Every finding on record at Pleasant Valley Healthcare Center

Based on observation and staff interviews the facility failed to distribute and serve food in accordance with professional standards for food service safety. The facility did not ensure all equipment used for meal deliveries was clean. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 99.Findings included: A) Review of policy for Equipment Policy Statement : All food service equipment will be clean, sanitary, and in proper working order. Procedures read in part: 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 4. All nonfood contact equipment will be clean and free of debris. B) On 05/04/2026 at around 1:00PM, the food cart was delivered for lunch service on the 400 unit. State Agency (SA) observed dried sticky debris on bottom of cart next to shelves that was white in color. On the outside of the cart along the base, where the rubber met the metal, a moderate amount dried white substance was present. Certified Nursing Assistant (CNA) #46 confirmed there were dried debris on and in the cart. On 05/05/2026 at around 8:05 AM, during further observations of food carts on each unit were made. On the 400 unit, there was moderate amounts of dried red substance on outside of cart and on the inside of the door there was a moderate amount of dried white substance. There was food debris on the bottom of cart along the shelf. CNA #24 confirmed the food debris was inside and outside the cart. On the 100 unit, the SA observed on the inside of the doors a moderate amount of dried red substance. CNA #24 confirmed the red dried substance was on inside of the doors. On the 200 unit, SA observed on the inside of cart on the bottom shelf a moderate amount of dried red substance. CNA #46 confirmed the red dried substance on the inside of the cart. On the 300 unit, SA observed on the outside of the cart along the edges there was build up of debris. CNA #9 verified on the outside of cart along edges a build up of debris. District Manager for Food and Nutrition #127 was made aware of observations, verified the findings., and reported, I will ensure these get cleaned. C) On 05/04/2026 11:54 AM, during lunch meal service, the beverage carts that were sent to 100, 200, 300 and 400 halls were all soiled with debris. On 05/04/26 11:56 AM Certified Nurse Assistant (CNA) #34 was asked if the beverage cart on 100 hall was sent to them soiled, and she stated Yes, it was sent that way. The CNA agreed that the beverage cart was soiled and should have not been sent that way. On 05/04/26 12:01 PM, the Assistant Director of Nursing #79 and CNA #4 were asked if the 300 hall beverage cart was sent to them soiled. They both stated that it was soiled, and sent that way. On 05/04/26 12:02 PM, I let the Administrator know that the beverage carts were all soiled and showed her the one on 100 hall. She agreed that it was soiled, and said I will take care of it. On 05/04/26 12:04 PM, the Administrator was cleaning the beverage cart on the 200 hall.

Based on record review and staff interview, the facility failed to ensure a complete and accurate minimum data set (MDS) assessment. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of hospice. Resident Identifier: #20. Facility census: 99. Findings included:a) Resident #20 Review of Resident #20's physician orders showed an order, written on 12/17/25, which showed the resident was receiving hospice services for end-of-life services related to cerebral infarction. The resident's comprehensive care plan showed the resident was receiving hospice services. A hospice communication book located at the nursing desk showed the resident was receiving hospice services. Resident #20's quarterly minimum data set (MDS) assessment, with assessment reference date (ARD) of 03/16/26, did not indicate the resident was receiving hospice services. On 05/05/26 at 11:34 AM, MDS Nurse #52 confirmed the MDS assessment was incorrect and should have indicated the resident was receiving hospice services. No further information was provided through the completion of the survey process.

Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Infection control breaches occurred during medication administration. This was a random opportunity for discovery during the medication administration facility task. Resident identifier: #12 Facility Census: 99 Findings included: a) Resident #12 On 11/19/24 at 8:07 AM medication administration observation with Licensed Practical Nurse (LPN) #65 found an infection control breach. When LPN #65 opened the packet of medications for Resident #12 the three (3) pills spilled out. One (1) pill fell into the bottom opened drawer of the medication cart and two (2) pills landed on the top of the medication cart, off of the barrier that was in place. LPN #65 then retrieved the three (3) pills and placed them in the medication cup to administer to the resident. This was confirmed with the Director of Nursing on 11/19/24 at 8:10 AM.

Based on record review, policy review, and staff interview, the facility failed to develop and implement a Medication Regimen Review (MRR) policy that accurately addressed the time frames for steps in the MRR process. The facility also failed to ensure monthly pharmacy medication reviews were completed by the consulting pharmacist. This was true for four (4) out five (5) residents reviewed for unnecessary medications. Resident identifiers: #6, #20, #90, and #41. Facility census: 97. Findings included: a) Resident #6 A record review, completed on 11/08/22 at 4:23 PM, found there was no Medication Regimen Review (MRR) in the record for the month of August 2022. On 11/09/22 at 9:51 AM, the Administrator stated that the pharmacist had a 37 day window to complete monthly reviews and had completed a MRR on 07/31/22 to compensate for not being in the building the month of August. The Director of Nursing (DON), on 11/09/22 at 10:02 AM, shared the Pharmaceutical Services Policy, with a revision date of 11/28/2017, which stated the consultant pharmacist will perform a formal review of the drug regimen of each patient monthly, at an interval not to exceed 37 days. During an interview, on 11/09/22 at 10:57 AM, the Administrator acknowledged the facility policy did not match the federal guidance which states the consultant pharmacist must complete monthly medication reviews for each resident. The Administrator stated the policy will be updated. b) Resident #20 A record review, completed on 11/09/22 at 8:15 AM, found there was no MMR in the record for the month of August 2022. On 11/09/22 at 9:51 AM, the Administrator stated that the pharmacist had a 37 day window to complete monthly reviews and had completed a MMR on 07/31/22 to compensate for not being in the building the month of August. The Director of Nursing (DON), on 11/09/22 at 10:02 AM, shared the Pharmaceutical Services Policy, with a revision date of 11/28/17, which stated the consultant pharmacist will perform a formal review of the drug regimen of each patient monthly, at an interval not to exceed 37 days. During an interview, on 11/09/22 at 10:57 AM, the Administrator acknowledged the facility policy did not match the federal guidance which states the consultant pharmacist must complete monthly medication reviews for each resident. The Administrator stated the policy will be updated. c) Resident #90 A record review, completed on 11/08/22 at 3:41 PM, found there was no MMR in the record for the month of August 2022. On 11/09/22 at 9:51 AM, the Administrator stated that the pharmacist had a 37 day window to complete monthly reviews and had completed a MMR on 07/31/22 to compensate for not being in the building the month of August. The Director of Nursing (DON), on 11/09/22 at 10:02 AM, shared the Pharmaceutical Services Policy, with a revision date of 11/28/2017, which stated the consultant pharmacist will perform a formal review of the drug regimen of each patient monthly, at an interval not to exceed 37 days. During an interview, on 11/09/22 at 10:57 AM, the Administrator acknowledged the facility policy did not match the federal guidance which states the consultant pharmacist must complete monthly medication reviews for each resident. The Administrator stated the policy will be updated. d) Resident #41 During an unnecessary MRR on 11/09/22 for Resident #41, showed it did not contain the required MRR's completed in the months December 2021, May 2022 and August 2022. During an interview on 11/09/22 at 9:51 AM the Administrator verified the MRRs for December 2021, May 2022 and August 2022 were not completed monthly.

Based on record review and staff interview, the facility failed to implement their Abuse Prohibition policy by failing to report all allegations of neglect to appropriate state agencies as required. Resident #398, #399, #8 and #11 made allegations of neglect at the same time regarding Nurse Aide (NA) #73 nor providing care to them when requested. These allegations of neglect were not reported to the appropriate state agencies as required by the facility's policy. This was true for four (4) of five (5) residents reviewed for the care area of abuse during the long term care survey process. Resident identifiers: #398, #399, #8, and #11. Facility census: 97. Findings included: a) Grievance/Complaint Form dated 05/23/22 A review of the Grievance/Complaint form dated 05/23/22 which read, Each resident was interviewed separately by social services . After interviews were complete, the complaints are as followed: -- Residents expressed concern with Ms. (Last name of Nurse Aide #73) customer service. They residents feel she is rude with the. She does not complete her duties in a timely manner. Ex: She will come in room, turn off call light and say, I'll be back and doesn't come back to provide the care or waits 30 plus minutes. -- Residents say they can hear her in the hall joking, laughing, and talking instead of helping them. -- Residents feel that Ms. (Last name of NA #73) does not listen to their needs or concerns to provide proper care. -- Residents feel they are not being cleaned properly. The complaint grievance form identified the residents voicing this concern as Resident #399, Resident #398, Resident #8 and Resident #11. An interview with the Nursing Home Administrator (NHA) on 11/08/22 at 2:19 PM confirmed these allegations of neglect were not reported. She indicated they felt it was more of a customer service issue and not neglect, but she did agree if the NA was not not providing care and turning of the call light and not coming back to provide the care that would be neglect. b) Policy Review A review of the facility's policy titled Freedom form Abuse, Neglect, and Exploitation with an effective date of 07/19/21 found the following in regards to reporting of alleged neglect, .e. The facility will report allegation of abuse, neglect, exploitation, events resulting in serious bodily harm, or misappropriation of resident property in accordance with state and federal requirements.

Based on record review and staff interview, the facility failed to report all allegations of neglect to appropriate state agencies as required. Resident #398, #399, #8 and #11 made allegations of neglect at the same time regarding Nurse Aide (NA) #73 not providing care to them when requested. These allegations of neglect were not reported to the appropriate state agencies as required. In addition, an incident of resident to resident altercation involving Resident #81 abuse was not reported to appropriate state agencies as required. This was true for five (5) of five (5) residents reviewed for the care area of abuse during the long term care survey process. Resident Identifiers: #398, #399, #8, #11 and #81. Facility Census: 97. Findings Included: a) Grievance/Complaint Form dated 05/23/22 A review of the Grievance/Complaint form dated 05/23/22 which read, Each resident was interviewed separately by social services . After interviews were complete, the complaints are as followed: -- Residents expressed concerns with Ms. (Last name of Nurse Aide #73) customer service. The residents feel she is rude with them. She does not complete her duties in a timely manner. Ex: She will come in room, turn off call light and say, I'll be back and doesn't come back to provide the care or waits 30 plus minutes. -- Residents say they can hear her in the hall joking, laughing, and talking instead of helping them. -- Residents feel that Ms. (Last name of NA #73) does not listen to their needs or concerns to provide proper care. -- Residents feel they are not being cleaned properly. The complaint grievance form identified the residents voicing this concern as Resident #399, Resident #398, Resident #8 and Resident #11. An interview with the Nursing Home Administrator on 11/08/22 at 2:19 PM confirmed these allegations of neglect were not reported. She indicated they felt it was more of a customer service issue and not neglect, but she did agree if the NA was not not providing care and turning off the call light and not coming back to provide the care that would be neglect. b) Resident #81 On 11/07/22 at 3:58 PM in an interview with Resident #81, Resident #81 reported that she was recently hit by a male resident with his fist causing the resident to fall and hit her head and shoulder. Resident #81 stated she was going to be singing for an activity in the dining room and she asked the other resident to turn the television down for this event and he in turn punched her. Resident #81 gestured by physically showing the staff how the other resident punched her in the center area of her chest. Resident #81 refused to go to the emergency room after being evaluated by the nursing staff. Based on record review on 11/08/22 at 11:04 AM, Licensed Practical Nurse (LPN) #19 documented on 9/23/22, It was brought to my attention that the resident was hit by a resident from hall 4. When this nurse entered the dining room, staff was helping resident to a chair. When assessing the resident I noticed slight redness to the back of residents head and left shoulder. When asking the resident what happened she stated that boy hit me and made me fall down and I hit my head on a chair. During an interview with the Nursing Home Administrator (NHA) on 11/08/22 at 3:30 PM, all evidence related to this incident was requested from the NHA. The evidence received included staff progress notes, neurological checks and incident report. No evidence related to a reportable event was provided. The NHA stated that they did not believe this event was a reportable as they believed the male resident put his hand up and that Resident #81 accidentally walked into his hand causing her to fall backwards. Based on record review on 11/08/22 at 4:40 PM, the Nurse Practitioner (insert name) on 10/03/22, documented Resident reports she was struck in the chest by another resident with his fist which caused her to fall backwards and she hit her head on a chair. Based on medical record review on 11/09/22 at 8:10 AM, Registered Nurse (RN) #97 documented in a Care Plan Review patient reports that she was struck in the chest by a male resident and this caused her to fall hitting her head on a chair in addition to hitting her left shoulder and left hip. On 11/09/22 at 1:01 PM an interview was held with the NHA. The NHA was advised that all documentation provided states Resident #81 was either struck or hit by the other resident not that Resident #81 ran into the other resident's hand. The NHA was notified that if any additional records were available to provide additional support of the facility investigating this event and their determination that it again would be accepted. No additional documentation was provided prior to exiting the facility. 47119

Based on staff interview, resident interview, and record review, the facility failed to ensure facility staff, responsible for presenting the binding arbitration agreements to residents/responsible parties could explain the nature and implications of the proposed binding arbitration agreement to inform their decision on whether or not to enter into such agreements. This had the potential to affect more than a limited number of residents at the facility. Resident identifiers: #87, #248, #2. Facility census: 97. Findings included: a) Resident Council meeting At 1:30 PM on 11/08/22, the resident council meeting was held. The question was asked of the members attending: Did the facility ask you or any residents you know to enter into a binding agreement to resolve disputes? The Resident Council President shook his head, indicating the answer was yes. The facility Social Worker (SW) #50, was in attendance at the meeting. The residents granted permission for SW #50 to attend the meeting. SW #50 was asked if the facility used arbitration agreements. The response was I don't think we have any right now. Review of the entrance conference worksheet on the morning of 11/09/22 found the facility does offer arbitration agreements and the facility staff member responsible for the arbitration agreements was listed as SW #50. Further review of the entrance admission forms found Residents #87, #248, and #2 were listed by the facility as having signed an arbitration agreement. At approximately 8:56 AM on 11/09/22, Resident #2 said she did not remember signing an arbitration agreement. She stated that she could have signed it, but she doesn't remember anything about it. Resident #2 said she did not know what an arbitration agreement means. Review of the arbitration agreement found Resident #2 signed the agreement with SW #50 listed as the facility representative on 01/25/22. On 01/24/22 Resident #2 was deemed by the physician to have capacity to make decisions. At approximately 9:00 AM on 11/09/22, Resident #248 stated she did not know what a arbitration agreement was, and if she signed it she has no memory. Resident #248 said she didn't understand what an arbitration agreement is. Review of the arbitration agreement found Resident #248 signed the agreement on 10/27/22 with SW #50 listed as the facility representative. On 11/01/22 the resident was deemed to have capacity to make decisions by the physician. At 9:09 AM on 11/09/22, SW #50 was interviewed regarding the arbitration agreement as she was identified as the staff member responsible for presenting the arbitration agreements. SW #50 was asked to explain the arbitration agreement and what she tells the residents about the agreement. She stated, We discuss falls with them. SW #50 was asked, what does falls have to do with an arbitration agreement? SW #50 stated, I discuss their rights that they can seek legal advise if they need to. I can assist them with legal counsel. When asked if residents need to sign the arbitration agreement to be admitted , SW #50 said, yes, residents with capacity sign their own. SW #50 stated before they decide to go that route we can pull together as a team. I think with arbitration you need to have that conversation. I think there is a difference in suing somebody and just talking about what's wrong, as a team you get together. When asked if she could tell the surveyor the key points of an arbitration agreement, she said she would have to look at the agreement again because she has only been here 1 and 1/2 years. The surveyor provided a copy of the arbitration agreement to SW #50. SW #50 said the first step is allowing getting together. Later in the conversation, SW #50 said residents can refuse to sign the agreement, but she has to fill out a paper if the resident or the responsible party refuses. On 11/09/22 at 9:43 AM, Resident #87 said she could have signed the arbitration agreement but she doesn't remember. When asked if she could explain an arbitration agreement, she replied, the word arbitration sounds like, some sort of case that needs reviewed. Review of the arbitration agreement found Resident #87 signed the agreement on 01/06/22 with facility representative #50. On 01/07/22 the resident was deemed by the physician to have capacity to make decisions. On 11/09/22 at 10:18 AM, the administrator said, SW #50 was very upset and was crying after the interview with the surveyor, so SW #50 may not have understood the questions, I will make sure she is in-serviced.

Based on record review, and staff interview, the facility failed to ensure 2 of 22 residents reviewed had a person-centered comprehensive care plan developed for Resident #89's wandering and Resident #41's positioning / comfort device. Resident identifiers: #89 and #41. Facility census: 97. Findings included: a) #89 An observation on 11/07/22 at 11:30 AM revealed Resident #89 wandering on the 400 hall. A second observation on 11/07/22 at 1:15 PM found resident #89 continuing to wander on the 400 hall. A review of Resident #89's medical record showed it did not contain a care plan for wandering. Further review revealed the Quarterly Minimum Data Set (MDS) assessment for Resident #89, with an Assessment Reference Date (ARD) of 09/01/22, Resident #89 was assessed No for Wandering. On 11/08/22 at 2:11 PM, during an interview Registered Nurse #7 (RN), verified Resident #89 does wander. She confirmed Resident #89 did not have a care plan for wandering and Wandering was missed on the Quarterly MDS Assessment. b) #41 An observation and interview on 11/07/22 at 2:24 PM revealed a right arm positioning device on Resident #41's wheelchair. Resident #41 verified that she was unable to move her right arm. A review of resident #41's Medical Record on 11/08/22 found a diagnosis for Right Side Hemiplegia and Limited ROM. Continued review showed it did not contain a physician order or a comprehensive care plan for positioning devices. During an Interview on 11/09/22 at 9:15 AM the Administrator stated that the positioning device is used for her comfort. She verified there was no Physician's order or care plan developed for her right side hemiplegia positioning / comfort device.

Based on observation, record review, and staff interview, the facility failed to ensure one (1) of one (1) residents reviewed for the care area of skin conditions, non pressure had the care plan updated for treatment of a diabetic ulcer. Resident identifier: #73. Facility census: 97. Findings included: a) Resident #73 Review of the resident's medical record found the resident has a diabetic ulcer on the bottom of the right foot. Review of the care plan found a focus: Diabetic ulcer r/t (related to) diabetes, vascular insufficiency. The goal associated with the focus: Will have no complications related to ulcer through review date and ulcer will improve by review. A current intervention included: Diabetic shoes with insoles as ordered. The intervention was initiated on 10/05/22 and revised on 06/27/22. On 11/08/22 at 3:08 PM, the resident was observed to be in the dining room wearing a plastic shoe with the back open. When asked about diabetic shoes, the resident said, I don't have any. Staff members #111 and #70, the Registered Nurse Minimum Data Set Coordinators were present during the interview. Employees #111 and #70 searched the resident's room with permission and no diabetic shoes were located. At approximately 4:15 PM on 11/09/22, the Administrator said the diabetic shoes had been discontinued by the physician.

Based on observation and interview, the facility failed to ensure medications and biological's used in the facility were stored and labeled in accordance with currently accepted professional principles. Multiple medications stored in the medication room refrigerators were unlabeled and undated. This practice had the potential to affect a limited number of residents. Facility census: 97. Findings included: a) Medication Room An observation of the facility's Medication Room Refrigerator, on 11/09/22 at 8:17 AM, revealed a refrigerator containing one (1) open container 10 dose Influenza Vaccine High Dose Prefilled Syringes with four (4) remaining, not dated or labeled when opened. Continued observation revealed three (3) bottles of Zinc 50 MG, with a use by date 10/22. An interview with the Administrator on 11/09/22 at 8:18 AM, verified the Influenza Vaccine High Dose Prefilled Syringes was not labeled or dated when opened and the Zinc was outdated.

Based on observation, staff interview and record review, the facility failed to ensure a medicaid resident who was in need of routine and/or emergency dental care received needed care as soon as possible. Resident #93 returned from a dental appointment on 11/02/22 and returned with recommendations for teeth extractions, fillings and fittings for a top denture and lower partial. On 11/09/22 the facility confirmed they had not begun the process of setting up this recommended dental work. This was true for one (1) of one (1) residents reviewed for dental. Resident identifier: #93. Facility census: #97. Findings included: a) Resident #93 An observation of Resident #93 on 11/07/22 at 12:02 pm found the resident had missing teeth on the top and lower gums. Her remaining teeth were discolored and did not appear to be in good repair. A review of Resident #93's medical record found a dental consult dated 10/03/22. The consult indicated the resident was sent to the dentist related to a toothache. The recommendations sent back with the resident were for the resident to schedule a cleaning due to the patient having excessive plaque. The facility staff made this appointment and the resident returned to the dentist on 11/02/22 and returned to facility with the following recommendations, advised to have top two (2) teeth extracted and top denture. extraction and 2 fillings on lower with partial denture. Further review of the medical record on 11/08/22 found no indication the residents appointment for the recommendations made 11/02/22 had been scheduled or set into motion. An interview with the Medical Record Clerk (MRC) #81 on 11/09/22 at 10:37 AM, confirmed Resident #93's appointment for extractions has not been made. She stated that she typically is the one who makes the appointments but she did not get these recommendations. MRC #81 had not made the appointment yet for Resident #93 to get her teeth extracted because she had no knowledge of the need for the appointment. An interview with the Nursing Home Administrator at 1:26 pm on 11/09/22, confirmed the appointment had not been made prior to surveyor intervention. She stated the MRC #81 was not the only one who could have made the appointment but no one actually made the appointment.

Based on observation, facility documentation review, and staff interview, the facility failed to provide food services in accordance with professional standards. The facility failed to ensure food were dated to indicate when opened. The facility also failed to ensure temperatures for the walk-in freezer were consistently recorded. The practice had the potential to affect a limited number of residents. Facility census: 97. Findings included: a) Undated Food and Incomplete Temperature Log During a tour of the kitchen with the Dietary Manager, on 11/07/22 at 11:00 AM, a 25 lb. bag of Panko bread crumbs was opened but not dated. Approximately half of the bag had been used. Additionally, the temperature log for the for walk-in fridge was incomplete for the following dates: -11/05/22 -11/06/22 -11/07/22 The Dietary Manager acknowledged the facility failed to follow protocol when food was opened but not dated and when the facility failed to complete the temperature log for the walk-in fridge on a daily basis.

Based on observation and staff interview, the facility failed to maintain current food handler cards as required by County law for one (1) of ten (10) employees reviewed in the Dietary Department. This practice had the potential to affect a limited number of residents who receive their nutrients from the kitchen. Facility census: 97. Findings included: a) Food Handlers Cards During a record review on 11/08/22 at 11:20 AM, it was determined that Dietary Services Assistant #11 did not have an active food handlers card on file. The Dietary Manager stated he believed new staff had 90 days from hire to obtain certification. Further review from the [NAME] County Health Department's website, https://www.statefoodsafety.com/food-handler/west-virginia/[NAME]-county, determined all food service personnel should obtain their food handlers cards within 30 days of hire. Dietary Services Assistant #11's first day of employment was 09/07/22. On 11/08/22 at 1:45 PM, the Dietary Manager acknowledged the within 30 days of hire requirement had not been met for Dietary Services Assistant #11.

Based on record review and staff interview, the facility failed to maintain an accurate medical record for two (2) of 21 sample residents reviewed during the Long-Term Care Survey process. The facility failed to ensure Physician Orders for Scope of Treatment (POST) forms were legally valid. Resident identifiers: #90 and #248. Facility census: 97. Findings included: a) Resident # 90 A record review, on 11/07/22 at 2:23 PM, revealed a POST form in Resident #90's electronic medical record. The POST form was dated 07/13/22. Section F of the POST form, entitled Signature: Health Care Provider, was undated, no telephone number was provided, and no physician license number was provided. The directions for completing the POST form, compiled by the West Virginia Center for End of Life, state, The health care provider completing this form (MD, DO, APRN, or PA) must print their name, sign, and date this section for the form to be legally valid. Failure to print their name or provide a license number may result in the WV e-Directive Registry being unable to verify the provider's information, thus preventing the form from being available through the Registry. Failure to provide a contact number may result in the inability to contact the provider regarding any errors in the form completion that need to be addressed. During an interview, on 11/08/22 at 12:07 PM, the Administrator acknowledged the POST form was not completed according to guidance. b) Resident #248 A record review, completed on 11/07/22 at 3:30 PM, revealed a POST form in Resident #248's electronic medical record. The POST form was dated 10/27/2022. Section F of the POST form, entitled Signature: Health Care Provider, was undated, no telephone number was provided, and no physician license number was provided. The directions for completing the POST form, compiled by the West Virginia Center for End of Life, state, The health care provider completing this form (MD, DO, APRN, or PA) must print their name, sign, and date this section for the form to be legally valid. Failure to print their name or provide a license number may result in the WV e-Directive Registry being unable to verify the provider's information, thus preventing the form from being available through the Registry. Failure to provide a contact number may result in the inability to contact the provider regarding any errors in the form completion that need to be addressed. During an interview, on 11/08/22 at 12:07 PM, the Administrator acknowledged the POST form was not completed according to guidance.

Based on facility documentation and staff interview, the facility failed to maintain documentation related to current students training in the facility for COVID-19 vaccination for eight (8) of eight (8) nurse aide and nursing students reviewed for compliance with Covid -19 vaccinations. Facility Census: 97 Findings included: a) COVID-19 Vaccination Documentation Facility documentation review of the facility's Infection control practices found the facility was unable to provide the required student's Covid-19 documentation for vaccinations. During an interview on 11/09/22 at 12:30 PM, Registered Nurse #8 stated that the facility did not have Covid -19 vaccination documentation for the students training in the facility. She stated that the facility failed to get the documentation.

Based on record review, and staff interview, the facility failed to accurately complete section E (Wandering) of the MDS. This is true for one (1) of (22) medical records reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: 89. Facility census: 97. Findings included: a) Resident #89 An observation on 11/07/22 at 11:30 AM revealed Resident #89 wandering on the 400 Hall. A second observation on 11/07/22 at 1:15 PM found resident #89 continuing to wander on the 400 Hall. A review of Resident #89's medical record showed it did not contain a care plan for wandering. Further review revealed the Quarterly Minimum Data Set (MDS) assessment for Resident #89, with an Assessment Reference Date (ARD) of 09/01/22, Resident #89 was assessed No for Wandering. On 11/08/22 at 2:11 PM, during an interview Registered Nurse #7 (RN), verified Resident #89 does wander. She confirmed Resident #89 did not have a care plan for wandering and Wandering was missed on the Quarterly MDS Assessment. No further information was provided prior to the end of the survey on 11/09/22 at 4:30 PM

Based on medical record review and interview, the facility failed to ensure treatment and care in accordance with professional standards of practice for two (2) of five (5) residents reviewed for unnecessary medications. Laboratory orders were not followed for Resident #17 and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: #17 and #32 Facility census: 94. Findings included: a) Resident #17 A medical record review on 07/27/2, revealed the physician managing the [CONDITION(S)] medications for Resident #17 on 05/25/21 had requested specific laboratory orders for a [MEDICATION(S)] level to be completed twelve (12) hours from the last dose of [MEDICATION(S)] received. Further review of the Medication Audit for 06/03/21 indicated Resident #17 had received a dose of [MEDICATION(S)] at 8:19 AM. Laboratory results for a [MEDICATION(S)] level indicated it was collected on 06/03/21 at 9:34 AM. This failed practice did not allow for the [MEDICATION(S)] level to be completed twelve (12) hours after the last dose of [MEDICATION(S)] received. In an interview with the Director of Nursing (DON) on 07/27/21 at 11:05 AM, the DON verified the order for lab work had not been followed for a [MEDICATION(S)] level to be completed twelve (12) hours after the last dose of [MEDICATION(S)] received. b) Resident #32 A review of the medical record on 07/28/21, revealed Resident #32 had a order for [MEDICATION(S)] 12.5 milligrams (mg) two times a day related to hypertension and hold for systolic blood pressure less than 100. An interview with the Director of Nursing (DON) on 07/28/21 at 8:30 AM, verified the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was unable to provide any blood pressure results for 07/01/2 to 07/03/21, 07/09/21 to 07/10/21 and 07/12/21 to 07/21/21.

Based on record review and staff interview, the facility failed to ensure residents were free from unnecessary non-[CONDITION(S)] medication. This failed practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #82. Facility census: 94. Findings included: a) Resident #82 Review of Resident #82's medical records showed the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Medication Administration Review (MAR) for July 2021 revealed the resident's heart rate was below 60 on the following dates and times: - 07/01/21 at 9:00 PM; heart rate 55 - 07/02/21 at 9:00 PM; heart rate 58 - 07/04/21 at 9:00 PM; heart rate 54 - 07/05/21 at 9:00 PM; heart rate 59 - 07/09/21 at 9:00 PM; heart rate 59 - 07/10/21 at 9:00 PM; heart rate 59 - 07/11/21 at 9:00 PM; heart rate 50 - 07/12/21 at 9:00 PM; heart rate 52 - 07/13/21 at 9:00 AM; heart rate 58 - 07/13/21 at 9:00 PM; heart rate 53 - 07/14/21 at 9:00 AM; heart rate 58 - 07/15/21 at 9:00 AM; heart rate 57 - 07/15/21 at 9:00 PM; heart rate 57 - 07/16/21 at 9:00 AM; heart rate 55 - 07/16/21 at 9:00 PM; heart rate 53 - 07/17/21 at 9:00 AM; heart rate 57 - 07/19/21 at 9:00 PM; heart rate 52 - 07/20/21 at 9:00 AM; heart rate 56 - 07/21/21 at 9:00 AM; heart rate 54 - 07/22/21 at 9:00 PM; heart rate 53 - 07/23/21 at 9:00 AM; heart rate 50 - 07/24/21 at 9:00 AM; heart rate 57 - 07/24/21 at 9:00 PM; heart rate 57 On each of these occasions, the nurse had documented a check mark on the MAR to indicate the medication had been given. During an interview on 07/27/21 at 09:50 AM, Nursing Coordinator ##2 stated that a code of 10 would have been documented on the MAR if the medication had been held. During an interview on 07/27/21 at 10:15 AM, the Director of Nursing confirmed the physician-ordered parameters for Resident #82's [MEDICATION(S)] had not been followed. No further information was provided through the completion of the survey.

Based on record review and interview, the facility failed to ensure complete and accurate documentation in the area of pain assessment. This failed practice had the potential to affect one (1) of five (5) residents reviewed for the area of unnecessary medications. Resident identifier: #82. Facility census: 94. Findings included: a) Resident #82 Resident #82 was interviewed at 07/26/21 at 1:00 PM. During the interview, the resident denied pain. Review of Resident #82's medical records revealed an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #82's Medication Administration Record (MAR) revealed check marks had been documented by nurses every day shift and night shift to indicate pain assessment had been performed. However, the resident's pain level was not recorded on the MAR nor in the nursing progress notes. There was no spaces on the MAR for the pain level to be recorded. During an interview on 07/27/21 at 3:01 PM, the Director of Nursing (DON) stated she did not believe Resident #82 was having pain because the quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 07/12/21 indicated the resident had no pain. Additionally, the resident had a standing order for Tylenol as needed for pain but had not required the medication. Also, the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the DON confirmed the resident's pain level was not documented during the twice daily assessment. She stated she would have additional lines added to Resident #82's MAR to make areas for the pain level to be documented. No further information was provided through the completion of the survey process.

Based on medical record review and interview, the facility failed to provide notice of transfer to the State Ombudsman for one (1) or two (2) residents reviewed for hospital discharges. This had the potential to affect any residents being transferred/discharged to an acute hospital. Resident identifier: #32. Facility census: 94. Findings included: a) Resident #32 During a medical record review on 07/28/2, it was discovered the facility had failed to provide three (3) notice of transfers to the State Ombudsman for acute hospital transfers on 05/09/21, 05/14/21 and 05/24/21 for Resident #32. In an interview with the Social Services Supervisor (SSS) on 07/28/21 at 9:12 AM, the SSS was unable to locate any notifications sent to the State Ombudsman regarding the hospital discharges for Resident #32 on 05/09/19, 05/14/21 and 05/24/21.

Based on water temperature measurements, observations, staff interview, and review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), the facility failed to ensure the resident environment, over which it had control, was as free from accident hazards as possible. At 3:10 p.m. on 09/15/14, a water temperature measurement of the water at the hand sink in Room 402 was obtained by facility staff using facility equipment. The water was 131.8 degrees Fahrenheit (F). According to CMS Guidance to Surveyors, a 3rd degree burn can occur in 15 seconds when the water temperature is 133 degrees F. This discovery was determined an immediate jeopardy (IJ) situation, with the potential to affect more than an isolated number of residents. At 4:18 p.m. on 09/15/14, the Nursing Home Administrator (NHA) was notified of the IJ, and that it was due to the elevated water temperature. The NHA was informed the IJ began at 3:10 p.m. on 09/15/14, when a water temperature of 131.8 degrees F was obtained in resident Room 402. During an interview with the NHA, after notification of the IJ, she stated the maintenance department was making adjustments and the temperatures should already be below 120 degrees F. The water temperature in Room 402 was obtained, at 4:22 p.m. on 09/15/14, by facility staff using the facility's thermometer. The temperature of the water in the hand sink in Room 402 was even higher. It was 135 degrees F. The NHA was notified the temperature was hotter than before and would be included in the determination of the IJ. The facility's plan of correction (POC) was accepted by the state agency at 5:30 p.m. on 09/15/14. The facility submitted the following plan to remove the immediacy of the deficient practice: (typed as written) "4:20 p.m. All employees working were inserviced to immediately inform the Administrator, DON (Director of Nursing) and/or the maintenance director if water is hot when washing hands. 4:30 (pm) Staff was instructed to do no baths in shower room until further notice. 4:35 (pm) All of the hot water valves in the resident areas were turned off until maintenance can verify a safe temp. (temperature). 4:50 (pm) It will be the goal of the facility to maintain a safe temperature of 110 (degrees Fahrenheit) in resident areas. 5:20 (pm) The day shift charge nurse will educate the oncoming shift of the water temperature issue and that the employees must use the warm water in the utility rooms to provide incontinence care to the residents." The hot water to all resident areas was observed to be turned off at 6:05 p.m. on 09/15/14; therefore, the immediacy of this deficient practice was abated at 6:05 p.m. on 09/15/14. A deficient practice in the area of accident hazards still existed, so the scope and severity was decreased from a "K" to an "E". Other accident hazards were also identified during the survey. Razors were left in an unsecured area which was accessible to residents. A can of disinfecting spray was also found in an unlocked shower room where residents had access. These practices also had the potential to affect more than an isolated number of residents. Facility census: 98. Findings Include: a) Water temperatures 1. During stage 1 of the Quality Indicator Survey the following water temperatures were obtained on 09/15/14 in resident hand sinks. The temperatures were obtained by the facility's maintenance staff using their thermometer: -- Room 402 at 4:22 p.m. the water temperature was 135.0 degrees F. -- Room 402 at 3:10 p.m. the water temperature was 131.8 degrees F. -- Room 204 at 3:04 p.m. the water temperature was 130.3 degrees F. -- Room 212 at 3:01 p.m. the water temperature was 129.8 degrees F. -- Shower room on 200 hall at 3:06 p.m. the water temperature was 129.7 degrees F. -- Shower room on 400 hall at 3:15 p.m. the water temperature was 128.6 degrees F. -- Room 105 at 3:23 p.m. the water temperature was 121.5 degrees F. -- Room 113 at 3:25 p.m. the water temperature was 121.3 degrees F. -- Room 404 at 3:13 p.m. the water temperature was 120.8 degree F. 2. According to Table 1 in the Guidance to Surveyors related to comfortable/safe water temperatures, found in Appendix PP of the CMS State Operations Manual, a third (3rd) degree burn can occur at 120 degrees F with an exposure time of five (5) minutes, at 124 degrees F with an exposure time of three (3) minutes, at 127 degrees F with an exposure time of one (1) minute, at 133 degrees F with an exposure time of 15 seconds, and at 140 degrees F with an exposure time of 5 seconds, noting that burns can occur even at water temperatures below that level depending on the exposed individual's condition and the length of exposure. 3. Review of the facility's "Weekly Check Form" for the previous three (3) months, at 5:00 p.m. on 09/15/14, revealed the following notable water temperatures: -- On 09/09/14 hall 4 sink water temperature was 125.3 degree F and Room 406 water temperature was 124.1 degrees F. -- On 08/28/14 hall 2 sink water temperature was 123.6 degrees F. -- On 08/18/14 hall 2 shower room water temperature was 120.8 degrees F and hall 4 sink water temperature was 120.7 degrees F. -- On 08/14/14 hall 2 sink water temperature was 121.4 degrees F and water temperature in room 204 was 124.3 degrees . -- On 08/05/14 hall 2 sink water temperature was 126.9 degrees F, water temperature in room 204 was 125.3 degrees F, and water temperature in the shower room was 121.2 degrees F. -- On 07/30/14 hall 2 sink water temperature was 123.8 degrees F. -- On 07/17/14 hall 2 sink water temperature was 119.9 degrees F, and unidentified room on 200 hall had a water temperature of 120.2 degrees F, and room 407 had a water temperature of 120.8 degrees F. -- On 07/08/14 the water temperature in the 200 hall shower room was 123.5 degrees F, the temperature in the hall 2 sink was 126.4 degrees F, the water temperature in room 205 was 120.3 degrees, and the water temperature in the hall 4 sink was 123.4 degrees F. -- On 07/01/14 the water temperature in hall 2 shower room was 112.7 degrees F, the water temperature in hall 2 sink was 131 degrees F, the water temperature in room 202 was 128.8 degrees F. The facility had hot water temperatures in excess of 120 degrees F weekly since 07/01/14. At 5:15 p.m. on 09/15/14, when the Environment Plant Operations Supervisor (EPOS) was asked why the water temperature was running so high, he stated, "I don't really have a range to go by when regulating the temperatures." He indicated he would like to keep the temperatures below 120 degrees F. He stated sometimes nursing will ask him to "bump it up" a few degrees because residents were complaining the water was too cold. He confirmed that 131.8 degrees F and 135 degrees F was "way too hot" and the hot water should not have been at that temperature. On 09/18/14 at 10:15 a.m., the EPOS was asked about the purpose of the temperature ranges noted on the "Weekly Check Form." He stated, "That is the range for the water temperatures. It is right there on the form." He confirmed the water temperatures should be maintained between 100 degrees F and 110 degrees F, as indicated on the weekly check form. The EPOS stated he knew the range was indicated on the form, but he was "playing dumb" when previously asked at what range the water temperatures should be maintained. . . b) 200 Hall shower room During the initial tour of the facility, on 09/15/14 at 9:06 a.m., the 200 Hall was observed with a room labeled "shower room." The door was observed propped open and no one was in the room. One (1) spray can of surface citrus fragrance disinfectant cleanser and five (5) new razors were on a plastic storage cabinet. Employee #74, registered nurse- treatment nurse (RN-TN), was present. She was asked if the razors and surface disinfectant cleanser were allowed to be lying in an opened and unattended shower room. RN #74 stated, "No, the disinfectant is to be locked in this cabinet here." The cabinet key was in the key hole, but the cabinet was not locked. She stated razors were stored in the nursing department, and employees were to go there to get razors when needed. RN #74 confirmed they should not be left on the plastic storage cabinet. According to the material safety data sheet (MSDS), the surface citrus fragrance disinfectant cleanser hazardous identification routes were dermal, eye, and inhalation. The MSDS sheet revealed that prolonged exposure or repeated contact may dry skin and cause irritation. It indicated liquid in the eye may cause irritation with possible damage if not rinsed immediately. The MSDS also noted to avoid breathing vapors or spray mists, as over-exposure by inhalation may cause respiratory irritation. The information also noted the disinfectant can cause central nervous system depression, and it may be harmful if swallowed. .

Based on observation, medical record review, staff interview, review of facility policies, and review of information published by the Centers for Disease Control and Prevention (CDC), the facility failed to implement an infection control program effective in preventing the development and/or transmission of infections. This deficient practice affected three (3) of five (5) sampled residents. The facility caused harm to Resident #50, who was totally dependent on staff for all activities of daily living secondary to quadriplegia, by placing this compromised resident in a room with another resident (#2) who was being actively treated for [REDACTED]. Resident #50 subsequently developed a urinary tract infection with VRE as the infectious organism. The facility failed to appropriately cohort residents with multi-drug resistant organisms (MDRO), failed to assure the admissions coordinator was provided with information concerning residents with MDROs to assure compromised residents were not admitted into rooms occupied by residents with active or colonized infections, failed to assure licensed nurses utilized sanitary techniques while administering glucose testing, and failed to ensure direct care staff washed their hands prior to exiting an isolation room. These practices placed all residents at risk for more than minimal harm. Resident identifiers: #50, #24, and #26. Facility census: 96. Findings include: a) Resident #50 1. During the initial tour of this facility on 03/15/11 at 1:00 p.m., observation found Residents #2 and #50 were roommates in a semiprivate room. Observation noted an empty container of the intravenous (IV) antibiotic Invantz hanging from an IV pole next to Resident #50's bed. Further observation found Resident #50 had a recent tracheostomy (covered with a dressing) and a gastrostomy tube. - 2. Review of Resident #50's medical record revealed this [AGE] year old female was readmitted to the facility (into a semi-private room already occupied by Resident #2) on 02/16/11, following an acute hospital stay. According to her re-admission minimum data set (MDS) with an assessment reference date (ARD) of 02/21/11, Resident #50 did not have an infection with an MDRO and did not have a urinary tract infection (UTI) at the time of her readmission to the facility. In this MDS, the assessor also noted the resident had quadriplegia and was totally dependent upon staff for toilet use and personal hygiene. - 3. Review of Resident #2's medical record found a laboratory report, dated 02/18/11, documenting that Resident #2 had VRE in her urine. She was treated with [MEDICATION NAME]. Review of her physician orders [REDACTED]. Review of Resident #2's assessment information on her discharge record of 02/11/11, she was always incontinent of bladder and bowel and, like Resident #50, was totally dependent on staff for toilet use and personal hygiene. - 4. Review of Resident #50's medical record revealed that, after her return to the nursing home (at which time she was placed in the room already occupied by Resident #2), she tested positive for VRE in her urine on 02/26/11. - 5. According to the CDC: "VRE is often passed from person to person by the contaminated hands of caregivers. VRE can get onto a caregiver's hands after they have contact with other people with VRE or after contact with contaminated surfaces. VRE can also be spread directly to people after they touch surfaces that are contaminated with VRE. VRE is not spread through the air by coughing or sneezing." (URL: http://www.cdc.gov/HAI/organisms/vre/vre.html) - 6. In an interview with the infection control nurse (Employee #21) and the director of nursing (DON) on 03/16/11 at 12:00 p.m., Employee #21 stated that, when she returned to the facility on Monday 02/28/11, she noted Resident #2 had not been properly placed on contact isolation, and she obtained a physician's orders [REDACTED]. Both employees agreed the facility's policy on cohorting had not been followed when Resident #50 was allowed to remain in the room with Resident #2 following the [DIAGNOSES REDACTED]. Neither the DON nor the infection control nurse could provide evidence that Resident #50 had any history of VRE prior to this infection. - 7. Review of the facility's infection control policy (effective 8/2000) found the policy only addressed one (1) MDRO - Methicillin-resistant Staphylococcus aureus (MRSA). The policy had not been updated since August 2000 to include other MDROs, such as VRE. Both VRE and MRSA are considered MDROs requiring the implementation of transmission-based precautions. The policy contained the following language: "2. If isolation or cohorting is not possible, residents who are colonized with MRSA... can be placed in a semiprivate room with a non-MRSA affected resident who is at low risk for developing infection. To be considered low risk the roommate: ... f) Should not have invasive devices such as tracheostomy tubes, gastrostomy tubes..." - 8. An interview with a licensed practical nurse (LPN - Employee #100), on 03/16/11 at 12:00 p.m., elicited that she was the full time admissions coordinator who handled all admissions within the facility. She stated she worked Monday through Friday from 9:00 a.m. to 5:30 p.m. She expressed confusion concerning residents who were colonized with MDROs. She stated she was unaware that compromised residents could not be placed in the same room as residents with colonized MRSA, VRE, etc. She stated she thought only residents who were actively being treated for [REDACTED]. She also stated she was not provided a list of residents with a history of MDRO colonization. -- b) Residents #24, #50, and #26 1. A licensed practical nurse (LPN - Employee #66) was observed while administering a fingerstick and glucometer check to Resident #24 on the afternoon of 03/17/11. She prepared supplies for the procedure at her medication cart in the resident hallway. Without washing her hands, she procured gloves from a box on her medication cart and carried the supplies into the resident's room. She put on the gloves she had contaminated with her unwashed / unsanitized hands, cleaned the resident's finger with alcohol, and then stuck the resident's finger with a lancet. After obtaining the reading of 331 mg/dl, she cleaned the glucometer with alcohol, disposed of the lancet, removed her gloves, and then exited the room without washing her hands. Employee #66 returned to her cart and drew up the appropriate amount of insulin. She then noticed that Resident #24 was not in his room. She placed the insulin syringe in her med cart and walked up the hallway to retrieve the resident. She pushed the resident in his wheelchair into his room and returned to the medication cart. She was observed to remove her keys from her uniform pocket, touch her glasses, touch the cart, and remove the insulin syringe and alcohol pads from her cart. She was noted to repeatedly touch her hair to place it behind her ears. Without washing her hands, she procured gloves from a box on the medication cart and carried the supplies into the resident's room. Without washing her hands, she put on the contaminated gloves, cleaned the resident's left upper arm with alcohol, and administered the insulin. She disposed of the syringe, removed her gloves, and without washing her hands, exited the room and returned to her cart. - 2. Without washing her hands, Employee #66 then assembled supplies to perform a fingerstick on Resident #50 (recently treated for [REDACTED]. Without washing her hands, she put on gloves, cleaned the resident's finger with alcohol, and performed the fingerstick and glucometer test. She disposed of the lancet, removed her gloves, and without washing her hands, exited the room and returned to her cart. She then drew up the appropriate amount of insulin with her bare hands, placed the syringe on the top of the cart, and returned the insulin to her cart. She was again observed to repeatedly touch her hair and glasses. Without washing her hands, she obtained gloves from a box on the cart and carried the supplies to the resident's room. She placed the syringe on the overbed table without a clean field, donned her contaminated gloves, cleansed the resident's arm with alcohol, and administered the insulin. She then disposed of the syringe, removed her gloves, and without washing her hands, returned to her medication cart. Employee #66 prepared to move her cart to a different resident's room to perform a fingerstick when this surveyor reminded her that she had not washed her hands at any time during the observation. - 3. Observation of Employee #16 (an LPN), at 11:05 a.m. on 03/17/11, noted she touched the bedside table and contaminated her gloves prior to performing a fingerstick on Resident #26. -- c) A nursing assistant (Employee #49) was observed to assist Resident #25 following a vomiting episode at 8:30 a.m. on 03/16/11. Employee #49 then discarded her gloves in the resident's room and exited into the resident hallway without first washing her hands. Review of the medical record found Resident #25 was placed in a private isolation room for an upper respiratory MRSA infection. Review of the facility's isolation precaution policy (effective 8/2000) found the following: "c. Gloves and Handwashing... 3. Remove gloves before leaving room and wash hands immediately with an antimicrobial agent..."