAME] Cup and reported the resident had never had a [NAME] Cup. The resident had a two-handled cup with a spouted lid. d) Resident #62 On 07/27/26 at 12:38 PM, no Dycem was observed under Resident #62's plate. Dycem was printed in blue on the resident's tray card. The resident's order stated, Dycem mat and scoop plate with all meals. Nurse Aide #56 confirmed there was no Dycem under the plate and stated the plate usually has a ring around it . this one doesn't. e) Resident #68 On 07/27/26, Resident #66 stated, Tonight I probably got everything, but I usually don't. The resident did not receive the two-handled cup with lid as printed on her tray card. Licensed Practical Nurse (LPN) #126 confirmed the resident did not receive the cup. LPN #126 stated, I've never seen it in three (3) years. The resident reported she never gets a special cup. The resident was observed to be drinking out of a regular coffee cup during the dinner meal.

Based on record review, observation, resident interviews, and staff interviews, the facility failed to ensure the menus were prepared in advance and followed to meet the nutritional needs of the residents. This failed practice affected five (5) of 21 residents. Resident Identifiers: #68, #40, #104, #111, and #65. Facility Census: 114. Findings included: a) The facility's policy and procedure for meal distribution stated, For point of service dining, the Dining Services Department staff, under the supervision of the licensed nurse, will assemble the meal in accordance with the individual meal card and present it to the resident/patient or care staff for delivery to the resident/patient. b) On 07/27/26, the dining observation was initiated. Monday's posted menu stated the following: Chicken Stir Fry w/Vegetables, Broccoli Florets, Steamed Rice, Buttered Dinner Roll, and Pear Crisp. The menu extension for the Dysphagia Advanced diet also included poultry gravy, two (2) ounces, to be served with the meal. On 07/27/26, the following menu and tray card errors were noted for the following residents: c) Resident #68 Resident #68 stated, Tonight I probably got everything, but I usually don't. The resident did not receive eight (8) ounces of milk per her tray card and stated, I never get milk at suppertime. Licensed Practical Nurse (LPN) #126 confirmed the resident did not receive milk or a cup. The resident was asked if she wanted milk by the LPN, and the resident stated, Chocolate, when given a choice. d) Resident #40 Resident #40 did not receive poultry gravy per his tray card and menu extension. The resident's tray card stated, Poultry Gravy - 2 Oz and Buttered Dinner Roll - 2 Ea. The resident only received one (1) roll. At 12:20 PM, Nurse Aide #64 confirmed the resident did not receive the poultry gravy or two rolls and stated, That is correct. e) Resident #111 Resident #111 received a regular buttered dinner roll with her pureed meal. The resident's tray card stated, Pureed Buttered Dinner Roll - #15 Scp in pink lettering. Special instructions for tray cards are printed in a pink color. The State Surveyor intervened before the resident consumed the regular consistency roll. The resident's diet and tray card were confirmed by Nurse Aide #64, who stated, Yeah, you're right, and reported she didn't think that looked right. f) Resident #104 At 12:10 PM, Resident #104 did not receive poultry gravy. The resident's tray card stated, Poultry Gravy - 2 Oz. Account Manager #145 confirmed there was no gravy on the resident's food and went to get gravy for the resident. g) Resident #65 At 12:05 PM, Resident #65's tray card and tray were observed. The resident's tray card stated, [NAME] Crunchies Cereal - 2 Srv. The resident only received one bowl of cereal on her lunch tray. No milk was provided for the cereal. Account Manager #145 confirmed the resident's tray and tray card and stated, I'll get it, and added, Sometimes she only wants one.

Based on record review and staff interview, the facility failed to ensure an allegation of resident-to-resident abuse was reported immediately (but not later than two (2) hours for an allegation of abuse resulting in serious bodily injury), failed to notify administration immediately per facility policy, and failed to submit a Five-Day Follow-Up to the state agency. This failed practice affected two (2) of 21 residents. Resident Identifiers: #65 and #3. Facility Census: 114. Findings included: a) Resident #65 The facility's policy and procedure for WEST VIRGINIA Abuse, Neglect & Misappropriation concerning investigations stated, V1.12.a. If the events that cause the allegations involve abuse and/or serious bodily injury, the self-report must be made immediately, but no later than 2 hours after the allegation is made. A Facility Reported Incident (FRI) was reviewed for resident-to-resident abuse. The Initial Reporting of Allegations stated, Per staff interviews perpetrator was found in resident room holding the victims I-Pad. Staff felt Perpetrator was in victims room rummaging through her belongings and victim attempted to take it back-during struggle victim lost her balance. The date and time when the alleged incident occurred was 03/02/26 at approximately 10:30 PM. The description of the injury stated the resident was bleeding from occipital scalp. Resident complained of nausea and positioned on her side. She did have a large emesis at that time. Resident #65 was transferred to the Emergency Department for further evaluation. Education included in the incident file was provided on 03/04/26 and 03/05/26 concerning the following: All incidents need reported to the DON/ED/Supervisor immediately to identify which events report to state and to meet the time frame for reporting. Please make sure you are reporting timely. Please sign off on the educational form with a supervisor prior to starting your next shift. Resident #65's Trauma History and Physical report stated, Impression: Acute medial right frontal lobe multifocal areas of subarachnoid hemorrhage, with parafalcine and right tentorium subdural hematoma measuring up to 5 mm. No midline shift. An initial report of the incident was emailed to the Office of Health Facility Licensure and Certification (OHFLAC) and the Ombudsman on 03/03/26 at 10:37 AM. The incident of resident-to-resident abuse was not reported within two (2) hours. On 07/27/26 at 4:44 PM, the Director of Nursing (DON) confirmed the incident was not reported within the two (2) hours and stated, So that should have been reported . within two (2) hours. The DON reported that corporate had come to the facility and completed education for reporting abuse in a timely manner. b) Resident #3 On 11/20/25, an initial reporting of allegations was made to all required entities, including the Office of Health Facility Licensure and Certification (OHFLAC). It was reported that Resident #3 grabbed Resident #115's right arm. Fingernail marks were noted on Resident #115's right arm. Residents were separated immediately by nursing staff. Investigation was performed with resident and staff interviews. It was determined that Resident #3 screamed that Resident #115's chair was squeaking and driving him crazy. However, no five (5) day report was located in the file provided to the surveyor by the facility.On 07/28/26 at 3:00 PM, the Director of Nursing (DON) stated he was unable to locate a five (5) day report for the incident that occurred on 11/20/25. He stated he believed it had been submitted, but he did not work at the facility when the incident between Resident #3 and Resident #115 occurred.On 07/29/26 at 11:30 AM, the State Agency confirmed a five (5) day follow-up was not submitted to OHFLAC. No further information was provided through the completion of the survey process.

Based on observation, staff interview, record review, the facility failed to revise a resident's comprehensive care plan for behavior management interventions and activities. This failed practice affected one (1) of 21 residents. Resident Identifier: #42. Facility Census: 114.Findings included: a) Resident #42. Resident #42's care plan for behaviors was reviewed. The care plan listed resident physical aggression episodes towards other residents. Interventions included the resident to be educated about potential harm to other residents when pushing or attempting to push them and education to request staff assist rather than pushing other residents. The Social Worker #50 confirmed the resident would have difficulty with comprehending the education due to cognitive status. On 07/28/26 at 1:30 PM, Social Worker #50 confirmed there was no resident to resident interventions on the plan of care. Resident #42 was incapacitated and a BIMS was not completed secondary to the resident hardly/never understood. On 07/29/26 at 10:45 AM, Activities Leader #117 reported Resident #42 had family one (1) to one (1) time. The activities leader reported that Resident #42 does not go to group activities, but likes music and church. The activities leader reported currently the facility does not provide one (1) to one (1) activities. There is an activity in the afternoon provided for each side of the building. Resident #42 was encouraged to attend activities and likes to walk up and down the halls per the activity leader's' report. The resident was given packets of images for self-directed activities. The Activities Leader reported the resident is not able to attend to activities and groups for long periods of time. Resident #42's care plan was reviewed for interventions and addressing the resident's behaviors. Activities Leader #117 confirmed there were no recent updates or changes since 03/8/25 and 06/16/25.

Based on record review, facility incident report review, and staff and resident interviews, the facility failed to ensure that necessary activities of daily living (ADL) services, specifically bedtime hygiene and incontinence care, were provided for the residents. This was discovered during the Long Term Survey complaint review process and affected one (1) of 21 residents. Resident Identifier #76. Census: 114.The facility was in past non-compliance. The facility identified the deficient practice on 07/27/26, implemented comprehensive corrective actions, completed staff education, and monitored implementation prior to the start of the survey on 07/28/26. Findings included:a) Resident #76Review of the medical record for Resident #76 revealed a care plan initiated on 11/04/25, and revised on 04/23/26, which stated:Assistance required with ADL's may fluctuate based on time-of-day, mood, pain, or fatigue. Adjust and document as indicated. Report significant changes to charge nurse.Place call light within reach. Remind Resident to call for assistance. Resident will use call light if they need something at night. She doesn't want to be disturbed during her sleep. Review of a facility-reported incident (FRI) log dated 07/27/26, at 2:35 PM, detailed an allegation of resident neglect. The initial report indicated that Resident #76 was left overnight in soiled clothing without bedtime care.The facility's investigation concluded that the resident was left in her daytime street clothing overnight and was found wet/soiled by the oncoming morning shift.The internal investigation noted that night shift staff misunderstood the resident's care plan (did not want to be disturbed during her sleep) to mean that no evening preparation, bedtime hygiene, or clothing changes were required because the resident did not illuminate her call light. On 07/28/2026 at 9:30 AM an interview was conducted with Resident #76. The resident was able to recall the incident. She confirmed that she was left in her street clothes overnight and slept in a soiled brief. She stated, The morning staff got me all taken care of though.Resident Follow-Up Interview (07/28/2026 at 1:56 PM): Resident #76 clarified her preferences regarding her care plan, stating, I ask them (staff) not to come in at all hours of the night. They come in every two hours and annoy me and I can't sleep. She further noted she expects assistance getting ready for bed before she goes to sleep, and enjoys staff assistance picking out clothes from her closet.Written statements from the morning shift staff confirmed that Resident #76 was still dressed in the prior day's clothing and was heavily saturated with urine when they assumed care. The night-shift Certified Nursing Assistant (CNA), [Perpetrator], provided a statement contradicting the incident and stated, I ensured that Resident #76 was changed and in a nightgown and dry before they went to bed. The facility's investigation found [Perpetrator]'s statements to be false based on the matching independent testimonies of the resident and the oncoming morning staff, alongside the physical evidence of the resident being found in heavily saturated street clothing.Past Non-Compliance and Corrective ActionsThe facility's failure to differentiate between preventing sleep disruptions during the night shift and providing standard evening hygiene and bedtime ADLs resulted in the resident being left overnight in her soiled clothing until the next morning. However, the facility successfully demonstrated that it corrected this deficiency before the survey team arrived.The survey team validated the following components of the facility's corrective actions, implemented between 07/27/26 and 07/28/26.The facility placed the implicated staff member on administrative leave pending the investigation. A verbal warning was executed and placed in her personnel file. Adult Protective Services (APS) and the local Police Department (PD) were immediately notified per state reporting mandates.The facility conducted comprehensive physical and skin assessments for all residents assigned to that unit/shift to ensure no other residents were left soiled, wet, or missing bedtime care. No other negative outcomes or omissions were identified.Immediate education was given for nursing and CNA staff. The training focused on interpreting care plans accurately-clarifying that a resident's right to undisturbed sleep does not eliminate the requirement to offer or perform nighttime care, clothing changes, and evening toileting prior to a resident going to sleep.The facility instituted administrative tracking and shift-change audits to ensure PM and AM care handoffs accurately communicate residents' current clothing and continence status.

Based on staff interview and record review, the facility failed to ensure a resident was provided an ongoing program to support the resident in their choice of group and individual activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of the resident. Resident Identifier: #42. Facility Census: 114. Findings included: a) Resident #42 The facility's policy and procedure for Activities Program Policy stated, It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional need and concerns of the residents. Safety is a primary concern for our residents, staff and visitors. The Procedures for the activity process included: c. Consists of individual and small and large group activities which are designed to meet the needs and interests of each resident and includes at a minimum: viii. Individual activities. The activities are to be comprised of individual and group activities. On 03/19/26, an Activities Note stated that the resident prefers to be self-directed. On 07/28/26, Registered Nurse/Minimum Data Set Coordinator (RN/MDS) #130 reported Resident #42's behavioral interventions were a hit or miss and the resident can sometimes communicate. The social worker updates the care plan for resident to resident behaviors. The RN/MDS coordinator #130 confirmed the only update on the care plan for behaviors was for wander guard on 03/06/26 and reported unit nurses update care plans for daily changes. No intervention edited/revised from 2024. Resident #42. care plan for behaviors was reviewed. The care plan listed resident physical aggression episodes towards other residents. Additional behavioral episodes were documented on the following dates: 02/18/26, 02/21/26 and 06/20/26 and were not updated on the care plan. Interventions included the resident to be educated about potential harm to other residents when pushing or attempting to push them and education to request staff assist rather than pushing other residents. The Social Worker #50 confirmed the resident would have difficulty with comprehending the education due to cognitive status. On 07/28/26 at 1:30 PM, Social Worker #50 confirmed there was no resident to resident interventions on the plan of care. Resident #42 was incapacitated and a BIMS was not completed secondary to the resident hardly/never understood. On 07/29/26 12;30 PM, the incident resulting in harm between Resident #65 and Resident #42 was reviewed with the Administrator and the Director of Nursing (DON) including interventions, resident supervision, progress notes and care plans for Resident #42. The Administrator reported he thought there were no issues with the care plans and he would follow-up with the care plan nurse. The DON reported the resident was seen by psych services this date. On 07/29/26 at 1:00PM, the State Surveyor reviewed the findings with the Regional Director of Operations (RDO) including interventions, progress notes and care plans for Resident #42. On 07/29/26 at 1:30 PM, the DON reported there was no additional information concerning supervision and interventions for Resident #42. Resident #42's Activity Participation Log was reviewed. Activities were not provided for the following dates: February 2026 - 02/04/26, 02/07/26, 02/11/26, 02/12/26, 02/13/26, 02/20/26, 02/21/26, 02/22/26, 02/25/26, 02/26/26, and 02/28/26.March 2026 - 03/02/26, 03/03/26, 03/05/26, 03/06/26, 03/07/26, 03/08/26, 03/10/26, 03/11/26, 03/13/26, 03/17/26, 03/18/26, 03/26/26, 03/29/26, and 03/30/26.April 2026 - 04/05/26, 04/06/26, 04/08/26, 04/09/26, 04/12/26, 04/13/26, 04/17/26, 04/18/26, 04/19/26, 04/20/26, 04/24/26, 04/25/26, and 04/26/26.May 2026 - 05/01/26, 05/03/26, 05/11/26, 05/12/25, 05/13/26, 05/14/26, 05/15/26, 05/16/26, 05/17/26, 05/17/26, 05/18/26, 05/20/26, 05/23/26, 05/25/26, 05/27/26, 05/29/26, 05/30/26, and 05/31/26.June 2026 - 06/02/26, 06/04/26, 06/05/26, 06/06/26, 06/07/26, 06/07/26, 06/08/26, 06/10/26, 06/12/26, 06/14/26, 06/16/26, 06/16/26, 06/17/26, 06/06/19/26, 06/20/26, 06/21/26, 06/23/26, and 06/30/26.July 2026 - 07/04/26, 07/05/26, 07/06/26, 07/07/26, 07/08/26, 07/09/26, 07/10/26, 07/11/26, 07/13/26, 07/15/26, 07/16/26, 07/15/26, 07/16/26, 07/19/26, 07/20/26, and 07/25/26. On 07/29/26 t 10:45 AM, Activities Leader #117 confirmed the missing activities on the Activity Participation Log. Activities Leader #117 reported Resident #42 had family visitors frequently for one (1) to one (1) time The activities leader reported the resident doesn't go to group activities often, but likes music and church. Activities Leader #114 stated that currently the facility does not provide individual one (1) to one (1) activities for the residents in the facility. She reported there is an activity in the afternoon for each side of the building. The activities leader reported the resident is encouraged to attend activities and that she likes to walk up and down the halls. The resident is given packets of images to look through for self-directed activities. No further information was provided through the completion of the survey process.

Based on record review, staff interview, resident interview and observations, the facility failed to ensure a resident who experienced a traumatic event received appropriate treatment and services. This failed practice affected one (1) resident. Resident identifier: #65. Facility Census: 14. Findings included: a) Resident #42 a) Resident #65 A Facility Reported Incident received 03/03/26 was reviewed for alleged resident to resident abuse. Resident to resident physical abuse was substantiated by the facility. The Initial Reporting of Allegations summary included: Resident #42 was found in resident room holding Resident #65's I-Pad. Staff felt Resident #42 was in victims room rummaging through her belongings and Resident #65 attempted to take it back and during a struggle Resident #65 lost her balance. The report stated that Resident #65 was lying flat on her back in the doorway to her room. and she was bleeding from a wound on her head. Resident #65 was transferred to the Emergency Department for further evaluation at 11:15 PM. Resident #42 was placed on one (1) to one (1) supervision. Resident #65's Trauma History and Physical report dated 03/03/26 stated, Impression: Acute medial right frontal lobe multifocal areas of subarachnoid hemorrhage, with parafalcine and right tentorium subdural hematoma measuring up to 5 mm. No midline shift.Resident #65 was capacitated with a Brief Mental Status Score (BIMS) of 14. Resident #42 was incapacitated and a BIMS was not completed secondary to the resident hardly/never understood.On 07/28/26 at 9:50 AM, Resident #65 was interviewed by the surveyor concerning the reported abuse incident resulting in a major injury. The resident recalled the incident from March 2026 and reported that Resident #42 took her blanket and threw it. The resident said, I fell down. My head bumped. I didn't wake up.When asked what staff does when Resident #42 comes into her room, Resident #65 stated, They take her away. She reported she was afraid she would have to have surgery if something happened. The resident reported she had angels watching over her. Resident #65 again reported she was afraid, but said Name (Resident #42) don't know what's going on. and They don't have no medicine for her. The resident reported she was afraid when Resident #42 comes in her room and stated, I was afraid. Big woman. You have to watch her. Even a man would. It's dangerous. Resident #65 was capacitated with a Brief Mental Status Score (BIMS) of 14. Resident #42 was incapacitated and a BIMS was not completed secondary to the resident hardly/never understood.Resident #42's progress notes were reviewed and summarized: On 02/16/26, the nurse's note stated that redirection was not effective; the resident was agitated, combative, and exit-seeking. On 02/18/26, an Alert Note stated Resident #42 hit another resident in the face and pulled her hair. However, further investigation by the State Surveyor of the risk assessment determined Resident #42 had gone into another resident's room and was hit in the face and her hair was pulled. On 02/19/26, Clinical Psychological Services (CPS) recommended the following: continue consistent re-direction and frequent re-orientation strategies, Utilize structured environment and limited overstimulation. Monitor for further agitation or interpersonal conflicts. On 02/21/26, an Alert Note stated the resident entered another resident's room causing agitation with other residents; both were screaming and staff intervened by removing the resident. On 02/25/26, CPS's note had no change in recommendations. On 02/27/26, the Physician Monthly Visit note documented no change in cognition and no increased nervousness or depression. On 03/02/26 at 15:14, an Alert Note documented one-on-one supervision failed. Resident #65 reported Resident #42 still comes in her room even with stop sign and two (2) nights ago slept in her roommates bed all night. The resident reported she was afraid and she tried to stay up, but she fell asleep. Reported the stop sign works sometimes. Resident #65 stated, I'm praying hard, she don't know. The resident reported she still has residents coming into her room even with the 'Stop Sign' across the door. Resident #65's progress notes were reviewed. On 03/05/26, the resident denied any needs at that time. Social Worker progress noted dated 03/10/26 documented the resident denied having any psychosocial needs. No additional documentation of psychosocial needs were found. Additional progress notes reviewed included: 4/14/26 - Increased anxiety documented with Buspar ordered.4/14/26 - eInteract change of condition for anxiety.7/11/26 - Verbally agitated wit staff. Resident's #65's care plan stated, Resident had a R subdural hemorrhage in March 2026. Interventions/Tasks included: Observe for changes in mental status. Report Abnormal findings to medical provider; resident/resident representative. On 07/28/26 at 1:30 PM, Social Worker #50 reported there was no documentation of monitoring psychosocial impact for Resident #65. On 07/29/26 12;30 PM, the Director of Nursing reported the resident was seen by psych services this date.

Based on record review, staff interview and observation, the facility failed to ensure food was provided in a form designed to meet individual needs for a resident ordered a pureed diet. This failed practice had the potential to affect a limited number of residents. Resident identifier: #111. Facility Census: 114. Findings included: a) The facility's policy and procedure for Therapeutic Diets stated the definition of a Therapeutic Diet is a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. One of the purposes of a therapeutic diet is to provide food that a resident is able to eat (e.g., mechanically altered diet). b) Resident #111 Resident #111's diet order stated, Regular Diet Dysphagia Puree texture, Thin liquids consistency, fortified cereal breakfast, fortified soup lunch and dinner, two-handled cup with lid with meals. On 07/27/26, during the dining room observation, Nurse Aide #64 served the resident her lunch tray in the dining room. A regular consistency roll was buttered by staff and given to the resident. The State surveyor intervened prior to the resident eating the roll and had Nurse Aide #64 remove the regular roll. Nurse Aide #64 confirmed the resident was on a puree diet and should not have received a regular roll. Nurse Aide #64 stated, Yeah, you're right, and reported she didn't think that looked right.

Based on interview and record review, the facility failed to provide residents with a written notice of the room change, including the reason for the change. Additionally, the facility failed to provide the resident with the opportunity to visit the new room prior to relocation. Resident Identifiers: #69 and #70. Facility Census: 118.Findings Include a) Resident #69During an interview on 10/14/25, at approximately 12:45 PM, Resident #69 stated that she had been living in her current room since 04/0/25. She mentioned that on 07/31/25, Administrator #160 informed her that she would need to pay $327.00 a month to remain in her room. Resident #69 expressed that she was unable to afford the additional charge. She conveyed her distress over the situation and informed her daughters about Administrator #160's comments. Resident #69 then motioned to her daughter, who was present in the room, and indicated that she could explain what had happened. Resident's daughter stated that she had spoken with Administrator #160 regarding her mother's stay at the facility. She noted that her mother had been in the same room for over two years, during which time they had never been required to pay an additional charge. The daughter stated that Administrator #160 had responded, That is the way it is working now! Due to her inability to resolve the issue, the resident's daughter contacted the Regional Director of Operations (RDO) #162. He scheduled an appointment to meet her at the facility on 08/04/25. However, the resident's daughter reported that RDO #162 did not attend the meeting. Instead, another corporate representative arrived and spoke with her, but she described this person as unhelpful. The resident's daughter mentioned that she had agreed to pay the necessary fees to ensure her mother could stay in her room while she worked on resolving the issue. She also reported that she attempted to contact RDO #162 on his cell phone on 08/04/25 but did not receive a response. The resident's daughter went on to state that since she had been unable to resolve the matter, she submitted a complaint to Communicare on 08/04/25. She also stated that she spoke to the Ombudsman on 08/04/25. Resident #69 reported that on 08/13/25, while heading to activities, she was approached by SW and informed that she was being moved to a semi-private room for non-payment. She mentioned that she had not received any invoices from the facility and expressed her distress over not having the funds to cover the required balance. Resident #69 explained that she relies on her daughters for financial support and that, after her last meeting with the facility representative, her daughters had agreed to pay the additional charges. She assumed that the matter had been resolved. The resident's daughter mentioned that her other sister had entered the facility on 08/13/2525, and asked Administrator #160 why they had not been contacted. Administrator #160 responded by saying, We cannot notify you of every little detail! The resident's daughter also stated that Administrator #160 later entered her mother's room and told her sister, You are not representing yourself very well; you are being too emotional! The resident's daughter reported that she made an online payment for the extra charge on 08/13/25, and attempted to contact RDO #162 but did not receive a response. She also mentioned that she spoke with the Ombudsman on the same day, who promised to return her call; however, she has not heard back from the Ombudsman since then. Additionally, the resident's daughter indicated that she has not received any communication from the facility regarding the complaint she submitted. During an interview with SW on 10/14/25, at approximately 2:22 PM, SW confirmed that the facility had not provided Resident #69 with advance written notification regarding her non-payment. She also confirmed that the resident had not received an invoice for the additional charges associated with her private room. Furthermore, SW stated that on 08/13/25, Administrator #160 had instructed her to inform Resident #69 that she would be moved to a semi-private room immediately due to non-payment.During an interview with [NAME] Office Manager (BOM) #62 on 10/14/25, at approximately 3:11 PM, BOM #62 stated that the facility had previously decided not to enforce an additional charge for private rooms. However, she mentioned that Administrator #160 had made the decision to selectively start charging residents for their private rooms. When asked if the residents had been informed about the additional cost to remain in their private rooms, she indicated that selected residents had been verbally notified.On 10/14/25 at approximately 3:30 PM, BOM #62 provided a list of residents who were being billed for their private pay rooms. A review of the list revealed the following information:There were a total of thirty-two (32) residents in private rooms. Ten (10) of these residents were Medicaid residents who were being charged an extra fee for a private room.Two (2) of these residents were private pay.Twenty (20) of these residents were Medicaid residents, and they had not been billed for their private rooms.During the interview on 10/14/25 at 3:11 PM, BOM #62 was questioned about the facility's policy for billing these residents. BOM #62 stated that during the previous years, the facility had elected not to bill medicaid residents in private rooms the extra charge. However, Administrator #69 had decided to bill residents or attempt to move them if they were unable to pay. BOM #62 went on to state that Administrator #160 had arbitrarily selected Resident #69 as the first resident to be required to pay the extra charge for her private room. BOM #62 confirmed that the residents had not been notified of this policy change in writing. BOM #62 further stated that Administrator #69 had planned to transfer residents from private pay rooms to semi-private rooms as they became available.Upon being again questioned whether residents in private pay rooms had been notified of this plan in writing, and offered the option of either moving to a semi-private room, or paying the extra charge, the BOM #62 stated that Administrator #160 had handled that process, and to the best of her knowledge, no notifications had been sent out.During the interview with Resident #69 on 10/14/25 at approximately 12:50 PM, Resident #69 further stated that the resident occupying the room opposite her, Resident #70, had her belongings moved from her private room to a semi-private room while Resident #70 was at lunch. Resident #69 went on to state that she had stopped attending activities and stayed in her room for almost two weeks after that, because she was so upset and fearful that the facility would attempt to move her belongings while she was occupied in an activity. b) Resident #70During an interview with Resident #70 on 10/15/25 at 11:20 AM, the resident stated that she had been in her current room since 01/11/24. The resident stated that her daughter was contacted by the facility on 07/31/25 and notified over the phone that she would have to pay an additional charge to continue staying in her room. Resident #70 stated that the SW informed her on (Thursday) 07/31/25 that she would have to pay an extra fee of $327.00 a month to stay in her current room, or she would be moved to a semi-private room on (Monday) 08/04/25. Resident #70 continued to state that on Friday, 08/01/25, while she had been at lunch, facility staff approached her and said that she was being moved immediately. Resident stated, I was so pissed because I had been in my room for over a year and a half with no problems. Resident stated that she was still very upset about the way in which she was treated. Furthermore, Resident #70 stated that the facility had moved her to a room without considering her needs or preferences. She stated that the bathroom of the room she was moved into could not accommodate her wheelchair, so she had difficulty using the bathroom. The resident continued her narrative by stating that she had to wait until another room became available. On August 13, 2025, she was finally moved to a room with a bathroom large enough to accommodate her wheelchair.During a phone interview with the resident's daughter on 10/15/25 at approximately 11:50 AM, she stated that she received a call from the facility on 07/31/25, notifying her that private rooms were only given to residents when medically necessary. She was further informed that her mother could no longer stay in her room. She was told that there would be an extra monthly charge if her mother were to stay in the room. The resident's daughter had stated that she was unable to pay the additional charge, and she was then told that her mother would be moved to a semi-private room. The resident's daughter stated that she had not received any written notification, or invoice explaining the extra charge, or an explanation of the facility's policy for moving her mother. During an interview with Interim Administrator #161, who had been at the facility for just one (1) week, he stated that he had been unaware of the actions taken by Administrator #160, who was no longer employed at the facility. He further noted that no additional residents had been moved to semi-private rooms.

Based on record review and staff interview, the facility failed to maintain the dietary staff's appropriate competencies for food service handling. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 116. Findings included: a) Food Safety Certificates The State Food Safety Certificate of training had expired for the Certified Dietary Manager #161 on 02/08/24. -The Certified Dietary Manager #161 renewed the certificate of training on 04/30/25 following survey intervention. The State Food Safety Certificate of training had expired for Dietary Aide #166 on 02/09/24. -On 04/30/25 at 3:44 PM, the Regional Certified Food Manager #189 stated, Dietary Aide #166 had resigned on 04/23/25. Dietary Aide #166 had worked without a Certificate of Training for Food Safety on the following dates:02/10/25, 0214/25, 02/15/25, 02/16/25, 02/17/25, 02/19/25, 02/20/25, 02/21/25, 02/24/25, 02/25/25, 02/25/25, 02/26/25, 02/28/25, 03/01/25, 03/02/25, 03/04/25, 03/05/25, 03/06/25, 03/07/25, 03/10/25, 03/11/25, 03/12/25, 03/14/25, 03/15/25, 03/16/25, 03/18/25, 03/19/25, 03/20/25, 03/21/25, 03/24/25, 03/25/25, 03/28/25, 03/31/25, 04/01/25, 04/02/25, 04/05/25, 04/06/25, 04/07/25, 04/11/25, 04/12/25, 04/13/25, 04/14/25, 04/16/25, 04/17/25, 04/19/25, 04/20/25, 04/21/25 and 04/22/25. The Administrator confirmed the expired certificates, on 05/01/25 at 9:50 AM, and stated the Regional Certified Food Manager #189 had told me yesterday.

Based on record review, staff interview and observation, the facility failed to store food in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 116. Findings Included: a) On 04/29/25 at 07:15 AM, the kitchen investigation was initiated. Cookies were found in the freezer with an incomplete date (no year). The Regional Certified Food Manager #189 stated, I'll discard. b) On 04/30/25 at 11:50 AM, the A-Wing pantry was investigated. The following items were found: -[NAME] pickles open and not dated -Cotton candy - open and not dated -Refrigerator temperature 76 degrees Fahrenheit. Items in the pantry were confirmed by Licence Practical Nurse #28 at 12:00 PM. c) On 04/30/25 at 12:01 PM, the B-Wing pantry was investigated. The following items were found: -[NAME] John's sandwich was not sealed or dated with a used by date -Multiple Individual juice cups (Orange, Apple and Cranberry) were not dated -Refrigerator temperature was 44 degrees Fahrenheit. Items in the pantry were confirmed by Registered Nurse #19 at 12:09 PM. d) Interview with Regional Food Manager #189 On 05/01/25 at 10:19 AM, the Regional Certified Food Manager #189 stated that opened food items are to be labeled and dated for seven (7) days and items have to be dated in the refrigerator.

Based on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to water management. This practice had the potential to affect all residents that reside in the facility. Facility census: 116. Findings included: a) Water Management During facility record review of the water management revealed, the documentation was not maintained to prevent growth of water borne pathogens including description of the building water system. The flow diagram did not Identify the buildings water systems for which Legionella control measures are needed. No documentation was provided describing the building water systems using text or testing protocols. On 05/05/25 at 2:20 PM, the Maintenance Director verified the facility did not maintain the water management program. He stated that it would be corrected.

Based on observation and interviews, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery of a resident smoking in non-designated areas. Resident Identifier: #79. Facility census 116. Findings included: a) Resident #79 On 04/30/25 at 11:54 AM, surveyor observed Resident #79 smoking outside the front door on the sidewalk. On 05/01/25 at 8:10 AM, there was a second observation of Resident #79 smoking out front of the facility in a non-smoking area. During an interview on 05/01/25 at 8:13 AM, the Assistant Administrator stated that the facility did not have any smokers. During a continued interview on 05/01/25 at 8:15 AM, the Assistant Administrator stated that she was not supposed to be out there smoking, but that's where she goes. He verified at this time that Resident #79 was smoking in a non-smoking area. An observation of the area found no ash can, no fire blanket, nor a fire extinguisher in the vicinity. A No Smoking sign was displayed. During an interview with the Corporate Administrator and the Director of Nursing (DON) on 05/01/25 at 8:19 AM, she stated that Resident #79 was supposed to sign out and go off the facility property, but Resident #79 continues to smoke there. She continued to say that they made the resident a place across the parking lot in a grassy area at the top of a hill to smoke but she won't go over there. The DON stated that the resident was grandfathered in and could smoke at the facility. The DON and Corporate Administrator confirmed Resident #79 was not supposed to smoke in the non-smoking area.

Based on staff interview and record review, the facility failed to update Resident #107's care plan for discontinuation of an anticoagulant and to clarify Resident #264's care plan for level of assistance needed for activities of daily living. These failed practices were a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifiers: #107 and #264. Census: 116. Findings included: a) Resident #107 On 04/29/25 at 03:56 PM, Resident #107 had an order for Lovenox Injection which was discontinued on 02/17/25. The resident's current care plan (revised 02/18/25) stated, Resident is at risk for abnormal bleeding or hemorrhage due to anticoagulant/antiplatelet use for prophylaxis. Resident will be free from abnormal bleeding / hemorrhaging through review date. Educate resident / resident representative on benefits and potential risks of anticoagulant drug use. Encourage resident to use electric razor when shaving, soft bristled toothbrush. If excessive bleeding / hemorrhage occurs, provide emergency care. Monitor for s/sx [signs and symptoms] of bleeding (i.e. bruising, petechiae, epistaxis, GI bleeding, hematuria, nose bleeds, tarry/black stools bleeding gums). Notify medical provider, resident / resident representative, as needed. Provide anticoagulant//antiplatelet medication per medical providers order. Monitor for effectiveness, and side effects (bleeding, embolism). Report abnormal findings to medical provider, resident / resident representative. The Administrator confirmed there was not a current order on 04/30/25 at 12:05 PM and stated, It's not there .okay. b) Resident #264 On 05/06/25 at 10:15 AM, Resident #264's care plan stated: Helper does ALL of the effort or 2 or more helpers assist. The state surveyor interviewed Minimum Data Set (MDS) Nurse #44 and MDS Nurse #120. Information for the care plan is based on the usual performance during the look back dates per report. The MDS Nurse's stated Activities of Daily Living may fluctuate and Resident #254's care may change if patient is resistive to care. If cooperative - maybe one person. When asked how the nursing assistants know when to use one or two person to assist a resident, it would depend on how the resident's behavior is that day. The State Surveyor interviewed the Administrator on 05/06/25 and reviewed the care plan and interview with MDS Nurses. The Administrator stated, I agree. when questioning how the nursing assistant would know if the person is a one or two person assist.

Based on observation, interview, and record review, the facility failed to provide activities intended to enhance the resident's sense of well-being and to promote or enhance physical, cognitive, and emotional health to ensure the resident's highest practicable state of well-being. Resident Identifier: #110. Facility Census:116. Findings Included: a) Resident #110: Resident #110 was diagnosed with cardiomyopathy, heart failure, hypertension, muscle weakness, localized edema, pain in left and right knees, diabetes mellitus - on insulin, and lack of coordination. During an interview with Resident #110 on 04/29/25 at 2:22 PM, the resident stated that he was unable to get out of bed. Upon being asked what activities he has planned for him, the resident said that there isn't much being offered. He reported that he spends his day lying in bed and sometimes watches TV. A review of Resident #110's Care Plan revealed that residents' activity interests were listed as: -Bingo -Hunting -Fishing -Watching TV -Baking -Cooking -Spending time outside -Gardening An observation on 04/30/25, at approximately 3:13 PM revealed the resident in bed. Another observation and interview with the resident, on 05/01/25 at approximately 2:12 PM, revealed the resident was in bed watching TV. Resident stated that he was supposed to have a 1:1 activity, but no one had visited him since 04/23/25. The resident was observed throughout the survey process from 04/29/25 to 05/06/25 and was not observed participating in any activity. The Director of Nursing (DON) provided copies of the resident's activity participation sheets, and activity plan. The documents revealed that the resident had not had any activities from 04/23/25 to 04/30/25. DON confirmed that they were the only participation sheets available for Resident #110. During an interview with Activity Staff (AS) #30 on 05/01/25 at approximately 10:18 AM, it was revealed that resident has been care-planned for self-directed activity. AS #30 stated that resident does not like to go out of his room.

Based on observation, interview, and record review, and staff interview, the facility failed to address and notify the physician about an incorrect medication order. It also neglected to ensure that the order was corrected and updated. This was a random opportunity for discovery. Additionally, the facility failed to complete a Speech Therapy Evaluation per physician's order in a timely manner for Resident #107. This was also a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifiers: #221 and #107. Facility Census: 116. Findings Included: a) Resident #221 During observation of medication administration on 05/01/25 at 8:45 AM, RN #19 stated that Resident #221 was prescribed 37.5 MG of Metoprolol. RN #19 further stated that the resident would be administered half (½) a tablet. Inspection of the medication revealed that the pharmacy had provided Metoprolol 75 MG tablets. RN #19 administered Metoprolol 37.5 MG (1/2 tablet) during med pass on 05/01/25 at 8:49 AM. At approximately 10:08 AM on 05/01/25, a review of Resident #221's orders revealed the following order: -Metoprolol Tartrate 50 MG oral tablet. Give 37.5 MG two times a day for HTN [hypertension]. During an interview with RN #19 at 11:15 AM, the RN confirmed that the dose ordered by the physician had been accurately administered. RN #19 also confirmed that the physician's prescription should have stated Metoprolol Tartrate 75 MG. After the surveyor's intervention, at 12:05 PM on 05/01/25, the Director of Nursing (DON) confirmed that the order entered by the physician was inaccurate. The DON further stated that the order would be changed to Metoprolol Tartrate 75 mg tablets. b) Resident #107 On 04/29/25, Resident #107 was observed by the state surveyor in the hallway eating his lunch meal. The resident was coughing while eating. The unit nurse observed the coughing and went to assist the resident. Orders for the following interventions included: CXR STAT Diagnostic Active 4/29/2025 15:20 GuaiFENesin Liquid 100 MG/5ML Give 10 milliliter by mouth every 4 hours as needed for Cough Pharmacy Active 4/29/2025 19:19 ST to eval and treat as indicated No directions specified for order. Other Active 4/29/2025 Nursing Progress Note stated: 4/29/2025 16:20 Resident noted to have increased coughing this shift. NP [Nurse Practitioner] to assess resident. New orders to start PRN [as needed] tussin 10ml q4h, obtain CXR, CBC, BMP, procal STAT, ST [Speech Therapy] to eval. Orders placed in PCC [electronic medical record] and MPOA [medical power of attorney] aware. Labs drawn and pending pickup at this time. A chest x-ray was completed on 4/30/2025 8:29:06 AM. On 05/05/25 at 12:41 PM, the Administrator confirmed there was no Speech Therapy evaluation per order. The Administrator stated, They didn't do it not happening until today. The resident was not evaluated by speech therapy until surveyor intervention.

Based on medical record review, staff interview, the facility failed to take actions to thoroughly investigate an alleged violation related to physical abuse. Resident identifier #76. Facility census: 116. Findings included: a) Resident #76 A record review found an allegation from 06/06/24 where a staff member allegedly fingerpainted with feces on Resident #76. A reportable was completed with the following details: -On 06/06/24 an anonymous call was placed to the corporate hotline. The caller alleged that a Nurse Aide (NA) defecated on a male resident and drew pictures on the resident with her feces. The anonymous caller may have been a disgruntled employee who believed that this NA got her terminated. During an interview on 04/30/25 at approximately 10:00 AM with the Assistant Administrator, he verified that he helped complete some of the resident interviews after the allegation was reported on 06/06/25. He stated that he was unsure if the allegation had occurred. He continued to state that at the time he believed that it was a disgruntled employee. A review of an investigation revealed that the issue was reported to Nurse Aide Registry on 06/06/24, the NA no longer works at the facility, but a situation did occur just not as reported by caller. Continued review of the reportable found no witness statements from the employees that may have knowledge of the allegation. During the interview on 05/01/25 at 9:30 AM the Administrator verified that there was no documentation or statements from all staff working at the time or that may have knowledge of the allegation.

Based on record review and staff interview, the facility failed to ensure one (1) of 29 residents reviewed during the long-term care survey process for Physician Orders for Scope of Treatment (POST) forms completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifiers: #42. Facility census: 116. Findings included: a) Resident #42 Record review on 04/30/25 at 8:55 AM, revealed section for Section D (Signature of Resident, or Guardian /Medical power of Attorney -MPOA Mandatory) was not completed with a MPOA Signature, a verbal signature in place dated 03/03/24 on Resident #42's active Physician Order for Scope of Treatment Form (POST Form). During an interview on 05/01/25 at 10:08 AM, the Director of Nursing (DON), confirmed Resident #42's POST form was incorrect without an MPOA signature in a timely manner.

Based on observations, interview, and record review, the facility failed to ensure that the oxygen concentrator for a resident with a tracheostomy was set to deliver the exact dose of oxygen prescribed by the physician. Resident Identifier: #94. Facility Census: 116. Findings included: a) Resident #94 Resident #94 is diagnosed with the following: -Traumatic Brain Injury -Dependence on supplementary oxygen -Seizures -Epilepsy -Paraplegia -Tracheostomy -Gastrostomy. Physicians Orders stated the following: -Cool air mist via trach collar continuous with O2 bled in at 5LPM -Suction via trach and prn (lung sounds pre and post, O2 sat pre and post) every shift and as needed -Trach-Type Shiley Size 6 -Trach care q shift and prn as needed -Replace inner cannula during trach care q day and prn every shift and as needed -Have the same size trach and one size smaller at bedside at all times -Change trach ties Mon, Wed, Fri, and prn -Change suction tubing and canister once per week and prn - every shift every Fri AND as needed -Change O2 Mask and initial and date tubing - every day shift every Fri for 02 mask/tubing care -Trach: Ambu Bag at bedside During an observation of resident on 04/29/25 08:12 AM, resident was asleep, and the oxygen concentrator was noted to be set to 4.0 Liters per minute. A review of the physician's orders showed that the resident was to receive oxygen at 5 liters per minute. During an observation on 04/30/25 2:00 PM, the oxygen concentrator was noted to be set to deliver 4.0 liters per minute. On 05/01/25 at approximately 12:14 PM during an observation, accompanied by RN #19, the oxygen concentrator was noted to be set to deliver 4.5 liters per minute RN #19 confirmed that the concentrator should be set up to deliver 5.0 liters per minute. RN #19 checked physician's order and confirmed that the physician's order specified 5 Liters per minute. RN #19 adjusted the oxygen concentrator to deliver the prescribed dose.

Based on observation, record review, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. A large chef's knife was found lying on the sink in the dementia care unit. The knife handle was leaned up against the sprayer making it more accessible to the residents. The knife was easily reached and accessed by the Surveyor from the resident's side of the counter. The memory care unit had a census of 24 ambulatory residents with diagnosis of Dementia and/or Alzheimer's Disease. Any of the 24 Residents could have obtained access to the knife potentially causing serious harm and/or death to self or others due to their cognitive impairments and decreased safety awareness. The state agency (SA) determined this to be an immediate jeopardy (IJ) which placed all twenty-four (24) Residents at risk for serious harm and/or death. The facility was notified of the IJ on 06/06/23 at 12:40 PM. The facility submitted a Plan of Correction (POC) at 2:00 PM on 06/06/23 at which time it was accepted by the SA. The plan of Correction read as follows: a. The knife was immediately removed by Memory Unit Manager at 11:06am on 6/6/23. b. A sweep was performed by the Administrator/Designee throughout the building to ensure that no other accident/safety hazards were present throughout the facility at 12:45 pm on 6/6/23. c. An in-service was immediately conducted by the administrator/designee to all staff to ensure no staff leaves hazardous items within reach of residents on 6/6/23, anyone not available for the training will be educated before they return prior to their first worked shift. d. The Administrator/designee will audit the facility each shift daily for four weeks for any hazardous items left within reach of residents and then as needed thereafter to ensure there are no hazardous items within reach of residents. e. Trends identified will be reported monthly to the Quality Improvement Committee (QIC) for any additional follow up and/or in-servicing until the issue is resolved then randomly thereafter as determined by the QIC committee f. Corrective Action Completion date 6/6/23. Upon return to the facility at 9:11 PM on 06/06/23, two (2) employees were found to be working which did not have the specified in-service training prior to the first worked shift, as stated in the plan of correction. Licensed Practical Nurse (LPN) #171 and Nurse Aide (NA) #170 were interviewed by Surveyor and both employees stated they did not receive any in-services prior to starting shift at 7:00 PM. The Administrator was informed at 9:20 PM of the employees working without being in-serviced. The employees were then provided with the in-service training by the Administrator. On 06/07/23, the state agency (SA) completed review of in-service trainings and found all employees had been educated as indicated in the POC. Observation and tour of the memory unit determined all hazards had been removed, all storage doors secured, and no other accident hazards were present. The IJ was abated on 06/07/23 at 10:00 AM at which time a deficient practice remained and the scope and severity was decreased from a K to an E. The IJ began on 06/05/23 when the night shift nurse used the knife and left it out in reach of residents. The IJ ended on 06/07/23 when the SA abated the immediacy. A deficient practice remained because the facility failed to ensure medication and treatment carts were secured and locked while unattended by staff. This failed practice was a random opportunity and had the potential to affect all residents residing on the memory unit. The remaining deficient practice had the potential to affect more than an isolated number of residents. Resident identifiers: #49, #103, #87, #62, #114, #40, #13, #41, #96, #64, #89, #95, #101, #99, #93, #33, #35, #83, #78, #3, #43, #100, #68, #108. Facility census: 116. Findings included: a) Memory Unit Knife On 06/06/23 at 11:05 AM, an observation was made of a large chef knife lying the sink of the kitchenette area. The knife was leaned up against the sink water sprayer, with the handle sticking up above the raised counter, in the dementia care unit. The knife was easily accessed from the resident's side of the counter by surveyor. The knife was approximately eight (8) inches long and had a sharp edge. On 06/06/23 at 11:06 AM the Resident Service Director (RDS) confirmed the knife had been there since last night (06/05/23) when a nurse aide was cutting up vegetables for her own consumption. Nurse Aide #84 was named by unit manager as to be the one that left the knife out during her shift the night before (06/05/23). Resident Service Director (RDS) agreed the knife should not have been left out, and instead stored in a drawer at the back side of the kitchenette. The RDS then picked up the knife and moved it to the back counter, out of reach to residents. When the RDS was asked if anyone had been in the kitchen area this morning (06/06/23), she stated, I was back here this morning getting ice water for medication pass, but I never paid any attention to the sink area. At 1:30 PM on 06/06/23 the Administrator confirmed all Residents residing on the memory unit were ambulatory and were considered to be Residents who wandered. On 06/06/23 at 2:10 PM, a baby doll was observed laying in the sink where the chef knife was previously located . NA #61 stated, Yea one of Residents puts the doll into the sink sometimes. Resident #101 was then observed reaching across the counter of the Kitchenette in the memory unit and obtaining a foil wrapped sandwich that was lying on the lower counter. NA #61 intervened and said, They pilfer over here all the time on counter, they like to grab and go. NA #61 was asked if she had saw the knife which was leaned up on the kitchen sink sprayer in the sink earlier and she stated, I really didn't pay any attention, but that's bad news. Record review showed all 24 Residents residing on the memory unit had a diagnosis of some form of dementia. Residents #41 and #78 also had a diagnosis of delirium due to physiological condition. Resident #49 also had a diagnosis of Paranoid Personality Disorder and Delusional disorder. Review of the Residents most recent MDS, section C showed only two (2) residents to have a Brief Interview for Mental Status Score (BIMS) score above 8. A cutoff score of 13 is recommended to indicate the presence of any cognitive impairment. A score of 0 to 7 suggests severe impairment. During an interview on 06/07/23 at 9:30 AM, the Administrator stated he did not condone what happened with the knife being left out over on the memory unit. The Administrator stated, That was a careless act, the memory unit is supposed to be a specially designed place for that population to be safe and wander about. The Administrator further stated all staff have been educated on Resident safety on the memory unit and something like that will not happen again. b) D Wing Medication Carts On 06/06/23 at 9:14 PM, observations made on D wing, revealed two (2) medication carts were unlocked and unattended. During an interview at 06/06/23 at 9:16 PM, LPN #132 acknowledge both medication carts were left unlocked and unattended. On 06/06/23 at 9:30 PM, the Administrator was notified of the two (2) medication carts being unlocked and unattended. 45174

Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure that one resident (Resident #94) out of two residents reviewed for accidents had an environment free from clutter that resulted in a fall with serious injuries. Resident #94 experienced actual harm from an unavoidable fall with serious injuries requiring admission to the intensive care unit of the hospital and immediate survey. Findings included: a) Resident #94 A chart review was conducted on 10/10/18 at 8:45 AM. Per clinical record review, the Admission Record noted Resident #94, was admitted to the facility on [DATE], with [MEDICAL CONDITION]. A care plan, dated as initiated 02/15/17, identified Resident #94 had the potential for injury from falls and identified the resident sustained [REDACTED]. The goal was to prevent the resident from further falls and noted to keep her room and hallways free from clutter. This goal was initiated on 02/15/17. Another focus area for the care plan for Resident #94 to be placed on a memory care unit due to her confusion and memory loss related to dementia. The date of the identified problem was 02/16/17. The intervention for this issue was to .keep environment free of hazards . This intervention was dated 02/16/18. The quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C for Cognition identified Resident #94 Brief Interview for Mental Status (BIMS) as 0 out of 15, which identified her as being severely cognitively impaired. Under Section G for Functional Status, noted the resident was independent with ambulation with a walker. Per review of the Progress Notes, Resident #94 sustained the following falls: 1: On 11/01/17, the resident was found on the floor in the lounge of the secured unit. There were no injuries noted. The Fall Investigation Form 5-15 noted fall prevention measures were in place, i.e., shoes and socks were on, it was determined the resident was not incontinent, and she was with others. There was no decline in function determined because of this fall. The care plan was updated accordingly. 2: The resident sustained [REDACTED]. An investigation revealed Resident #94 was found on her right side and outside of her room. Staff reported the resident fell , due to another resident's front wheeled walker (FWW) .lightly hit . Resident #94 and the resident slowly fell to the ground. The investigation revealed the resident had fall prevention measures in place. The resident was not injured and there was no decline in function because of this fall. The care plan was not updated after this fall. 3: Resident #94 sustained a fall on 11/23/17. The investigation noted another resident alerted staff the resident fell in the hallway. There were no injuries noted. It was noted the resident attempted to get herself up off the floor at this time. There was no decline in function determined because of this fall. The investigation noted that fall prevention measures were in place. Both the family and the physician were notified of the incident. The care plan was not updated after this fall. 4: Another fall took place on 12/10/17 with Resident #94. The investigation stated the resident sustained [REDACTED]. There were no apparent injuries, but the resident did complain of pain and she was administered pain medication after the incident. The resident did have fall prevention measures in place. The care plan was updated at this time. The updated included to place hipsters (hip brace) on the resident and to removed them during hygiene. 5: Resident #94 sustained a fall on 06/22/18 while attempting to sit in the dining room and missed the chair. The resident hit the back of her head against the wall and sustained a small bump on the back of her head. The resident denied any injuries or pain. The interdisciplinary team met after the fall and determined there was some decline and directed staff to offer her assistance with her seating and common areas. 6: On 08/14/18 the resident had another witnessed fall. Resident #94 fell while in the lounge area and it was noted that she lost her balance. The resident had no injuries and there was no decline in function noted. The care plan was updated at this time. The care plan noted that staff were to frequently reorient the resident to surroundings. The interdisciplinary team met and discussed the resident's fall with therapy and a certified nursing assistant (CNA). It was documented the resident has [MEDICAL CONDITION], difficulty with walking, impaired memory and unsteady gait and history of falls. The resident was noted to have fall prevention measures in place. 7: Resident #94 sustained a fall on 09/04/18. It was noted the resident was ambulating in the hallway with her front wheeled walker (FWW). The resident sustained [REDACTED]. The resident denied pain. Both the family and physician were notified after the incident. The care plan was updated. 8: Resident #94 sustained a fall on 09/07/18. A fall Progress Note with this same date noted the following, .Walking in hallway with FWW and proper footwear on .Resident observed with blood coming from left eye .vital signs taking (sic) at time of fall .Resident does not voice complaints of pain .Resident was observed walking in the hallway, resident tripped over wet floor sign and then over her walker. Resident was observed falling onto her left side ROM (range of motion) good, left eye observed with blood coming from eye. Residents (sic) walker was underneath of resident along with the wet floor sigh (sic), resident had on nonskid socks and resident was not incontinent at the times .Resident was assessed by NP (nurse practitioner) .ordered to send resident to ER (emergency room ) for further eval (evaluation) . The family and the physician were notified of the incident. The hospital discharge records dated 09/10/18 noted Resident #94 was admitted to the hospital on [DATE] and the admission [DIAGNOSES REDACTED]. The hospital records noted the resident was admitted to Intensive Care, and taken to the operating room for a fixation of the orbital region (boney structure surrounding the eye). The resident was readmitted back to the facility on [DATE]. A SBAR (Situation, Background, Assessment and Recommendation) form was completed on 09/12/18. The SBAR noted the resident's fall on 09/07/18 and the resident fell in the hallway and hit the left side of her face. Vitals signs taken at the time of the event were a blood pressure of 136/78, pulse was 64, respirations were 18, and her temperature was 97.1. It was noted that the resident had a functional status change. The SBAR continued by stating, .Resident was observed walking in the hallway, resident tripped over the wet floor sign and then over her walker. Resident was observed falling onto her left side .left eye observed with blood coming from eye . On 10/10/18 at 9:58 AM Certified Nursing Assistant (CNA) #40 was interviewed. CNA #40 confirmed he had worked for the facility for almost a year and primarily on the secured unit. The staff member confirmed Resident #94 was able to ambulate on her own. He said that he was present on the unit the day Resident #94 fell on [DATE]. CNA #40 said that when the resident fell , he was in another room and heard some commotion. He said that there was a wet floor sign (a hard plastic ladder style sign approximately two feet high) on the outside of her doorway which lead into the resident's room. During this interview, it was observed a wooden type of floor covering in the rooms of the residents and the hallway was carpeted. The staff member said he observed the resident on the hallway floor. He said that there are now paper signs posted which state caution wet floor. An interview was conducted with Housekeeper #62 on 10/10/18. She stated that she does not use the upright wet floor signs since the residents will mess with them and specifically stated, Residents will pick them up or use them as weapons. The Licensed Practical Nurse (LPN) #55 was interviewed on 10/10/18 at 10:11 AM. LPN #55 said that he worked the day that Resident #94 injured herself. He stated that the staff were cleaning up after breakfast and CNA #46 saw the resident on the floor. LPN #55 stated he grabbed the vitals machine and saw the resident with blood coming out from her orbital (eye) area. He stated Housekeeper #190 used the upright wet floor signs after she cleaned a room. He said that he did not remember Resident #94 messing with the wet floor sign before the incident. He said the resident did not have the capacity to understand the meaning of the wet floor sign. CNA #46 was interviewed on 10/10/18 at 10:16 AM. She stated that she had worked at the facility for the past [AGE] years and specifically worked on the secured unit for the past five years. CNA #46 said Housekeeper #190 would routinely place the wet floor sign up. CNA said the wet floor sign was on the outside of the resident's room. She stated that she heard some noise and saw Resident #94 fall and said the resident landed on her left side. The staff member said the wet floor sign was a triangle position over the resident's left leg and her walker was beneath her. A telephone interview was conducted with Housekeeper #190 on 10/10/18 at 12:06 PM. She said that she is no longer employed at the facility and confirmed she placed the wet floor sign on the floor on 09/07/18. She stated the facility never informed her that this would possibly be an environmental hazard for residents who wander. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were interviewed on 10/10/18 at 3:46 PM. Both stated that after the incident they made the change to use a sign to post on the doors of the residents on the secured unit. They confirmed there was no prior discussion that the wet floor signs might be an environmental hazard. On 10/10/18 at 4:01 PM, the DON and the Administrator were interviewed and said they had a video in which they had observed the resident seemed to get weak and then she fell . They confirmed they no longer have access to this video. A facility policy entitled Accidents and Supervision dated as implemented 11/27/17, noted the following, .The resident environment remains as free of accident hazards as possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes Identifying hazards(s) and risk(s) .Evaluating and analyzing hazard(s) and risk(s) .Implementing interventions to reduce hazard(s) and risk(s) .Monitoring for effectiveness and modifying when necessary . Resident #94 experienced actual harm from an unavoidable fall with serious injuries requiring admission to the intensive care unit of the hospital and immediate survey. The facility failed to ensure the resident's environment was hazard free.