Every finding on record at Pine View Center

Based on observation and staff interview the facility failed to serve food in a sanitary condition. This practice had the potential to afffect all residents receiving food from the kitchen area. Facility census: 47.Findings include:a) Lunch observationDuring dining room observation on 4/20/26 at 11:30 AM food was being served on trays that were reused without being sanitized in between. Staff placed trash on trays, dumped it into the trash can and then reused the same trays to serve food.An interview with the Administrator on 4/20/26 at 11:49 AM verified that trays were being reused without sanitization.

Based on record review and staff interview, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident. This was a random opportunity discovered during the completion of the Beneficiary Notification pathway throughout the Long-Term Care Survey Process. Resident Identifier: 57. Facility Census: 47. Findings included: a) Resident #57 An electronic medical record review revealed: -Resident #57 was admitted to the facility on [DATE]. -Resident #57 was discharged from the facility on 12/01/25. -The care plan scanned into the electronic medical record had blanks in the area of level assistance needed for transfer/mobility/activities of daily living (ADL). Upon request, on 04/22/26 at 9:05 AM, the Administrator produced a copy of Resident #57's baseline care plan. This was the same care plan scanned into the electronic medical record. The first focus area on the care plan was, Resident requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, toileting related to: Recent hospitalization, resulting in fatigue, activity intolerance. Date Initiated: 11/25/2025. The goal associated with the focus area was, Resident's ADL care needs will be anticipated and met throughout the next review period. Date Initiated: 11/25/2025. There were blanks (as outlined below) in several of the interventions listed on the base line care plan:Provide resident/patient with _________ (specify: set-up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of _____ (specify #) for bed mobility.Date Initiated: 11/25/2025Provide resident/patient with _________ (specify: supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of ______ (specify #) for transfers using a ___________ (specify: walker, roll walker, quad cane, straight cane, pivot transfer, slide board, etc.).Date Initiated: 11/25/2025Provide resident/patient with _________ (specify: set-up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of _____ (specify #) for eating.Date Initiated: 11/25/2025Provide resident/patient with _________ (specify: set up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of ______ (specify #) for toileting.Date Initiated: 11/25/2025Provide resident/patient with _________ (specify: set-up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of ______ (specify #) for dressing.Date Initiated: 11/25/2025Provide resident/patient with _________ (specify: set-up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of _____ (specify #) for personal hygiene (grooming).Date Initiated: 11/25/2025Provide resident/patient with _________ (specify: set-up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of _____ (specify #) for bathing.Date Initiated: 11/25/2025During an interview on 04/22/25 at approximately 10:40 AM, the MDS Coordinator acknowledged the baseline care plan had not specified the level of care needed for bed mobility, transfers, eating, toileting, dressing, grooming, and bathing.

Based on observation and staff interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible This failed practice was a random opportunity for discovery and had the ability to effect a limited number of residents Facility Census:47Finding Included: a) Resident Sitting room: During a facility walkthrough, the surveyor observed the following in the sitting room wall near the nurses' station: Loose, crumbling sheetrock pieces were falling from the wall onto the floor under the left side of the window. This area was easily accessible to residents. In an interview with Employee # 46 Licensed Practical Nurse(LPN) on 04/20/25 at 12:45AM, she acknowledged the crumbling sheet rock chunks falling .from the wall and onto the floor, stated she blocked it off and said she would notify the maintenance department. In an interview with the Administrator on 04/20/26 at 1:25 PM, she acknowledged the falling pieces of sheet rock around the window in the sitting room and stated shehad sent a message to maintenance. b) Inbound auxiliary wall heater: During facility walk through on 04/21/2026 11:40 AM, it was observed at the end of the 300 hallway, an inwall bound auxiliary heater that was fully functionaland became hot enough to burn flesh within a 15-second period. This was located approximately 2 feet from the floor and was easily accessible to any residentmoving through that hallway. Staff interviews:During an interview with the Unit manager on 04/21/26 at 11:45 AM, she acknowledged the inbound auxiliary wall heater and stated she would contact maintenance. During an interview with the Senior Maintenance Director on 04/21/26 at 11:50 AM, he stated, I must have overlooked that one. During an interview with the Senior Maintenance Director on 04/21/26 at 11:50 AM, he stated, I must have overlooked that one.

Based on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for residentsin room [ROOM NUMBER], #312, and #313 . This was a random opportunity for discovery and had the potential to affect a limited number ofresidents. Facility census: 47. Findings included:a) room [ROOM NUMBER]: Room and bathroom:During a facility walk through on 04/20/26 at 11:00 AM, it was observed in the room and the bathroom:-missing caulking around the sink in the room-missing caulking around the toilet base-stained tile around the toilet base- The far right corner had a buildup of a dirty substance around the base of the wall. b) Resident bathroom room [ROOM NUMBER]:During a facility walk through on 04/20/26 at approximately 11:20 AM, the following was observed in the bathroom: -missing caulking around the base of the toilet-stained tile at the base of the toilet- The far right corner had a buildup of a dirty substance around the base of the wall.c) Resident bathroom in room [ROOM NUMBER]:During a facility walk through on 04/20/26 at approximately 11:30 AM, we observed the following in the bathroom:-missing caulking around the base of the toilet-stained tile at the base of the toilet-yellow substance on the left wall next to the shower- The far right corner had a buildup of a dirty substance around the base of the wall. Resident #35 Interview:In an interview with Resident #35 on 04/20/26 at 11:20 AM, she reported that the toilet was leaking around the base and stated this had been occurring for over a month.Resident #2 Interview:In an interview with Resident #2 in room [ROOM NUMBER] on 04/20/26 at 11:35 AM, he reported water around the base of the toilet and stated it was leaking. Staff Interviews: During a facility walkthrough and interview on 04/21/26 at 12:46 PM the infection preventionist acknowledged issues in the bathrooms of Rooms #310, #312, and #313. She stated she would add it to the maintenance list. In an interview with the administrator on 04/22/26 at 9:31 AM she stated she was made aware of the environmental issues in the above listed resident rooms and bathrooms and that a list was created for the maintenance department.

Based on observation, staff interviews, and resident interviews, the facility failed to ensure an effective pest control program was in place.This was random opportunity for discovery with the ability to effect a limited number of residents. Room identifiers: #310, #312, and #313. Facility census: 47. Findings included:a) Bathroom [ROOM NUMBER]:During a facility walkthrough on 04/20/26 at 11:00 AM, gnats were observed flying around and landing on the base and on the seat of the toilet, bathroom fixtures, and the walls in the bathroom.In an interview with Resident #27 on 04/20/26 at 11:05AM, he acknowledged gnats in the bathroom and could not remember how long they had been there. b) Bathroom [ROOM NUMBER]:During a facility walkthrough on 04/20/26 at approximately 11:20 AM, gnats were observed flying around and landing on the base and on the seat of the toilet, bathroom fixtures, and the walls in the bathroom.c) Bathroom [ROOM NUMBER]:During a facility walkthrough on 04/20/26 at approximately 11:20AM, it was observed in the bathroom, gnats were flying around and landing on the base and on the seat of the toilet, bathroom fixtures, and the walls.In an interview with Resident #2 on 04/20/26 at 11:20 AM, she reported gnats in the bathroom that had been present for months, suggesting the cause was a toilet leak around the base. During a facility walkthrough and interview with the infection preventionist on 04/21/26 at 12:46 PM she acknowledged gnats in the bathrooms of Rooms #310, #312, and #313. She stated she would add it to the maintenance list. In an interview with the administrator, on 04/22/26 at 9:31 AM, she stated she was aware of the gnats in the above listed rooms and could not verify that the drains were treated during the last pest control service.

Based on record review and staff interview, the facility failed to maintain accurate records for two (2) of two (2) Hospice residents sampled throughout the Long-Term Care Survey Process. Resident identifiers: #44 and #6. Facility census: 47.Findings included: a) Resident #44 A record review on 04/21/26 at 9:20 AM, revealed a Physician Orders for Scope of Treatment (POST) form dated 04/13/25. Section A of the POST form revealed Resident #44 did not wish to receive cardiopulmonary resuscitation if he had no pulse and was not breathing. Section B of the POST form revealed the resident wished to receive selective treatments in the event he had a pulse and was breathing. This means the resident could be transferred to the hospital if treatment needs could not be met in the facility. The section asking if the patient was enrolled in hospice was left blank on the POST form. Additionally, the record reflected Resident #44 started receiving hospice services on 05/06/25. The directions for completing the POST form, compiled by the [NAME] Virginia Center for End of Life, state the form should be reviewed whenever the patient transfers from one care level to another, has a substantial change in health status, or changes their treatment preferences or goals of care. Review of Social Service notes revealed the following care plan conference dates and times:-05/21/15 at 9:45 AM-07/02/25 at 10:45 AM-12/17/25 at 10:00 AM-02/25/26 at 11:15 AM During an interview on 04/22/2026 at 9:25 AM, the Director of Social Services acknowledged there had been four (4) care plan conferences since Resident #44 began receiving hospice services. The Director of Social Services agreed that the section asking if the patient was enrolled in hospice should have been updated to reflect the hospice agency's name and phone number. Findings include: b) Resident #6 Based on the record review on 4/21/26, Resident #6 began Hospice services on 01/30/26 and the POST form was not revised. The section asking if the patient enrolled in hospice services was left blank. During an interview on 04/22/26 at 9:25 AM, the Director of Social Services acknowledged that there had been one (1) care plan conference since Resident #6 began receiving hospice services. The Director of Social Services agreed that the section asking if the patient was enrolled in hospice should have been updated to reflect the hospice agency's name and phone number. Review of the Social Service note revealed a care plan was held on 02/11/26.

Based on interviews and record review, the facility failed to provide privacy for visitation. This is true for one (1) of one (1) resident reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #1, #40. Facility census: 47. Findings Included: a) Resident #1 On 10/29/24 at 10:55 AM during an interview with Resident 1's Medical Power of Attorney, she stated that all Resident 1's visitor's including her, have issues with Resident #40 opening the door, cursing the visitors and trying to come into the room. A record review on 10/29/24 of grievances revealed no grievance form was filled out for these issues. A medical record review of progress notes revealed multiple occasions 10/22/2024 3:35 PM A note stated Resident #1's sister came to a nurse and stated Resident #40 came to resident's room opened the door and just laughed then left at 3:05 PM and 3:15 PM. 10/27/2024 2:37 PM Resident #1's sister came to the chart room notifying the nurse that Resident #40 came down the hallway opened Resident #1's door started laughing and went back into his room. 10/5/2024 11:59 AM A note revealed that Resident #40 was asked by another resident's family member to stay away from the room door. This Resident has chosen not to comply with the other resident family's wishes. This resident chose to curse and speak loudly at the other resident's family members when they asked him to be respectful. This resident did not respond to verbal redirection and continued to attempt to look in another resident's room. 10/6/2024 2:40 PM A note revealed that Resident #40 was found in Resident #1's room. When the nurse approached the room and asked Resident #40 to leave, he immediately left the room quickly. Resident#40 refused to stop moving his chair to be questioned as to why he was in the room, nor would he listen when they tried to redirect him. 10/6/2024 6:00 PM A progress note stated Resident #40 had been verbally aggressive toward the staff due to his being redirected to stay out of Resident #1's room. Resident #1 had multiple family members coming in and out of her room which has caused an increase in Resident #40's behavior. Staff tried to redirect Resident #40, but he refused to listen or follow directions. 10/6/2024 4:43 PM A progress note stated Resident #40 was in the hallway screaming, (fxcx) them, I can see her if I want, in response to a resident #1's family coming in to see her. The family of Resident #1 has asked that this resident not come in the room and to stay away from her. Resident #1 was upset and verbalizing his aggravation in response. When Resident #40 was asked to stop yelling he responded with, hell no. Resident could not be redirected at this time. 10/20/2024 2:00 PM Resident #40 became verbally and physically aggressive when Resident #1's family came to visit her. He tried to kick and hit me with his fist as I walked down the hall. The resident believed that I called the family of Resident #1 to come in. Resident #40 had to be redirected by two other staff members due to he wasn't listening to what I had to say. He was removed from the area in order for him to settle down. He made multiple trips down the hall and stopped in front of Resident #1 door. When he would see someone coming down the hall, he moved on quickly. During an interview with the Administrator on 10/29/24 at 1:52 PM, she stated she was aware of the complaint about the issues for Resident #1, She verified that Resident #1 and her visitors were not provided privacy during visitation. She stated that she would offer a room change now.

Based on observation, staff interview and record review, the facility failed to store and label food in accordance with professional standards for food service storage. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 47. Findings included: a) Observation in the pantry area of the kitchen revealed small unlabeled what appeared to be vanilla ice cream. No dates were present on the cups. b) Observation in the freezer revealed cooked frozen sausage with a date labeled 10/28/24 and use by date of 04/22/24. These findings were confirmed by the Dietary Manager on 10/28/24 during the kitchen investigation.

Based on interview, record review and policy review the facility failed to making prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for two (2) of two (2) reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #1 and #5. Facility census: 47. Findings included: a) Resident #1 Record review of the facility's policy titled, grievance /concern, showed: -Upon receipt of the grievance / concern, the grievance / concern form will be initiated by staff member receiving the concern. -Upon receipt of the grievance /concern form, the Administrator or designee will document the grievance / concern on the grievance / concern log. - Immediate action will be taken to prevent further potential violations of any patient right while the alleged violation is being investigated. -Notify the person filing the grievance of resolution in a timely manner. Resident #1 On 10/29/24 at 10:55 AM during an interview Resident #1's Medical Power of Attorney, she stated that all Resident 1's visitors including her have issues with Resident #40 opening the door, cursing the visitors and trying to come into the room. A record review on 10/29/24 of grievances revealed no grievance form were filled out for these issues. A medical record review of progress notes revealed multiple occasions During an interview with the Social Services Director (SSD) on 07/12/22 at 9:52 AM, she stated she was aware of the complaint about the noise of the other resident but had never offered a room change to Resident #45 or completed a grievance form. She stated that she would offer a room change now. 10/22/24 3:35 PM Resident #1's sister came to this nurse stated resident #40 came to resident's room opened the door and just laughed then left at 3:05 PM and 3:15 PM. 10/27/24 2:37 PM Resident #1's sister came to chart room notified this nurse Resident #40 came down the hallway opened Resident #1's door started laughing and went back into his room. 10/05/24 11:59 AM Note: Resident was asked by another Resident family member to stay away from their room door. This Resident has chosen not to comply with the other Resident family's wishes. This resident chose to curse and speak loudly at the other Resident family members when they asked him to be respectful. This Resident did not respond to verbal redirection and continued to attempt to look in other Resident room. 10/06/24 3:40 PM A note revealed Resident #40 was found in Resident #1s room. When the nurse approached the room to ask Resident #40 to leave, he immediately left the room quickly. Resident#40 refused to stop moving his chair to be questioned as to why he was in the room, nor would he listen when the nurse was trying to redirect him. 10/06/24 6:00 PM A note revealed Resident #40 had been verbally aggressive toward the staff due to being redirected to stay out of Resident #1's room. Resident #1 had multiple family members coming in and out of her room. This caused an increase in Resident #40's behavior. Staff tried to redirect Resident #40 but he refused to listen or follow directions. 10/06/24 4:43 PM Resident #40 was in the hallway screaming fuck them, I can see her if I want, in response to Resident #1's family coming in to see her. Family of Resident #1 asked that this resident not come in the room and to stay away from other resident. Resident #40 was upset and verbalizing his aggravation in response. Resident #40 was asked to stop yelling and he responded with, hell no. Resident #40 could not be redirected at this time. 10/20/24 2:00 PM Resident #40 became verbally and physically aggressive when Resident #1's family came to visit her. He tried to kick and hit me with his fist as I walked down the hall. Resident believed that the nurse called the family of Resident #1 to come in. Resident #40 had to be redirected by two (2) other staff members due to he wasn't listening to what I had to say. He was removed from the area in order for him to settle down. He made multiple trips down the hall and stopped in front of Resident #1 door. When he would see someone coming down the hall, he moved on quickly. During an interview with the Administrator on 10/29/24 at 1:52 PM, she stated she was aware of the complaint about the issues for Resident #1, She verified no one completed a grievance form. She stated that she would offer a room change now. 50795 b) Resident #5 During an interview with Resident #5 on 10/2824, at approximately 11:55 AM, the resident stated that she had filed a verbal grievance against a staff member on 09/03/24. She mentioned that she had not received any response from the facility regarding the status of the investigation. A telephone interview was conducted with the Medical Power of Attorney (MPOA) for Resident #5 on 10/28/24, at 2:44 PM. During the conversation, the MPOA noted the facility had not yet responded to the grievance. She expressed her desire to understand whether the facility had conducted an investigation and, if so, what the outcome was. Further investigation, interviews, and record review revealed that the facility conducted an investigation, interviewed staff and residents, and concluded that the grievance could neither be substantiated nor refuted. Record review of the facility's policy titled, Grievance/Concern, revised on 10/15/24, showed that the department manager would notify the person filing the grievance in a timely manner, and written resolution for grievances would be offered per the resident's rights and will include: Date the grievance was received; Summary statement of the grievance; Steps taken to investigate the grievance; Summary of the pertinent findings or conclusions regarding the grievance; Statement as to whether the grievance was confirmed or not confirmed; Any corrective action(s) taken or to be taken by the center as a result of the grievance/concern; and Date the written resolution was issued. During an interview with Administrator #41 and Director of Nursing #46 on 10/30/24, at approximately 3:18 PM, they confirmed the facility had not submitted a written resolution of the grievance to the resident.

Based on record review and staff interview, the facility failed to complete a new Pre-Admission Screening and Resident Review (PASARR) for residents with newly evident or a possible serious mental disorder. This was true for two (2) out of two (2) residents reviewed under the category of PASARR, during the Long-Term Care Survey Process. Resident identifiers: #6 and #28. Facility census: 47. Findings included: a) Resident #6 A record review, completed on 10/29/24 at 1:50 PM, revealed Resident #6 had been admitted to the facility on [DATE]. Review of resident's diagnoses revealed a Major Depression diagnosis with an effective/active date of 11/01/23. There was only one (1) PASARR, dated 11/02/2022, on file. Section III MI/MR Assessment Question #30 had NONE selected regarding any pertinent diagnosis. Additionally, Section V Supplemental Questions #40 had NONE selected regarding any major mental illness (MI) or suspected MI. There was no evidence that a new PASARR had been done when the Major Depression diagnosis was given. During an interview, on 10/29/24 at 2:15 PM, the Social Worker reported there was not a new PASARR on file that addressed Resident #6's Major Depression diagnosis. b) Resident #28 A record review, completed on 10/29/24 at 2:00 PM, revealed Resident #28 had been admitted to the facility on [DATE]. Review of resident's diagnoses revealed a Bipolar Disorder diagnosis with an effective/active date of 09/26/24. There was an initial PASARR, dated 03/26/24 on file. Section III MI/MR Assessment Question #30 had NONE selected regarding any pertinent diagnosis. Additionally, Section V Supplemental Questions #40 had NONE selected regarding any major mental illness (MI) or suspected MI. There was a second PASARR, dated 07/16/24 on file. Section III MI/MR Assessment Question #30 had DX (diagnosis) of Depression and PTSD selected regarding any pertinent diagnosis. Additionally, Section V Supplemental Questions #40 had DX (diagnosis) of Depression and PTSD selected regarding any major mental illness (MI) or suspected MI. There was no evidence that a new PASARR had been done which captured resident's Bipolar Disorder diagnosis. During an interview, on 10/29/24 at 2:20 PM, the Social Worker reported there was not a new PASARR on file that addressed Resident #28's Bipolar Disorder diagnosis.

Based on record review and staff interview, the facility failed to ensure the consulting pharmacist performed a medication regimen review, which included a review of the resident's medical record, at least monthly. This was true for two (2) of five (5) residents reviewed under the unnecessary medication's pathway throughout the Long-Term Care Survey Process. Resident identifiers: #27 and #28. Facility census: 47. a) Resident #27 A record review, completed on 10/29/24 at 1:33 PM, revealed there was no evidence in the electronic medical record that a monthly medication regimen review had been completed for Resident #27 during the months of November 2023 and December 2023. During an interview on 10/30/24 at approximately 3:15 PM , the Administrator reported the facility was unable to produce any evidence the monthly medication regimen reviews had been completed by the consulting pharmacist and/or reviewed by the attending physician. b) Resident #28 A record review, completed on 10/29/24 at 1:15 PM, revealed there was no evidence in the electronic medical record that a monthly medication regimen review had been completed for Resident #87 for the month of August 2024. During an interview on 10/30/24 at approximately 3:15 PM, the Administrator reported the facility was unable to produce any evidence the monthly medication regimen review had been completed by the consulting pharmacist and/or reviewed by the attending physician.

Based on record review and staff interview, the facility failed to issue the required Notification of Medicare Non-Coverage (NOMNC) in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident identifier: #146. Facility census: 47. Findings included: a) Resident #146 On 10/29/24 at 12:00 PM, a review was completed regarding the beneficiary protection notification liability notice(s) given for Resident #146. Resident #146 was discharged to home following his last covered day of Medicare Part A services. Resident #146's last covered day of Part A Services was on 06/06/24. The facility failed to produce evidence that the required Notification of Medicare Non-Coverage (NOMNC) was issued. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two calendar days before Medicare covered services end . The instructions also state: A NOMNC must be delivered even if the beneficiary agrees with the termination of services. During an interview on 10/29/24 at 12:45 PM, Occupational Therapist #31 reported that Resident #146 had been admitted to the facility with an altered mental state and had demonstrated overall weakness. She recalled that it was the resident's desire to be able to return to home/community living when his skilled care days ended. Occupational Therapist #31 reported that the resident was discharged home on 06/06/24 once he had plateaued (meet a particular level of functioning and then stayed the same). During an electronic medical record review, completed on 10/29/24 at 8:30 PM, review of Resident#146's care plan revealed that resident had a desire to be discharged to the home following his skilled care/strength-building placement. Review of the resident's physical therapy, occupational therapy, and speech therapy discharge summaries revealed that the resident had met the therapeutic goals that had been established for him for to return to home/community living. During an interview on 10/30/24 at 8:35 AM, the Business Office Manager #60 confirmed a NOMNC was not issued prior to Resident #146's last covered day of Medicare Part A skilled services and subsequent discharge to home

Based on medical record review and staff interview, the facility failed to ensure a written Notice of Transfer / Discharge was provided to the resident and the long-term care Ombudsman for one (1) of two (2) residents reviewed for hospitalization s during the long-term care survey process. This had the potential to affect all residents being transferred or discharged . Resident identifier: #27. Facility census: 47. Findings included: a) Resident #27 A medical record review was completed on 10/3024 at 12:04 PM. The record review revealed Resident #27 was transferred to the hospital on 05/17/24. The record did not reflect the resident/resident's representative was provided with a written Notice of Transfer/Discharge indicating the reason for transfer, the effective date of transfer, the location to which the resident was being transferred, and a statement of the resident's appeal rights. There was also nothing in the electronic medical record to indicate the long-term care Ombudsman had been notified. During an interview on 10/01/24 at 2:55 PM, the Administrator reported the facility could produce no evidence that resident/resident's representative was provided a Notice of Transfer/Discharge or that the long-term care Ombudsman was notified of the transfer.

Based on medical record review and staff interview, the facility failed to provide evidence that a resident/resident's representative was provided with a written Bed Hold notice for an acute hospital transfer. This was true for two (2) out of two (2) residents reviewed under the hospitalization pathway in the annual Long-Term Care Survey Process. Resident identifiers: #27, and #16. Facility census: 47. Findings included: a) Resident #27 A medical record review was completed on 10/3024 at 12:04 PM. The record review revealed Resident #27 was transferred to the hospital on 05/17/24. There was no evidence in the electronic medical record that the facility had provided Resident #27 or his representative with a written Bed Hold notice. During an interview, on 10/01/24 at 2:55 PM, the Administrator reported the facility could not produce evidence that a Bed Hold notice had been issued for Resident #27's hospitalization on [DATE]. 42120 b) Resident #16 Record review, on 10/30/22 at 9:27 AM, revealed Resident #16 was discharged to a local hospital on 10/20/24. Continued review of Resident #16's medical record showed it did not contain documentation that the resident or the resident's representative received a copy of the bed hold policy at the time of transfer. In addition, there was no documentation in the medical record of contacting the resident/resident representative regarding the bed hold policy. In an interview with the Director of Nursing on 10/30/24 at 12:12 PM, the she confirmed that there was no documentation regarding staff notif0ying the resident/resident representative of the bed hold policy for the hospital transfer on 10/2/24.

Based on personnel file record reviews review and staff interview, the facility failed to provide a completed performance review of every nurse aide at least once every 12 months. This failed practice had the potential to affect more than a limited number of residents. Employee identifiers: #49, #5. Facility census: 47. Findings included: a) Employee performance reviews were not available for #49 or #5. During an interview, on 10/30/2024 at 11:34 AM, the Scheduling/payroll Manager #35 confirmed the yearly performance reviews were not on file for employee #49 and #5.

Based on resident representative interview, record review, and staff interview, the facility failed to collaborate with resident trauma survivors, and as appropriate, the resident's family, to identify triggers which may re-traumatize the resident, and develop care plan interventions to minimize or eliminate the effect of the trigger on the resident. This was true for one (1) of two (2) residents reviewed with a Post Traumatic Stress Disorder (PTSD) diagnosis. Resident identifier: #27. Facility census: 47. Findings included: a) Resident #27 During a resident representative interview, completed on [DATE] at 11:02 AM, Resident #27's wife reported his PTSD diagnosis stemmed from a work event when he was in his mid-20's. She went on to report that there was a disaster in 1978 in (name) County when a cooling tower under construction at the power plant collapsed, killing 51 construction workers. Resident #27 remembered the incident vividly and recalled people going around and just collecting the severed left arms of the deceased construction workers. He explained the way the scaffolding fell meant the majority of the workers lost their left arms during the fall. This image was something that had stuck with Resident #27 and something he would frequently talk about later in his life and prior to his admission to the facility. A record review completed on [DATE] at 10:39 AM revealed the following details: -A significant change in status Minimum Data Set (MDS), dated [DATE], revealed resident had a Brief Interview for Mental Status (BIMS) score of 02. A BIMS score of ,d+[DATE] is suggestive of a person having severe cognitive impairment. -A review of the comprehensive person-centered care plan for Resident #27 showed a focused area as, Resident/Patient reports past experience of trauma as evidenced by: Other Dx: PTSD. -Resident #27 had the following goal listed, Resident/Patient will identify stressors and report to staff through the next review. This goal had a revision date of [DATE]. -Additionally, Resident #27 had the following intervention listed in his comprehensive care plan as it related to his PTSD diagnosis, Encourage Resident/Patient to identify personal trauma and triggers and take steps to eliminate/minimize. During an interview on [DATE] at 11:00 AM, the Social Worker reported she did not have knowledge of why Resident #27 had a PTSD diagnosis and could not readily identify any triggers that might re-traumatize the resident. The Social Worker acknowledged that asking a resident with severe cognitive impairment to identify his personal trauma and triggers would be unrealistic and that a conversation should have been held with the resident's family to gain the information.

Based on observation, staff interview, and clinical record review, the facility failed to follow physician orders regarding oxygen administration, and did not monitor residents on oxygen therapy as prescribed. Resident identifiers: #5, and #11. Facility census: 47. Findings include: a) Resident #5 During a brief interview and inspection on 10/28/24 at approximately 11:40 AM, the resident was observed to be on oxygen therapy. The resident continued to be observed throughout the survey, and the following readings were obtained: On 10/28/24 at approximately 11:55 AM an oxygen concentrator was observed to be set to two (2) liters per minute. On 10/29/24 at approximately 3:11 PM the oxygen concentrator was observed to be set to deliver two (2) liters per minute. Record review revealed a physician's order dated 09/29/24 at 7:09 PM that stated: Oxygen at 3 L/min via Nasal Cannula PRN; notify MD if more than 3 shifts in a row below 90% O2 sat or having symptoms of respiratory distress. On October 29, 2024, at approximately 3:14 PM, LPN #29 confirmed that the oxygen was not set to the prescribed dosage. After adjusting the concentrator to deliver the correct dose, she remarked, These are not my patients; I was just asked to cover this hallway a few minutes ago. On 10/30/24 at approximately 8:11 AM this surveyor requested a record of Resident #5's oxygen saturation, while on oxygen therapy. Administrator #41 submitted a record with the following information: O2 SATS SUMMARY: -10/21/24 at 11:13 AM 99% (Room Air) -09/19/24 at 9:42 AM 98% (Room Air) -09/06/24 at 12:38 AM 96% (Room Air) -09/04/24 at 11:41 PM 96% (Room Air) -09/03/24 at 2:41 PM 96% (Room Air) PULSE SUMMARY: -10/21/24 at 11:13 AM 70 bpm (Regular) -10/01/24 at 8:14 AM 69 bpm (Regular) -09/19/24 at 9:42 AM 68 bpm (Regular) -09/06/24 at 12:38 AM 80 bpm (Regular) -09/04/24 at 11:41 PM 78 bpm (Regular) -09/03/24 at 2:40 PM 76 bpm (Regular) -09/01/24 at 9:52 AM 72 bpm (Regular) RESPIRATION SUMMARY: -10/21/24 at 11:13 AM 18 Breaths/min -10/01/24 at 8:14 AM 18 Breaths/min -09/19/24 at 9:42 AM 18 Breaths/min -09/06/24 at 12:38 AM 18 Breaths/min -09/04/24 at 11:41 PM 18 Breaths/min -09/03/24 at 4:41 PM 18 Breaths/min -09/01/24 at 9:52 AM 20 Breaths/min These records indicated that monitoring was not consistently conducted as prescribed by the physician. Additionally, no records were available for the dates of 10/28/24, and 10/29/24. During an interview with Administrator #41 on October 30, 2024, at approximately 9:44 AM, she stated that she had submitted all available monitoring records. b) Resident #11 On 10/28/24, at approximately 1:20 PM, Resident #11 was observed receiving oxygen therapy. The resident was continuously observed throughout the survey, and the following readings were recorded: On 10/28/24 at approximately 1:23 PM an oxygen concentrator was observed to be set to two (2) liters per minute. On 10/29/24 at approximately 11:5 AM the oxygen concentrator was observed to be set up to deliver two (2) liters per minute. On 10/30/24 at approximately 10:40 AM the oxygen concentrator was observed to be set to deliver two point five (2.5) liters per minute. Record review revealed a physician's order dated 11/03/23 at 6:00 PM that stated: Oxygen at 3 L/min via Nasal Cannula, continuously. Every day and night shift Notify MD if Pulse Ox < 90% more than 3 shifts in a row or having symptoms of respiratory distress. On 10/30/24, at approximately 10:42 AM, LPN #49 confirmed that the oxygen was not set to the prescribed dosage. She adjusted the concentrator to deliver the correct dosage, and then stated that she would ensure the other oxygen concentrators in the hallway were also checked. On 10/30/24 at approximately 8:11 AM this surveyor requested a record of Resident #11's oxygen saturation while on oxygen therapy. Administrator #41 submitted a record on 10/30/24 at approximately 8:15 AM, with the following information: O2 SATS SUMMARY: -10/13/24 at 6:28 AM 98% (Oxygen via nasal cannula) -10/12/24 at 9:44 PM 98% (Oxygen via nasal cannula) -10/12/24 at 8:48 AM 98% (Oxygen via nasal cannula) -10/12/24 at 12:51 AM 98% (Oxygen via nasal cannula) -10/10/24 at 10:43 PM 97% (Oxygen via nasal cannula) -10/10/24 at 4:30 PM 97% (Oxygen via nasal cannula) -10/09/24 at 9:37 PM 98% (Oxygen via nasal cannula) -10/09/24 at 9:34 PM 98% (Oxygen via nasal cannula) -10/12/24 at 12:51 AM 98% (Oxygen via nasal cannula) -10/10/24 at 10:43 PM 97% (Oxygen via nasal cannula) -08/19/24 at 1:00 AM 96% (Oxygen via nasal cannula) -08/17/24 at 11:18 PM 96% (Oxygen via nasal cannula) -06/28/24 at 9:32 AM 96% (Oxygen via nasal cannula) -06/27/24 at 11:40 PM 95% (Oxygen via nasal cannula) -06/27/24 at 10:41 AM 95% (Oxygen via nasal cannula) -06/26/24 at 11:55 PM 96% (Oxygen via nasal cannula) -06/26/24 at 5:01 PM 98% (Oxygen via nasal cannula) -06/25/24 at 12:57 AM 98% (Oxygen via nasal cannula) -06/25/24 at 12:17 AM 97% (Oxygen via nasal cannula) -06/20/24 at 2:17 AM 96% (Oxygen via nasal cannula) This record showed that while the resident was continuously on oxygen, monitoring was not consistently conducted daily, as prescribed by the physician. Furthermore, there were no records available for 10/28/24, 10/29/24, and 10/30/24. During an interview with the Administrator #41 on 10/30/24 at approximately 9:44 AM she confirmed that the monitoring had not been consistent.

Based on Interview and record review, the facility failed to contact the physician; and request a re-assessment of resident's capacity; after a Brief Interview for Mental Status (BIMS) evaluation revealed severe impairment. Resident identifiers: #18. Facility census: 47. Findings included: a) Resident #18: During a brief interview, on 10/28/24, at approximately 11:40 AM, Resident #18 was unable to state when she had entered the facility, or how long she had been there. The resident responded to other questions with unrelated answers. Record review on 10/28/24 at approximately 3:15 PM revealed a document by the resident's physician dated 08/29/24, that stated the resident had capacity. Further record review revealed the following note on 8/23/24 at 10:44 AM by Social Worker (SW) #23: BIMS Summary score: 12.0 Record review further revealed that Resident #18 had been admitted to the hospital on 09/14/24 for an acute urinary tract infection (UTI). A note by Physician #62 on 9/21/2024 at 8:13 PM stated the following: Resident is an (age/gender) who presents to the Pineview Center in Harrisonville, [NAME] Virginia after an acute hospitalization from [DATE] through 09/14/2024 at (name of acute care hospital) due to adult failure to thrive secondary to a acute urinary tract infection. She was evaluated by orthopedics who recommended against any further workup or interventions. They recommended PT/OT in order to help mobilize. Neurosurgery was consulted for T6 compression fracture in which they felt that this was more chronic in nature. Blood cultures eventually grew gram-negative rods and urine cultures grew Klebsiella. ID had been consulted and recommended broad-spectrum antimicrobials. Concern for lower extremity blood clot which was unable to be confirmed by ultrasound but treated with empiric heparin drip. Patient did have positive fecal occult blood test and GI was involved. Due to risks outweighing the benefits, heparin drip was discontinued and Protonix 40 mg IV twice daily was initiated. Palliative care had also evaluated the patient towards the end of admission, family and patient were agreeable to hospice. She was determined to be stable for discharge on 9/21/2024 in which she re-presented to the Center for long-term care on hospice. A note by SW #23 on 9/24/2024 at 08:33 AM stated: - BIMS Summary score: 5.0 During an interview on 10/30/24, at approximately 1:30 PM, SW #23 was unable to explain why the facility failed to contact the physician and request a re-assessment of Resident #18's capacity following the BIMS evaluation. An interview with Administrator #41 on 10/30/24 at approximately 3:00 PM confirmed that the facility had not contacted the physician to request a reassessment of the resident's capacity.

Based on record review and staff interview, the facility failed to develop and implement a comprehensive person-centered care plan for one (1) of 24 residents reviewed in the Long-Term Care Survey process. The facility failed to address Resident #145's preferred bedtime preference. Facility identifier: #145. Facility census: 47. Findings included: a.) Resident #47 A record review, completed on 10/29/24 at 7:40 PM, revealed that Resident #145 was admitted to the facility on [DATE] A review of the Recreation Comprehensive Assessment completed for resident, dated 10/18/24, found that the resident had reported she liked to go to bed whenever she wanted. A review of the comprehensive person-centered care plan for Resident #145 showed a focused area of Resident #145 as, While in the facility, resident/patient states that it is important that s/he has the opportunity to engage in daily routines that are meaningful relative to their preferences. Additionally, Resident #145 had the following intervention listed in her comprehensive care plan as it related to her daily routine, It is important for me to choose my bedtime and I prefer to go to bed (Delete all that do not apply) earlier than 7 pm, between 7-9 pm, or whenever I want. This intervention was created on 10/21/24. During an interview on 10/30/24 at 11:40 AM, the Administrator confirmed the care plan was not person-centered, and the reader would have no way of knowing what Resident #145's preference for bedtime would be by reading the intervention listed.

Based on observation and staff interview, the facility failed to provide care in a manner that protected personal and medical resident information for each resident. Resident care sheets were noted laying in the hallway, easily accessible and information not secured and the medical information entry kiosk had a code for entry access posted above the kiosk which when entered allowed access to resident medical and personal information. The observations were based on a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: Residents #2, #5, #15, #12, #17, #20, #27, #22, #21, #18, #8, #31, #10, #29, #25, #26, #28, and #32. Census: 31 Findings included: a) Policy review A review of the policy titled:: Electronic Health Record Documentation, dated, 01/2015, showed the facility must maintain clinical recorders on each resident in accordance to accepted practices. A review of the policy titled: Confidentiality of Computerized Medical Records #19, dated 07/2012, noted only authorized users will be able to gain access to the records and an assigned user code would be kept confidential. Employees were responsible for ensuring security and confidentiality of all resident information created, obtained or maintained by the facility. b) Resident care sheets An observation, on 06/13/23 at 12:35 PM, revealed 18 resident forms laying on top of two (2) of two (2) documentation stations on the Orange Hall, unsecured with resident identifying and personal and health information listed on the forms. Diet orders, special equipment required for the resident's care were noted for Residents' #2, #5, #15, #12, #17, #20, #27, #22, #21, #18, #8, #31, #10, #29, #25, #26, #28, and #32. c) Access code for electronic medical record access An observation, on 06/13/23 at 12:40 PM, revealed a kiosk where medical information was entered by staff utilizing a special and secure code. Above the kiosk, an observation was made of information which included an employee's name and access code posted above the kiosk in plain view. When the individual's name and access code was entered, the electronic medical information appeared for residents and was easily accessible for review of the medical information of each resident. d) Staff interview An interview, with Licensed Practical Nurse (LPN) #31, on 06/13/23 at 12:50 PM, verified the forms with personal and health information were laying at both Orange Hall documentation stations, currently being utilized for documentation in plain view and should have been secured. Additionally, LPN #31 verified during the interview, on 06/13/23 at 12:50 PM, the employee names and access codes were posted in an ability observed and accessible area and when entered would allow access to the resident matrix which included the electronic medical record for each resident. LPN #31 stated That is a problem. An interview with the Administrator, on 06/14/23 at 08:20 AM, confirmed staff were not to place any confidential resident information in plain view and the access code to the kiosk should be maintained in a confidential manner and was not acceptable practice for names and codes to gain access to the electronic health record being posted. .

Based on observation, medical record review, staff interview, and resident interview, the facility failed to prevent the development of a clinically avoidable Stage II pressure ulcer. This was true for one (1) of twelve (12) sampled residents. Resident #42 was admitted to the facility on [DATE], with a Stage II pressure ulcer to the coccyx and "mushy heels". The ulcer to the coccyx was treated and later resolved on 08/05/09; however, no treatment was initiated at the time of admission for the "mushy heels". On 07/25/09, the resident complained of pain to the heel of the left foot, and assessment of the foot revealed a fluid filled blister (Stage II pressure ulcer). There was no evidence to reflect the facility implemented measures upon admission to prevent the development of this pressure ulcer, given that the resident's heels were assessed as being "mushy" at that time and the resident was at high risk for developing additional breaks in skin integrity related to the presence of the Stage II ulcer on the coccyx. Once interventions to the Stage II ulcer on the left heel were ordered by the physician, the facility failed to ensure these interventions were consistently implemented, and the ulcer to the left heel increased in size. Facility census: 52. Findings include: a) Resident #42 Resident #42's medical record, when reviewed on 09/01/09 at 2:45 p.m., disclosed a [AGE] year old female resident who was admitted to the facility on [DATE], for rehabilitative services after a fractured right hip. The resident had dementia and a history of falls. The facility form titled "Nurses Admission and Assessment Record", dated 06/25/09, recorded the resident as having a "Stage II Decubitus coccyx" and "heels mushy". The resident received treatment to the coccyx pressure ulcer, and this ulcer resolved on 08/05/09. The physician did not ordered a treatment to the heels at the time of admission. A nursing note, dated 07/25/09, recorded the resident's complaint of heel pain to the left foot. The resident was found to have "a 2 cm long x 0.4 cm wide fluid filled blistered area noted to inner aspect of Lt. (left) heel". The physician ordered, "Skin repair cream to inner aspect of Lt. heel BID (twice daily) (10 a.m. and 10 p.m.) times two (2) weeks then review, apply heel protectors bilaterally when in bed q (every) shift, monitor skin condition of heels q shift." The July and August 2009 treatment sheets, when reviewed on 09/02/09 at 8:30 a.m., disclosed treatments were not consistently completed as ordered. The skin repair cream was ordered twice a day. The July 2009 treatment sheet was not initialed, indicating the treatment was completed as ordered for the following dates: 07/25/09 at 10:00 p.m., 07/26/09 at 10:00 p.m., 07/28/09 at 10:00 a.m., 07/29/09 at 10:00 a.m., and 07/31/09 at 10:00 a.m. The physician ordered bilateral heel protectors every shift when in bed beginning on 07/25/09. The shifts at this facility run from 6:00 a.m. to 2:00 p.m. (6-2), 2:00 p.m. to 10:00 p.m. (2-10), and 10:00 p.m. to 6:00 a.m. (10-6). The treatment sheet was not initialed for this intervention for the following dates: 07/26/09 (10-6 shift), 07/27/09 (10-6 shift), 07/28/09 (6-2 shift), 07/29/09 (6-2 shift), 07/30/09 (10-6 shift), 07/31/09 (10-6 and 6-2 shifts). The physician's orders [REDACTED].), 08/14/09 (6-2 shift), 08/15/09 (6-2 shift), 08/16/09 (2-10 shift), 08/23/09 (2-10 shift), 08/27/09 (10-6 shift), and 08/28/09 (10-6 shift). On 08/05/09, the physician ordered, "Topically apply Marathon to reddened area on left heel, air dry, and if necessary cover with bordered foam for added protection. Reapply Q week and prn (as needed) x four weeks and review." Review of the treatment sheet for August 2009 disclosed the Marathon treatment was not completed 08/17/09 through 08/24/09, as required by the physician's orders [REDACTED]. On 09/01/09 at 4:00 p.m., Resident #42 was observed in her room. The licensed practical nurse (LPN - Employee #55) changed the dressing to the left heel. The resident was observed to have a 4 cm x 3 cm x 0.1 cm Stage II pressure ulcer to the left heel. The wound bed was pink without drainage. The surrounding tissue was not [MEDICAL CONDITION] or red. Resident #42, when interviewed on 09/01/09 at 4:15 p.m., reported it "hurt a little". The director of nurses (DON - Employee #31), when interviewed on 09/02/09 at 3:15 p.m., was asked for evidence of the implementation of measures to prevent skin breakdown to the heels at the time of admission to the facility, when the resident's heels were found to be "mushy" on the 06/25/09 admission assessment. The DON did not provide any additional evidence of preventative measures for the heels having been implemented prior to 07/25/09. The DON, when informed of the omissions noted on the resident's July and August 2009 treatment records, was also unable to provide evidence that these interventions were completed as ordered by the physician. .