Every finding on record at Parkersburg Center

Based on observations, record review and staff interview the facility failed to ensure residents who were ordered honey and nectar thickened liquids received liquids at a correct consistency. This was true for two (2) of four (4) residents reviewed for thickened liquids. Providing a resident with the wrong consistency of liquids could result in choking, aspiration pneumonia which can lead to serious harm and or death if not immediately corrected. This situation could occur again and have the likelihood of resulting in serious injury or death for any residents requiring thickened liquids.This failed practice was a random opportunity of discovery and the State Agency (SA) determined this to be an immediate jeopardy situation. Resident identifiers: #1 and #24 Facility Census: #63.Findings include: a) Resident #1On 12/08/25 at 12:10 PM an observation found that Resident #1 was ordered honey thickened liquids but had a bottle of water and a facility pitcher of thin water at bedside. She was eating her lunch meal and was able to reach and drink the liquids provided. Record review showed she had a medical diagnosis of oral phase dysphagia and pharyngeal phase dysphagia. There were current orders for a regular/liberalized diet dysphagia puree texture, thick liquids honey consistency, mashed potatoes with lunch and dinner. According to the Administrator it is unknown how long or who gave Resident #1 the water.The Speech Language Therapist (SLP) currently saw Resident #1 and the resident had therapy for a diagnosis of silent aspiration. She had a Modified Barium Swallow (MBS) on 11/11/25 at a local hospital. The resident was safest on honey thickened liquids. The SLP #72 had educated the staff, the resident and her MPOA (husband) concerning the need for thickened liquids. The resident's husband wishes her to remain on thickened liquids. He is present daily for lunch and dinner to assist her if needed. The SLP watches labs and vital signs for signs and symptoms of infection indicating aspiration pneumonia.b) Resident #24 On 12/08/25 at 12:30 PM an observation found that Resident #24 had a current order for Regular Liberalized Dysphagia Advance Texture with Thick Liquid-Nectar consistency two handled cup with inset lid. Further observation showed he had a facility pitcher of water at bedside containing thin liquids. Further record review of the facility's Food and Nutrition [NAME] Policies and Procedures showed thickened liquid modifications may be used in conjunction with any diet for individuals having difficulty swallowing thin liquids. Liquid modifications include Nectar like, Honey like and Spoon thick modifications. The Regulatory Compliance Advisor took the pitcher of water belonging to Resident #24 and bought it to the State Surveyor that is licensed as a Speech/Language Pathologist (SLP) to confirm by the spoon test that the water was not the correct consistency.On 12/08/25 at 3:25 PM during a telephone interview with SLP #72 she stated the purpose and risk of not receiving thickened liquids would be to avoid aspiration pneumonia. She stated the resident was evaluated at bedside and if signs or symptoms of choking were present. She said she would recommend a modified barium swallow (MBS) or a Fiberoptic Endoscopic Evaluation of Swallowing (FEES)SLP #72 has discharged Resident #24 due to noncompliance with his therapy exercise which she believed he was cognitively unable to do. He continued to aspirate liquids.The SLP stated, I expect staff to know exactly who is on thickened liquids as there are only four (4) out of sixty-three (63) residents that required thickened liquids. I have educated staff several times. The plan of correction (POC) for the immediate jeopardy (IJ) was as follows: Resident (#1) and (#24) was served a liquid that did not match the ordered consistency on 12/8/2025. MD notified at 16:49 (4:49 PM) on 12/8/2025. All thickener packets were removed from the floors and placed in the medication room. Pre-Thickened liquids only will be used at this time, unless a resident requires a manually thickened drink, per orders. All residents of the facility have the potential to be affected. The Director of Nursing (DON)/designee conducted an audit on 12/8/2025 of all residents with diet orders specifying thickened liquids (nectar/mildly thick, honey/moderately thick, pudding/extremely thick) to ensure:Liquid consistency orders are current, accurate, and clearly listed in the medical record.Correct consistency is reflected on the electronic health record.All cups, pitchers, and beverage containers delivered to residents match the ordered consistency. Nursing staff who hand beverages to residents are using the correct consistency. Any discrepancies identified were immediately corrected, and all impacted diet slips and kardex entries were updated.Re-education was provided by the DON/designee/Speech-Language Pathologist (SLP) or Dietary Manager starting on 12/8/2025 to all staff, including nursing assistants, licensed nurses, and tray passers. Education included:Review of the standardized liquid consistency levels (e.g., nectar/mildly thick honey/moderately thick, pudding/extremely thick).Following manufacturer's directions on manually thickening liquids, if required.How to verify consistency before serving.The importance of cross-checking diet orders, tray tickets, and posted consistency lists.A post-test and return demonstration of preparing each consistency level were completed to validate understanding. Any staff not present during this timeframe will receive re-education, including post-test and competency validation, prior to their next scheduled shift. All new dietary and nursing staff will receive this training during orientation. Annual in-servicing will include liquid consistency preparation, dysphagia safety, and safe feeding practices.The Dietary Manager and Unit Managers (UM)/designee will conduct observations starting on 12/9/2025 to ensure correct liquid consistencies are prepared and served. Observations will include:Tray line checks for accuracy of liquid consistency.Verification that nursing staff are serving beverages correctly.Checking nourishment rooms, hydration carts, and bedside beverages for compliance.Observations will be completed:Daily across all shifts for two weeks (including weekends and holidays),Then five times per week for four weeks,Then three times per week for four weeks,Then randomly thereafter.Results of audits will be reported monthly by the DON/designee to the Quality Improvement Committee (QIC) for review, follow-up, and/or additional in-servicing until the issue is fully resolved and sustained. Random monitoring will continue thereafter as determined by the QIC.During the abatement procedure the following questions were asked of all staff members present at the time: Were you educated on thickened liquids for residents? (Yes)Which is thicker, nectar thick or honey thick? (honey)Who can thicken liquids at this time? (Two different RN names provided)How do you know the amount of packaged thickener to use? (manufacturer's directions on the back of the packet) Where are thickener packets stored at this time? (Locked in the medication room) Once all staff members interviewed and correctly answered the above questions the IJ was abated.IJ was given to the facility on [DATE] at 4:46 PMIJ was accepted by the facility on 12/08/25 at 4:49 PMThe Plan of Correction (POC) was accepted by the state survey team on 12/08/25 at 6:38 PMThe IJ was abated by the state survey team on 12/09/25 at 4:12 PM.

Based on observation, staff interview and resident interview, the facility failed to ensure the food served to the residents was palatable, attractive and prepared by methods that conserved the nutritive value, flavor, and appearance of the food. Resident Identifiers: #36, #14, and #40. Facility Census: 63. Findings included: a) On 12/08/2025 at 11:55 AM, the state survey team tested a lunch tray for palatability. It was determined the scalloped potatoes had chewy edges and were not soft. they had an inconsistent consistency. The Salisbury steak was judged to be tough, hard to cut and had crunchy edges. The vegetables were judged to be too soft, especially the broccoli, and have no seasoning. These findings were confirmed by the Regulatory Compliance Officer at 12:05 PM. b) On 12/07/2025 at 2:10 PM, Resident #36 reported the food was awful and the food was never hot .always lukewarm. On 12/08/2025 at 03:50PM, when the resident was asked about today's lunch, Oh, I can't eat that. The potatoes were okay and the roll. That's all I ate. On 12/08/25 at 06:15 PM, another state surveyor observed that Resident #14 did not eat dinner due to the sandwich being excessively toasted. The sandwich was burned to a black color, and the resident reported that it was too hard and tasted unpleasant. c) On 12/07/2025 at 12:05 p.m resident #40 stated Food doesn't taste good at times. A food tray was tested on [DATE] that contained Scalloped Potatoes that had chewy edges and not soft - inconsistent consistency, Salisbury steak was hard to cut tough, crunchy edges - crunchy, tough steak, and vegetables were too soft especially broccoli, no seasoning. Interview with employee #107 on 12/08/25 at approximately 12:05 p.m., informed of the surveyor's findings.

Based on observation, interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure effective administrative oversight related to freedom from neglect and abuse, quality of care, staffing, infection control, dietary services, investigation and reporting of incidents, staff training, and an immediate jeopardy situation that affected multiple residents. Facility Census: 63Findings include:During the survey conducted from 12/07/25 through 12/10/25, the following concerns were identified:a) Failure to Investigate and Report Facility Reportable Incidents (FRIs):Review of facility records revealed the facility failed to ensure reportable incidents were thoroughly investigated and that the results were reported to the State Agency within five (5) working days, with appropriate corrective actions taken. This was found to be true for eight (8) of nine (9) residents reviewed.b) Resident #15 Review of the FRI dated 11/03/25 for Resident #15 revealed no documentation of staff interviews and no documentation demonstrating a five (5) day follow-up report was submitted to the State Agency.c) Resident #39Review of the FRI dated 10/23/25 for Resident #39 revealed no documentation of staff or resident interviews conducted during the investigation.d) Resident #67Review of the FRI dated 07/27/23 for Resident #67 revealed no documentation that staff received education related to proper handling of emergency situations.These findings were verified with the Administrator on 12/09/25 at approximately 12:30 PM and again during the exit conference on 12/10/25. The Administrator acknowledged responsibility for self-reporting, investigations, follow-up, and staff re-education related to reportable incidents. Failure to Ensure Residents Were Free From Abuse and Neglect:Administrative oversight failed to ensure residents were free from neglect and/or abuse, including refusal to toilet or change residents and failure to appropriately treat a resident who sustained a fall resulting in a fracture.Failure to Ensure Adequate Staffing:The facility failed to:Provide the services of a registered nurse for at least eight (8) hours per day, seven (7) days per week.Post accurate daily staffing information, including facility name, date, nursing hours worked by staff category, and resident census. This was found to be true for two (2) of thirteen (13) days reviewed.Failure to Ensure Required Nurse Aide Training:The facility failed to ensure nurse aides completed at least twelve (12) hours of annual in-service education, including dementia management training and resident abuse prevention training. This was found to be true for three (3) of five (5) nurse aides reviewed.Failure to Ensure Resident Hygiene and Dignity:Observation on 12/09/25 at approximately 2:00 PM revealed a resident with uncombed hair and visible facial hair.On 12/10/25 at approximately 2:30 PM, Resident #56 approached a surveyor visibly distressed and crying and reported she could not recall the last time she received a shower and was only receiving bed baths.The Administrator stated the resident could not fit through the shower room doors. Interviews with Occupational Therapy and the Physical Therapy Assistant confirmed the resident exceeded the weight limit of the available shower chair and therefore could not receive a shower at the facility. The facility failed to ensure alternative accommodation was provided to meet the resident's hygiene needs.Failure to Ensure Timely and Appropriate Care:d) Resident #66The facility failed to treat a fall for Resident #66.e) Resident #9The facility failed to administer medications as ordered by the physician in a timely manner for Resident #9.Failure to Ensure Dietary Safety and Services:Administrative oversight failed to ensure:Food was stored and served in accordance with professional standards.Residents ordered honey-thick and nectar-thick liquids received the correct consistency. This was found to be true for two (2) of four (4) residents reviewed and was determined by the State Agency to constitute Immediate Jeopardy.Kitchen equipment, specifically the freezer, was maintained in safe operating condition.h)Failure to Maintain Effective Infection Control Program:The facility failed to maintain an effective infection control program as evidenced by staff not wearing masks during a COVID outbreak and ice scoops being left in ice containers. These were identified as random opportunities for discovery.i)Failure to Maintain Safe Environmental Conditions:The facility failed to ensure hot water temperatures did not exceed 110 degrees Fahrenheit, placing residents at risk for injury.Failure to Provide an Ongoing Activity Program: The facility failed to provide an ongoing activity program designed to meet residents' interests and support physical, mental, and psychosocial well-being.in conclusion, the nature of these deficient practices demonstrates a systemic failure of administrative oversight. The facility failed to identify, investigate, correct, and prevent deficient practices despite being aware or having the means to be aware through daily reports and routine operations.

Based on observation, record review, staff interview and resident interview, the facility failed to ensure the menus were followed and met the nutritional needs of the residents. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 63. Findings included: a) The facility's policy and procedure for Menus stated menus will be planned in advance to meet the resident's nutritional needs. Menus will be served as written unless a substitution is provided in response to preference, unavailability of an item, or a special need. Menus will be posted. On 12/07/2025, the posted menu in the dining included: Turkey, Cornbread, Dressing, Broccoli, Rolls, Pumpkin Pie and Whipped Topping. The Week at a Glance Menu stated the following items were to be served: Maple Sage Turkey,, Dinner Roll, Homemade Pumpkin Pie w/Whipped Topping, Seasoned Peas and Cornbread Dressing. The lunch meal that was served included: Turkey, Cauliflower, Pumpkin Cake, and Cornbread. On 12/07/2025 at 01:20 PM in the Dining Room, Recreation Assistant #6 confirmed rolls, peas and broccoli were not served cauliflower and stated, If they can't prepare it, they change the menu. Recreation Assistant #6 confirmed cornbread, cauliflower and cake were served.c) Residents that did not receive the posted lunch menu items included: Residents #11, #56, #24, #35, and #58 as observed by the state surveyor.On 12/07/2025 at 12:47 PM, Resident #58 received broccoli and stated, I like broccoli if it's done right. Resident received cake, not pie and cauliflower, not peas or broccoli on the served lunch tray.On 12/07/2025 at12:50 PM, Resident #16 stated, Looks like cake. The resident did not receive peas or broccoli which was confirmed by Nursing Assistant #42.On 12/02/2025 at 02:10 PM, Resident #36 reported lunch was awful and all she received was bits of turkey, cauliflower, and cornbread. The resident reported she did not receive pumpkin pie.

Based on observations, interviews, and document reviews, the facility failed to thoroughly investigate reportable incidents and report the results of those investigations to the State Agency within five (5) working days of the incident and if the alleged violation was verified include the appropriate corrective action taken. This was found to be true for eight (8) of nine (9) residents reviewed during the long term care survey process. Resident identifiers: #6, #14, #15, #24, #35, #39, #56, #57, and #68. Facility census: 63. a) Resident #15 During the survey process between 12/07/25 through 12/10/25, reviewed the facility reported incident (FRI) documents from 11/03/25 regarding Resident #15. There were no documentation readily available of staff interviews conducted during the investigation. There were no documentation readily available to demonstrated that the facility submitted a five (5) day follow up investigation report to the State Agency. These findings were verified with the facility Administrator on 12/09/25 at approximately 12:30 p.m. b) Resident #39 During the survey process between 12/07/25 through 12/10/25, reviewed the facility reported incident (FRI) documents from 10/23/25 regarding Resident #39. There were no documentation readily available of staff and resident interviews conducted during the investigation. This finding were verified with the facility Administrator on 12/09/25 at approximately 12:30 p.m. c) Resident #67 During the survey process between 12/07/25 through 12/10/25, reviewed the facility reported incident (FRI) documents from 0727/23 regarding Resident #67. There were no documentation readily available of where staff completed education on how to properly handle emergency situations. This finding was verified with the facility Administrator on 12/09/25 at approximately 12:30 p.m. d) Resident #35 On 12/10/2025 at 2:58 PM, a review of Resident #35 facility's incident investigation records revealed residents were asked the following questions: Have you ever heard a resident use derogatory terms toward you? Have you ever received threats of harm from a resident? Have you ever had a resident yell at you? Further record review indicated Resident #56 answered Yes to the question, Have you ever had a resident yell at you? stating, Happens all the time from (residents name here). e) Resident #3 Continued record review revealed Resident #3 also answered Yes to the question, Have you ever received threats of harm from a resident? stating, Once a long time ago from (resident name here). There was no documentation to demonstrate that these responses were investigated or that any follow-up actions were taken. An interview with the Regulatory Compliance Advisor on 12/10/25 at around 4:25 PM who confirmed there were no documentation showing further investigating were completed for Resident #3 and #56 for answering Yes on the questioner. The administrator was asked to provide the email or fax for the five day follow up on 12/10/2025 at approximately 4:30 PM. No other information provided. f) Resident #24 The facility self reported an incident of resident to resident abuse involving Resident #24 and Resident #74 on 10/19/24. The incident involved Resident #24 rolling in his wheelchair into the dining room where he pulled up to sit next to Resident #74. Resident #24 then proceeded to grab the breast of Resident #74. g) Resident #74 Resident #74 told him to stop, and then smacked his hand away. Shortly afterwards, she reported the incident to facility staff. The residents were immediately separated. Resident #24 was taken back to his room and placed on 1:1 supervision. Staff performed a skin assessment on Resident #74, and found no findings of bruising or skin issues. Witness statements were obtained from all the parties involved, as well as other residents who were sitting in the dining room at the time of the incident. The incident was reported to the WV Office of Health Facility and Licensure (OHFLAC), the WV Office of the Ombudsman, and Adult Protective Services on 10/19/24. Upon review of the facility reported incident, no five day follow up report was submitted to the above offices as required, outlining their investigation, findings, and any action taken on the concern. During an interview with the interim Director of Nursing (DoN) when asked to see the five day follow-up report, she stated on 12/08/25 at approximately 1:38 PM, the five day follow-up report could not be found

Based on observation and staff interview the facility failed to provide a safe, clean, comfortable homelike environment. These failed practice findings were random acts of discovery. Room Identifiers: #225, #226, #229 and #222. Facility Census: #63Findings Include: a) Room # 225 On 12/07/25 at 11:40 AM upon the initial observations and interview the window blinds by Resident #60 were found to be broken and missing. b) room [ROOM NUMBER] On 12/07/25 at 11:45 AM upon the initial observations and interview the privacy curtain by Resident #1 was found to be dirty with a dark brown substance. c) room [ROOM NUMBER] On 12/07/25 at 12:05 PM upon the initial observations and interview the floor at the head of the bed (under the pole holding the tube feeding) for Resident #9 was dirty. There were sticky, dirty spots on the floor where the feeding appeared to have leaked or spilled and the entire floor was dirty and had a sticky substance on it. The above findings were confirmed with the Environmental Services Manager #78 on 12/07/25 at 12:08 PM and the Administrator on 12/07/25 at 3:10 PM at which time they both agreed the items listed above needed attention. d) Resident #36 On 12/07/2025 at 02:10 PM, during the initial resident interview, Resident #36 reported her floor was dirty and the wall was dirty behind her bed and needed painted. The resident also reported the there was no baseboard replaced in her bathroom and that the paint job was poor. The state surveyor observed the dirty walls, dirty floor and baseboard missing in the bathroom behind the toilet and around the vanity. On 12/08/2025 at 10:15 AM, the Regulatory Compliance Officer accompanied the state surveyor to the resident's room and verified the dirty wall, scuffmarks and missing paint on the wall. The resident's floor had been cleaned. The missing baseboard in the bathroom behind the toilet and around the vanity was verified at 12:40 PM. On 12/08/2025 at 10:45 PM, the facility reported they were looking for documentation the resident was in the toilet using her phone and they were unable to replace baseboard. A Facility Work Order created on 11/14/2025 was reviewed and it stated on 11/24: Baseboard applied.

Based on staff interviews, resident interviews, and record reviews, the facility failed to ensure residents were free from abuse and/or neglect by refusing to toilet/Change residents and treating a resident who had a fall that resulted an facture. This failed practice was found true during the long-term care survey process and had the potential to affect more than a minimal number of residents residing in the long-term care facility. Resident Identifier #21, #66, and #50. Facility Census: 63.Findings include: a) Resident #21 Record review completed on12/08/25 2:15 PM of a reported incident (FRI) was reviewed and found to be true according to the credible evidence provided by the facility. As written on the five (5) day follow up – The resident reported that she is able to get up and walk to the bathroom but CNA's tell her to just soil her brief. It was reported to APS, OHFLAC, and Ombudsman. Skin check was completed on 10/25/25. On October 23, 2025 (Facility name here) Care Center reported an allegation of neglect for Resident #21. (resident name here) alleges that Certified Nursing Assistant (CNA's) {as written} told her to soil her brief, even though she is capable of going to the toilet. (resident name here) was given a skin check with no new negative outcomes noted. Allegation of neglect was reported to OHFLAC, APS, and the Ombudsman. (Resident name here) is a long term care patient who was admitted to(Facility name here) Care Center on June 27 2023. She is alert and oriented but does not have capacity to make her own medical decisions; BIMS of 13. (Resident name here) has a diagnosis of aftercare following joint replacement surgery, right artificial knee joint, obesity, muscle weakness, type 2 diabetes, afib, repeated falls, cognitive communication deficit, polyneuropathy, Ogilvie syndrome, foot droop, difficulty in walking, anxiety disorder, major depressive disorder, irritable bowel syndrome, and age-related osteoporosis. She is a part assist of one using stand with pivot for transfers and a total assist of one or two for toileting. Certified Nursing Assistants were interviewed by Nursing Home Administrator/Designee regarding allegations with CNAs reporting they have not made those statements or head (as written) another CNA tell a resident to soil his/her brief. All residents within the facility with a BIMS of 8 or higher were interviewed with corrective action immediately upon discovery of any additional concerns. Skin checks were completed of all current residents with a BIMS of 7 or lower with no new skin concerns identified. When interviewed, (resident's name here Resident #21)stated that she can't recall when this happened who made the statement but knows it has happened in the past. (residents name here) has been referred to Dr. Office name here) Health for any emotional distress. Allegation of neglect is substantiated. Residents' statements consistently remained the same. Residents were unable to recall details, and staff did not indicate any concerns, so they were unable to determine when and/or which staff member. On 12/09/25 at approximately 3:00 PM then Administrator stated this FRI was verified but could not pinpoint which staff said it due to residents not being able to recall what the staff member looked like or when they said it. b) Resident #66 Record review completed on 12/10/2025 at 9:38 AM of a facility reported incident (FRI) was reviewed and found to be true according to the credible evidence provided by the facility. As written on the five (5) day follow up – To whom it concerns: While conducting an investigation into an injury of unknown origin regarding the long-term care facility resident #66, a Certified Nursing Assistant (CNA) reported that she had previously been notified in report resident #66 had sustained a fall on 2/28/2024. Resident #66's roommate, who is alert and oriented, also confirmed that he had a fall on 2/28/24 and a nurse and CNA placed resident #66 back into his bed. Review of resident #66 medical record showed no documentation of a fall on 2/28/24, no neuro-checks, and no treatment or follow-up. His nurse on duty at the time, Registered Nurse (RN) #110, has since submitted and completed her resignation, and this allegation of neglect was reported to the [NAME] Virginia Board of Registered Nurses. She has declined to return phone calls when attempting to contact her for a statement. Resident #66 returned to (facility name her) care center on 3/14/24 with new Thoracic-Lumbar-Sacral Orthosis {a rigid spinal brace, often plastic, that supports the mid-back (thoracic) down to the lower back (sacral)} in place, as well as Vancomycin (antibiotic for infections) HCl Intravenous Solution 500 MG/100ML one time a day for left hip infection until 04/20/2024. He is to follow up with (Dr office name here) Orthopedics on 4/1/2024 and (Dr. name here), Hematologist, on 4/2/2024. Resident #66 lacks medical decision-making capacity related to Alzheimer's disease and dementia diagnoses. He was unable to recall to (hospital name here) Medical Center staff if he had a recent fall or injury. He also has diagnosis of osteoporosis. On 12/10/2025 at11:04 AM At 11:03 am this allegation of neglect was verified by the administrator. Who stated Yes, this reportable was verified. c) Policy Record review of the facilities Abuse Prohibition Policy and Procedure reads in part as follows. {as written in policy} Manual title: Center operations policies and procedures Policy Title: Abuse Prohibition Effective date: 02/23/21 Review Date: 02/23/21 Policy: HealthCare Centers prohibit abuse, mistreatment, neglect, misappropriation of residents property, and exploitation for all residents. This includes, but not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patients medical symptoms. The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, and involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property. The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. If the patient/resident sustains serious bodily injury, the employee who forms the suspicion ir witnesses the incident must report no later than two (2) hours after forming the suspicion. Whether abuse or neglect occurred and to what extent; Clinical examination for signs of injuries, if indicated; causative factors; and Interventions to prevent further injury. The investigation will be thoroughly documented. Ensure that the documentation if witnessed interviews included. Report findings of all completed investigations within five (5) working days to the Licensing District Office. During the Facility Reportable Incident (FRI) investigation dated 09/23/25 on 12/09/25, it was determined that the allegation of neglect based on a thorough investigation performed by the facility was verified for Resident #50. Interview on 12/09/25 at approximately 4:00 p.m. with the facility Administrator verified the finding of neglect related to the FRI for Resident #50.

Based upon record review and staff interview, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program when a new mental health diagnosis or change in condition is presented. This was found to be true for four (4) of five (5) residents during the long term care survey process. Resident identifiers: #44, #56, #59, and #5. Facility census: 63Findings included: a) Resident #56 The resident's PASARR was completed on 08/19/24 at another facility. Diagnoses on this PASRR included Bipolar disorder and depression, unspecified. Upon review of the medical record, the resident had the following diagnoses related to mental health upon admission to the nursing home facility: BIPOLAR DISORDER, CURRENT EPISODE MANIC WITHOUT PSYCHOTIC FEATURES, UNSPECIFIED 8/9/2024 Upon Admission/Readmission The PASARR was completed as a Level I, with no Level II required. During the resident's stay at the facility, she received a new diagnosis of: MAJOR DEPRESSIVE DISORDER, RECURRENT, MILD 07/15/25 The facility failed to initiate a new PASRR to notify the state-designated mental health or intellectual disability authority promptly with the resident's new diagnosis of major depressive disorder. An interview was conducted with the facility's Director of Social Services on12/09/25 at1:20 PM. The Director was asked if a resident in this facility initially had a diagnosis upon admission of depression, unspecified, and later received a new diagnosis of major depressive disorder, mild and recurrent, would the facility normally do a new PASRR for this change. The social worker said yes. b) Resident #59 The resident's PASRR was last completed on 08/21/24 at this facility. It did not require a Level II screening. This PASARR contained the following mental health diagnoses: Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety A review of the medical diagnoses, documented the following mental health disorders for the resident: Mood Disturbance, and Anxiety 06/10/24 Admission Major Depressive Disorder, Recurrent Mild 08/16/25 The facility last completed a Medical Diagnostic Screening (MDS) assessment on the resident on 11/16/25. The MDS had the following mental health diagnoses: Depression Comparing the diagnoses on the MDS to the [NAME], the diagnosis for Major Depressive Disorder could not be found. The facility failed to initiate a new PASRR to notify the state-designated mental health or intellectual disability authority promptly with the resident's new diagnosis of major depressive disorder. c) Resident #44 The resident's PASRR was completed on 04/27/25 at an acute care facility. It was evaluated for and approved as Level I. Level 2 was not required. On the PASARR, the resident only had one mental health disorder, Schizophrenic Disorder. A review of the resident's medical record shows the following mental health diagnoses: Schizophrenia, Unspecified 04/28/22 Admitting Anxiety Disorder, 04/28/25 Admission/Readmission Auditory Hallucinations 04/28/22 Admission/Readmission Visual Hallucinations 04/28/22 Admission/Readmission Major Depressive Disorder, Single Episode 06/11/25 During Stay Generalized Anxiety Disorder 09/04/24 During Stay Disturbance, Mood Disturbance, and Anxiety 06/20/34 During Stay The MDS was last updated on the resident on 10/27/25. Diagnoses for mental health conditions documented on this MDS were: Schizophrenia, Unspecified Anxiety Disorder Depression Schizophrenia Auditory Hallucinations Verbal Hallucinations Comparing the diagnoses on the MDS to the PASRR, the diagnosis for Major Depressive Disorder could not be found. The facility failed to initiate a new PASRR to notify the state-designated mental health or intellectual disability authority promptly with the resident's new diagnosis of major depressive disorder. Resident #44 and #59 PASRR findings were reviewed with the Regional Compliance Advisor for the facility on 12/09/25 at approximately 4:20 PM. d) Resident #5 A record review of Resident #5 Diagnoses was completed and found the following diagnoses; As written in medical chart- MAJOR DEPRESSIVE DISORDER, RECURRENT, MILD Medical Management 10/08/25 10/23/25 SCHIZOAFFECTIVE DISORDER, UNSPECIFIED Medical Management 5/8/2025 Admission/readmission [DATE] Further record review of the Preadmission Screening and Resident Review (PASRR) reviled Major Depressive Disorder and Schizoaffective Disorder was not marked on the PASRR as an active diagnosis. An interview with Administrator on 12/07/25 at approximately 1:30 PM confirmed that PASRR was not coded correctly.

Based on record reviews, staff interviews, resident interviews, and observations, the facility failed to ensure Activities of Daily Living (ADLs) and care were provided to dependent residents for showers, oral care and grooming. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #28, #56, #23. Facility Census: 63.Findings included: a) Resident #28 The facility's policy and procedure for Oral Health stated, Oral hygiene will be performed, at a minimum, two (2) times per day (morning and night - after dinner, if possible). The facility's policy and procedure for Activities of Daily Living (ADLs) stated a patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. Resident #28 had a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side. The resident's care plan interventions started to provide resident with dependent assist of one (1) to two (2) for bathing and to provide assist of one (1) for personal hygiene (grooming). The resident had a history of refusal of having her teeth and hair brushed by staff per the care plan focus. Review of the Oral Care Task for the past thirty (30) days documentation revealed oral care had not been provided for Resident #28 two (2) times a day per the policy and procedure on the following dates: 11/11/2025, 11/13/2025, 11/17/2025, 11/20/2025, 11/21/2025, 11/25/2025, 11/29/2025, 11/30/2025, and 12/01/2025 (refusal x2 days 11/17/2025 and 11/21/2025). The resident's shower schedule was for Tuesday on Night Shift and Friday' on Day Shift. The resident had received no showers for the past thirty (30) days. No refusals of bd baths or showers were documented. Review of the resident's showers and bed bath task documentation: for the past thirty (30) days revealed the following: No showers or bed baths on the following scheduled shower days - 11/18/2025 11/21/2025 12/05/2025 12/09/2025 On 12/10/25 at 10:35 AM, the task documentation for Resident #28's showers and oral care were reviewed and verified by the Regulatory Compliance Officer. b) Resident # 56 During an interview with the resident on 12/07/25 at approximately 1:20 PM, the resident stated, I am tired of always getting a bed or sponge bath. I want to shower! A review of the resident's care plan documents revealed the resident required assistance of one (1) to two (2) staff for bathing and required the assistance of two (2) staff for mechanical lift. Under interventions, the care plan read It is important for me to choose between a tub bath, shower, bed bath or sponge bath. I prefer showers. Date initiated: 09/29/25 An observation of the resident found hair on head to be uncombed, significant facial hair appeared on her upper lip line and at chin level. Facial hair was approximately 1/4 - 1/2 inch. During the interview with the resident, she was questioned about her preference for her facial hair. She responded that she wanted it removed, but that staff did not bother to help her. The resident's current Medical Diagnostic Screening (MDS) assessment documents the following response to this question: How important is it to you to choose between a tub bath, shower, bed bath or sponge bath?Response was : Very important. A review of the facility's shower schedule documents resident is supposed to receive a shower on Mondays and Thursdays on day shift. The documentation in the medical record for showers was requested from the facility for the past two (2) months of showering. The results were: 10/1/25 Wednesday at 11:59 AM bed bath/sponge provided10/2/25 - 10/09/25 no bath or showers documented (one week span)10/10/25 Friday at 2:59 PM bed bath/sponge provided10/11/25-10/13/25 no bath or showers documented10/14/25 Tuesday at 11:17 AM shower provided10/15/25 - 10/31/25 no bath or showers documented11/01/25 Saturday at 12:59 PM bed bath/sponge provided11/02/25 no bath or shower documented11/03/25 Monday at 2:59 PM bed bath/sponge provided11/04/25 Tuesday at 10:20 AM bed bath/sponge provided11/05/25 - 11/06/25 no bath or shower documented11/07/25 Friday at 10:56 AM bed bath/sponge provided11/08/25 - 11/24/25 no bath or shower documented (> two week span)11/25/25 Tuesday at 10:40 AM bed bath/sponge provided11/26/25 Wednesday at 10:46 AM bed bath/sponge provided11/27/25 Thursday at 10:36 AM bed bath/sponge provided11/28/25 - 11/29/25 no bath or showers documented11/30/25 Sunday at 12:57 PM bed bath/sponge provided12/01/25 - 12/08/25 no bath or showers documented (> one week span)12/09/25 Tuesday @ 2:59 PM bed bath/sponge provided The facility's Regional Compliance Advisor was asked about why residents' choices were not being honored as it related to bathing and hygiene on 12/09/25 during the afternoon. He responded by saying I do not really know. Another observation was made of the resident on 12/09/2025 @ 2:00 PM, and the resident's hair had not been combed. Her facial hair was still present. On 12/10/25 at approximately 2:30 PM, a surveyor was approached by this resident, who appeared visibly distressed and was crying. The resident stated that she could not recall the last time she had received a shower and reported that she was only receiving bed baths. The resident further expressed concern that her hygiene needs were not being fully met and stated she required more thorough washing than what she had been receiving. This concern was reported immediately to the Administrator. During an interview, the Administrator stated that the resident was unable to fit through the shower room doors. Interviews with Occupational Therapy (OT) and the Physical Therapy Assistant (PTA) revealed that the resident exceeded the weight limit for the available shower chair and, as a result, could not receive a shower at the facility. The resident was subsequently transported to a nearby facility, where she received a shower. During an interview with Staff #27 on 12/09/25 at approximately 4:00 PM, Staff #27 stated the facility was going to expand the entry way into the 100 Hallway shower room to allow Resident #56 to enter the area. Staff #27 was asked why they need to expand the doorway. Staff #27 replied To allow Resident #56 to get in the shower room safely and with dignity. c) Resident #23 On 12/07/25 at 12:40 AM during the initial interview process Resident #23 stated he does not get his shower/baths as scheduled. He states he prefers a bed bath. According to the shower/bath schedule reviewed on 12/08/25 at 2:10 PM which was provided by the facility, Resident #23 is scheduled for a shower/bath Sunday and Wednesday on day shift. Review of the care plan shows the resident requires assistance for ADL care in bathing, grooming, personal hygiene, dressing and eating. It also states an intervention is to provide resident with extensive assist of 1 for bathing. The care plan states the resident has vision impairment related to: Diagnosed blindness in both eyes. According to the task for the last 30 days for bathing Resident #23 received a bath/shower four (4) out of nine (9) scheduled baths/showers. Resident #23 was scheduled and received baths on the following dates during the last 30 days: due  received 11/9/25 yes 11/12/25 no 11/16/25 no 11/19/25 yes 11/23/25 no 11/26/25 yes 11/30/25 no 12/3/25 no 12/7/25 no but did on 6tth The above information was confirmed with the Administrator on 12/08/25 at 3:20 PM, at which time she agreed the showers/baths were not sufficient.

Based on record review resident interviews and staff interview the facility failed to provide an ongoing activity program to support residents in their choice of activities, through facility-sponsored group activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, This found practice has the potential to affect more than a minimal number of resident residing in the long term care facility. Facility Census: 63.Findings include:a) ObservationAn observation on 12/08/25 at 11:00 AM of the large Monthly Activity Program Calendar posted near the facilities nurses stated to have the same activities each week other than a few volunteer days, and showed Monday through Friday the last activity was at 4:30 PM and was a Movie. On Saturday and Sunday, the last activity was at 5:00 PM which was Dinner and Movie that would interrupt for some a dignified dining experience.Further observation revealed there were no locations on the calendar where these activities would be held.b) Record review A review completed on 12/09/25 of the facilities Monthly Activity Program calendar for the months of August, September and October revealed the same activities for each day of the week repeated every week unless volunteer or holiday event . Further review revealed a movie was the only thing occurring as an evening activity and this was at 4:30 PM Monday through Friday and at dinner time 5:00 PM on weekends. Further record review of Resident Council meetings revealed the following; 06/25/25- Activity assistant does nothing entertaining and wants more evening activities 08/11/25 more volleyball, horseshoes badminton, comedians, and get Elvis to come 09/01/25 Weekends are boring, no crafting when scheduled, the Activity Assistant states the Activity Director does not tell her what crafts to do. 10/13/25 Weekends are bad11/04/25 states activities are ok except on weekends12/02/25 stated Activity assistant is not doing activitiesc) Resident concerns during Resident Council During resident council meeting completed on 12/09/25 at 11:30 AM residents that attended all agreed to each other's concerns regarding activities and those concerns were as follows:Not everyone enjoys watching movies of the eveningsWe need more craftsWe would like to play the golf game more We go to bed early on weekends because there is nothing else offered to doThe activity assistant does not do the stuff we are supposed to do, the activity director does it all here. The Activity Director does hold her assistant countable for her jobWe do not say this to the activity director, we like her, she does a lot, she cannot do it all and we do not want to hurt her feelings. An interview with the Activity Director was completed on 12/09/25 who stated she only has one other assistant and evening activities were movies because it was easier that way. The AD said someone can just run back and start the movies and set everything up and continued to say this was not the first time she had concerns about her assistant, however, could not provide education regarding not completing activity duties confirming evening activities not being completed correctly and evening and weekend activities.

Based upon record review and staff interview, the facility failed to review and take action on the consultant pharmacist's recommendations on irregularities found in residents' drug regimen reviews. This was found to be true for three (3) of five (5) residents reviewed during the long term care survey process. Resident identifiers: #44, #59, #14. Facility census: 63Findings included: A) Resident #44A review of Resident #44's medical record documents the resident had the following diagnoses as it relates to psychosocial health: SCHIZOPHRENIA, UNSPECIFIED 4/28/2022 Upon admissionANXIETY DISORDER, UNSPECIFIED 4/28/2022 Upon Admission/ReadmissionAUDITORY HALLUCINATIONS 4/28/2022 Upon Admission/ReadmissionVISUAL HALLUCINATIONS 4/28/2022 Upon Admission/ReadmissionMAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, MILD 6/11/2025 During Stay GENERALIZED ANXIETY DISORDER 9/4/2024 During StayUNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY 6/20/2023 During StayThe resident had the following physician orders as it related to the above diagnoses: DULoxetine HCl Capsule Delayed Release Particles 20 MGGive 1 capsule by mouth one time a day for Depression aeb social with draw monitor for side effects; sedation, dry mouth, nausea, dizziness, insomnia, apathy, constipation, diarrhea, akinesia, muscle rigidity, extra pyramidal reactions, Parkinson's-like symptoms, tremor, drooling from mouth, photo sensitivityPharmacy Active 11/22/2025 Mirtazapine Oral Tablet 15 MG (Mirtazapine)Give 1 tablet by mouth at bedtime for Depression aeb poor po intake monitor for side effects; sedation, dry mouth, nausea, dizziness, insomnia, apathy, constipation, diarrhea, akinesia, muscle rigidity, extra pyramidal reactions, Parkinson's-like symptoms, tremor, drooling from mouth, photo sensitivityPharmacy Active 11/21/2025 Loxapine Succinate Oral Capsule 10 MG (Loxapine Succinate)Give 10 mg by mouth three times a day for Schizophrenia AEB Hallucinations and delusions for blurred vision, sedation, dry mouth, drowsiness, insomnia, apathy, constipation, diarrhea, akinesia, muscle rigidity, extra pyramidal reactions, Parkinson's like symptoms, tremor, drooling from mouth, photosensitivity, weight gain, edemaPharmacy Active 11/21/2025 BusPIRone HCl Tablet 5 MGGive 1 tablet by mouth two times a day for anxiety aeb hallucinations and delusions Monitor for SE of AA; Common SE:Sedation, drowsiness, ataxia, dizziness, nausea, confusion, nasal congestion; Less common SE: vomiting, skin rash, falls, agitation. Rare SE: hypotension, blurred vision, ataxia, mood swings. Notify provider if presentPharmacy Active 4/21/2025 CBC, BMP, TSH, A1C every 6 months (May/Nov) A1C is for antipsychotic therapy) one time a day every 182 day(s)Laboratory Active 5/7/2025 A review of the consultant pharmacist's monthly medication regimen review assessments documented irregularities on 12/22/24. 09/21/25, 10/14/25, 11/12/25. The surveyor requested on 12/08/2025 at 2:25 PM to see the pharmacist's reports of what the irregularities were on these dates and what actions were taken on the recommendations. On 12/09/2025 at 11:54 AM upon asking for these a second time, the NHA stated they could not find these. B) Resident #59 A review of the resident's medical record for physician orders documented the following medications: Eliquis Oral Tablet 2.5 MG (Apixaban)Give 1 tablet by mouth two times a day for history of transient ischemic attackPharmacyActive 08/20/2025 Anticoagulant Medication Monitoring: Monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath, nose bleeds, document in supplemental documentation if any of the above was observed and any findings in a progress note.every shiftOther Active 08/14/2025 A review of the consultant pharmacist's monthly medication regimen review assessment reports documented irregularities found on 09/23/24, 12/22/24, 01/20/25, and 04/14/25. The surveyor requested these irregularities and action taken by the facility on 12/09/2025 at 9:58 AM. During a discussion with the NHA on 12/09/2025 at 11:54 AM, she stated they could not find these. C) Resident #14 This resident has the following diagnosis: TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED 05/14/2024 Admitting For this illness, the physician ordered: LANTUS SOLOSTAR 100UNIT/1ML INSULN PENInject 30 unit subcutaneously every morning and at bedtime Pharmacy Active 06/26/2024A review of the consultant pharmacist's monthly medication regimen review assessment reports documented irregularities found on 10/08/25, 04/12/25, 01/18/25, 11/16/24. The surveyor requested these irregularities and action taken by the facility on 12/08/25 at 1:17 PM. During a discussion with the Regional Compliance Advisor on 12/08/2025 at 2:15 PM, he stated they could not find these.

Based on record review, staff interview and observation, the facility failed to ensure food was stored and served in accordance with professional standards for food service safety This failed practice had the potential to affect more than a limited number of residents. Facility Census: 63.Findings included: a) The facility's policy and procedures for Food Storage: Cold Foods stated, all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The facility's policy and procedure for Food Storage: Dry Goods stated, all food would be stored according to the Food and Drug Administration) (FDA) Food Code. and that the food storage areas would be neat, arranged for easy identification and the date marked as appropriate. b) On 12/07/2025 at 11:35 AM, the kitchen investigation was initiated. The following items were found and verified by [NAME] #62: Dry Storage - Beverage cart was sitting in the dry food storage area for lunch. The cart contained milk that was not labeled or dated., a carafe of hot water that was not labeled or dated and an ice scoop in a serving container with a small amount of water. Dietary Aide #76 confirmed the cart was in the storage area and stated, It goes out first to the dining room. Additional items found in the dry storage included ripple potato chips - opened, not dated and not sealed, House Recipe Saltines with stored date 10/23 and no use by date and bananas which were not labeled with a received or use by date. The items were verified by [NAME] #63 at 12:00 PM and she reported We just got that Friday. Cold Storage - The following items were found during the initial kitchen tour: Four (4) pitchers of tea - not labeled or dated.Three (3) gallons of United brand mild - opened with no open or use by date.Sysco Imperial Mayonnaise with use by date 12/02/25.French's mustard - mustard dripping and dried on the outside of the container.House Fancy Ketchup - ketchup dripping and dried on the outside of the container.Raw hamburger patties - dated 12/02/25-12/06/25.Gold 'N Sweet Margarine - opened and no use by date.Reliance Italian Dressing - opened date 08/02/25 and us by date 12/02/25.Large container of fruit punch - not labeled and not dated.Bowl of Cheerios - not labeled or datedAngel food cake not labeled and dated 3/10-4/10.Salami dated 4/12-5/17.Box of frozen biscuits - not sealed and not dated. On 12/09/2025 at 09:15 AM, the facility's Nourishment Center was investigated. A bottle of [NAME] Creamy French Dressing was found opened with manufacturer expiration date of 10/07/2024. On 12/09/25 at 9:20 AM, Environmental Service Staff #78 confirmed and removed the item from the refrigerator. On 12/09/25, during a follow-up visit to the kitchen, serving utensils were found not stored with the handles in the same direction in two (2) investigated drawers. This was confirmed by the Dietary Manager and the Corporate Dietary Manager.

Based on observation, and staff interview the facility failed to ensure garbage and refuse disposed of properly by blocking trash cans This had the potential to affect more than an isolated number of residents. Facility census: 63. Findings included:a) According to the facility's policy and procedure, garbage and refuse will be disposed of in a safe and efficient manner. The policy and procedure indicated the Dining Service Director (DSD) would ensure lined containers wiould be available within the food service area and garbage and refuse would be removed routinely from the kitchen area during the day and at the end of the workday.b) On 12/07/2025 at 11:35 AM, during the initial kitchen observation, five (5) empty and opened boxes were under the handwashing sink on the floor covering the trash can. A plunger was under the boxes. The boxes had to be moved to dispose of paper towels when the state surveyor's hands were washed. Dietary [NAME] #62 confirmed the boxes on the floor and difficulty disposing of paper towels after hand hygiene was completed.

Based on observation, document review, and staff interviews, the facility failed to maintain an effective infection control program by staff not wearing masks during COVID outbreak and staff leaving ice scoops in ice containers. These were random opportunities for discovery during the survey process. Facility census 63. Findings included: a) On 12/07/25 at approximately 11:30 a.m., upon initial entry observed that the facility was under COVID outbreak and observed Employee #18 and Employee #42 sitting at the nurse's station not wearing any masks. Reviewed the facility's COVID outbreak policy and policy requires all staff to wear masks during outbreak. Interview on 12/07/25 at approximately 11:38 AM with Employee #20 verified that during a COVID outbreak all staff were required to wear masks inside of the facility. b) On 12/07/25 at 12:00 PM, the state surveyor observed no separate container for the ice scoop as drinks were passed on the 200 Hall. The ice scoops were placed in the ice bucket. Nurse Aide (NA) #24 confirmed the scoop was in the ice container during the drink pass and stated, No, there's not. ( a separate container). On 12/07/2025 at 12:45 PM, the state surveyor observed no separate container for the ice scoop as drinks were passed on the 100 Hall. NA #9 confirmed the scoop was in the ice container during the drink pass. On 12/08/25 and 12/09/25, ice scoops remained in the ice containers on both halls during the drink passes. The observation was reviewed and verified with the Regulatory Compliance Officer on 12/09/25.

Based on observation, record review and staff interview, the facility failed to ensure the kitchen equipment was maintained in safe operating condition. for the freezer. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 63.Findings included: a) The facility's policy and procedure for Safety as related to kitchen and associated equipment safety stated, the equipment will be properly maintained and the Dining Service Director Will ensure that all equipment is in proper working condition and equipped with safety guards, as appropriate. b) On 12/07/2025 at 12:10 PM, ice and significant frost was observed by the state surveyor on the right side of the freezer door during the initial kitchen inspection. Small ice drips were frozen on the freezer's fan, and a large block of ice was formed under the freezer fan. Dietary [NAME] #62 confirmed the finding and reported there was no frost this morning and that it must have been when the dietary aide was going in and out of the freezer.

Based upon record review and staff interview, the facility failed to ensure twelve hours of in-service education for nurse aides, which includes dementia management training and resident abuse prevention training. This was found to be true for three (3) of five (5) nurse aide personnel reviewed during the long term care recertification process. Staff identifiers: #24, #9, #54, #43, #21. Census: 63 Findings included: A) Nurse Aide (NA) #9 Nurse Aide #9 only had sixteen (16) minutes of dementia management training during the twelve-month period from 12/01/24 to 11/30/25. This falls short of the two hours minimum required annually. B) Nurse Aide (NA) #43 Nurse Aide #43 had a hire date of 09/17/25. She only had twenty-four (24) minutes of dementia management training during the period from 09/17/25 through 11/30/25. This fails to comply with WV regulations of receiving two hours of education within her first 30 days or at next orientation. She also had not been educated on resident abuse prevention, or resident rights. The Nurse Aide had no competencies completed prior to assuming direct care of residents, following her date of hire. C) Nurse Aide (NA) #21 Nurse Aide #21 had a hire date of 10/08/25. She had no education on dementia management training during the period from 10/08/25 through 11/30/25. The Nurse Aide had no competencies completed prior to assuming direct care of residents, following her date of hire. During an interview with the facility's Regional Compliance Advisor on 12/09/25 mid-morning, this was reviewed with him. He had no comments.

Based upon record review, resident interviews, staff interview and observation, the facility failed to honor resident's preferences for showers.This was found to be true for two (2) of eleven (11) residents reviewed during the long term care survey process. Resident identifiers: #6, and #56. Facility census: 63. Findings included: A) Resident #6 During an interview with the resident on 12/07/25 at approximately noon, the resident stated he would like to get a shower. He stated, All they do is give me a bed bath. Resident's hair appeared oily, and hair did not look like it had been combed. He had facial beard growth of a few days length. A review of the resident's current care plan, developed on 03/10/25, documents, It is important to me to shower. The facility's shower/bathing schedule showed Resident #6 was scheduled showers for Wednesdays and Saturdays on day shift. A review of the ADL tasks for showering for the last three (3) months documents the following: 9/9/25 through 9/16/25 no bath or showers documented 9/17/25, Wednesday 1:18 PM shower provided 09/18/25-09/20/25 no bath or showers documented 9/21/25, Sunday 11:25 AM bed bath/sponge was given 9/22/25 - 10/02/25 no bath or showers documented 10/03/25 Friday 10:58 AM bed bath/sponge was given 10/04/25 - 11/12/25 no bath or showers documented 11/13/25 Thursday 1:02 PM bed bath/sponge provided 11/14/25 - 11/19/25 no bath or showers documented 11/20/25 Thursday @11:36 AM bed bath/sponge provided 11/21/25 - 12/1/25 no bath or showers documented 12/02/25 Tuesday @10:48 AM tub bath provided 12/03/25 - 12/08/25 no bath or showers documented A review of the facility census documents the resident was not on leave during last 90 days. B) Policy The facility's policy on Activities of Daily Living (ADLs) of 05.01.23, reads: Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's activities of daily living (ADL) abilities are maintained and improved and do not diminish unless circumstances of the patient's clinical condition demonstrate that a change was unavoidable. Activities of daily living include:Hygiene - bathing, dressing, grooming, and oral care Purpose: To ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and the patient's choices and preferences. C) Resident #56 A review of the resident's care plan documents revealed the resident required an assist of one to two staff for bathing, and requires the assistance of two for mechanical lift. Under interventions, the care plan reads, It is important for me to choose between a tub bath, shower, bed bath or sponge bath. I prefer showers. Date initiated: 09/29/25 During an interview with the resident on 12/07/25 at approximately 1:20 PM, the resident stated, I am tired of always getting a bed or sponge bath. I want to shower! An observation of the resident found hair uncombed, female facial hair appeared on mustache line and at chin level. Facial hair was approximately 1/4 inch. During the interview with the resident, she was questioned about her preference for her facial hair. She responded that she wanted it removed, but that staff did not bother to help her. The resident's current Medical Diagnostic Screening (MDS) assessment documents the following response to this question: How important is it to you to choose between a tub bath, shower, bed bath or sponge bath? Response was : Very important. A review of the facility's shower schedule documents resident is supposed to receive a shower on Mondays and Thursdays on day shift. The documentation in the medical record for showers was requested from the facility for the past two (2) months of showering. The results were: 10/1/25 Wednesday 11:59 AM bed bath/sponge provided 10/2/25 - 10/09/25 no bath or showers documented 10/10/25 Friday 2:59 PM bed bath/sponge provided 10/11/25-10/13/25 no bath or showers documented 10/14/25 Tuesday 11:17 AM shower provided 10/15/25 - 10/31/25 no bath or showers documented 11/01/25 Saturday 12:59 PM bed bath/sponge provided 11/02/25 no bath or shower documented 11/03/25 Monday 2:59 PM bed bath/sponge provided 11/04/25 Tuesday 10:20 AM bed bath/sponge provided 11/05/25 - 11/06/25 no bath or shower documented 11/07/25 Friday 10:56 AM bed bath/sponge provided 11/08/25 - 11/24/25 no bath or shower documented 11/25/25 Tuesday 10:40 AM bed bath/sponge provided 11/26/25 Wednesday 10:46 AM bed bath/sponge provided 11/27/25 Thursday 10:36 AM bed bath/sponge provided 11/28/25 - 11/29/25 no bath or showers documented 11/30/25 Sunday 12:57 PM bed bath/sponge provided 12/01/25 - 12/08/25 no bath or showers documented 12/09/25 Tuesday 2:59 PM bed bath/sponge provided The facility's Regional Compliance Advisor was asked about why residents' choices were not being honored as it related to bathing and hygiene on 12/09/25 during the afternoon. He responded by saying I do not really know. During an interview with employee # 27 on 12/09/25 at approximately 4:00 p.m., stated that the facility was going to expand the entry way into the 100 Hallway shower room to allow Resident #56 to have entry into the area. Asked Employee #27 why the need to expand the doorway? Employee #27 replied To allow Resident #56 to get in the shower room safely and with dignity.

Based on record review and staff interview, the facility failed to ensure all alleged violations involving verbal abuse are reported immediately, but not later than 2 hours after the allegation is made. This failed practice has the potential to affect more than a minimal number of residents residing in the long-term care facility. Resident identifier: #35 Facility census: 63. Findings include:Review on 12/10/25 of a Facility Reported Incident (FRI) revealed the Initial Reporting of Allegations for verbal abuse which should be reported immediately or within two (2) hours had a date and time of 12/18/25 12:00 AM.Further record review of the FRI revealed there no fax or email confirmation of when the incident was reported.Continued record review on 12/10/25 revealed the incident happened on 11/18/25 according to some immediately witness statements taken, however no time of incident was noted in that statement. Other witness statements taken were on 11/25/25 and 11/26/25 which were 6 days after the allegation of verbal abuse was made.During an interview on 12/10/25 at 4:24 PM with the Regulatory Compliance Advisor (RCA) the RCA confirmed there was no fax or email confirmation of date and time the FRI was sent.Further information and email/fax confirmation were requested from the facility administrator on 12/10/25 at approximately 4:30 PM, and no other information was provided to this surveyor.

Based on record review and staff interview the facility failed to provide the appropriate documentation when a resident was transferred out of the facility to the hospital. This was true for one (1) of one (1) resident reviewed for hospitalizations. Resident Identifier: #9. Facility Census: #63. Findings Include: a) Resident #9On 12/09/25 at 1:15 PM record review of hospitalizations for Resident #9 shows she was transferred to the hospital on the following days.08/20/25 no bed hold documentation available09/15/25 no transfer documentation available09/22/25 no bed hold documentation availableAccording to the Policy OPS404 Discharge and Transfer for a resident being transferred to a hospital includes but is not limited to the following:5.1 For unplanned, acute transfers, the patients must be permitted to return to the Center. Prior to the transfer, the patient and patient representative will be notified verbally followed by written notification using the Notice of Hospital Transfer or state specific transfer form. 5.3 For any hospital transfers, the following will be sent to the hospital with the patient. 5.3.1 State specific transfer form (e.g. Universal Transfer Form) if required by the state or 5.3.2 E-Interact Nursing Home to Hospital Transfer Form in states where no state specific form is required and 5.3.3 Medication list and 5.3.4 Patient's advance directives and 5.3.5 POLST, MOLST, POST, etc.5.4 A copy of the E-interact Form will be placed in the patient's medical record.5,5 The Bed Hold Notice of Policy & Authorization form will be provided per the Accounts Receivable Policies and Procedures. The above findings were confirmed with the Regional Compliance Advisor #107 at which time it was confirmed the missing documentation was not available for these transfers.

Based on observation, record review and staff interview the facility failed to ensure the resident's comprehensive care plan was revised relating to a resident using a straw, tube feeding orders, a urinary (Foley) catheter, an actual pressure ulcer and a Peripherally Inserted Central Catheter (PICC) line in place. These were random opportunities of discovery. Resident Identifiers: #9 and #11. Facility Census: #63Findings Include: a) Resident #9 On 12/08/25 at 11:55 AM record review shows that Resident #9 has orders for Enteral Feed Order every shift. Osmolite 1.5 Cal. 60 ml/hr. Runs for 22 hours/day with downtime from 1100-1300 (11:00 AM to 1:00 PM). 25ml H20 flushes every 4 hours. There are no current orders for a Peripherally Inserted Central Catheter (PICC) line, urinary foley catheter or pressure ulcer treatment. Review of the care plan states: Resident at risk for skin breakdown related to actual pressure ulcer, decreased activity, frail fragile skin, impaired sensation, incontinence, Foley catheter in place, tracheostomy in place, g tube in place and PICC line in place. The care plan also states under interventions for the focus of Resident has an enteral feeding tube to meet nutritional needs related to status post right cranioplasty and NPO status that the tube feeding is to be off between 1000-1400 (10 AM until 2:00 PM) daily when the order is for 11:00 AM until 1:00 PM daily. At this time it was confirmed by Licensed Practical Nurse #102 that Resident #9 does not have an actual pressure ulcer, a urinary catheter nor a PICC line at this time. She also confirmed that the down time for the tube feeding is actually 11:00 AM until 1:00 PM. b) Resident #11 On 12/07/2025, a dining room observation was initiated. Resident #52 had a straw in a [NAME] Cup in her wheelchair cup holder in the dining room during the lunch meal and a straw in her water pitcher in her room at bedside. At 01:35 PM, NA #52 verified the resident's tray card for 2 Handled cup w/no lid, Food in mugs, [NAME] Cup, and NO STRAWS The resident and Nursing Assistant (NA) #52 the resident has been using straws in the dining room and her room. At 01:35 PM, NA #52 verified the resident's tray card for 2 Handled cup w/no lid, Food in mugs, [NAME] Cup, and NO STRAWS. Resident #11's diet order stated, Regular/Liberalized Dysphagia Puree texture, Standard Thin Liquids consistency, no bread, may have regular cottage cheese, cheeseballs, and Reese's mini cups, food in coffee cups, Kennedy cup for beverages no straws. Resident #11 care plan report stated, Provide regular, dysphagia puree diet as ordered. No bread, may have regular cottage cheese, food in coffee cups 2 handled cup no straws. The resident's care plan also stated, Divided scoop plate pureed solids, thin liquids, use straws and handled cups. On 12/07/2025, the two differences in the care plan for straw utilization were verified by the Regulatory Compliance Officer. On 11/17/2025, a staff message from the Speech-Language Pathologist (SLP) stated the resident was to use straws.

Based on personnel file review, staff interview, and review of the facility's policy for screening of employees, the facility failed to verify two (2) of four (4) direct care staff hired by a staffing agency and used by the facility were thoroughly screened for a history of abuse, neglect, exploitation, and/or any applicable criminal activity that would identify the individual as unfit to work in a long-term care facility. The facility failed to ensure two (2) of three (3) individuals were screened through the West Virginia Clearance for Access and Employment Screening (WV CARES) system, a program initiated by the Centers for Medicare and Medicaid Services (CMS) National Background Check Initiative. Employee identifiers: #64 and #7. After consultation with the State Agency, a determination of immediate jeopardy was made based on the facility's failure to thoroughly screen the backgrounds of two (2) of three (3) Licensed Practical Nurses (LPNs). In addition, two (2) of three (3) LPNs did not have proof of West Virginia Licensure and were currently working at the facility. This practice had the potential to affect all residents residing in the facility. Notice of the immediate jeopardy (IJ) was given to the Administrator on [DATE] at 6:19 PM. An acceptable plan of correction (P[NAME]) was received from the Administrator on [DATE] at 6:35 PM. After verification of the implementation of the plan of correction (P[NAME]), the immediate jeopardy (IJ) was abated on [DATE] at 6:35 PM. After removal of the immediate jeopardy, a deficient practice remained at a scope and severity of E for this requirement for failure to ensure Nurse Aide #83 maintained a current registration. Facility census: 61 The findings included: a) LPN #64 A review of personnel files, on [DATE] at 3:00 PM, revealed the facility had employed agency staff, LPN #64 on [DATE]. When the employee files were brought to the surveyor for review, the file for Employee LPN #64 was not included. When this omission was brought to the Administrator's attention on [DATE] at 3:06 PM, the Administrator stated, The employee's file is here in the facility and I was trying to find it. On [DATE] at 4:01 PM, Corporate RN #87 stated there was no employee file for LPN #64 at the facility. It was verified at that time that LPN #64 was currently on the schedule to work and had been working in the facility since [DATE]. A review of the time record for LPN #64 on [DATE] at 4:02 PM, revealed the employee worked at the facility on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE]. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] ,[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. LPN #64 was scheduled to also work [DATE] from 6:45 PM-07:15 AM. b) LPN #7 A review of personnel files on [DATE] at 03:00 PM, revealed the facility employed agency staff, LPN #7 on [DATE]. The file did not contain documentation that LPN #7 had been screened by WV CARES system for background information. Additionally, LPN #7's LPN license was for a distant state, and there was no evidence of current West Virginia licensure. An interview with the facility administrator on [DATE], at 3:06 PM, verified LPN #7 did not have a background check completed through WV CARES and had only the license from another state on file. Further interview on [DATE], at 4:01 PM with Corporate RN#87, revealed there was no background check completed on LPN #7 through WV CARES and they only had proof of a LPN license from another state. Employee LPN#7 was hired to work at the facility 0n [DATE]. A review of the time records for dates worked were as follows: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and was working on the unit providing direct care when the deficient practice was discovered on [DATE]. c) A review of the facility's policy, OPS300 Abuse Prohibition included, The Center will screen potential employees for a history of abuse, neglect, or mistreating patients, including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries. (Refer to Human Resources Policies and Procedures, Background Investigations policy.) 2.1 The Center will not employ or otherwise engage individuals who 2.1.1 Have been found guilty by a court of law of abuse, neglect, exploitation, misappropriation of property, or mistreatment; or 2.1.2 Have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. 2.1.2.1 Knowledge of actions by a court of law against an employee, which would indicate unfitness for service will be reported to the state nurse aide registry or licensing authority; 2.1.3 Have had a disciplinary action in effect against his/her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of [REDACTED].>or misappropriation of resident property. The facility's failure to follow its policy, failure to verify whether employees had current licenses to practice in the State of West Virginia, and to obtain or verify background checks were completed through the WV CARES system to determine whether these employees were eligible to work with the nursing home residents, placed all resident of the facility at risk for serious harm. These findings resulted in a determination of immediate jeopardy. Notice of the immediate jeopardy (IJ) was given to the Administrator on [DATE] at 6:19 PM. An acceptable plan of correction (P[NAME]) was received from the Administrator on [DATE] at 6:35 PM. After verification of the implementation of the plan of correction (P[NAME]), the immediate jeopardy (IJ) was abated on [DATE] at 6:35 PM. d) The facility's plan of correction for the immediate jeopardy [DATE], (YEAR) Administrator immediately removed the identified agency LPN from the floor at 6:30pm on (MONTH) 11, (YEAR). Staffing was immediately adjusted accordingly to meet resident needs. All residents of the facility have the potential to be effected. No residents of the facility have experienced any negative outcome. A list of all Agency Employee's was immediately complied by the CED, on (MONTH) 11, (YEAR) at 7:03pm. All agency Employee's identified were immediately notified by the Administrator/Designee to come to the Center to complete the WV Cares Application to initiate the background check process. Agency personnel who have not submitted their application and completed their fingerprints will not be placed on the schedule to work. Administrator/Designee will re-educate Human Resource Manager/Designee on the WV Clearance for Access (WV Cares) and Employment Screening System as required by the Centers for Medicare and Medicaid Services (CMS) with a post- test to validate understanding. Administrator/Designee will complete a review of New Hire/Agency personnel files on (MONTH) 11, (YEAR) to ensure an application and fingerprints have been initiated prior to new hire beginning work in the Center to ensure completion of the WV Cares with confirmed eligibility to work in the Center for 30 days. Trends identified will be reported by the Administrator/Designee monthly to the Quality Improvement Committee for any additional follow-up until the issue is resolved and randomly thereafter as determined by QIC. e) After removal of the immediate jeopardy, a deficient practice remained at a scope and severity of E for this requirement for failure to ensure a nurse aide maintained a current registration. A review of the personnel file for Nurse Aide (NA) #83, on [DATE] at 3:15 PM, revealed this employee did not have a current Nurse Aide Registration. NA #83's registration had expired on [DATE]. An interview with Corporate RN #87, on [DATE] at 3:20 PM revealed the facility had obtained the nurse aide results after requested by the surveyor. A current registration was not present prior to surveyor intervention. NA #83 was hired by the facility on [DATE]. A review of the time records revealed the employee worked after his/her NA registration expired on : [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].

Based on observation, staff interview, review of the reported allegations of elopement to the nursing home program, and review of facility policy, the facility failed to provide an environment free from accident hazards over which the facility had control. Secure care equipment failed to function properly which had the potential to allow a resident, utilizing the secure care equipment, to leave the facility without staff knowledge. Once the door was opened by a visitor, a resident, or anyone not wearing a secure care alarm, any resident with a secure care alarm could exit the building without activating the alarm. Resident #34 was observed attempting to leave the facility when another resident exited the building. No alarm sounded although the resident had secure care devices on her ankle and wheelchair. Testing of the system found it failed to activate an alarm when a resident wearing a secure care device went through the door when opened by a visitor or other person not wearing a device. Further investigation found an incident when a former resident, Resident #58, had exited the facility while the door was held open by another resident. The report regarding that incident noted, Equipment will be tested , . The transmitter was tested and was working properly according to the immediate action taken. However, the investigation did not indicate if the testing was done when the door was opened or closed. After consultation with the State office a determination of immediate jeopardy was made based on the facility's failure to ensure the secure alarm system was working properly to prevent residents with secure care systems from exiting the facility without staff knowledge. The facility was previously aware of the elopement of Resident #58 on 05/24/18. This incident should have alerted the facility the secure care system was not operating properly. The facility NHA was notified of the immediate jeopardy on 07/11/18 at 12:05 PM The facility provided an acceptable plan of correction. After verifying implementation of the plan, the immediate jeopardy was abated on 07/11/18 at 12:15 PM This practice had the potential to affect five (5) of five (5) residents with a secure care system. Resident identifiers: #2, #38, #34, #37, and #45. After removal of the immediate jeopardy, deficient practices remained at a scope and severity of E. A random opportunity for discovery found the facility failed to ensure the environment over which it had control was free from accident hazards for Resident #4, who fell outside the facility while smoking. A cabinet was unlocked in the shower room creating a potential for more than an isolated number of residents to be exposed to a hazardous chemical. Facility census: 61. Findings included: a) Resident #34 On the morning of 07/10/18, at approximately 10:30 AM, observations found Resident #34 attempting to leave the facility when another resident, without an alarm system, was exiting the building. No alarm sounded at that time. At the time of the incident, the surveyor was unaware Resident #34 was wearing a secure alarm system. The surveyor was alerted to the incident when the male resident was cursing Resident #34, telling her to get back into the building. Licensed Practical Nurse, #52 intervened and assisted Resident #34 back inside the building. Review of the resident's medical record at 8:30 on 07/11/18, found a ninety-eight (98) year old female resident admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's current care plan found a focus/problem of, Resident is at risk for elopement related to Cognitive Loss/ Dementia, dated 09/08/16. The goal associated with the focus/problem: Resident will not attempt to leave the facility without an escort. Interventions included: Secure care device to maintain safety, dated 10/26/17. On 04/29/18, this intervention was revised to include, Utilize and monitor security bracelet left ankle and left side of wheelchair per protocol. At 9:30 AM, on 7/11/18, LPN #52 was asked about the observation on Resident #34 occurring on 07/10/18. LPN #52 said the resident would try to exit the facility because she thought she needed to get her kids or get her mother and father. When asked why the secure care alarm did not activate yesterday, LPN #52 said the other resident had already opened the door. The other resident did not have a secure care alarm bracelet because he was allowed to go outside, unattended. Since the door was open, she could get out. LPN #52 said the door did not alarm if someone else already had it opened. The resident is smart enough to know she could make a beeline to the front door because the door was opened. At 10:00 AM on 07/11/18, investigation found Resident #34 had two (2) secure care alarm devices - one device was on her ankle and one device attached to her wheelchair. The alarm system of the front door was tested on [DATE] at 10:05 AM, by the NHA and the Maintenance Supervisor (MS). When a secure care bracelet was held by the MS, within approximately two to three feet of the front door, the door locked. However, once the MS stepped back from the door, the door could be opened. When the door was held open by the surveyor, the MS was able to pass through the front doors, while holding the secure care bracelet, without the alarm sounding. The MS said the alarm system should always activate when any resident with a secure care system passed through open doors. This had the potential to affect Residents #2, #38, #34, #37, and #45. At 11:05 AM on 07/12/18, the NHA said, As for the wander guard system we just had random checks in place that were not documented. It was just verbal saying the doors were checked. I have changed that now. b) Review of the facility reports of elopement to the nursing home program Further investigation of the facility's reportable allegations of elopement to the nursing home program found another resident, Resident #58, (now discharged ) had exited the facility on 05/24/18. The facility's investigation found, (Name of resident) and another male resident were found taking a walk outside of the facility back by the employee smoking area. (Name of Resident) does not have capacity and currently has a secure care transmitter in place. (Name of Resident) exited the facility while the door was held open by another resident who is alert/oriented and does not have a secure care transmitter. No injury occurred to (Name of Resident) or the other Resident. (Name of resident) re-entered the building without difficulty or issue. Equipment will be tested . alert/oriented resident will be educated. The transmitter was tested and was working properly, according to the immediate action taken. At 10:32 AM on 07/11/18, the NHA said she did not know how staff tested the doors after the elopement on 05/24/18. She could not verify the door was tested after being opened. Observation with the NHA found a secure care system on the front door, the patio door, leading to the staff smoking area and the service entrance doorway. At 10:50 AM on 7/11/18, the NHA said she called the Secure Care Company. She said, It is a fluke and Secure Care is on the way. The NHA verified the Secure Care Alarm System was supposed to alarm even if the door was already opened when any resident wearing a secure care alarm passed through the open door. c) Review of the facility's policy for, Patient Security Bracelet. The facility's policy, effective 05/01/16 included, Patient security bracelets (e.g., wander guard) will be inspected per manufacturer's recommendations but at a minimum of: Every shift for placement, and Daily for function d) Notification of immediate jeopardy At 12:05 PM on 07/11/18, the NHA was notified in writing the immediate jeopardy was being called due to the failure of the Secure Care Alarm System to function properly. The NHA was also informed the facility should have known about the malfunctioning system on 05/24/18 when an actual elopement occurred during which time the resident was wearing a secure care bracelet. e) Plan of correction Doors 1. All doors were manned by facility staff at 10:55AM to ensure no resident exited the building who were wearing secure care equipment. The Administrator (NHA) contacted the secure care health systems at 10:47AM to request tech support for secure care equipment failure. Call received from secure care tech at 11am to review step by step process of resetting the master code for the secure care system with the Maintenance Director. At 11:20am the secure care function was reset by the Maintenance Director and all doors were functioning appropriately with the door opened or closed when a resident with a secure care transmitter in place was trying to exit. Residents #2, #34, #38, #37, #45 have not experienced any negative outcomes. Resident #58 no longer resides in the facility. 2. All residents of the facility who have secure care transmitter in place have the potential to be affected. The Maintenance Director/designee checked all residents who have secure care transmitter bracelet to ensure proper functioning with or without the code entered and door was opened or closed on 7/11/18 at 2:16pm with no additional corrective action required. 3. The NHA/designee will reeducate all staff beginning 7/11/18 regarding ensuring the safety of residents with the secure guard wander system including the functioning of the secure care system with the door opened or closed and notifying Maintenance and NHA immediately if the system does not function appropriately with a posttest to validate understanding. Staff not available will be provided reeducation and complete posttest upon return to work by the NHA/designee. New staff will receive education and complete posttest during orientation by the NHA/designee. The maintenance director/designee will check the secure care system functioning daily across all shifts X 2 weeks including weekends then three times a week for two weeks then randomly thereafter to ensure the secure care alarm are function properly when the doors are opened and closed. 4. Trends identified will be reviewed by the Maintenance Director/designee monthly at the Quality Improvement Committee (QIC) for any additional follow up and/or inservicing until the issue is resolved and randomly thereafter as determined by the QIC committee. At 12:05 PM on 07/11/18, the immediate jeopardy was abated after verifying staff were posted at each exit door. The secure care system was repaired with technical support of the alarm company and the doors were repaired at 11:20 AM on 07/11/18. After removal of the immediate jeopardy, deficient practices remained at a level of E. f) Resident #4 At 11:25 AM on 07/09/18, Resident #4 said she fell the first night she came to the facility. She said she went outside to smoke, alone. She said she was not used to riding in a wheelchair, it was dark, and she was not familiar with the place and somehow, her wheelchair got stuck on the sidewalk and fell . She said an ambulance driver came along and found her. They didn't know I had fallen. She said she went to the hospital. I had a nasty black eye, broke some bones in my face and had a big knot on my head. They thought I broke my nose. After that I wasn't allowed to smoke alone again. Medical record review found the resident was admitted to the facility on [DATE]. Review of the nursing notes found the following entries: - 03/29/2018 at 10:26 AM, Admission Note: Resident admitted /readmitted to 220-A. Arrived by private car and wheelchair. Information upon admission obtained from patient family and/or significant other chart. Reason for admission is Long Term Care. A Braden score of 20.0 and Fall Risk score of 6.0 were obtained as part of this assessment. Call bell placed within reach. Physician notified/orders verified: Yes. See nursing admission assessment (UDA) for detailed clinical findings. 03/29/18 at 8:54 PM, Resident fell while outside smoking, staff notified by EMS (Emergency Medical Services) staff bringing in new resident, EMS had already gotten resident up and placed in wheelchair and brought in building. Resident had notable swelling to left eye and forehead. Abrasions to left forehead, left eye and left nose. Neuro's (neurological check) intact. Patient requested to go to Hospital. (Name of physician) and Niece notified. 03/29/18 at 11:30 PM, Report called in from (name of local hospital) stating Resident was being released that CT (computerized tomography) was negative resident dx (diagnosis) was facial fracture and hematoma to left forehead Review of the hospital discharge summary, dated 03/29/18, found the resident had a traumatic hematoma of her forehead and a closed [MEDICAL CONDITION] bones. The smoking assessment completed on 03/29/18 at 10:26 AM, noted the resident did not use oxygen, did not have dementia, and independent smoking was allowed. According to the assessment, the resident was able to demonstrate the location of smoking area, able to hold, light and discard appropriately. Review of the risk management system found the resident fell on [DATE] at 8:30 PM Resident was outside smoking when EMS came to drop off a new admit and found resident on side walk. EMS picked resident up off of sidewalk and brought her inside in her wheelchair before alerting staff. Nurse assessed patient after being alerted of fall. Abrasions noted to left side of nose, left eye, left forehead and left cheek. Wounds cleansed with normal saline and [MEDICATION NAME] placed to avoid infection, resident alert and oriented stated she was trying to turn around to come back in and her wheelchair went off side walk and got stuck, she attempted to get herself unstuck and fell on left side of face. No other injuries noted. Resident requested to be sent to ER A second smoking assessment, completed on 03/30/18 at 4:22 PM (the day after the first assessment), noted the resident lacked capacity and lacked safety awareness with history of falls and was not allowed to smoke. This assessment noted the resident had dementia, poor memory and was unable to demonstrate the location of the designated smoking area. At 2:32 PM on 07/10/18, the Director of Nursing (DoN) was unable to provide any further information related to the resident's fall while smoking. She was unable to provide documentation the facility assessed the resident for the ability to physically transport herself to and from the smoking area. At 10:02 AM on 07/12/18, the DoN was again asked if she had any information to validate the resident was thoroughly assessed for safe smoking upon admission. No further information was provided. c) An observation of the 100 Hall shower room, on 07/10/18 at 7:35 AM, revealed the wall cabinet containing a bottle of Virex, a hazardous item, was unlocked. This was an area accessible to residents. According to the Material Safety Data Sheet (MSDS), Virex is a corrosive agent capable of causing permanent damage to the eyes and skin and is an irritant to the respiratory tract. It also noted Virex is capable of causing permanent damage to the gastrointestinal tract if swallowed. An interview with Nurse Aide (NA) #43, on 07/10/18 at 07:40 AM, verified the cabinet was unlocked and the side containing the Virex could not be locked with the key present. Additionally, there were keys hanging that did lock the left side of the cabinet, making locking and unlocking the left side accessible to anyone. An interview with the NHA, on 07/10/18 at 8:50 AM revealed that cabinets containing hazardous items should be locked and keys not readily accessible to anyone in the shower room.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure Resident #14 received pain management consistent with his needs and physician's orders [REDACTED]. Resident #14 said he had to beg for pain medication and expressed anger at the staff. Due to a transcription error, Resident #14's pain medication ([MEDICATION NAME]) was given on an as needed (PRN) basis, although the physician's orders [REDACTED]. The failure to ensure the resident received adequate pain management was determined to be actual harm, both physical and psychosocial. Resident identifier: #14. Facility census: 61. Findings included: a) Resident #14 During an interview with Resident #14 on 07/09/18 at 11:30 a.m., he stated, I am hurting all over. A staff nurse was immediately notified of the resident's complaint of pain. On 07/10/18 at 10:45 a.m., when asked about his pain he said, I don't know why I can't get my pain medication. I had it four (4) times daily and then it was increased to six (6) times a day when I was having pain in my suprapubic area. I am supposed to get it four (4) times a day now and I can only get it if I beg for it. The resident expressed anger at the staff and referred to them in a derogatory manner. On 07/10/18 at 11:40 a.m., review of Resident #14's physician's orders [REDACTED]. This was to be given around the clock. Prior to (MONTH) 14, (YEAR), the resident had received [MEDICATION NAME] six (6) times a day as he stated during the interview. Review of the resident's medication administration records (MAR) found from 06/14/18 until the end of June, the resident received [MEDICATION NAME] 4 times a day, around the clock. He received it at 12 midnight, 6:00 AM, 12:00 noon, and 6:00 PM until July, when the medication was entered into the computer as a PRN medication in error. Review of Resident #14's Medication Administration for (MONTH) (YEAR), found beginning on 07/01/18, the pain medication [MEDICATION NAME] was only administered on as needed basis (PRN). Record review also identified this resident's [DIAGNOSES REDACTED]. He was essentially bedridden, dependent on staff for activities of daily living other than eating, and had impairment of functional range of motion in both upper and lower extremities. Observations noted he had contractures of his hips and knees. During an interview with the Director of Nursing (DON) on 07/10/18 3:43 pm, verified the order for Resident #14's pain medication ([MEDICATION NAME]) had been inaccurately entered into the computer. She confirmed the resident had not received his pain medication as ordered since 06/30/18, causing Resident #14 to experience pain. The failure to ensure the resident received pain medication as ordered, resulted in inadequate pain management and caused the resident to be angry. These findings were determined to be physical and psychosocial harm.

Based on staff interview and medical record review, the facility failed to ensure a resident received sufficient fluid intake to maintain proper hydration and health. One of seven (7) sample residents was transferred to the hospital and admitted with the [DIAGNOSES REDACTED]. Facility census: 61. Findings include: a) Resident #63 Review of the medical record, on 01/28/13 at 2:30 p.m., included a review of a hospital discharge summary. It verified Resident #63 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Lab results included a blood urea nitrogen (BUN) of 36, Serum Creatinine (Cr) of 1.5, and Serum Sodium (Na) of 161 on the date of admission. On 01/08/13, the hospital lab report indicated the resident ' s BUN was 13, Cr was 1.00 and Na was 147. Upon admission to the hospital the urine was noted as, "turbid in clarity." A hospital history and physical visit note, dated 12/27/12, described the chief complaint on admission was altered mental status and shortness of breath. " . . . while at the nursing home the resident was found to have altered mental status compared to his baseline as well as a low oxygen saturation and low grade fevers . . . On arrival to the emergency department, the patient was significantly obtunded (mentally dulled) as well as being significantly tachypneic (rapid respirations) with gurgling respiration . . . was significantly hyperglycemic (high blood sugar) . . . The patient had a corrected sodium value 168 with estimated free water deficit of 7.4 liters. The patient appeared to be severely dehydrated, and per patient's family had significantly decreased p.o. (oral) intake over the past several weeks . . . The patient was volume resuscitated with two liters of [MEDICATION NAME] ringers with some improvement in blood pressure. The patient remained significantly obtunded. . . ." On 12/28/12, an interdisciplinary note, completed by the licensed social worker, noted ". . . Fluid intake reviewed for month of December with adequate intake noted. Nursing to obtain order for regular hydration periods. . . ." However, a dietary note, completed on 11/07/12, by Employee #77, the registered dietitian revealed the resident should be consuming "1700-2040" ml daily. The following is a list of amount of fluids consumed each day from 12/08/12 through 12/24/12, as reported on the resident's functional performance record: 12/24 1440 ml 12/23 1260 ml 12/22 1440 ml 12/21 720 ml 12/20 1200 ml 12/19 1160 ml 12/18 1800 ml 12/17 1320 ml 12/16 1440 ml 12/15 1680 ml 12/14 960 ml 12/13 1080 ml 12/12 1440 ml 12/11 1320 ml 12/10 840 ml 12/09 840 ml 12/08 1680 ml During an interview with Employee #42, the director of nursing (DNS), on 01/29/13 at 10:30 a.m., she related the resident also received fluids during snack pass. She was unable to provide evidence fluids were provided and consumed. She stated no other record was utilized, related to fluid intake. An interview with the registered dietitian, Employee #77, on 01/29/13 at 11:30 a.m., indicated fluids were provided via nourishment - up to 800 ml per day. Insensible fluid loss was not considered, related to fluid intake and output for Resident #63. The care plan, dated 10/22/12, identified a risk for altered nutritional status. staff were to observe for signs and symptoms of dehydration and aspiration. During an interview, on 01/30/13 at 9:30 a.m., with the unit manager, Employee #25, and Employee #68 (licensed practical nurse), they stated hydration was tracked in the resident functional performance record. They also stated the record was reviewed during care plan meetings. Otherwise, the nursing assistants notified licensed staff of declines. Employee #68 stated the nurses do not monitor fluid intake. The Physician order [REDACTED]. It revealed the resident was to receive care which included medical treatment, IV (intravenous) fluids, cardiac monitoring, antibiotics, and a feeding tube for a defined trial period. .

Based on medical record review and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being for one (1) of seven (7) sampled residents. The facility failed to assess, monitor, and provide interventions to potentially prevent hospitalization of a resident with a urinary tract infection, [MEDICAL CONDITIONS], and mental status changes. Resident identifier: #63. Facility census: 61. Findings include: a) Resident #63 Review of the medical record, on 01/28/13 at 2:30 p.m., revealed an interdisciplinary note completed on 12/24/12 at 10:00 p.m. It noted the resident's temperature was 101.3 degrees Fahrenheit. Tylenol was administered for the fever. On 12/25/12 at 6:35 a.m., according to a nursing entry, the resident's temperature was 101.8 and his apical heart rate was 109. He was "suctioned for copious amount of sputum . . . MD (physician) faxed." On 12/25/12 at 7:10 a.m., a nurse noted "rales scattered throughout bilateral lungs, oxygen saturation was 77-82%." His oxygen was applied at 4 lpm (liters per minute) and his sat (oxygen saturation) increased to 86%. The physician was notified at 7:20 a.m., and the resident was transferred to the hospital. A physician's orders [REDACTED]." Another order, dated 12/22/12, indicated a urinalysis with culture and sensitivity (U/A C&S) was to be obtained on 12/23/12 Further review of the medical record, revealed a hospital discharge summary, dated 01/10/13. It verified Resident #63 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Additionally, a hospital progress note, dated 12/26/12, noted altered mental status due to infection, dehydration, underlying dementia, and [MEDICAL CONDITION]. A hospital history and physical visit note, dated 12/27/12, noted the chief complaint on admission was "altered mental status and shortness of breath . . . while at the nursing home the resident was found to have altered mental status compared to his baseline, as well as a low oxygen saturation, and low grade fevers . . . On arrival to the emergency department, the patient was significantly obtunded as well as being significantly tachypneic with gurgling respiration . . . was significantly hyperglycemic . . . The patient had a corrected sodium value 168 with estimated free water deficit of 7.4 liters. The patient appeared to be severely dehydrated, and per patient's family had significantly decreased p.o. intake over the past several weeks . . . The patient was volume resuscitated with two liters of [MEDICATION NAME] ringers with some improvement in blood pressure. The patient remained significantly obtunded. . . ." The hospital case management assessment note, completed on 12/28/12, also indicated Resident #63 was admitted with dehydration and urinary tract infection [MEDICAL CONDITION]. Lab results completed at the hospital on the day of admission, 12/25/12, included a blood urea nitrogen (BUN) of 36, Serum Creatinine (Cr) of 1.5, and Serum Sodium (Na) of 161. On 01/08/13, after intravenous fluids, the hospital lab report indicated the BUN was 13, Cr was 1.00 and Na was 147. Review of a nursing facility resident encounter sheet, completed by the nurse practitioner on 12/05/12 (prior to the onset of symptoms), noted lab results of a BUN of 13, Cr of 1.00, and the Na of 138 on A monthly summary, completed on 12/23/12 by a nurse at the long term care facility, described Resident #63's skin turgor as "fair." A dietary note, completed on 11/07/12, by the registered dietitian (RD), revealed the resident should be consuming "1700-2040" mls daily. The following is a list of mls consumed each day from 12/08/12 through 12/24/12 as reported on the resident's functional performance record: 12/24 1440 ml 12/23 1260 ml 12/22 1440 ml 12/21 720 ml 12/20 1200 ml 12/19 1160 ml 12/18 1800 ml 12/17 1320 ml 12/16 1440 ml 12/15 1680 ml 12/14 960 ml 12/13 1080 ml 12/12 1440 ml 12/11 1320 ml 12/10 840 ml 12/09 840 ml 12/08 1680 ml During an interview with Employee #42, the director of nursing (DNS), on 01/29/13 at 10:30 a.m., she related the resident also received fluids during snack pass. She was unable to provide evidence fluids were provided and consumed. She stated no other record was utilized related to fluid intake. An interview with the registered dietitian, Employee #77, on 01/29/13 at 11:30 a.m., indicated fluids were provided via nourishment - up to 800 mls per day. Insensible fluid loss was not considered, related to fluid intake of Resident #63. The care plan, dated 10/22/12, identified a risk for altered nutritional status. Staff were to observe for signs and symptoms of dehydration and aspiration. A swallowing evaluation was completed on 12/28/13. This noted the resident was admitted to the hospital with [REDACTED]. . . ." Mucosal quality was noted as, "bruising present; cracked, dry." A hospital consultation visit note of 01/03/13 indicated the resident was "evaluated for PEG (percutaneous endoscopic gastrostomy or feeding tube) tube placement. . . The family is agreeable to a PEG tube after apparently failing a swallowing evaluation." The hospital nutrition assessment revealed a "feeding tube placed on 01/05/13." She also noted the resident was confused and unable to remain upright in bed. It noted Resident #63 had a history of [REDACTED]. . . Pharyngeal phase: penetration occurred during and after swallow . . . residue in the pharynx of all consistencies post swallow is noted . . . . significant risk of aspiration is observed." During an interview with Employee #68 (licensed practical nurse), on 01/30/13 at 9:30 a.m., she stated lung sounds were documented per physicians order. She related when a resident was skilled, a head to toe evaluation was completed daily and documented in the nurses' notes. She said breath sounds were documented on the medication administration record (MAR). She also related staff was to document daily on areas related to skilled services or change in condition. Additionally, oxygen saturations were to be monitored per physician order. Review of the December 2012 MAR, on 01/29/13, found no evidence lung sounds were monitored. The schedule for [MEDICATION NAME]-[MEDICATION NAME] inhalation to be administered as needed, was blank. The December 2012 treatment administration record (TAR), revealed Resident #63 was not using his oxygen prior to discharge to the hospital. The schedule for oxygen administration was blank and the schedule for oxygen tubing and humidifier changes was noted as "not using." The care plan, dated 10/22/12, was reviewed on 01/28/13 at 4:00 p.m. It indicated staff were to monitor the resident for signs and symptoms an of upper respiratory infection and aspiration. The urinalysis, dated 12/25/12, described the urine as, "turbid in clarity." Employee #35 (nursing assistant) was interviewed on 01/29/13 at 2:10 p.m. She noted signs and symptoms of a UTI to be "odor, pain, and complaints of hurting when they pee." She stated, "I can not think of anything else." Employee #50 (nursing assistant) was interviewed at 3:30 p.m., on 01/29/13. She related "behavior changes, they get mean and their urine smells." Review of the behavior monthly flow sheet, dated December 2012, revealed behavior episodes documented as zero (0) from 12/01/12 through 12/16/12. Behaviors were documented as observed daily from 12/17/12 through 12/24/12 (immediately prior to the resident's hospitalization ). The care plan, dated 10/22/12, indicated staff were to monitor for a urinary tract infection. Staff were to report changes in amount, frequency, color or odor of urine. An entry in the interdisciplinary notes, dated 12/22/12 at 5:00 a.m., noted the resident was "guarding peri area and grimace when urinating." An order was received at 5:00 p.m. on 12/22/12 for a straight cath urinalysis and culture and sensitivity. No further notation was found concerning the urinary tract infection. An interview with the director on nurses, on 01/30/13, confirmed no evidence of further assessment, monitoring, or implementation of care of the UTI was completed. The hospital physician note, dated 12/27/12, noted Resident #63 was "significantly hyperglycemic" on arrival to the emergency room (ER) on 12/25/12. The long term care facility medication administration record (MAR), dated December 2012, was reviewed on 01/28/13. It revealed the resident was to have fingerstick blood sugars (FSBS) at 7:00 a.m. and 4:00 p.m., weekly. According to the MAR, the resident had refused the FSBS at 4:00 p.m. on 12/11/12 and 7:00 a.m. and 4:00 p.m. on 12/18/12. No evidence was provided to indicate other attempts were made to monitor his blood sugar until 12/25/12. During an interview with the DNS, on 01/30/13, she reviewed the chart and verified a lack of evidence related to assessment, monitoring and implementation of care. She stated her expectation for prudent care would be "an assessment related to comorbidities to be completed daily." Additionally, the Physician order [REDACTED]. It revealed the resident was to receive care which included medical treatment, IV (intravenous) fluids, cardiac monitoring, antibiotics, and a feeding tube for a defined trial period. .

Based on record review and staff interview, the facility failed to provide a safe environment for a resident who was newly admitted and had been identified as having repeated falls just prior to coming to this facility. It was identified Resident #67 required the assistance of two (2) staff members for transfers and toileting assistance. This resident had a recent CVA (cerebral vascular accident) and suffered from left hemi-paresis. She was noted to have experienced some periods of confusion, memory impairment problems, impaired balance, she had functional limitations of her entire left side, she was impulsive, and had a history of [REDACTED]. This resident was left unsupervised sitting on the toilet in the bathroom alone. She fell from the commode sustaining multiple left-sided facial fractures and subsequent hospitalization . Actual harm was identified for one (1) of nine ((9) sampled residents. Resident identifier: #67. Facility Census: 65. Findings include: a) Resident # 67 This resident was admitted to the facility on [DATE] from another nursing home. Documents were provided from the transferring facility to the receiving facility about her status at the transferring facility, including information she had fallen two (2) times in the two (2) weeks prior to her transfer. Her recapitulation of stay from the prior facility stated under the section titled "Rehabilitation services" that the resident "continues to remain impulsive with behaviors thinking she can walk independently. Currently walking with max (maximum) assist of two." The day the resident was admitted to this facility, her admission nursing assessment indicated in Section twelve (12) that she had range of motion impairments on one side that interfered with daily functions or placed the resident at risk for injury. This section was also coded that she was not steady and only able to stabilize with human assistance for moving from seated to standing position, walking, moving on and off toilet, and surface to surface transfers. She was identified on this admission assessment as being at risk for falls. The answers provided on the assessment directed the nurse to complete other assessments to further evaluate identified problems. An assessment titled "device evaluation" was completed. This assessment indicated this resident had some memory impairment, she had decreased awareness of her safety needs, she had impaired balance, she had functional limitations in her left arm, hand, leg, and foot. She was described as being impulsive. A summary of risk factors stated the resident was impulsive and had a history of [REDACTED]. Section C of the assessment contained interventions. It was recorded that it would be necessary to use a bed and chair alarm when the resident was out of bed to a chair and while in bed. A review of her physician's orders [REDACTED]. A Multidisciplinary Screening form, dated 05/22/12, requested an evaluation for the resident's recent fall, change in bed mobility, change in transfer status, change in ambulation/mobility status, change in ADL (activity of daily living) ability, change in toileting/continence status, change in active/passive ROM (range of motion/ contracts status, change in w/c (wheel chair) positioning. The Physical Therapy (PT) Evaluation, completed on 05/22/12, stated the resident had a CVA (cerebrovascular accident) in May 2012 and this had resulted in left side hemiparesis. She also had a history of [REDACTED]. Her positioning was in a wheelchair tight with cushions placed. They recommended brake extenders. Her safety was assessed at fair and she had alarms to her bed and chair in place. Her cognition was assessed as being alert and oriented to person and place, but not to time. She was to receive Physical Therapy services 5 times a week for 8 weeks. The Occupational Therapy (OT) Evaluation for this resident noted she required "max assist" (maximum assistance) with toileting. Her sitting balance was evaluated as fair/poor, her wheelchair management/mobility /positioning was assessed as "max assist". Under the area of safety, the resident was described as "impulsive". OT was treating this resident 5 times a week for 8 weeks. Her treatment was to include increasing toileting to supervision. Her baseline status was assessed at "max assist". A nursing note, written on 05/24/12 at 9:20 p.m., stated "family transferred resident to bed and didn't place alarm back on resident bed. This nurse found resident on the side of the bed with no alarm. Family was educated on the importance of alarms for resident safety and in agreement with care. Resident was repositioned in bed comfortably." A nursing entry on 05/27/12 noted the resident continued with "left side flaccid." A Change in Condition form, recorded on 06/01/12 at 3:35 p.m. , stated the "resident was on toilet and fell off landing on the left side and hitting her head on floor. Laceration left eyebrow 3.7 cm skin tear left FA (forearm) 1.5 cm x 2.5 cm) c/o (complained) of head and neck pain". She was then sent to the hospital emergency room to be evaluated. According to the record, the resident kept stating she felt like she was having TIAs (transient ischemic attack). An interview was conducted, on 06/19/12 11:30 a.m., with the nurse who was present at the time of Resident #67's fall. She was questioned about the resident's safety and whether she should have been left alone on the toilet. She stated she was not aware they were leaving the resident in the bathroom by herself. She was questioned whether they typically left residents in the bathroom alone who had alarms for falls preventions and she stated "No". Nursing assistant #71 was interviewed 06/19/12 at 2:50 p.m.. She stated they always allowed her to sit on the toilet because she knew what she was doing. She also stated that she was aware the resident had alarms, but the resident knew what she was doing and she wanted her privacy. An interview was conducted with nursing assistant #34 at 2:55 p.m.. She stated that "you look at the care card to see what they need". No one had ever told them not to leave her alone in the bathroom. In an interview with the nursing assistant (Employee #1) who was taking care of this resident when she fell , he stated the resident had capacity and she wanted him to step out of the bathroom, so he did as she requested. He verified that no one had ever told him that she could not be left in the bathroom alone. The care plan that was established on 05/22/12 was viewed. The care plan did not identify whether the resident could remain in the bathroom alone. The records were obtained from the hospital and it was verified that on 05/22/12, this resident presented in the emergency room with a head injury. According to the resident;s statement to the hospital, she was sitting on the toilet reaching for toilet paper and fell striking her head on the floor. It was verified that she had injuries and she was admitted to the hospital with [REDACTED]. The resident remained in the hospital from 05/22/12 to 06/02/12. She was discharged from the hospital to another nursing home. .

Based on staff interview, review of facility documents, medical record review, and mechanical lift manufacturer representative interview, the facility failed to ensure one (1) of thirty (30) Stage 2 sampled residents was transferred in a manner to prevent injury. Facility staff utilized a lift pad (sling) not designed for use with the facility's mechanical lift to transfer Resident #77 from a wheelchair to her bed. The resident fell out of the lift pad (sling) while suspended in the air and struck the floor. The resident sustained [REDACTED]. The facility failed to ensure lift pads (slings), not intended for use with their current mechanical lifts, were removed from the facility's inventory. The facility failed to ensure facility staff were adequately trained in the use and operation of mechanical lifts and lift slings. These deficient practices resulted in harm to Resident #77, and placed all residents who required transfers with a mechanical lift at risk of injury. Resident identifier: #77. Facility census: 64. Findings include: a) Resident #77 - Licensed practical nurse (LPN), Employee #15, was interviewed on 04/23/12 at 2:13 p.m. as part of the Stage 1 Quality Indicator Survey (QIS). When asked whether Resident #77 had any falls or fractures in the previous 30 days, Employee #15 stated the resident fell from a mechanical lift on 04/18/12 and sustained a fracture of her left humerus. - Review of facility documents found at 7:30 p.m. on 04/18/12, nursing assistants (NA), Employees #35 and #33 were transferring Resident #77 from the wheelchair to the bed using a mechanical lift. The report documented, "Resident in Hoyer lift & (and) fell out". The report documented the resident complained of pain to her left shoulder, left hip, and right foot. - Review of the medical record found the minimum data set (MDS), with an assessment reference date (ARD) of 02/01/12, Section G, found the resident required the total assistance of two (2) or more staff members for transfers. Review of the current care plan with a target date of 05/04/12 found staff were to, "Assist resident getting in and out bed using mechanical lift with two staff members". The care plan did not specify what type of lift sling to utilize for this resident. - Further review of the medical record found the resident was transported to an acute care facility following her fall on 04/18/12. She was returned to the facility from the emergency room in the early morning hours of 04/19/12 with [DIAGNOSES REDACTED]. An x-ray report, dated 04/18/12, documented acute fractures of the right third through fifth metatarsal necks (toes). an order for [REDACTED]. On 04/21/12 at 8:00 a.m., a nursing note documented the resident complained of pain to the left shoulder with yellowish discoloration to her left upper extremity, just above the elbow. A physician's orders [REDACTED]. Review of the x-ray results, dated 04/22/12, found the following, "...There is a large effusion at the elbow. This is secondary to a nondisplaced supracondylar fracture with very slight posterior angulation. There may be a subtle fracture of the radial head as well...". -- An interview was conducted with the director of maintenance, Employee #63 at 9:00 a.m. on 04/25/12. He was asked whether he inspected the mechanical lift following Resident #77 falling from the lift on 04/18/12. Employee #63 stated he attended a meeting concerning the fall and learned the type of sling utilized to transfer the resident was not intended for use with the lifts they currently utilized. He stated the "white" sling was to be used with a different model of mechanical lift which had been placed out of commission. -- An interview was conducted with the administrator, Employee #55, at 9:00 a.m. on 04/25/12. She stated the white lift pad was removed from use following the resident's fall on 04/18/12. She stated the lift pad had not been removed from inventory when the model of mechanical lift intended for use with the white slings was placed out of commission. -- The staff development nurse, Employee #1 was asked, at 9:00 a.m. on 04/25/12, to provide evidence of NAs #35 and #33 competency related to the use of mechanical lifts. She provided an in-service document dated 03/09/12 on the proper use of the mechanical lift and lift pads (slings). Both NA #35 and #33 were listed. --Employee #1 was asked to demonstrate the use of the different slings and her training methods related to mechanical lifts at 11:15 a.m. on 04/25/12. She stated the NAs watched a video, and then she takes them two-at-a-time and watches them demonstrate lifting individuals using the mechanical lift. She was asked to demonstrate which color and type of lift pad (sling) to utilize for residents of different sizes and different body types. Employee #1 was unable to demonstrate what pads (slings) to utilize in differing situations. She was asked how she taught aides the proper lift pad (sling) to utilize if she could not determine it herself. She stated that she relies heavily on the senior aides. She was asked whether she was aware the facility had a white lift pad present in the building prior to Resident #77's fall. Employee #1 stated she was aware the facility had white lift pads, but had not evaluated the use of this lift pad during the training she provided. -- A NA, Employee #36, was asked at 11:30 a.m. on 04/25/12, about the use of mechanical lift pads. She stated, "There are some white ones (slings) from the old lift that we can still use". Employee #1 agreed this information was not accurate. -- Another NA, Employee #47, was asked at 11:45 a.m. on 04/25/12, how aides determined which color and type of sling to use with a mechanical lift. She stated in the presence of the DON that aides use their own judgement when choosing a sling to utilize. -- An interview was conducted, on 04/30/12 at 9:58 a.m., with a representative from the manufacturer of the mechanical lifts currently utilized by the facility. The representative was asked if it was appropriate to utilize a sling from a different manufacturer with the lifts currently utilized by the facility. The representative stated when facilities called and ask that question, they are told no. The manufacturer recommends only use of the slings intended for the model utilized by the facility to ensure safety. .