Every finding on record at St. Barbara's Memorial Nursing Home

Based on observation and staff interviews, the facility failed to dispose of garbage and refuse properly.This failed practice had the potential to affect all residents in the facility. Facility census: 48Findings Included:a) Observation and staff interview:On 08/12/25 at 2:45PM, during an observation walk around interview with Maintenance employee # 60 who acknowledged Dumpster #2 was observed to be heavily rusted and leaking around the bottom and the right side lid was hooved up and not [NAME] closing. He stated he would call the waste company and request a replacement dumpster to be sent out.

Based on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. This is true for the facility kitchen Coolers and also 2 staff members not wearing proper hair covering during lunch meal prep. This had the potential to affect all residents in the facility. Facility census: 48Findings included:On 08/11/25 at 11:49 AM, during Initial Brief Tour of Kitchen, with The Dietary Manager #52 who acknowledged the following: 2 staff members without proper hair covering while preparing resident's lunch, apple juice in 2 door cooler without an opening date and multiple garden salads with no date labels in the 3 door cooler. Policy and Procedures:On 08/13/25 at 1:00 PM a review Food Safety Policy, Food Storage: labeled C. Refrigerated Foods. Practices to maintain safe refrigerated storage, number's 3.C, iv. stated labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen/discarded. On 08/13/25 at 1:00 PM a review of Food Safety Policy, Staff safe hygienic practice labeled 7. e. Hairnets should be worn when cooking, preparing, or assembling food, such as stirring pots or assembling ingredients of salads.

Based on staff and resident interviews, and observation The Facility failed to ensure residents rights to file grievances anonymously. This deficient practice had the potential to affect more than a limited number of residents. Facility census: 48 Findings included: Based on the facilities Grievance policy and Procedure, the residents have the right to file grievances without discrimination or reprisal. The facility will notify residents individually and through postings on the right to file grievances verbally, in writing, or anonymously. During Residential Council Meeting on 8/12/2025 at 1:30 PM, residents #18, #7, #39, and #42, were in attendance with capacity stated they normally just discuss concerns at Resident Council or talk to the social worker without fear of retaliation. When asked if they could file anonymously, they stated they did not know where or how.Based on record review of Section C of the most recent MDS record, Resident Council President #42 had capacity and was cognitively intact. Based on record review of Section C of the most recent MDS record verified Residents #18, #7, #39, and #45, had capacity and were cognitively intact. On 08/12/25 at 2:15PM, during an interview with Activities Director # 20, She confirmed the facility put a suggestion box up for the residents to file grievances and verified residents probably were not aware of it being used for grievances and the grievance forms were not in the same location where residents could fill it out anonymously.

761 Based on staff Interviews and Record review the facility failed to keep an accurate record of the medication rooms refrigerator temperature logs. This failed practice was a random opportunity for discovery, and had the potential to affect all residents residing in the long term care facility that require temperature controlled medications.Resident Identifier: All residents with medications in refrigerator Facility Census: 48The facility FAILED TO MEET THE STANDARD OF PRACTICE as evidenced by the following findings: Findings Include:Record review: 8/11/2025 Medication room refrigerator log is missing days where it was checked/signed off on. Multiple days in August (6days) and July (5 days).August days - 8/3, 8/4, 8/5, 8/7, 8/10 and 8/11 - All missing documentation showing temps were checked for those days.July days - 7/3, 7/17, 7/24, 7/27 and 7/31 - all missing temp log sign off Interview: 8/11/2025 Director of Nursing #19 stated that it is the duty of the night shift to maintain the record and ensure temps are correct. She said there would be an Inservice performed to ensure this won't be missed anymore.

684 Based on staff Interviews and Record review the facility failed to maintain proper MDS documentation ensuring the quality of care was maintained. This failed practice was a random opportunity for discovery and effected 1:16 residents sampled in the facility.Resident Identifier: #4 Facility Census: 48The Facility FAILED TO MEET THE STANDARD PRACTICE, as evidenced by the following findings:Findings Include: There was a wound found on Resident #4 R heel on 2/3/25 that should have triggered a MDS change in condition being filed within 14 days. This was not done. There were also errors on the next MDS filed on 2/20/25, there were no mention of this wound on the heel. The annual MDS filed on 5/22/25 does mention the R heel wound. 08/11/2025 3:14 PM Record review: Chart Review: 8/11/252/3/25 wound found - noted in skin eval notesweekly checks performed. from 2/3 - resolution date 5/21 Healing partners - noted consistent progress on wound condition in notes on 5/21/25 MDS review: 8/11/252/3/25 NO change in condition (CIC) MDA filed when wound found 2/20/25 Quarterly - section M (skin) section M0100 -no pressure wound noted stated there were no pressure wounds noted. (M0300) no open areas on feet noted (M1040) The R heel wound was not resolved at this time. 5/22/25 Annual - section M (skin) section M0100 -pressure wound noted section (M0300) - G1 - Deep tissue injury noted no open areas on feet noted (M1040) Observation: 8/11/25Wound appears resolved on resident's heel. No open areas or discoloration noted Interview: 8/11/25 Wound care nurse #36 - She said that they try to coordinate with the MDS nurse weekly in a meeting about any changes or issues of note with residents so that they can ensure the charting / MDS stay up to date.

637 Based on staff Interviews and Record review the facility failed to maintain proper MDS documentation after a significant change in condition (CIC), specifically a wound to the Right Heel of resident #4. This failed practice was a random opportunity for discovery and effected 1:16 residents sampled in the facility.Resident Identifier: #4 Facility Census: 48The Facility FAILED TO MEET THE STANDARD PRACTICE, as evidenced by the following findings:Findings Include: Change of Condition There was a wound found on Resident #4 R heel on 2/3/25 that should have triggered a MDS change in condition being filed within 14 days. This was not done. There were also errors on the next MDS filed on 2/20/25, there was no mention of this wound on the heel. 08/11/2025 3:14 PM Record review: Chart Review: 8/11/252/3/2025 - Wound found, no CIC MDS filed2/3/25 wound found - noted in skin eval notesweekly checks performed. from 2/3 - resolution date 5/21 Healing partners - noted consistent progress on wound condition in notes on 5/21/ MDS review: 8/11/252/3/25 NO change in condition (CIC) MDA filed when wound found 2/20/25 Quarterly - section M (skin) section M0100 -no pressure wound noted stated there were no pressure wounds noted. (M0300) no open areas on feet noted (M1040) The R heel wound was not resolved at this time. 5/22/25 Annual - section M (skin) section M0100 -pressure wound noted section (M0300) - G1 - Deep tissue injury noted no open areas on feet noted (M1040) Observation: 8/11/25Wound appears resolved on residents heel. No open areas or discoloration noted Interview: 8/11/25 Wound care nurse #36 - She said that they try to coordinate with the MDS nurse weekly in a meeting about any changes or issues of note with residents so that they can ensure the charting / MDS stay up to date.

Based on record review and staff interview, the facility failed to update the Resident Pre-admission Screening(PASARR) after admission to the facility, resident #2 was diagnosed with a major mental disorder. This was true for one (1) of six (6) residents reviewed for PASARRs during the survey process. Resident Identifier #2 Facility census: 48.Findings Included:Resident #2 Record Review:On 08/12/2024, a review of Resident #2's medical record was performed including diagnoses and Resident's Pre-admission Screening (PASARR). His last updated PASARR was completed on 07/262024. Resident #2 was noted to have received a diagnosis of Psychotic Disorder on 05/28/25. An updated PASARR has not been completed since 07/26/2024. Staff Interview:At approximately10:40 AM on 08/12/2025, an interview was conducted with the Administrator concerning the PASARR for Resident #2, she confirmed the absence of an updated PASARR.

Based on record review, and interview, the facility failed to update the resident's Preadmission Screening and Resident Review (PASARR) with a new diagnosis of mental illness. This was true for one (1) of four (4) residents sampled. Resident Identifier #15. Facility Census: 58. Findings Include Resident #1508/11/2025 10:22 PM PASSAR 07/25/16No MI documented Record review on 07/11/25 at approximately 2:52 PM revealed that the most recent PASSAR for Resident #15 was dated 07/25/16. The PASSAR noted that there were no mental illness or mental retardation (MI/MR) diagnoses for the resident. Ongoing record review on 07/11/25 at 3:06 PM revealed that the resident was diagnosed with the following on 07/01/25: UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH PSYCHOTIC DISTURBANCEDELUSIONAL DISORDERS Further record review revealed that the facility failed to update the PASSAR with the new diagnosis. During an interview with the Director of Nursing and Administrator on 07/13/25 at 11:23 AM, the stated that they had performed a whole house review and updated the resident's PASSAR's during the month of March 2025. They further stated that their understanding was that the PASSAR did not have to be updated for a diagnosis of dementia. During an interview with the Social Worker (SW) #55 on 07/13/25 at approximately 1:15 PM, SW confirmed that Resident #15's PASSAR had not been updated since 07/25/16. SW #55 stated that he would review the resident's diagnoses and update the PASSAR.

Based on medical record review, staff interview, and operation policy, the facility failed to take actions to thoroughly investigate an alleged violation related to physical abuse. Resident identifier #1. Facility census: 52. Findings include: a) Resident #1 Record review of the facility's policy titled, Abuse, neglect, and exploration, showed: - Report allegations to appropriate state and local authorities involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property not later than two (2) hours after the allegation is made if it does result in serious bodily injury. - Report allegations to appropriate state and local authorities involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property not later than (24) hours after the allegation is made if it does not result in serious bodily injury. - Written procedures for investigations include: - Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others that might have knowledge of the allegations; - Focusing the investigation on determining if abuse, neglect, exploration, and / or mistreatment has occurred, the extent, and the cause; and - Providing complete and through documentation of the investigation. A record review found an allegation from 10/14/24 where a Feeding Assistant (FA) #200, hit Resident #1 on the shoulder. A reportable was completed with action notes: FA #200 involved was suspended immediately. The incident was reported to all appropriate outside agencies. A statement was obtained from FA #200 that confirmed she was upset with Resident #1, and she may have struck her in attempt to redirect her hands away from her face. Continued review found a social services summary stating during the process of interviewing FA #200, she became argumentative asking why it was ok for a resident to hit and spit on her but, not ok for her to do anything about it. During the interview, on 05/07/25 at 3:30 PM, the Administrator verified that all staff working at the time were not asked for witness statements or other residents interviewed regarding FA #200.

Based on observations and staff interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The ice machine had been improperly installed, with the drain line in direct contact with the floor drain. There was no gap between the drip line and floor drain to prevent backflow from siphonage or back pressure. Additionally, the facility failed to pass ice in a safe and sanitary manner. The ice scoop was improperly stored during the hydration pass. Facility census: 49. Findings included: a) Kitchen tour During the kitchen tour on 10/10/23 at 11:30 AM, it was discovered the ice machine was not draining properly. The drain pipe was in direct contact with the floor drain, there was no air gap to prevent backflow from siphonage or back pressure. In an interview with the Dietary Manager on 10/10/23 at 11:40 AM, verified the drain line for the ice machine was in direct contact with the floor drain. b) Ice Pass On 10/11/23 at 11:38 AM, Nurse Aide (NA) #51 was observed passing ice and left the ice scoop in the ice chest between passes. During an interview immediately following this observation, NA #51 acknowledged that the scoop should not have been left inside the ice chest. During an interview on 10/11/23 at 1:53 PM, the Director of Nursing (DON) stated she would not recommend the storing of the ice scoop between passes to be inside the ice chest. She also stated there should be a holder for the scoop. 49650

Based on observations, staff interviews, and policy review, the facility failed to ensure an environment was free from accident hazards over which the facility had control to prevent avoidable accidents. The medication cart was left unlocked on the Old Wing hallway and items were stored improperly on the shelves above resident beds. Room identifiers: 29, 26, 27, 14, 12, 9, 30, 22, 10, and 18. Facility census: 49. Findings included: a) Unlocked medication cart A random opportunity for discovery of a medication cart located on the Old Wing hallway between room [ROOM NUMBER] and 13 was observed to be unlocked and not visible by staff. There were two (2) residents near the medication cart. During an interview with Licensed Practical Nurse (LPN) #57 on 10/11/23 at 9:31 AM, verified he left the medication cart on the Old Wing hallway unlocked and this was not his standard of practice. In an interview with the Director of Nursing (DON) on 10/11/23 at 9:38 AM, agreed this was not the standard of practice and was an unsafe situation for wandering residents. b) Observations made on 10/10/23 On 10/10/2023 at 3:45PM an observation of the following 5 resident rooms revealed items shelved on the over the bed light directly above residents' head of bed: -room [ROOM NUMBER] Bed 2 had numerous stuffed animals shelved on top of the light fixture frame above the bed; -room [ROOM NUMBER] Bed 1 observed to have numerous stuffed animals shelved on top of the light fixture frame above the bed; -room [ROOM NUMBER] Bed 2 observed to have several stuffed animals shelved on top of the light fixture frame above the bed; -room [ROOM NUMBER] Bed 1 observed to have 1 (one) tin can flower arrangement, 1 (one) basket flower arrangement, 1 (one) medium size stuffed animals and 1 (one) paper popup card shelved on top of the light fixture frame above the bed; -room [ROOM NUMBER] Bed 1 observed to have wooden plaque, Christmas flower arrangement and a plastic trophy shelved on top of the light fixture frame above the bed; -room [ROOM NUMBER] Bed 2 observed to have 2 (two) wooden plaques, flower arrangement and stuffed animals shelved on top of the light fixture frame above the bed; -room [ROOM NUMBER] Bed 1 observed to have 2 (two) large stuffed animals a glass picture frame and a wooden wall plaque shelved on top of the light fixture frame above the bed; c) Observations made on 10/11/23 On 10/11/2023 at 8:50AM an observation of the following 5 resident rooms revealed items shelved on the over the bed light directly above residents' head of bed: -room [ROOM NUMBER] Bed 1 observed to have 1 (one) glass picture frame, 1 (one) picture frame of hard plastic appearance and 2 (two) stuffed animals shelved on top of the light fixture frame above the bed; -room [ROOM NUMBER] Bed 2 observed to have 1 (one) large tin can flower arrangement shelved on top of the light fixture frame above the bed; -room [ROOM NUMBER] Bed 1 observed to have a large plastic figurine lamp, 2 (two) medium plastic dogs, a medium size wooden bird house and a flower arrangement shelved on top of the light fixture frame above the bed; -room [ROOM NUMBER] Bed 1 observed to have a glass flower vase and a [NAME] mouse stuffed animal shelved on top of the light fixture frame above the bed; -room [ROOM NUMBER] Bed 2 observed to have numerous stuffed animals and a hand pump container of alcohol base hand sanitizer shelved on top of the light fixture frame above the bed; -room [ROOM NUMBER] Bed 1 observed to have 2 (two)flower arrangements with ceramic bases and several stuffed animals shelved on top of the light fixture frame above the bed; -room [ROOM NUMBER] Bed 1 observed to have 4 (four) 5X7 picture frames with glass, 1 (one) 8X10 picture frames with glass, 1 (one) 11X17 picture frame with glass, small resin angel and a small plastic trophy shelved on top of the light fixture frame. d) Interview with Maintenance Director #72 On 10/11/23 at 9:10AM, the Maintenance Director #72 was interviewed regarding the items being shelved on the over the bed light and requested a policy for such. A check list was later provided that did not indicate the policy for the safety of storing items on resident over the bed light. Upon requesting the policy again at 10:36AM, the policy provided did not disclose any information regarding the safety of shelving items in the residents' rooms. On 10/11/23 at 10:36AM, a request was made for the Maintenance Director #27 to provide a copy of the manufacturer's recommendations of use for the above the bed light fixture. The provided document was not the manufacturers recommendations. On 10/11/23 at 11:39 AM, a more specific recommendation of the manufacturer was requested from the Maintenance Director to reflect recommendations of the weight ratio and mounting recommendations for the light fixture. The Manufacturers recommendations noted that the shelf weight for storage is 15 pounds. e) Interview with the Director of Nursing (DON) and Administrator (NHA) On 10/11/23 at 1:53PM, an interview with the Director of Nursing (DON) and Administrator (NHA). NHA stated she was aware of the plush animals but indicated she was not aware of the other items referenced, such as the glass covered picture frames, large religious items, flower arrangements and other items identified as being shelved above the residents' heads. Requested a policy and procedure on shelving items on the over the bed light. Policy was not provided prior to surveyor exit from the building. 49650

Based on observation and staff interview, the facility failed to maintain an effective infection control program. Staff touched medications with bare hands, failed to follow enhanced barrier precautions during care and failed to provide incontinence care in a safe and sanitary manner. In addition, hand hygiene was not performed by staff between residents during assistance with meals. These deficiencies were random opportunities for discovery and have the potential to affect more than a limited number of residents. Resident identifiers: #30 #49, #5, and #41. Facility census: 49. Findings included: a) Medication administration On 10/10/15 at 8:50 AM, License Practical Nurse (LPN) #22 opened a Neurontin 300 milligram (mg) capsule with her bare hands, poured the contents into the medication cup, mixed the contents with Resident#30's crushed meds and administered the medication to the resident. LPN #22 confirmed she touched the Neurontin capsule with her bare hands while opening it, during an interview immediately following this observation. On 10/10/23 at 2:35 PM, the Director of Nursing (DON) confirmed staff should not handle or touch medications with their bare hands. b) Enhance barrier precautions (EBP) Repeated observations during the survey identified Resident #49's room marked with a sign for EBP. The sign stated providers and staff must wear gloves and a gown for high contact resident care activities including changing briefs. Resident #49 was on EBP for a centrally placed intravenous catheter. On 10/11/23 at 2:21 PM, Nurse aide (NA) #1 was observed providing incontinence care to Resident #49 with gloves and no gown. At 2:29 PM on 10/11/23, NA #1 confirmed Resident #49 was on EBP and she should have worn a gown with her gloves during incontinence care. During an interview on 10/11/23 at 2:35 PM, the DON acknowledged staff were to wear a gown and gloves during incontinence care of a resident in EBP to prevent the spread of infection. c) Incontinence care On 10/11/23 at 2:21 PM, NA #1 donned gloves, placed a stack of clean wash cloths in the bottom of the sink without a wash basin, turned on the water to moisten, added soap to a few of the cloths and preceded to Resident #49's bedside to provide care. She closed the privacy curtain, undressed the resident and preceded to clean the stool off of the resident. Without changing gloves, she applied a clean brief, covered the resident up and pulled back the privacy curtain. NA #1 then removed her gloves, picked up the soiled brief and linen and exited the room. The above findings were reviewed with NA #1 at 2:29 PM on 10/11/23. NA #1 confirmed she never changed her gloves after cleaning stool off of R #49, before applying a new brief, covering him up, pulling back the curtain and cleaning up the room. The DON and the Infection Preventionist were interviewed on 10/11/23 at 2:35 PM. The DON acknowledged placing the wash cloths in the sink without a basin was an infection control concern. The DON also agreed staff should change their gloves after removing the soiled brief before continuing care.

Based on record review and staff interview, the facility failed to complete a new Pre-Admission Screening (PAS) for one (1) of one (1) residents reviewed for the category of PASARR (Pre-Admission Screening and Resident Review), during the long-term care survey process. Resident identifier #29. Facility census 49. Findings included: a) Resident #29 A review of the Resident #29's electronic medical record, completed on 10/11/23 at 10:39 AM, revealed the following: -Referral paperwork which included active diagnoses as: Atrial Fibrillation, Coronary Artery Disease, Hypertension, Urinary Tract Infection, Diabetes Mellitus, Hyperlipidemia (high cholesterol), Thyroid Disorder, Anxiety Depression, and Bipolar Disorder. -A Pre-Admission Screening (PAS), dated 04/25/23, completed by the referring entity for admission to the facility. The referring entity did not identify Resident #29 had a bipolar diagnosis on Section III, Question 30 of the PAS. -Resident #29 was admitted to the facility on [DATE]. -Review of the April 2023 Treatment Administration Record (TAR) revealed a physician order for resident to take lamotrigine (brand name Lamictal). The order read, Give 50 mg by mouth two (2) times a day related to bipolar disorder. -A general note, dated 09/30/23 and written by Licensed Practical Nurse (LPN) #45, stated, Lamictal dose recently increased to 100 mg PO (by mouth) BID (two times a day) - tolerating well, so far. Will continue to monitor and document any changes in condition accordingly. During an interview, on 10/11/23 at 11:11 AM, the Director of Nursing (DON) confirmed the referral PAS was the only PAS the facility had for Resident #29. The DON also confirmed resident's Lamictal dose was doubled per a physician order dated 09/29/23. During an interview, on 10/11/23 at 1:15 PM, the Administrator confirmed that the facility had failed to complete a new PAS for which would have identified Resident #29 had a bipolar diagnosis and had experienced a need for a medication increase to determine if a Level II review was necessary. A PASARR Level II is a comprehensive evaluation by the appropriate state-designated authority and determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs.

Based on observation, staff interview, policy and procedure review, the facility failed to ensure a resident who was experiencing an acute episode of pain was provided appropriate interventions to assist with pain management. Resident identifier: #5. Facility census: 49. Findings included: a) Resident #5 On 10/11/23 at 10:15 AM observed Resident #5 crying in pain while doing a self administration of a nebulizer treatment. When asked about the level of pain she stated 9. When the Licensed Practical Nurse (LPN) #22 was asked when the resident had pain medication she stated that she had Tylenol at 9:03 AM and it was now 10:15 AM. LPN #22 explained that the resident received Tylenol with Codeine every 6 hours and Norco every 24 hours at HS. When LPN # 22 was asked about assessing the effectiveness of pain medication she stated that in an hour. When asked what she was to do if the pain medication was ineffective, she stated that she should call the physician. An additional order for the Tylenol with Codiene was increased to every four hours. An additional observation of Resident #5 at 1:30 PM found her resting in bed. In an interview with the Administrator and Director of Nursing (DON) on 10/11/23 at 1:50 PM revealed the facility had no policy regarding the assessment of effectiveness of scheduled pain medication. As the Tylenol for Resident #5 was scheduled no additional assessment would have been completed. On 10/11/23 at 11:09 AM a review of the care plan as follows: Focus The resident is at risk for pain related to chronic back pain, generalized discomfort, rheumatoid arthritis, gout, history of compression fracture. Interventions - Pain will be controlled with scheduled medication as evidenced by resident will express satisfaction with her level of pain control and will have no related decline in tolerance for functional activities or quality of life through next review - Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Notify MD as needed.

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. A Physician Orders for Scope of Treatment (POST) form was incomplete for one (1) of 16 records reviewed for accurate POST forms. Resident identifier: #29. Facility census: 49. Findings included: a) Review of Using the POST Form Guidance for Health Care Professionals, 2021 Edition The 2021 POST form guidance states, The health care provider completing this form 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. b) Resident #29 A medical record review, completed on 10/10/23 at 12:45 PM, revealed a 2021 POST form in Resident #29's medical record. The POST form had been signed and dated by Physician Assistant #77 on 04/29/23. There was no license number or telephone number listed for Physician Assistant #77. During an interview on 10/11/23 at 1:00 PM, the Administrator acknowledged the license number and telephone number sections for Physician Assistant #77 were left blank and should have been addressed.

Based on medical record review and staff interview, the facility failed to collaborate with hospice services to develop a coordinated person-centered care plan for one (1) of one (1) residents reviewed for the area of hospice. The care plan for Resident #10 did not specify when and what specific services were to be provided by the hospice staff. Resident identifier: #10. Facility census: 49. Findings included: a) Resident #10 During a medical record review on 10/11/23, it was discovered the care plan was not developed to collaborate when and what specific services were to be provided by the hospice staff. In an interview with the Director of Nursing (DON) on 10/11/23 at 11:42 AM, verified the care plan did not specify when and what services were to be provided by the hospice staff.

Based on observation, resident interview, and staff interview the facility failed to offer appealing options of similar nutritive value to residents who chose not to eat food that was initially served or who requested a different meal choice. This practice had the potential to effect every resident receiving nutrition from the kitchen. Resident identifier: #35. Facility census: 48. Findings Inluded: a) resident #35 11/28/22 11:40 PM Staff interviewed resident #35 who states she did not like lunch meal and asked for alternative meal. Told only had soup and peanut butter and jelly sandwiches. She had a peanut butter and jelly sandwich. Stated food quality has gone downhill since January 2022. Must be cutting costs. She states she likes the chef and he tries his best. On 11/29/22 at 10:07 AM, staff interviewed Dietary Manager (DM) #5 concerning alternative meal menu. DM #5 advised there is no menu for full alternative meals available to residents who prefer to not eat the main meal. When asked if the facility has any menu of food substitutes which would be consistent with the usual and/or ordinary food items provided by the facility, DM #5 stated the facility has posted and staff has observed what the facility calls the Always Available Menu which contains the following items: Cold cut sandwich - ham or turkey as available Bowl of soup - Chicken Noodle, Vegetable or tomato soup as available Grilled Cheese Peanut Butter and Jelly Sandwich Chef Salad with Choice of dressing Garden Salad with choice of dressing Pudding Yogurt Jell-O Ice Cream Assorted sugar free items also available CMS Guidance defines substitute meals as A food substitute should be consistent with the usual and/or ordinary food items provided by the facility. On 11/29/22 at 11:25 AM, staff met with Administrator #1 and advised her about the lack of a substitute menu and she advises they are aware of this area being an issue. The Administrator advised that DM #5 has been working with the dietician to be able to find a new process to be able to offer a secondary meal choice on a regular basis for the residents but this process is not in place as of this time.

Based on staff observation, the facility failed to assure that food was stored and prepared in accordance with professional standards for food service safety as evidenced by the downstairs freezer temperatures not being monitored on a daily basis and additionally, the ceiling in the kitchen was perforated potentially allowing dust and other particles to contaminate food. The lack of temperture checks and the perforated kitchen ceiling had the potential to affect more than a limited number of residents in the building. Facility census: 48 Findings included: a) Freezer Temperature Checks On 11/28/22 at 11:45 AM, staff observed the downstairs freezer did not have daily checks completed every day for the month of November, 2022. The temperature check log was not completed on this freezer for 11/6/22, 11/12/22, 11/13/22 and 11/20/22. On 11/29/22 at 9:30 AM, Dietary Manager #5 agreed with the determination by survey team that freezer needed to be monitored daily and would have the issue addressed immediately with new instructions to staff today. b) Kitchen Ceiling On 11/29/22 at 1:30 PM, staff observed during follow up visit to kitchen that the ceiling above the entire kitchen is not solid, the tiles have small perforated openings throughout the tiles, creating openings throughout the entire ceiling. These small openings within the ceiling present a potential for contamination of food and surfaces directly underneath by dust or other particles falling through the tiles. On 11/30/22 at 8:37 AM, staff met with Assistant Administrator #2 to notify her of the kitchen ceiling issue. She states that they have been made aware of the issue and are in agreement that they want to correct this item. On 11/30/22 at 12:00 PM, staff met with Administrator #1 and Director of Maintenance #6 concerning the potential issue with the ceiling. Staff advised that with the openings throughout the ceiling tiles, any changes in air flows within that area could have the potential to draw dust and other particulates that may be on on top of the tiles down upon the surfaces of the kitchen. Staff and Administrator discussed that USDA Food Code 2017, 6-201.11 Floors, Walls, and Ceilings states floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE. USDA Food Code 2017 further defines SMOOTH as A floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean. The Administrator #1 and Director of Maintenance #6 advised that they are aware of the ceiling and they will begin looking into correcting this issue.

Based on resident interviews, resident representative interviews, review of the Payroll-Based Journal (PBJ) Staffing Data Report, review of Center for Medicare and Medicaid Services (CMS) Nursing Home Compare's report for the facility, and staff interview, the facility failed to ensure sufficient qualified nursing staff were available on weekends to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being. The low weekend staffing had the potential to affect more than a limited number of residents in the facility. Facility census: 48. Findings included: a) Anonymous Resident Interviews During an anonymous resident interview the resident reported, Staffing is a little light on weekends. During a second anonymous resident interview, the resident stated there was low staffing on weekends. The resident's family member was present during the interview and stated, On Sunday my family member (resident) was not dressed when I came in at lunch time. Resident's family member then dressed resident and got up for the day. During a third anonymous resident interview the resident stated the facility does not have enough staff to meet resident care needs. b) Anonymous Resident Representative Interviews During an anonymous Resident Representative interview, the family member stated, Weekends is definitely a problem. I wish staffing was a bit higher for the residents' needs. The family member went on to say he was fearful that his loved one may need more assistance than he can provide at some point in time due to reduced staffing on the weekends. During another anonymous Resident Representative interview, the family member reported, She is not getting the care she needs right now. They are really short in the evenings on weekends. I know this because when I come over there to visit on day shift, I have to park down below because the upper lot is full. If I visit later in the afternoon, I can park anywhere I want to park in the upper lot because there are so many available slots. c) PBJ Staffing Data Report On 11/30/22 at 12:44 PM, a review of the PBJ Staffing Data report revealed the facility had a one (1) star staff rating and low staffing on weekends in the 3rd quarter (April 1, 2022 - June 20, 2022). d) CMS Nursing Home Compare's Report for the Facility On 11/20/22 at 1:00 PM, a review of the CMS Nursing Home Compare's report revealed the following: The total number of nurse staff hours (including Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Nursing Assistant (CNA]) per resident per day on the weekend was 2 hours and 35 minutes, less than the national average of 3 hours and 15 minutes, and the West Virginia average of 3 hours and 15 minutes. The facility's RN hours per resident per day on the weekend was 11 minutes, less than national average of 27 minutes, and the West Virginia average of 22 minutes. The RN turnover for the facility was 75%, higher than the national average of 52.3%, and the West Virginia average of 45.9%. e) Staff Interview The Assistant Administrator, Director of Nursing, and the Facility Scheduler were interviewed on 11/30/22 at 2:30 PM. All three (3) staff members reported they were aware of the low weekend staffing issue. The Assistant Administrator acknowledged low direct care staffing (RNs, LPNs, and CNAs) on the weekends has been an on-going issue the facility has taken seriously and are in the process of trying to resolve. The Facility Scheduler reported that call-offs on the weekends had been a significant problem in the April 1, 2022 - June 30, 2022. Since that time, the facility has taken steps to recruit CNAs specifically hired to work only on weekends. In addition, outside agency staff have been hired to help address the low weekend staffing issue.

Based on record review and staff interview, the facility failed to provide the required Notification of Medicare Non-Coverage (NOMNC) liability notice in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification and failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) Form CMS-10055 for one (1) of three (3) residents. This failure placed residents at risk of not being informed of their appeal rights prior to the end of Medicare covered services. Resident identifiers: #21 and #41. Facility census: 48. Findings included: a) Resident #21 On 11/30/22 at 1:46 PM, staff completed a review regarding the beneficiary protection notification liability notices given for Resident #21 who had been discharged from a Medicare Covered Part A stay: The last covered day of Part A service for Resident #21 was 07/15/22. There was no evidence the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) Form CMS-10055 was completed. The SNFABN stated Medicare requires SNFs to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers. b) Resident #41 On 11/30/22 at 1:48 PM, the facility staff completed a review regarding the beneficiary protection notification liability notices given for Resident #41 who had been discharged from a Medicare Covered Part A stay. The last covered day of Part A service for Resident #41 was 10/12/22. The NOMNC CMS-10123 liability notice form reflects notification of the resident's representative on 10/12/22. No advanced notice was provided to the resident's representative. The NOMNC CMS-10123 states: The NOMNC must be delivered at least two (2) 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. On 11/30/22 at 1:50 PM, staff interviewed Social Worker #4 who advised that she was the one responsible for not completing these required forms in a timely manner.