Every finding on record at Moundsville Healthcare Center

Based on record review and staff interview, the facility failed to ensure documentation of residents' pain and treatment was performed in accordance with professional standards of practice. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of pressure ulcers. Resident identifier: 90. Facility census: 124.Findings included- On 11/29/25 at 8:25 AM, for a pain level of 8. Non-pharmacological interventions of repositioning, conversation, and redirection were attempted. The pain medication was effective in relieving the resident's pain. Review of Resident #90's Controlled Substance Administration Record showed Tramadol had been removed from the resident's supply at these additional dates and times: - 11/21/25 at 9:00 PM- 11/22/25 at 8:00 PM- 11/23/25 at 9:11 PM- 11/24/25 at 8:00 PM- 11/28/25 at 9:00 PM- 11/29/25 at 10:00 PM- 11/30/25 at 7:12 PM None of these administrations were recorded on the MAR. As such, the pain level and non-pharmacological interventions, as well as whether the medication had been effective, had not been documented. Review of Resident #90's Medication Administration Record (MAR) for December 2025 showed the resident was administered Tramadol on the following dates: - On 12/01/25 at 1:35 AM, for a pain level of 8. Non-pharmacological interventions were not attempted. The pain medication was effective in relieving the resident's pain.- On 12/08/25 at 10:24 AM, for a pain level of 5. Non-pharmacological interventions 1 and 4 were attempted. (The MAR did not specify what these interventions were.) The pain medication was effective in relieving the resident's pain. - On 12/09/25 at 1:31 AM, for a pain level of 8. Non-pharmacological interventions were not attempted. The pain medication was effective in relieving the resident's pain.Review of Resident #90's Controlled Substance Administration Record showed Tramadol had been removed from the resident's supply at these additional dates and times:- 12/04/25 at 8:30 PM- 12/05/25 at 9:40 PM- 12/06/25 at 9:00 PM - 12/07/25 at 8:00 PM- 12/08/25 at 2:00 AM- 12/09/25 at 7:54 PMNone of these administrations were recorded on the MAR. As such, the pain level and non-pharmacological interventions, as well as whether the medication had been effective, had not been documented. On 12/11/2025 at 10:28 AM, the Director of Nursing (DON) confirmed Resident #90's the inaccuracies between the MAR and the Controlled Substance Administration Record. She confirmed that the medical record contained no documentation of the resident's pain level, the non-pharmacological interventions, or the effectiveness of the interventions and pain medication for the occasions when pain medication administration was not documented on the MAR. No further information was provided through the completion of the survey process.

Based on observation, record review and staff interview, the facility failed to ensure medication carts were locked when nurses were not in attendance. These were random opportunities of discovery. Facility Census: 124.Findings Include: a) Medication Administration Policy On 12/10/25 at approximately 9:15 AM, the facility Medication Administration policy was reviewed. The review found under the heading of Procedure letter k. stated the following: Do not leave medication cart unlocked. (Typed as written.) b) Resident #15 On 12/10/2025 at 8:50 AM, an observation was made on the 200 hall which found the medication cart unlocked. The medication cart was left unattended for approximately three (3) minutes. On 12/10/25 at 8:53 AM, Licensed Practical Nurse (LPN) #127 exited Resident #15's room into the hallway. LPN #127 stated, I went into the room when the resident was calling out .I know I shouldn't have left my cart unlocked. On 12/10/25 at 9:35 AM, the Director of Nursing (DON) was notified and confirmed the medication cart should be locked at all times when unattended. c) 600 Hall Medication Cart Unlocked and Unattended On 12/10/2025 at 9:12 AM, an observation was made on the 600 hall which found the medication cart unlocked and unattended. The medication cart was left unattended for approximately six (6) minutes. On 12/10/25 at 9:18 AM, LPN #33 walked down the hallway coming from the 500 unit. LPN #33 acknowledged she was in charge of the 600 hall medication cart and stated, I thought I had locked it.

Based on food tray temperatures and resident interviews, the facility failed to serve food to residents that was palatable and at an appetizing temperature. Based on resident interview and staff interview, the facility failed to ensure hot foods were served hot. This failed practice was true for one (1) of one (1) hallways tested for food tray temperatures throughout the complaint survey process Facility census: 124.Findings included:a) Resident #42During an interview on 12/08/25 at 2:45 PM, Resident #42 stated, The food sucks and the hot food is lukewarm at best.b) Resident #51During an interview on 12/08/25 at 3:10 PM, Resident #51 stated, The food is bad.c) Test TrayOn 12/09/25 at 12:59 PM, the Food Service Director and the District Manager temped a meal tray on the 200 hall. The egg salad sandwich temperature was recorded at 65.4 degrees F. The first carton of milk had a temperature of 57.6 degrees F and the second carton of milk on the tray had a temperature of 59.1 degrees F. d) PalatabilityThree (3) surveyors tried the diced white potatoes and found that they were not palatable and had no seasoning.e) Resident #100On 12/11/25 at 10:30 AM, Resident #99 stated, she said, My food is always cold, and the staff will heat it up for me in the microwave.f) Staff InterviewsDuring an interview on 12/11/25 at 10:45 AM, Staff #8 and Staff #98 both confirmed that they frequently find it necessary to reheat Resident #99's food because it is cold at the point of service.

Based on resident interviews, interviews during resident council, observation and staff interview, the facility failed to ensure a substantial/nourishing snack was provided between the evening meal and breakfast. This is true for Resident #115, Resident #39 and Resident Council. Facility Census 124.Findings included:a) Resident #115 During an interview on 12/09/2025 at 10:31 AM, Resident #115 reported he is not offered a snack at bedtime but is given one if they have any available and he has to ask for it. b) Resident #39 During an interview with Resident #39 on 12/09/2025 at 10:24 AM, resident reported he is a 6'4 grown man and he isn't given enough food. He reported he is given kool aid for meals and prefers juice and tea. He stated the food is often cold but his main concern is I DONT GET ENOUGH FOOD. They do not give snacks at bedtime unless we ask for it. During an interview on 12/10/25 at 1:10 PM with the Director of Nursing (DON) to discuss the possibility of extra portions for Resident. She reported she would discuss with dietician. c) On 12/10/25 at 10:30 AM Resident Council meeting brought up concerns regarding snacks, it was asked if they received snacks with the answer of no, was asked if they received snacks if they asked for them with the answer of no because they are kept in the kitchen and the kitchen isn't always accessible. This was unanimous from the council attendees. d) 12/10/25 Evening Snack During a visit to the facility, on 12/10/25 between 8:30 PM - 9:30 PM, the following residents were interviewed and stated they had not been offered an evening snack but would have like one: -Resident #35 (11/18/25 BIMS listed as 15, indicating that resident was cognitively intact) -Resident #17 (08/01/24 Physician Determination of Capacity indicated resident demonstrated capacity to make decisions) -Resident #39 (11/17/25 BIMS listed as 15, indicating that resident was cognitively intact) -Resident #100 (09/2025 BIMS was listed as 15, indicating that resident was cognitively intact) e) Staff Interviews During a visit to the facility, on 12/10/25 between 8:30 PM - 9:30 PM, the following staff members were interviewed and stated they had not offered residents an evening snack: -Staff #50 -Staff #104 -Staff #45 -Staff #88 -Staff #60

Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to maintain the equipment in safe operating condition. This practice had the potential to affect more than an isolated number of residents. Facility census: 124.Findings included:a) On 12/08/25 at 11:35 AM, during an initial walkthrough of the kitchen and nourishment room, the following issues were identified and acknowledged by the Director of Dining:-Two (2) cleaning cloths were found sitting on the counter tops and not in a bucket with sanitizer.-Two (2) cool check containers were chipped and cracked.-No opened date or use by date on one (1) case of mighty shakes located in the reach in cooler.-The reach in cooler had a black substance on the shelving.-The stove top was visibly soiled.-The grease trap for the stove top was soiled.-The steamer needed to be delimed and the shelves needed to be cleaned.-The wall behind the steamer was dirty.-Both convections ovens needed to be cleaned.-One (1) bag of shrimp not labeled in the freezer.-One (1) bag of ravioli was not sealed and was not labeled or dated.-One (1) opened case of beef patties and one (1) opened case of oatmeal raisin cookies did not have a use by date in the freezer.-The can opener was visibly soiled.-The knife rack and the handles of the knives were soiled with food splatter.-One (1) steam table pan of cream of chicken soup was not labeled and did not have a use by date in the walk in cooler.-One (1) container of opened sliced american cheese was given a one (1) year use by date.-Sliced tomatoes were outdated, with a use by date of 11/24/25.-One (1) bag of opened parmesan cheese was not dated properly.-One (1) container of beef base did not have an open date.-One (1) container of yellow mustard was outdated with a use by date of 12/5/25.-One (1) gallon of Italian dressing without a use by date.-One (1) container of egg salad without a use by date.-One (1) steam table pan of homemade cole slaw did not have a use by date.-Two (2) sheet pans of roll dough in the walk-in cooler was not labeled or dated.-The meat slicer was not covered while not in use.-One (1) employee beverage found in the dry food storage room.-A container of granulated sugar was outdated with a use by date of 11/12/25.-The toaster needed to be cleaned due to debris.-Two (2) bags of opened chicken gravy mix did not have a use by date.-One (1) container of opened raisin bran was given a use by date of 10 months.-One (1) bag of opened toasted oats did not have a use by date.-One (1) bag of dry white rice was opened and was not sealed and did not have an open or a use by date.-Multiple spices did not have an open or a use by date.-The microwave was soiled on the inside.-There were four (4) bags of spoiled potatoes sitting on a shelf under the food processor that were swarming with gnats and had juice running out of them onto the floor.-The handwashing sink near the dish room was soiled with food spills.-The juice machine nozzles for the juice gun need to be cleaned.-One (1) clean pot and one (1) clean bowl were not inverted on the clean dish shelf.-Two (2) trash receptables did not have a liner in them.-The refrigerator in the in the dining room needed the shelves cleaned and sanitized due to spills / debris.-One (1) Lunchable was found in the reach in refrigerator in the dining room and it was outdated with a use by date of 10/23/25.-The ice scoop holder needed to be cleaned in the nourishment room due to holding water and a small trash can liner was wadded up at the bottom.b) On 12/09/25 at approximately 11:55 AM, the following issues were identified and acknowledged by the Director of Dining: -The popcorn maker located in the dining room had a scoop that is sitting on top of the machine and it is soiled and not in a covered container.-There are individually wrapped whipped spreads located in multiple drawers located in the dining room without a date.c) During another visit to the kitchen, on 12/09/25 at 12:04 PM, the Director of Dining acknowledged there was paint chipping, cracking and peeling on the kitchen ceiling and the exhaust hood in the kitchen. The Director of Dining stated, Maintenance is aware.d) Observation on 12/09/25 at 12:45 PM-The 200 hall beverage cart had four (4) tumblers that were wet nesting. Nursing staff was asked if there was moisture in the tumblers. She said, Yes and pulled them from being used.e) On 12/09/25 at 2:44 PM, the Director of Dining acknowledged the following issues in the kitchen:-There was one (1) angel food cake not labeled or dated in the freezer.-There were two (2) cleaning cloths not located in a bucket with sanitizer on the steam table.-The grease trap was still soiled located under the stove.There was one (1) pan of roll dough on a sheet pan in the walk-in cooler without a label or date.f) Dining Room RefrigeratorA dining room observation was made with the District Manager from HCSG on 12/10/25. The District Manager confirmed the dining room refrigerator had debris on the shelves.

Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record for documentation of Resident #12's incontinence status and Resident #110's care plan. This was true for two (2) of 25 residents reviewed during the survey process. Resident Identifiers: #12 and #110. Facility Census: 124. a) Resident #110 -Activity staff had documented in resident's care plan, She does not eat meat, fish, eggs or caffeine due to her religious beliefs. - A dietary order stated Lacto-Ovo Vegetarian diet. A lacto-ovo vegetarian diet excludes meat, poultry, and fish but includes dairy products (lacto) and eggs (ovo). This type of vegetarianism is plant-based, with a foundation of fruits, vegetables, grains, nuts, and seeds, and it also incorporates milk, cheese, yogurt, and eggs for nutrients like protein, calcium, and vitamin B12. During a telephone interview on 12/10/2025 at 7:45 PM, Resident #110's Medical Power of Attorney (MPOA) confirmed that the resident did eat eggs. The MPOA communicated that eggs were an important source of protein for the resident. During an interview, on 12/11/25 at approximately 11:00 AM, the Director of Activities reported that the resident's care plan would need to be updated to reflect her current lacto-ovo vegetarian diet which did in fact include eggs. b) Resident #12 On 12/10/2025 at 1:00 PM, a record review was completed for Resident #12. The review of the bladder incontinence from 11/11/25 through 12/10/25 under the tasks tab found multiple inaccurate issues with documentation. The resident did have an indwelling urinary catheter for obstructive uropathy. The correct documentation should be under the heading of continence not rated due to indwelling catheter. The following issues were found: --11/14/25 Incontinent --11/15/25 Incontinent --11/16/25 Incontinent --11/20/25 Incontinent --11/21/25 Incontinent --11/23/25 Incontinent --11/24/25 Incontinent --11/25/25 Continence not rated due to condom catheter --11/26/25 Incontinent --11/28/25 Continence not rated due to condom catheter --11/30/25 Incontinent --12/04/25 Incontinent --12/05/25 Incontinent --12/09/25 Continence not rated due to condom catheter --12/10/25 Continence not rated due to condom catheter On 12/10/2025 at 1:11 PM, the Director of Nursing (DON) verified the resident did have an indwelling foley catheter. The DON stated, I see I need to do training for my CNAs (certified nursing assistants) .some are new.

Based on resident representative interview, record review and staff interview, the facility failed to accommodate a resident's dietary needs related to religious beliefs. This was a random opportunity for discovery. Resident identifier: #110. Facility census: 124. Findings included: a) Resident #110 A record review was completed on 12/10/2025 at 5:06 PM. Resident #110's care plan stated that the resident did not ingest caffeine due to her religious beliefs. However, the dietary order for Resident #110 only stated, Lacto-Ovo Vegetarian Diet. A lacto-ovo vegetarian diet excludes meat, poultry, and fish but includes dairy products (lacto) and eggs (ovo). This type of vegetarianism is plant-based, with a foundation of fruits, vegetables, grains, nuts, and seeds, and it also incorporates milk, cheese, yogurt, and eggs for nutrients like protein, calcium, and vitamin B12. It does not address a resident's desire to remain caffeine-free. During a telephone interview, on 12/10/2005 at 7:45 PM, the resident's Medical Power of Attorney (MPOA) stated that resident remaining caffeine-free was an absolute, 100% must due to her religious beliefs. The MPOA was insistent that not having caffeine ever was something that resident had been fervent about her entire life. The MPOA explained Hare [NAME] followers generally avoid caffeine (in coffee, tea, soda) because it's considered an intoxicant that clouds the mind, hinders spiritual focus, and disrupts sleep, contradicting the goal of clear consciousness.Resident #110's dietary slips were reviewed on 12/11/25 at 9:30 AM. Coffee and tea were listed for every lunch meal and every dinner meal. During an interview on 12/11/25 at 9:45 AM, Food Service Director #150 reported that both the facility's coffee and the tea contained caffeine and that the dietary slip would need to be updated to reflect caffeine free.

Based on record review, policy review, and staff interview, the facility failed to ensure a resident admitted with an existing pressure ulcer received the necessary treatment and services, consistent with professional standards of practice, to promote healing. This was true for one (1) out of three (3) residents reviewed under the pressure ulcer pathway throughout the Long-Term Care Survey Process. Resident identifier: #100. Facility census: 124. a) Resident #100 The CommuniCare Policies and Standard Procedures indicated that a Resident / patient admitted with skin integrity issues will receive treatment as indicated based on location, stage and drainage. A stage III or IV Pressure Ulcer has four options for treatment, and none of the options were started until 12/02/25. Resident #100 was admitted to Moundsville Healthcare on 11/26/25. Upon admission the Licensed Practical Nurse (LPN) employee #33 completed the Nursing admission Evaluation and noted there were only Non-Pressure Skin issues present. On 11/26/25 at 1:49 PM Employee #33 wrote a progress note that stated: Report received at 3:55 PM from RN at RMH that Resident #99 has a stage 2 on buttocks covered by boarder foam dsg. On 11/27/25 Resident #100 was seen by the attending Physician for an History & Physical (H&P). The Physician only noted bruising to the skin. No Pressure wound was identified per the Physicians progress note. On 12/1/25 Resident #100 was seen by the Nurse Practitioner (NP). She stated that the resident has pre-existing ulcer of the right buttock and has been present for less than 30 days. She completed the Wound Assessment Report. Wound Assessment Report dated 12/01/25: Location: Right buttock Stage / Severity: Stage 3 Wound Status: Present on admission Size: 1 cm x 1 cm x 0.3 cm. Calculated area is 1 sq cm. Physician's orders written on 12/01/25 to start on 12/02/25 for treatment of Right Buttock Stage 3 Pressure Ulcer as follows: Cleanse with normal saline, pat dry, apply hydrogel every day shift and as needed. Resident #100 Care Plan shows that resident was admitted with a right buttock Stage 3 Pressure Ulcer on 11/26/25 and treatment started on 12/02/25. The Treatment Administration Record for November 2025 showed that Resident #99 did not receive any treatment for the Pressure Ulcer located on her Right Buttock. The first Skin Grid Pressure Assessment that was completed by a facility Registered Nurse was not completed until 12/08/25. The assessment stated that Resident #100 has a Stage III Pressure Ulcer located to her Right Buttock. The size is 1.0 cm x 1.0 cm x 0.3 cm. The Treatment Administration Record for December 2025 shows that Resident #100 started to receive treatment from nursing for the Stage 3 Pressure Ulcer located on her Right Buttock on 12/02/25. On 12/10/25 at 2:35 PM, the Director of Nursing (DON) and Wound Care Nurse confirmed there was no documentation that Resident #99's pre-existing pressure ulcer had been assessed upon admission to the facility. They confirmed there was no documented pressure ulcer assessment until 12/01/25. They also confirmed pressure ulcer treatment was not ordered until 12/01/25 and was not started until 12/02/25. The Director of Nursing stated the border foam dressing present on the resident upon admission to the facility could be left on wounds for up to seven (7) days. However, she acknowledged there was no documentation as to when the border foam dressing had been applied at the hospital. The wound care nurse presented a picture of the pressure ulcer that she had obtained from the hospital. It was difficult to stage the wound from the picture. However, it appeared the wound could have been a stage III pressure ulcer at the hospital.

Based on record review and staff interview, the facility failed to consult a resident's physician when the resident experienced a change in condition related to oxygen saturation levels. This was true for one (1) of three (3) residents reviewed in the closed record review process during the Long-Term Care Survey Process. Additionally, based on record review and staff interview, the facility failed to notify the resident's representative / family member / emergency contact of a significant change and the need to alter treatment. The facility transferred Resident #25 to the hospital. However, the resident's representative / family member / emergency contact was not notified of the transfer. This was true for one (1) of two residents reviewed for hospitalizations during the Long-Term Care Survey Process. Resident Identifiers: #125. Facility Census: 124.Findings included:a) Resident #125Resident #125 was admitted to the facility on [DATE] as a skilled care patient. The resident had the following diagnoses during his hospitalization prior to being admitted to the nursing home:-Congestive Heart Failure-Acute hypoxic respiratory failure (a critical condition where the lungs can't get enough oxygen into the blood)-Acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD). COPD is a progressive lung condition causing airflow limitation, making it hard to breathe due to inflamed airways, excess mucus, and damaged air sacs. An electronic medical record review revealed the following 09/18/25 Physician Order for Oxygen (O2): 02 at 1-5L (liters) via NC (nasal cannula) continuous every shift for COPD/SOB [shortness of breath] Additionally, there was a nurse's note, dated 9/18/2025 10:00 PM, noting that oxygen saturations (O2 SATs) were 89% on 6 L oxygen via NC. The nurse documented an attempt to put resident on Bilevel Positive Airway Pressure (bipap), a non-invasive breathing support device that provides two pressure settings: a higher pressure for inhaling (IPAP) and a lower pressure for exhaling (EPAP), helping people with respiratory issues like COPD breathe more effectively. The nurse noted that the resident did not tolerate it and stated he couldn't breathe, stated he never used it at home, only in the hospital, and was put back on nasal cannula per his request. Frequent coughing was noted by the nurse. There was no evidence in the electronic medical record that the resident's attending physician was notified of Resident #125's low 02 sats and refusal to wear bipap.During an interview on 12/11/ 25 at approximately 10:00 AM, the Director of Nursing confirmed the facility was unable to produce evidence the physician had been notified of resident's low 02 sats and refusal to wear bipap.

Based on record review and staff interview, the facility failed to ensure a resident's Pre-admission Screening and Resident Review (PASARR) reflected pre-admission diagnoses. This was true for one (1) out of four (4) residents reviewed under the category of PASARR, during the Long-Term Care Survey Process. Resident identifier: #32. Facility census: 124.Findings included:a) Resident #32A medical record review, completed on 12/10/25 at 10:14 AM, revealed Resident #32 had been admitted to the facility on [DATE] with the following diagnosis:-Major Depression DisorderThe resident's admitting PASARR marked NONE under Section III Question 30 entitled, Current Diagnosis (Check all that apply). Additionally, Section V Question 40 entitled, Major Mental Illness (MI) or Suspected MI was also marked NONE. During an interview on 12/10/25 at 11:16 AM, Social Worker #47 reported that Resident #32's Major Depression Disorder diagnoses had not been captured on the admission PASARR and a new one had not been completed.

Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents with a newly evident or a possible serious mental health disorder. This was true for one (1) out of four (4) sampled residents reviewed under the PASARR pathway during the Long-Term Care Survey Process. Resident identifier: #3. Facility census: 124.Findings included: a) Resident #3 On 12/11/2025 at 8:45 AM, a record review was completed for Resident #3. The review found the Pre-admission Screening and Resident Review (PASSAR) dated 03/07/23. The following diagnoses were added after the resident was admitted to the facility on [DATE]. The following diagnoses were added to the medical record on the following dates: --Vascular dementia 03/04/25 --Anxiety disorder 04/10/24 --Psychotic disorder 04/10/24 --Auditory hallucinations 04/10/24 On 12/11/25 at 9:30 AM, the Administrator confirmed the diagnoses were added after admission and a new PASSAR should have been completed. The Administrator stated, Social Services started a new PASSAR.

Based on record review and staff interview, the facility failed to provide the residents / resident representatives with a written notice of the Notice of Transfer /Discharge (including the residents' right to appeal the discharge and the process and how to contact the long-term care Ombudsman) when being transferred to the hospital. This was true for one (1) of two (2) residents reviewed for hospital transfers throughout the Long-Term Care Survey Process. Resident identifiers: #25 and #123. Facility census: 124.Findings included: Resident #25 An electronic medical record review revealed that Resident #25 was transferred to the hospital on [DATE] for aspiration pneumonia. The facility had scanned an Acute Transfer Letter into the record. There was no separate Notice of Transfer / Discharge letter found in the electronic medical record. An electronic medical record review revealed that Resident #123 was transferred to the hospital on [DATE] for aspiration pneumonia. The facility had scanned an Acute Transfer Letter into the record. There was no separate Notice of Transfer / Discharge letter found in the electronic medical record. Interview with Administrator During an interview on 12/10/25 at 10:00 AM, the Administrator produced an Acute Transfer Letter and reported that the facility had combined the previous notice of transfer / discharge form and the bed hold form into one (1) form. The Administrator acknowledged that the acute transfer letter failed to include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. Nor did the facility's acute transfer letter provide the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman.

Based on observation, record review and staff interview, the facility failed to ensure privacy and confidentiality of medical records for Resident #15 during medication administration. This was a random opportunity for discovery. Resident Identifier: #15. Facility Census: 124. Findings Include: a) Resident #15 On 12/10/2025 at 8:50 AM, an observation of the computer screen was made on the 200 hall which was left unlocked as well as written shift report sheets visible to anyone passing by the medication cart. On 12/10/25 at 8:53 AM, Licensed Practical Nurse (LPN) #127 exited Resident #15's room into the hallway. LPN #127 stated, I went into the room when the resident was calling out .I know I shouldn't have left the computer screen unlocked and the shift report sheets visible. On 12/10/25 at 9:35 AM, the Director of Nursing (DON) was notified and confirmed the computer screen should have been locked and the shift report sheets should have been covered.

Based on observation, record review and staff interview, the facility failed to maintain and infection prevention and control program designed to prevent infections during medication administration to and failed to ensure proper storage of a urinal in Resident #7's bathroom. This was true for one (1) of three residents observed during medication administration and a random opportunity for discovery of the improper storage of a urinal. Resident identifier: #15. Facility Census: 124. Findings Include: a) Medication Administration Policy On 12/10/25 at 9:15 AM, a review of the facility Medication Administration Policy was completed. The review found under the heading of Procedure section s. states, Do not touch the medication, either when opening a liquid or dose pack. (Typed as written.) Also, under section u iii. states, Gloves must be worn for splitting tablets. (Typed as written.) b) Resident #15 On 12/10/25 at 8:55 AM, an observation of medication administration to Resident #15 was made. Licensed Practical Nurse (LPN) #127 dropped a white round pill while removing it from the medication card and picked it up with a bare hand. On 12/10/25 at 8:58 AM, LPN #127 broke a potassium chloride 20meq (millieqivalant) pill into with bare hands. At this time, LPN #127 stated, I know I should not have picked it up with my bare hand and should have worn gloves when I broke the potassium into. On 12/10/25 at 9:10 AM, the Director of Nursing (DON) was notified and confirmed the medication should not be picked up or broken with bare hands. c) Resident #7 On 12/08/25 at 12:48 PM, an observation was made in Resident #7's bathroom. The observation was a used urinal laying on top of a foley insertion kit and a foley drainage bag inside a pink bath basin. The urinal was not in a proper storage bag. At this time, Licensed Practical Nurse (LPN) #62 removed the urinal, urinary supplies and pink basin from the bathroom. LPN #62 stated, the urinal should be bagged and not laying on top of the urinary supplies in a bath basin. On 12/10/25 at 2:22 PM, the Director of Nursing (DON) was notified and confirmed the urinal was not stored properly.

Based on observation, record review and staff interview, the facility failed to meet the nutritional needs of the residents in accordance with established national guidelines due to not following the menu or recipes. The facility failed to follow the approved menus making random substitutions of food items. This had the potential to affect more than a limited amount of residents who received their meals from the kitchen. Facility census: 124. Findings Included: a) 12/08/25 Lunch MealOn 12/08/25, carrot cake with cream cheese frosting was on the lunch menu. Resident tray tickets and menu postings in the facility listed carrot cake with cream cheese frosting as the dessert. Instead, angel food cake was given to residents as a substitute.This was acknowledged by the District Manager for Healthcare Service's Group (HCSG) at approximately 12:35 PM. b) 12/09/25 Lunch MealOn 12/09/25, buttered green peas were on the lunch menu. Resident tray tickets and menu postings in the facility listed buttered green peas. Instead, whole kernel corn was given to residents as a substitute.This was acknowledged by the District Manager for HCSG at approximately 12:30 PM.c) 12/10/25 Lunch Meal On 12/10/25, garlic & rosemary roasted red skin potatoes were on the menu. Resident tray tickets and menu postings in the facility listed garlic & rosemary roasted red skin potatoes. Instead, diced white potatoes were given. This was acknowledged by the HCSG District Manager at 12:35 PM.

Based on record review, observations and staff interview, the facility failed to ensure one (1) resident was provided with a safe environment to prevent elopement. This resulted in Resident #101 leaving the facility and being found outside the facility, two (2) blocks away. The facility's failure to ensure the resident did not exit the facility unattended on 07/09/24 placed him at risk and in an Immediate Jeopardy (IJ) situation. This will be cited as past noncompliance because the facility corrected the failure as of 07/29/24, prior to this survey. Resident identifier: #101. Facility census: 117. Findings included: a) Resident #101 A record review revealed the following regarding Resident #101's activities. 06/19/24 at 8:59 PM Behavior Note Text: Resident attempting to exit building, calling staff names and cursing. Threw heart monitor at nurse from across nurse's station. Keeps screaming, 'call the fucking cops, call the cops' and getting up into this nurse's face and stated, Call doctor [NAME], you fucking fat ass bitch. 06/22/24 at 2:40 PM Nurses Note Text: Resident wondering about facility this afternoon telling staff he is breaking out tonight. Redirected resident that he has to be discharged by Dr. [NAME]. He wasn't happy with the answer. 07/09/24 at 5:35 PM Nurses Note Text: An off-duty staff member phoned the facility and notified of this resident being seen on 4th and Grant street. This staff member stayed with resident while he continued to sixth street to his sons house. I sent 3 staff members to pick resident up from son's house and notified ED of incident who then informed the DON, ADON, and resident family member. On 07/09/24 7:00 PM Resident #101 was found by an off-duty staff member two blocks away from the facility after 7:00 PM. Upon returning to the building at 7:35 PM, resident was assessed head to toe, neuros checked, and a WanderGuard was ordered. 07/09/24 8:20 PM Nurses Note Text: Resident returned to facility with staff members. Head-to-toe attempted and no injuries noted. Resident refusing neuros at this time. 7/9/2024 8:36 PM Nurses Note Text: MD notified of situation. New order given for trazodone 50 mg q12hr PRN for agitation. 07/09/24 at 11:00 PM Nurses Note Text: Resident's son at facility and meeting with resident. Residents demeanor is okay at this time as they walk throughout facility. 07/09/24 10:47 PM Behavior Note Text: Resident continues exit seeking, becomes agitated and combative with staff int. Attempts to hit and kick staff, calling names, such as lying bitch, asshole, etc. Difficult to redirect and refuses medications at this time. Resident does allow some CNAs to interact. 07/09/24 11:49 PM The patient has been fairly agitated tonight. He managed to leave the facility and walk to his son's house. PCP was made aware and trazodone ordered. Wander guard bracelet applied. Monitor for further behaviors. 07/09/24 11:54 PM Behavior Note Text: Resident kicked front door exit open and ran out front door into parking lot, Staff intervened and followed resident, attempting to get him to return to facility. At this point resident physically threatened staff, spit on a staff member, and getting into the faces of staff. Staff convinced resident to return to facility. Once inside resident kicked the front door again, causing damage to the door. Resident is now sitting in lobby; staff members are in lobby with resident as well. 07/10/24 Resident #101 had increased agitation and an acute transfer to the local emergency department (ED) took place. Resident #101 was transported to the local ED by his son due to his refusal to go with emergency medical services. The facility wanted the resident evaluted by psychiatry. At approximately 2:00 PM on 08/14/24 surveyors interviewed the administrator. When asked why no one heard the alarm to address the resident elopement within 30 minutes. The administrator stated they could not confirm if the doors were alarmed on that specific instance, nor could they comment on why no one heard or responded to the alarm. The administrator could only comment that upon testing after the event the alarms were functioning fine. Surveyors then asked how the administrator knew that resident #101 eloped at exactly 7:03 PM, and they stated that they had pulled video from the time of the event to confirm the time of exit and reentry into the facility. They stated that they could not provide this video evidence to surveyors because it is only retained for two (2) weeks. At 3:30 PM on 08/14/24 two (2) surveyors went to administration to request live testing of the alarms. The administrator demonstrated the emergency delayed egress on the door, and the alarm sounded as designed. The alarm was shrill and audible around the proximity of the door. Another surveyor ventured back to the nurse's station in the central hallway of the building surrounded by four wings of the building. At this location, a repeater alarm sounded. It was audible enough that all hallways were within hearing range around the station. The surveyor observed through the doorway, walking from the main lobby to the nurse's station. The repeater alarm had a second number pad by which to disable the alarm. At the time of the demonstration, a gentleman was rushing over to disable the alarm. Due to the sheltered location of the pad, it was not clearly within the eyesight of the door. By appearance, the gentleman took a moment to identify that the administrator was testing the door as he was already punching in the code to disable it. The facility completed training with all staff on 07/29/24. The training included the following: Increased Behavior/Elopement Education All staff have the responsibility to notify appropriate team members if they observe an increase or change in residents' behaviors such as agitation or wandering to ensure facility adjust care to ensure to provide resident with a safe environment. Different departments have different interactions with residents daily and assist with providing the best care possible by ensuring clear communication is had between departments. CNA's can create clinical alerts for nursing to review and managers can report in daily meetings. By working as a team, we can provide a safe environment for our residents based on their current needs. It is every staff member's responsibility to investigate the situation if they hear an alarm going off. If a door is found to be open a headcount is to be initiated by each nurse on their perspective hall. The staff were expected to complete a post test that included three (3) questions. The questions were: 1.If you notice an increase or change in resident behavior you need to report it to A .Administrator B .DON C. CNA D. Department Manager E. Assigned nurse F. Any of the above 2.True/False: By working together as a team and reporting increased behaviors the safest environment possible for our residents. 3. Is it my responsibility to investigate an alarm sounding A. Yes, everyone should investigate an alarm sounding B. No, that is the nurses and CNA ' s responsibility.

Based on record review, and staff interview, the facility failed to thoroughly investigate the elopement of Resident #101. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents in the facility. Resident identifier: #101. Facility census: 117. Findings included: a) Resident #101 A facility reported incident (FRI) dated 07/15/24 stated, Resident (#101) exited the center at 7:03 PM through the front door via emergency exit and at 7:35 PM staff was alerted that resident was seen by an off duty staff member RN who stayed until center showed up. Resident did not want to be at the center. At approximately 2:00 PM on 08/14/24 an interview was conducted with the Administrator (NHA). When asked why no one heard the alarm to address the resident elopement within 30 minutes. The NHA stated that they could not confirm if the doors were alarmed on that specific instance, nor could comment on why no one heard or responded to the alarm. The NHA could only comment that upon testing after the event the alarms were functioning fine. The NHA stated that Resident #101 eloped at exactly 7:03 PM. The NHA said this was verified by review of the video to confirm the time of exit and return to the facility. The NHA stated that the video evidence was no longer available due to the video's are only retained for two (2) weeks. At approximately 2:00 PM on 08/14/24 surveyors interviewed the administrator. When asked why no one heard the alarm to address the resident elopement within 30 minutes. The administrator stated they could not confirm if the doors were alarmed on that specific instance, nor could they comment on why no one heard or responded to the alarm. The administrator could only comment that upon testing after the event the alarms were functioning fine. Surveyors then asked how the administrator knew that resident #101 eloped at exactly 7:03 PM, and they stated that they had pulled video from the time of the event to confirm the time of exit and reentry into the facility. They stated that they could not provide this video evidence to surveyors because it is only retained for two (2) weeks. At 3:30 PM on 08/14/24 two (2) surveyors went to administration to request live testing of the alarms. The administrator demonstrated the emergency delayed egress on the door, and the alarm sounded as designed. The alarm was shrill and audible around the proximity of the door. Another surveyor ventured back to the nurse's station in the central hallway of the building surrounded by four wings of the building. At this location, a repeater alarm sounded. It was audible enough that all hallways were within hearing range around the station. The surveyor observed through the doorway, walking from the main lobby to the nurse's station. The repeater alarm had a second number pad by which to disable the alarm. At the time of the demonstration, a gentleman was rushing over to disable the alarm. Due to the sheltered location of the pad, it was not clearly within the eyesight of the door. By appearance, the gentleman took a moment to identify that the administrator was testing the door as he was already punching in the code to disable it.

Based on resident interview, record review and staff interview, the facility failed to provide pain management to Resident #318. Harm occurred when the facility failed to address the resident's complaints of continued pain resulting from a right humerus fracture. There were no orders for non-pharmacological interventions, or any pain medications prescribed for 21 days. In addition, Resident #75's pain management was not addressed. Resident identifiers: #318 and #75. Facility census: 120. Findings included: a) Resident #318 At approximately 2:32 PM on 04/01/24, an interview was conducted with Resident #318. During the interview, Resident #318 stated they were in severe pain, and had been since they arrived at the facility on 03/11/24. The resident reported they suffered a broken shoulder which had not healed in two and a half months. Resident #318 stated the facility would not give them anything other than Tylenol to manage their pain. Resident teary eyed and losing breath during interview when shoulder is moved. Record review was conducted for Resident #318's orders. Orders indicated there were no orders for non-pharmacological interventions, Tylenol, or any other pain medication to manage Resident #318's pain. At approximately 11:55 AM on 04/03/24, another interview was conducted with Resident #318 regarding their pain. Resident #318 stated they were given Tylenol that morning after returning from therapy, but it did not relieve the pain. Resident #318 states they requested more Tylenol but was told it was unavailable for 4 more hours. The resident stated their pain is 8/10 at the time of interview. At approximately 12:16 PM on 04/03/24, an interview was conducted with Licensed Practical Nurse (LPN) #22 regarding Resident #318's complaints of pain. LPN #22 stated We were told you were going to be asking questions about this, because the resident came here with a prescription of percocet and they didn't have it once they were admitted . LPN #22 stated, I gave Resident #318 a Tylenol this morning when they got back from therapy. LPN #22 confirmed there was no order for Resident #318 to receive Tylenol by saying I need to get an order in for PRN (as needed) Tylenol. A review of an encounter note from 03/27/24 at 1:00 PM, in which Resident #318 saw a Nurse Practitioner typed as written: Patient seen at nurses station, complaining of right shoulder pain. Patient has a history of a right surgical neck fracture in January of this year. States they saw Dr who put them in a shoulder sling but the fracture was non operable. Patient came to us without a sling and is now complaining of worsening pain. Right shoulder pain was entered on the encounter note. Progress note from 04/01/24 typed as written: Pt (patient) lying in bed with sling off. Encouraged to put sling on. States it hurts when it's on and off. I don't know what to do. Counseled without success. Progress note from 04/02/24 typed as written: Report called from ER (emergency room ) at 1830 (6:30 PM) stating resident was on way back to facility via EMS (emergency medical squad.) ER reports resident was placed in sling and orthopedic referral was made with Dr for right humerus fracture. Resident also Dx with pneumonia and UTI at ER, new order for doxycycline 100mg BID x 10 days. ER also reports resident was given 1 liter fluids and Dilaudid 0.5mg x 1. Resident returned to facility at 1840 (6:40 PM.) No complaints of pain or discomfort at this time. Will continue to monitor. Review of Resident #318's physical, occupational, and speech therapy evaluations on 03/12/24 noted the following: Pain at rest- Intensity= 4/10; Frequency/Duration= Constant; Location RUE (right upper extremities) Pain with movement- Intensity= 8/10; Frequency/Duration= Constant; Location RUE Pain Assessment- Patient verbalized pain level;Does pain limit patient ' s functional activities: yes. At approximately 12:40 PM on 04/03/24, the Director of Nursing (DON) and the Administrator were notified of Resident #318's complaints of pain, along with no orders for pain medication or non-pharmacological interventions to manage pain. b) Resident #75 During the initial interview on 04/01/24 at 1:40 PM, with Resident # 75 she stated, I hurt all in my legs and my hand. She then rubbed her left hand. A record review on 04/02/24 at 1:45 PM, of Resident #75's care plan, revised on 04/14/23 reads as follows: Focus: (Resident #75 name) is at risk for pain related to limited range of motion due to left sided flaccid Goal: - Resident will be able to verbalize relief of pain, through the target date. Target date of 03/19/24 - Resident will not exhibit non-verbal s/sx of pain (grimacing, groaning, agitation, yelling, moaning, resisting care, crying, refusal to eat), through the target date. Target date of 03/19/24. Interventions: -Administer non-pharmacological interventions (repositioning, diversion activities, snacks and fluids, ice / heat, music therapy, relaxation techniques, imagery) - Complete pain assessment on admission / readmission, quarterly, significant change, and PRN. - Notify medical provider, resident representative if interventions are unsuccessful, or if current complaint is a significant change from residents past experience of pain. - Observe for pain every shift. - Provide medication per orders. Monitor for s/sx of side effects. Evaluate effectiveness of medication. - PT / OT eval and treat, per orders. During an interview on 04/02/24 at 2:15 PM, with Licensed Practical Nurse (LPN) # 137, she stated, She has never indicated to me that she was in pain, and I am on this hall most of the time. No, we do not ask her daily if she is in pain. During an interview on 04/02/24 at 2:20 PM, with Resident #75, she stated, with LPN #137 present, No, I am not in pain today, but I was yesterday. I hurt all down in my legs and my hand. When asked by the surveyor if she hurt at other times Resident # 75 stated, Yes, sometimes. LPN # 137 then stated, I will see if I can get her an order for Tylenol. A record review on 04/02/24 at 2:20 PM, showed that Resident # 75 was ordered Acetaminophen on 03/02/22 650 milligrams (mg) to be given every 6 hours as needed for Generalized pain. Further record review revealed that there are no Pain Assessments in Resident # 75's current medical chart. The record review also revealed, according to the Medication Administration Record (MAR), during the months of February 2023, and March 2023 that Resident # 75 was not given any Tylenol, nor was she assessed for pain. During a record review on 04/02/24 at 3:14 PM, of Resident #75's Occupational Therapy (OT) notes dated 03/07/24 reads as follows: Typed as written Reason for Skilled Services: Continued OT services are necessary in order to maximize Activities of Daily Living (ADL's) increase safety awareness, minimize safety hazards/barriers, maximize rehab potential, decrease painful condition of UE (upper extremities,) provision of pain management techniques and provision of modalities and strengthening in order to enhance patient's quality of life by improving ability to be able to return to prior living level. During an interview on 04/02/24 at 4:00 PM, with the Administrator, she stated, I did not see any pain assessments in her chart, and no it does not look like Tylenol was given during those months according to this. 49467

Based on observation, policy review, 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, to help prevent cross-contamination and infections including Covid-19 in regard to, laundry services, water management, and meal services. This failed practice had the potential to affect every resident currently residing in the facility. Facility Census: 120. 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 building's water systems for which Legionella control measures are needed. No documentation was provided describing the building water systems using text or testing protocols or dead leg water flushes. On 03/05/24 at 2:20 PM the Maintenance Director verified the facility did not maintain the water management program. b) Laundry Services An observation during the laundry tour on 04/04/24 at 9:32 AM found, the laundry room did not have a sealed separation from the soiled laundry area to the clean laundry area. There was also no negative air flow pulling from the clean area to the soiled area, failing to maintain a functional and safe laundry area to avoid contamination. The laundry was in progress in both areas. An interview with the Laundry Supervisor, on 04/04/24 at 9:43 AM, confirmed there was no sealed separation from the soiled laundry area to the clean laundry area and the vent was not on. He at this time turned the air flow vent on. 49467 c) Tray Cart At approximately 12:31 PM on 04/02/24, Nurse Aide (NA) #122 was observed taking a tray into room [ROOM NUMBER]. NA #122 placed the tray on the table, removed the lid, and the resident stated, I don't want that. NA #122 then removed the tray from the room and placed it back on the clean cart with other trays. NA #122 stated, I didn't know I couldn't do that.

Based on record review, resident interview, and staff interview, the facility failed to honor the choices of Resident #82 by failing to schedule showers during the resident's preferred time of the day. This was true for one (1) of two (2) residents reviewed for choices during the long-term care survey process. Resident identifier: 82. Facility census: 120. a) Resident #82 At approximately 02:26 PM on 04/01/24, an interview was conducted with Resident #82. During the interview, when asked if they felt if the facility honored their choices, Resident #82 stated No, I keep getting flipped back and forth between day showers and night showers, and I don't want night showers. I've told them every time they move me to night showers that I don't like them because I don't want to go to bed with my hair wet. They moved me back to day showers and a couple days later, moved me back to night, and that's where I am still. They won't tell me why I can't have a shower on day shift either. Upon record review the following progress notes were found, pertaining to Resident #82's showers, typed as written: 3/21/2024 14:53 Nurses Note Note Text: pt (patient) did not refuse shower, pt is a afternoon shower now. 3/23/2024 00:40 Nurses Note Note Text: pt refused scheduled shower tonight due to pt has requested to be a day turn shower. pt states I don't like having night shower because I do not like to go to bed with wet hair. pt states she had requested to be moved to a day turn shower and was unaware they had switched her back to nighttime and would like changed back to day turn. Further record review of the Nurse Aide bathing task sheet revealed Resident #82 had day showers on 03/06/24, 03/11/24, 03/13/24, 03/15/24, 03/18/24, and 03/25/24. Resident #82 then received night showers on 03/26/24, 03/28/24, 03/30/24, and 04/02/24. At approximately 10:56 AM on 04/03/24, interviews were conducted with Licensed Practical Nurse (LPN) #22 and Nurse Aide (NA) #31 regarding showers for Resident #82. LPN #22 stated Resident #22 had been a day shift shower, but then was moved to night shift. LPN #22 acknowledged Resident #82 had requested day shift showers again due to not wanting to have wet hair at night, however, Resident #82 remained a night shift shower at this time. NA #31 stated, regarding Resident #82's shower preferences, Resident #82 was a day shift shower, then night, then day, then night. Resident #82 wants day showers because they don't like going to bed with wet hair. They were moved from day shift to night shift, due to another resident that had a night shower, wanted to move to days. They made the switch so the amount of showers would not be uneven between shifts.

Based on record review, staff interview and policy review, the facility failed to provide care and services in a manner that was free from sexual abuse. The findings were determined to pose an immediate jeopardy to the health and well-being of the residents. The facility Administrator was notified of the Immediate Jeopardy on 07/10/19 at 11:50 AM. The facility provided a Abatement Plan of Correction on 07/10/19 at 2:26 PM. The Abatement Plan of Correction was accepted by the state survey agency on 07/10/19 at 2:30 PM. The facility's Abatement Plan of Correction was: --Resident #89's care plan was reviewed and updated on (MONTH) 10, 2019 by facility social worker for sexually inappropriate behaviors. --Resident #89 was placed on 1:1 staff supervision on (MONTH) 10, 2019. --Resident #89's medical power of attorney was notified of 1:1 supervision and alleged incident on (MONTH) 10, 2019. --A psychiatry consultation will be scheduled for resident #89 by the Social Worker/designee by (MONTH) 10, 2019. Resident #89 was seen by the physician on (MONTH) 10, 2019 in relation to history of sexually inappropriate behaviors with recommendations to continue current medications and begin 1:1 supervision. --An initial audit of all nursing documentation since (MONTH) 6, 2019 for allegations of abuse will be completed by the Administrator/designee by (MONTH) 10, 2019. Any allegations will be immediately reported and investigated within 5 days. --All residents will be interviewed to determine if there are any allegations of abuse by the Administrator/designee by (MONTH) 10, 2019. Any allegations will be immediately reported and investigated within 5 days. --All facility staff will be educated on the definition of abuse and facility reporting procedures by the Staff Development Coordinator/designee by (MONTH) 12, 2019. Education began on (MONTH) 10, 2019. --Facility social worker will be educated on facility policy and procedure for investigation of abuse allegations by the Administrator/designee by (MONTH) 12, 2019. Education began on (MONTH) 10, 2019. The immediate jeopardy was abated on 07/10/19 at 3:30 PM. Upon abatement, the deficient practice scope and severity was reduced to a D. This practice affected one (1) of three (3) reportable incidents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #89 and #252. Facility census: #98. Findings included: a) Policy Review A review of the facility's policy Abuse Neglect and Exploitation with an implementation date of 11/27/17 was reviewed on 07/10/19. The policy stated Sexual abuse is non-consensual contact of any type with a resident. b) Record Review A review of the medical record for Resident #89, on 07/10/19 at 10:45 AM, revealed the Resident was admitted to the facility on [DATE] with the primary [DIAGNOSES REDACTED]. The Resident was alert and able to make his needs known upon admission. The resident was able to walk on his own. The Resident did not have capacity. The Resident had a healthcare surrogate. A review of the medical record for Resident #252, 07/10/19 at 10:55 AM, revealed the Resident was admitted to the facility on [DATE] with fractures sustained from a motorcycle accident. The Resident was fully capacitated. The Resident was discharged from the facility to home on 06/11/19. A review of the Nurses Notes for Resident #89, on 07/10/19 at 11:50 AM, revealed the following note: --06/06/19 at 10:45 AM-Resident #89 inappropriately touched a female resident's breast. The female was Resident #252. Further review of the medical records for Resident #89 and #252, on 07/10/19 at 11:05 AM, revealed no documentation the incident was investigated by anyone. Further review of the Nurses Notes for Resident #89, on 07/10/19 at 11:10 AM, revealed the following notes involving other instances of inappropriate sexual behavior with the Resident: -05/13/19 at 1:25 PM-Resident #89 is sexually inappropriate with staff and difficult to redirect. No documentation the physician or resident representative was notified. -05/14/19 at 7:25 AM-Resident #89 is combative with care, physically/verbally/sexually inappropriate with staff. No documentation the physician or resident representative was notified. -05/15/19 at 7:25 AM-Resident #89 has behaviors, sexual, physical and verbal. Resident is one on one for these behaviors as of right now. No documentation the physician or resident representative was notified. -05/16/19 at 7:25 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. No documentation the physician or resident representative was notified. -05/18/19 at 7:25 AM-Resident #89 has inappropriate sexual behavior with CNAs and other staff. No documentation the physician or resident representative was notified. -05/20/19 at 7:25 AM-Resident #89 makes sexual remarks. No documentation the physician or resident representative was notified. -05/22/19 at 3:14 AM-Resident #89 stated he did not want to hurt anyone, but is going to. -05/23/19 at 7:25 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. No documentation the physician or resident representative was notified. -05/29/19 at 11:10 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. No documentation the physician or resident representative was notified. c) Interviews An interview with the Director of Nursing (DON), on 07/10/19 at 11:15 AM, revealed Resident #252 had reported to the staff that Resident #89 touched her breast inappropriately on 06/06/19. The DON verified there was no documentation in Resident #252's record concerning the incident. The DON stated she did not know Resident #252 reporting that her breast was touched inappropriately was an allegation of sexual abuse. The DON stated there was no investigation completed and that there were no physician interventions put into place for the allegation on 06/06/19. The DON stated she could not provide any documentation showing that either Resident involved was assessed immediately after the incident occurred. An interview with the Clinical Continuous Quality Coordinator (CCQC), on 07/10/19 at 11:20 AM, revealed the incident on 06/06/19 with Resident #89 and Resident #252 was an allegation of sexual abuse. The CCQC verified there was no documentation in Resident #252's record concerning the incident on 06/06/19. The CCQC verified no investigation was completed concerning the alleged sexual abuse. An interview with the Administrator, on 07/10/19 at 11:30 AM, revealed she could not provide any documentation from 06/06/19 that assessments were done concerning the allegation, nor an investigation being initiated for Resident #89 or Resident #252 concerning the allegation of sexual abuse. The facility's failure to understand the definition of sexual abuse and the need to conduct an investigation posed an immediate jeopardy situation. A review of the Nurses Notes for Resident #89, on 07/10/19 at 11:50 AM, revealed the following note: -06/06/19 at 10:45 AM-Resident #89 inappropriately touched a female resident's breast. The female was Resident #252. Further review of the medical records for Resident #89 and #252, on 07/10/19 at 11:05 AM, revealed no documentation the physician was contacted for either resident concerning this incident. The Resident Representative for Resident #89 was also not notified. Resident #252's record had no documentation about the incident with her breast being touched by Resident #89. There is no documentation the incident was investigated or reported to anyone.

Based on observation, record review, manufacturers' product descriptions, staff interview, and policy review, the facility failed to develop and implement effective infection control practices. The facility failed to follow manufacturers' product information for single use resident items (wash basins and bedpans), did not ensure linen was handled in a safe and sanitary manner, staff failed to sanitize their hands during dispensing of ice and snacks to residents, failed to ensure Resident #96's toothbrush was stored in a sanitary manner, failed to ensure two (2) residents (#94 and #31) received proper catheter and/or peri care, failed to ensure bedpans were maintained to ensure use by the same person and were stored properly, and failed to ensure two (2) residents (#154 and #23) were cohorted appropriately. Thes issues had the potential to affect more than a limited number of residents. Resident identifiers: #94, #31, #96, #154, #23, #50, and #109. Census: 113. Findings include: a) Resident #94 A nurse aide (NA), Employee #164, was observed performing pericare and catheter care on Resident #94 on 06/11/13 at 9:00 a.m. The employee donned her gloves and then proceeded to pick up the fall mat off of the floor next to the resident's bed. Without changing her gloves, she sprayed baby wipes with an antimicrobial personal cleaner called "[MEDICATION NAME]" and began wiping the perineal area from front to back without changing wipes or folding them. She then cleaned the catheter tubing twice with the same wipe, wiping from proximal to distal. After the resident was redressed and covered, the NA picked up an alcohol wipe from the bedside table and cleansed the end of the drainage tubing before emptying the catheter bag. After emptying the catheter bag, she picked up a second alcohol wipe from the bedside table and cleaned the tubing before securing it to the catheter bag. She did not change her gloves. A review of the procedure was conducted with Employee #164 immediately after the procedure. She agreed the bedside table should have been covered to prevent her from contaminating it when she picked up the alcohol wipes with her contaminated gloves on. She also agreed she should not have completed pericare and catheter care with the same pair of gloves that she had picked up the floor mat with. In addition she acknowledged the [MEDICATION NAME] spray bottle she had just used had a brown colored substance in the groves of the cap and needed to be replaced. b) Resident #31 A second observation was conducted on 06/11/13 at 1:40 p.m., nursing aide (NA) Employee #88 was observed performing pericare and catheter care on Resident #31. She donned her gloves and then proceeded to gather her equipment and pull the window and bedside curtains closed. She then placed her baby wipes and [MEDICATION NAME] personal care cleaner on the bedside table. She discarded the first baby wipe after wiping once from front to back. The second and third baby wipes were used four (4) and five (5) times each, going deep into the resident's skin folds. Another wipe was then used repeatedly to wipe the catheter from proximal to distal end. The NA then cleaned up the area and opened the curtains before removing her gloves and washing her hands. During a review of the procedure immediately after she agreed she had left her dirty gloves on and had now contaminated the curtains and bedside table. She also agreed she should have only used the cloths once because of possible contamination from the rectal are and should have covered the bed side table before starting. c) An interview was conducted with the nurse educator, Employee #103, on 06/11/13 at 2:00 p.m. She stated the policies were routinely revised by the assistant director of nursing and it should not say to fold a wash cloth over and reuse. The staff should be using baby wipes and only using each wipe only once and then it should be discardd. Employee #103 taught personal care skills annually, but did not routinely perform observations of staffs' personal care and hygiene techniques. . d) Observation on 06/06/13 at 11:30 a.m. found a plastic bed pan stored directly on the bathroom floor in room [ROOM NUMBER]. There was no name to indicate ownership, and it was not contained in any type of storage bag. The previous day, a bed pan was observed sitting behind the grab bar on the wall by the toilet in this bathroom, approximately ten (10) inches above the roll of toilet paper. A nurse, Employee #60, said residents' bedpans were to be cleaned, then stored in the bedside stand. She was shown the bedpan that was sitting directly on the bathroom floor and said she would take care of it. Also at this time, a bedpan was observed sitting directly on the bathroom floor in room [ROOM NUMBER]. Again, there was no name to indicate ownership, and there was nothing covering the bedpan. Activity aide/nursing assistant, Employee #82, was shown this bedpan and said she see that it was taken care of. An interview was conducted with the wing charge nurse, Employee #45, on 06/06/13 at 11:55 a.m. She said bedpans were supposed to be stored in plastic bags in the bottom drawer of the bedside stands. e) A random observation on 06/06/13 at 11:50 a.m. found a nursing assistant, Employee #117, exiting a resident room on the 200 wing, with soiled, unbagged bed linens held directly against her uniform. There was at least a bed pad and a sheet. The latter was visibly soiled with bowel movement. Activity aide/nursing assistant, Employee #82, observed this scenario, and said that people do things differently. Employee #117 carried the linens in this manner down the hallway to the soiled utility area. This was reported to a nurse, Employee #45, on 06/06/13 at 11:55 a.m. She said staff were supposed to wear gloves, and transport soiled linens in a bag to the soiled utility room, without touching their clothing with soiled linens. f) Resident #96 An interview was conducted with nursing assistants, Employees #69, #84, and #87 on 06/12/13 at 2:15 p.m. They said that staff assisted this resident to walk to the bathroom to brush his teeth. When asked to find his toothbrush, the aides looked in his bedside table and found none. They then located a cream colored toothbrush that was lying directly on the sink in the bathroom. The handle portion was in the plastic wrap, and the head of the toothbrush was out of the plastic wrap, lying directly on the sink behind the faucet handles. An interview was conducted with a nurse, Employee #136, on 06/12/13 at 2:30 p.m. She saw the cream colored toothbrush with the head lying directly the bathroom sink. She said the toothbrush was not supposed to be stored in that manner, and got him a new toothbrush. g) Resident #154 and #23 . Medical record review revealed Resident #23 was admitted to the facility on [DATE]. She had a urine culture that indicated [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) on 05/18/13. She was in contact precautions from 05/18/13 until 05/20/13, when contact isolation was discontinued. Review of the Minimum Data Set (MDS), with an assessment reference date (ARD) of 04/05/13, found she was always incontinent of urine and stool. On 05/22/13, Resident #154 was admitted to the same room. Resident #154 had a Foley catheter on admission, and has had a Foley ever since then. She also had sustained a recent hip fracture and repair. She had staples in place initially, and for several days after admission to the facility. Medical record review found no evidence that Resident #154 had any history of VRE. During an interview with the Assistant Director of Nursing, on 06/10/13 at 2:30 p.m., she said they try to place residents with any type of multi-drug resistant organisms (MDRO) in a private room. If no private room was available, they cohorted residents. She said, for example, that you would not put a resident who had a portal, such as a Foley catheter, intravenous line, or gastrostomy tube, in the same room as a resident with a MDRO. She provided information from the facility's Infection Control Manual, Policy #78 B. This policy indicated a resident with a MDRO was to be placed in a private room. When a private room was not available, to place the patient in a room with a patient who had an active infection with the same microorganism, but with no other infection (cohorting). When a private room was not available and cohorting was not achievable, to consider the epidemiology of the microorganism and the patient population when determining patient placement. Consultation with infection control professionals was advised before patient placement. When asked about roommates, Residents #23 and #154, she said that both residents had the same physician, #172, and he said it was all right to have them in the same room. She said the physician said Resident #23 did not have a VRE infection. An interview was conducted with Physician #172 on 06/10/13 at 3:00 p.m.. He said that Resident #23, because of her fistula, would always be growing something in her urine. He said they did culture and sensitivity reports periodically on her urine. He said that Resident #23 was not spreading infection, and that Resident #154 would have her catheter for only a short while longer. When asked if the facility had policies about who they may or may not cohort with a resident who has VRE, whether active or colonized, to preclude rooming with those who have portals such as a Foley catheter, he said he would have to speak with the director about that as he was not certain. An interview was conducted with nursing assistants, Employees #157 and #117, on 6/11/13 at 10:10 a.m. They said that Resident #23 sometimes was continent, and sometimes was incontinent and used her brief. h) Resident wash basins and some bed pans were not being used as single patient use items per manufactures' product information that described the items as "Single patient use". These items were not labeled with resident names and were observed being disinfected for re-use by other residents. On 06/03/13 at 11:15 a.m., observations of the soiled utility room between the 100 wing and the 300 wing noted an unlabeled metal and [MEDICATION NAME] (plastic) bedpan sitting in the right side of a double sink with soapy water in it. On the left side of the double sink were unlabeled wash basins. At 11:20 a.m. Employee #40, a Licensed Practical Nurse (LPN), viewed the unlabeled bedpans and wash basins in the soiled utility sinks. She said these items were in the sink to be disinfected by night shift with 531 solution. At 11:45 a.m. Employee #38, a Registered Nursing Assistant (RNA), was observed disinfecting the unlabeled bedpans and wash basins that were placed in the same sink (the left side of the double sink) with 531 solution. The RNA said after the items were disinfected, they were dried and placed in the clean utility room for staff to use for any residents. She also commented this was the facility procedure for cleaning of resident items/equipment. During a confidential interview with a RNA, on 06/03/13, the RNA commented it was not sanitary to clean bed pans and wash basins and then given them to other residents, but this was what the facility had them do with these items. i) Residents #50 and #109 On 06/04/13 at 10:30 a.m., a random observation revealed Employee #156, a hospitality aide (HA) removed a container of Cheerios with milk, and a spoon from room [ROOM NUMBER]. She said it belonged to Resident #50. The HA opened the box on the cart and obtained snacks. She did not cleanse her hands after touching the soiled items, and prior to obtaining items from the snack container. She provided the snacks to Resident #50. Employee #156 removed her gloves, donned a new pair, and entered room [ROOM NUMBER]. She provided a snack to Resident #109, then went to the ice/snack cart, and poured ice and water. She removed her gloves and donned new ones. She did not sanitize her hands. The HA then poured ice for the roommate. .

Based on observation, medical record review, staff interview, resident interview, and family interview, the facility failed to investigate, control, and prevent an outbreak of a rash/scabies. Residents were not identified and isolated when they exhibited signs and symptoms of an unidentified rash; employees with suspicious rash/scabies were not identified and prohibited from providing direct resident care throughout the building; adequate and sufficient personal protective equipment was not readily available; signage was not posted to alert the staff and visitors; linens were handled improperly; the physical environment was not maintained to prevent the spread of infection and disease. This resulted in actual harm to more than a limited number of residents. Resident identifiers: #14, #15, #70, #64, #115, #119, #67, #145, #110, #79, #74, #104, #6, #29, #86, #34, and #101. Census: 111 Findings include: a) Resident #14 The resident ' s medical record was reviewed on 05/30/13 at 11:30 a.m. A rash was identified on Resident #14's body on 02/09/13 and on 02/16/13 the resident complained of "itching all over." A note written by LPN #125 stated "rash still evident to trunk, groin, lower face, all four limbs. Light pink in color, slightly raised bumps. More dense in right upper arm/axilla area. Charge nurse aware." The physician progress notes [REDACTED]. No evidence was found indicating the resident was isolated at the time. A body sheet skin audit, completed on 03/19/13 at 10:00 a.m., stated (typed as written) "pink dotted slightly raised rash covers chest, abd(omen), anterior and posterior thighs including knees." The skin assessment on 04/23/13 stated "nothing new noted." The skin assessment on 05/04/2013 states, "rash getting very red and spreading." A follow up skin assessment, completed on 05/07/13, confirmed the rash was all over the resident's skin. The body audit forms dated 05/14/13, noted Resident #14's rash was getting worse. On 05/16/13 a skin assessment completed by nursing assistant (NA), Employee #24 stated "rash seems to be getting worse." The skin assessment dated [DATE] noted "Rhe resident has red bumps all over body." An order was written on 05/28/13 to "Consult dermatology ASAP (as soon as possible." The quarterly assessment care conference nursing note written, on 03/12/13 by RN #139, noted Resident #14 had had a problem with a rash since February and he was treated with [MEDICATION NAME] on 02/26/13. The note included, "This was also ineffective as he continued to itch. [MEDICATION NAME] given, rash disappeared and itching decreased. " On 05/30/13 the resident was diagnosed with [REDACTED]. The resident was placed in contact isolation for one (1) week and orders were written to treat the resident with [MEDICATION NAME] 1% on 05/30/13 and again in one (1) week. b) Resident #70 A confidential interview with two (2) employees was conducted on 05/29/13. They had requested the nurses look at the rashes on five (5) residents: #14, #115, #110, #29, #74, and #70, two (2) weeks ago and nothing had been done to evaluate or treat the rash. The medical record for Resident #70 was reviewed on 05/30/13 at 11:00 a.m. The resident was assessed by RN #118 on 05/30/13 and found to have a "rash like area right shoulder, deltoid, c/o itching." She was treated with [MEDICATION NAME] cream on 05/31/13 and isolated over the weekend. The plan was then to reassess her and treat again if needed in fourteen (14) days and again in twenty-eight (28) days. c) Resident #104 The resident was assessed during the skin sweep conducted on the residents on 05/31/13. Her skin check sheet was completed by a RN, Employee #113, who noted "Red rash raised on (L) side neck, abd. upper legs." The resident was treated with [MEDICATION NAME] cream and isolated over the weekend. The plan was then to reassess her and treat again if needed in fourteen (14) days and again in twenty-eight (28) days. d) Resident #29 The medical record was reviewed on 05/30/13 at 2:30 p.m. The weekly skin assessment dated [DATE] identified a rash on the resident's left upper arm. The note was signed by a nursing assistant, Employee #134, but there was no signature or additional information written by the nurse indicating she assessed the resident's rash. The nurse ' s note written on 05/26/13 indicated [MEDICATION NAME] was being applied to the open areas on both of the resident's arms. The rash was described as having pinpoint open areas with scratch marks. A skin assessment completed on 05/29/13 by RN Employee #103 (typed as written) noted: "?pink dots on R/L arms - under right armpit. c/o (complained of) itching." The resident was treated with [MEDICATION NAME] 5% on 05/31/13 and isolated over the weekend, with plans for follow up skin assessments and to retreat if needed on days fourteen (14) and twenty-eight (28). e) On 05/30/13, a body audit tour was conducted with Employee #103 (RN), Employee #31 (RN), and Employee #118 (RN). The nurses were wearing only gloves when completing the assessments. Employee #103 and Employee #118 were questioned about the infection control policy related to a potential source of transmission based infection, and for scabies. Employee #103 said no one had actually been identified with scabies, so she was not wearing a gown, only gloves. She said she would expect staff to wear a gown if a resident was identified as having scabies, however, specimens were not going to be obtained to determine the cause of the rash. It was going to be treated presumptively. She also asserted that a scabies [DIAGNOSES REDACTED]. The inservice director said the resident was being treated for [REDACTED]. Employee #103 identified nine (9) residents with a rash during the tour on 05/30/13. Other residents observed on 05/30/13, with an undiagnosed rash, included the following: 1) Resident #74 Resident #74 was the roommate of Resident #14. He was returned to the room for his body audit. He had a rash in the axillary area, around the back of his neck, and down his left side, with scabs present. Again, Employee #103 said she did not believe the rash was contagious. After completion of the audit he was returned to the corridor. This resident was not tested for scabies, but his roommate tested positive on 05/30/13. The resident ' s body audit completed on 05/20/13 indicated he had a rash over his upper back. 2) Resident #101 complained of itching and presented with a rash on her left upper back, the back of her left arm, and on both shins. 3) Resident #110 had a rash over most of his body. 4) Resident #79 had a rash on right upper back and right shin. 5) Resident #6 had a rash over her left arm and scattered over her right arm. 6) Resident #29 ' s rash was on her right and left arms, and under her right armpit. She also complained of itching. 7) Resident #70 ' s skin observation revealed a rash on the resident's arms and chest. She, too, complained of itching. 8) Resident #64 had a rash all over his body. He said he had started itching three (3) to four (4) days prior to the body audit. 9) During lunch, Resident #67 complained of itching, and requested the RN look at his rash. He had multiple red bumps and vesicles over his chest area and down his left arm. The rashes were all very similar. The residents presented with small vesicles, many were scabbed, and there were scratch marks present. f) Resident #115 The body audit sheets, which were completed on 05/30/13 by the inservice educator (RN), were reviewed. The report noted Resident #115 as "skin clear." A request was made for another body audit, because an audit completed the previous week had noted a rash. A skin observation, on 05/30/13 at approximately 12:00 p.m., revealed a rash in the chest area and left arm area, as was described previously,on the body audit report completed by a nursing assistant. The resident had received a treatment order for [MEDICATION NAME], on 05/19/13, for pimple like areas on her chest and arms. Employee #103 said she was going to add Resident #115 to the line listing. g) Resident #15 During a random observation, on 05/30/13 at 10:55 a.m. Employee #22, a nursing assistant (NA), offered to assist Resident #15 to the toilet. The NA was dressed in an isolation gown, gloves and cap. When asked why she was wearing the PPE, she said it was to prevent the spread of infection. When asked what infection, she said she did not know, that she was not required to wear it, but was allowed to wear it. When asked where she had been, just prior to offering assistance to Resident #15, the NA said she had been in a room across the hallway, preparing the bed for Resident #66. Upon inquiry of the purpose of the personal protective equipment, Employee #22 said she should have removed the gown and gloves, and washed her hands, prior to exiting room the room of Resident #66. The NA added, "So, I would just be spreading the infection from one person to another." She confirmed she had been wearing the gown from one room to another without changing it. h) Resident #34 Another random observation, on 05/30/13 at 2:40 p.m., revealed Employee #107, a nursing assistant (NA), in the room of Resident #34 (located on the 400 hall.) She was holding clean linens against her uniform. When questioned about the linen handling policy, she related linens were to be carried away from the body to prevent cross contamination. Upon inquiry of who on the hallway required special precautions, she said only the one was the room where there was a person protective equipment (PPE) cart outside of the door. (Personal protective equipment consisted of items necessary to prevent cross contamination or the spread of infection. It included gowns, gloves, and masks.) She said no other residents were on isolation/special precautions at that time. i) Interviews A confidential family interview on 06/03/13 revealsed she had called the county health department because there were no isolation gowns available for staff. The family member said she was told the isolation gowns were being laundered. During the interview the individual also commented when the Health Department was contacted, he/she was informed the staff only needed to wear gloves when caring for the residents. The family member stated the person at the health department had been told that was incorrect according to the Centers for Disease Control guidelines and also the Occupation Safety and Health Administration guidelines. The family member further stated "After the phone call, isolation gowns magically appeared for the staff to use". An interview with Employee #116 (NA) and Employee #150 (NA), on 06/03/13 at 2:30 p.m., revealed body audits were completed once a week. The nursing assistants said forms were completed whether or not the resident had a skin issue, but if the issue had been previously identified, the form would be marked as skin clear, no new areas. They confirmed that if a rash was not new, it might not be identified from week to week, such as was the case with Resident #115. Confidential interviews revealed staff were concerned because people were going out to activities and to the dining room. They said "the man on 400 hall" had been a concern for over two (2) weeks, and his rash was ongoing. The interviewees also said staff had been pulled all over the building. Another interview revealed a resident had been treated previously for scabies, and it would have been better to treat initially and contain the rash. The interviewee said, "We are reinfesting each other." It was indicated at least 12 staff, in addition to residents, had been treated for [REDACTED]. Employee #103 (RN) said she had requested the residents remain in the room for lunch on 05/30/13, to contain a possible outbreak. The RN said the medical director was going to meet with the assistant director of nursing (ADON), once the audit was completed; and would decide what to do. At 2:30 p.m., Employee #103 said sixteen (16) residents were going to be treated for [REDACTED]. She also said the residents would then be showered in the a.m., and the rooms would be cleaned on 05/31/13. This included those with a rash, and the roommate. She said meals would continue to be served in the rooms until after dinner on 05/31/13. An interview was completed on 05/30/13 at 3:00 p.m., with the administrator and ADON (assistant director of nursing). The administrator said everyone on the 400 hall/wing was going to be treated for [REDACTED]. She said there was some confusion originally, and either the health department misguided them, or the facility had misunderstood what should have been done. She said she had no results yet related to staff who had received medical treatment. The ADON, said she may have results on Monday for Resident #14, and for the employees. The ADON said the facility was in constant contact with the health department. She said the staff who were off at that time, would be coming back, and they required treatment. She said gowns would be in the hallway as a source of PPE. Observations of infection control issues were reviewed. She affirmed, the staff would have to change gowns and gloves between residents. The ADON also confirmed no signage had been posted related to alert staff, residents or visitors of the need for precautions related to the undiagnosed rash. Employee #103, at 11:20 a.m. on 06/03/13, revealed all residents on the 400 hall/wing had received scabies treatment. Additionally, new cases of a rash had been identified on 100, 200, and 300 halls by the nursing assistants while performing hygiene care. With further questioning, she related body audits had not yet been completed on those halls. She said Resident #14 would continue on contact precautions, and staff would use gloves as a precaution, for all residents, for thirty (30) days. Employee #103 provided an updated line listing. The ADON, on 06/03/13 at 3:30 p.m., said she was becoming well versed as a public health nurse because she had been dealing with the scabies issue all weekend. The ADON said the residents were her concern, but she had to deal with staff also. She indicated there were no confirmed cases of scabies among staff, only probables, because scrapings were not completed for identification. The ADON said twenty (20) employees had been treated at that time, but the list was ongoing. When questioned about the facility policy related to treatment for [REDACTED]. .

Based on record review, interview with a clerk at the State Police office, an interview with an individual with the Division of Motor Vehicles, review of facility documents, and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. A resident was transported in the facility van without adequate safeguards to prevent an accident with injury. She sustained a fall while en route to an appointment in the facility's vehicle. Actual harm was incurred as she suffered a hematoma to her head and pain in her buttocks. Staff transported the resident to a nearby hospital. This was found for one (1) of five (5) residents reviewed. Resident #35. Facility census: 117 Findings include: a) Resident #35 This resident experienced a fall, on 11/29/11 at 9:25 a.m., while being transported in the facility's van to a scheduled appointment with a consultant psychiatrist. Review of the medical record of Resident #35, on the afternoon of 01/17/12, found she had been assessed as a falls risk upon admission on 01/3/11. The resident had an interdisciplinary care plan in place for being at risk for falls due to impaired mobility, unsteady gait, requiring extensive assistance with most activities of daily living (ADL's), incontinence of bowel and bladder, cerebrovascular accident (stroke), Alzheimer's / dementia, difficulty in walking, muscle weakness, physical agitation and resisting care. She also was identified as being at risk for elopement related to wandering without regard to safety and angry outbursts. Her minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/17/11, documented she required extensive assistance of two (2) or more persons for moving in bed, transferring to or from bed, chair, wheelchair, or to a standing position, and walking. Review of facility accident / incident reports, on 01/18/12 at 8:00 a.m., found Resident #35 had twenty-nine (29) documented falls since her admission on 01/03/11. All of these falls involved staff finding the resident on the floor after attempting to stand or transfer without assistance. According to the reports, sometimes staff were responding to a sounding monitor alarm, and at other times they just found her on the floor. According to the records, she had sustained injuries associated with the falls on 02/12/11, 03/01/11, 03/30/11, 10/15/11, and 11/17/11. A statement by the nurse regarding a fall, on 03/15/11 at 3:30 a.m., included (typed as written): ". . . this nurse step away from nurses' station for a minute & when this nurse walked back to station found resident sitting on floor in front of her wheelchair." Many episodes of aggressive behaviors were documented in the medical record. These often commenced suddenly and for no apparent reason. The resident was prescribed Remeron 7.5 mg orally every day for depression, Seroquel 50 mg three (3) times every day for dementia with behaviors, and Haldol 2 mg by intramuscular injection every eight (8) hours as needed for agitation. These psychoactive medications were being monitored by the consultant psychiatrist during quarterly visits. It was en route to such a visit that the fall took place at 9:25 a.m. on 11/29/11. Review of nurses' notes, for the night before the 11/29/11 van trip revealed the resident had one of her unpredictable behaviors at 1:00 a.m. on 11/28/11. The nursing documentation stated (typed as written), "Punching CNA's with both fists after CNA redirects resident from eloping from 200 wing, 400 wing, 300 wing, and front door - biligerent / cursing. Redirection effective for short periods." The incident report for the fall of 11/29/11 at 9:25 a.m. was reviewed at 3:30 p.m. on 01/16/12. The location of the incident was documented as "bus." Persons present were listed as the social services aide, Employee #6, and a registered nurse (RN), Employee #132. The type of occurrence was listed as "fall." The form was marked to indicate the fall was not witnessed. Under the section "Describe the Specific Incident" was recorded (typed as written): "Transporting (resident's name) to Appt (appointment): In facility bus. (Resident) fell to the right side, in her W/C (wheelchair). W/C attached with all 4 safety locks in place. (Resident) stated 'My butt hurts.' " Under the section "Actions / Interventions" was recorded (typed as written): "Neuro cks (checks) were done. Eyes PERRLA (pupils equal, round, reactive to light and accommodation), Grips equal, ROM (range of motion) - she was able to move All extremities, abduction to bilateral lower extremities without discomfort. (Resident) stated 'My butt hurts'. Findings - raised area to Rt. Side of head. Went to ER (emergency room ) at (name of hospital)." A visit was made to the hospital at 4:00 p.m. on 01/17/12. Review of records from the emergency room visit, on 11/29/11 at 10:15 a.m., found the statement: "Was in wheelchair in van when it toppled over & hit her head & now tailbone / buttocks hurt also complains right hand hurt." The record indicated the resident had a three (3) cm hematoma to the right parietal lobe of her head, a contusion of her right hand, and no bruising or tenderness to the buttocks / tailbone. She was subsequently admitted for exacerbation of chronic obstructive pulmonary disease (COPD). An interview was conducted with an RN, Employee #132, at 9:30 a.m. on 01/17/12. She was asked about the incident of 11/29/11 with Resident #35 in the facility bus. She stated she and the social services aide, Employee #6, had taken Resident #35 in the bus to go to an appointment with the psychiatrist. She said Employee #6 was driving and she was sitting on one of the bench seats, towards the front. She was getting papers ready that would need to be presented at the appointment. She was placing them in the front passenger side bench seat when something happened. She turned and saw that Resident #35 "had fallen." She said all four (4) straps securing the wheels of the chair were still fastened in place, but the whole wheelchair was laying over to the right with the resident still partially in it. She checked the resident, called the facility to ask them to notify the responsible party, and they decided to turn back and stop at the emergency roiagnom on the way back to the facility to be on the safe side, because they "were very close." She was asked whether she had any idea what caused the fall. She stated since she did not see it, she could not say for sure, but the resident may have tried to get up. She stated the resident was unpredictable, and could change her behaviors very suddenly. She stated there was no safety restraint or shoulder harness in use on the wheelchair. An interview was conducted with the social services aide, Employee #6, at 11:00 a.m. on 01/17/12. She was the driver of the van on the morning of 11/29/11. She stated the RN, Employee #132, was seated on the second row of bench seats on the passenger side, and Resident #35 was in her wheelchair at the very back of the bus on the driver's side. She said she was going around a left turn slowly when she heard "(Resident's name) is on the floor." She pulled off the road. According to the aide, the resident was on her right side, still partially in the wheelchair. It was bent over to the right as well. She said the wheelchair was distorted, like it had collapsed sideways with the wheels laying over. She said there was no safety restraint on the wheelchair. Employee #6 was asked if she had any opinion as to what may have happened. She said she had noticed the resident was somewhat sleepy and groggy that morning. She felt the resident may have dozed off, was awakened going around the curve, tried to get up, leaned against the chair, and it gave way or collapsed. During an observation of the inside of the facility van, on 01/18/12 at 1:30 p.m., Employee #6 pointed out there were three (3) rows of bench seats with a center aisle. She pointed out the second row of bench seats on the passenger side where the nurse had been seated, placing papers on the seat in front of her at the time of the fall. She also pointed out the area at the back entrance of the bus on the driver's side, where the wheelchair had been secured to the floor of the bus. The lift was noted to be on the passenger side when not in use. The administrator, Employee #42, was interviewed at 1:50 p.m. on 01/17/12. He stated the facility had owned the bus since 2008. After receiving the call the resident had fallen, he and the maintenance director had gone to the hospital to see what had happened. He said the medical power of attorney (MPOA) was there, and was upset because the resident had not yet been taken inside to the emergency room . Employee #42 stated they did not seatbelt anyone in a wheelchair at that time, however, they did seatbelt residents who were seated on the bench seats. He said apparently, the resident threw herself to the right side, because she collapsed the wheelchair. He was asked for any facility policies, procedures, and / or operations manuals that came with the bus. Training records for operators of the bus and / or the equipment were also requested. An interview was conducted with the director of nursing (DON), Employee #43, at 2:00 p.m. on 01/17/12. She clarified there was a safety belt on the wheelchair lift, but not on the wheelchairs themselves. She said they do now utilize safety belts in the wheelchairs depending upon the resident. She said there was no policy regarding when use of a safety belt would be appropriate. The DON said Resident #35 had many challenging behaviors. She described the resident as being violent at times, with unpredictable behaviors. She stated sometimes it required up to four (4) to six (6) employees to maintain her safety and the safety of others. Later in the afternoon of 01/17/12, the administrator advised there was a manual for operation of the lift, but no other manuals had been found. He stated there was no policy or procedure covering use of the van for transporting residents, and no records of any training of staff. He provided a two (2) page hand-written note delineating how to use the lift and to secure wheelchairs to the floor with the straps and metal hooks that were part of the bus equipment. It was noted that there was a sentence that said "Make sure any residents in seats have seat belts fastened before leaving." There was nothing specific to wheelchairs. A visit was made to the local detachment of the West Virginia State Police at 8:00 a.m. on 01/18/12. The clerk was asked about West Virginia seat belt laws pertaining to wheelchair transport. He replied that the law did not specifically address the subject, but leaves it up to other agencies, such as the Division of Motor Vehicles, to develop rules and recommendations on the subject. A telephone call was made to the Division of Motor Vehicles at 8:45 a.m. on 1/18/12. They stated they follow the Americans with Disabilities Act (ADA) on the subject, which says disabled persons are entitled to the same safety protections as other passengers, and gives specifications for safety belts and shoulder restraints. However, these were only recommendations, as there were currently no laws, codes, rules, or regulations that required use of safety restraints in wheelchairs during transportation. The facility's individualized assessment and care plan for Resident #35 noted she required extensive assistance of two (2) or more staff for transfers. They had documented a history of falls that had previously occurred as the result of her attempting to stand or transfer unassisted. There was an extensive record of her unpredictable and often abrupt behaviors, sometimes requiring multiple staff intervention. There was documentation of her being up at 1:00 a.m. the night before the trip, punching staff with both fists and trying to elope. There was no evidence of any policy, procedure, or staff training record related to safe transport of residents in the facility bus. The facility was aware of the resident's unpredictable behaviors, sometimes requiring several staff members to maintain her safety. They were also aware of the resident's history of frequent falls related to attempts to stand and transfer without assistance. With this knowledge, the facility had an obligation to individualize the resident's environment, including her environment during transportation in the facility's van, to ensure she was free from accident hazards over which the facility had control, and to ensure the provision of adequate supervision and assistive devices to prevent avoidable accidents. The facility did not protect the resident from an avoidable accident when they sent the resident out in the facility van, with only one (1) staff person available to supervise (the other staff member was driving the van) and assist her while the vehicle was in motion. This person was also sitting on one of the bench seats, towards the front, getting papers ready for the resident's appointment. The resident was not in the employee's view, as she had to turn to the see the resident "had fallen" when she realized something had happened. .