Every finding on record at Weirton Geriatric Center

Based on observation, resident interview, and staff interview, the facility failed to ensure resident dignity was met during meal service. This was found during the annual survey process. This failed practice has the potential to affect more than a limited number of residents. Resident identifiers: #43, and #40. Facility census 130. Findings include a) Resident #40 On 08/12/26 at around 12:10 PM, during observation of dining room meal service observation revealed Resident #40 received his meal, he then promptly began eating. Dining Services [NAME] (DSK) #129 then began serving others tables which left the three (3) residents at Resident #40's table without their meal. b) Resident #43 At around 12:20 PM this surveyor questioned Resident #43 If this occurs frequently, she replied, No usually they give us all our meals, watching him eat is making me more hungry. The other two (2) ladies agreed. Activities #18 came to this surveyor and reported, Resident #40 has a doctor's appointment in a few minutes, that is why he got his meal early. Resident #43 replied to the activities person, Why do we have to wait for ours then? I am getting hungry. Activities #18 replied to Resident #43, I am sorry I will get yours and the other two right now. At around 12:30 PM the surveyor questioned Dining Services [NAME] (DSK) #129 how the meal tickets are set. DSK #129 reported,They are set by tables and if changes are needed someone in here does that. This surveyor questioned DSK #129 if he would normally serve everyone at a table before moving to the next table, DSK #129 replied, Yes I do, today they told me he needed his early. I should have pulled the other table mates as well.

Based on observation, record and temperature review, facility policy, and staff interviews, the facility failed to maintain proper temperature controls in medication fridges and failed to properly store and date medication. These failures were true for two (2) of four (4) fridges looked at throughout the Long-Term Care Survey Process. Resident Identifier: #137. Facility Census: 130.Findings Include: a) 2nd Floor - [NAME] Fridge On 08/11/26 at 4:00 PM, the surveyor identified the medication storage fridge on the 2nd Floor - [NAME] had a reading temperature of 28 degrees Fahrenheit. The surveyor notified Nurse #212 and the Director of Nursing (DON) of these findings. b) 3rd Floor - [NAME] Temperature Logs The surveyor inspected the temperature logs for each fridge and the surveyor observed recorded temperatures that exceeded standards for storing medication per facility temperature log (greater than 46 degrees Fahrenheit) on the 3rd Floor West. There were two dates the temperature log for inside the fridge read 47 degrees Fahrenheit on 08/06/2026 and 08/08/26. The surveyor notified the DON and Nurse #213 of these findings as well. c) Resident #137 The surveyor observed a vial of insulin in the fridge in medication storage room on the 3rd Floor (Enchanted Garden) that was undated and the vial cap removed. The insulin is prescribed for Resident #137. The surveyor interviewed Nurse #210 and the DON about these findings. Nurse #210 stated, We do not use that one, because she (resident #137) is skilled and receives skilled medications instead of the vial. She has an insulin pen on the cart we use, but I guess we should throw this away since it is not dated. The surveyor asked the DON for a copy of the facility's policy on proper storage of medication and temperature controls. The policy stated, Medications requiring refrigeration or temperatures between 36 degrees (F) and 46 degrees (F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Refrigerated temperatures shall be recorded daily on a temperature log sheet located on the refrigerator door. Medicine room temperatures shall be recorded daily on the temperature log sheet located in the medicine room. Insulin Storage - unopened insulin vials and pens are stored in the refrigerator. Once opened, clearly labeled insulin vials and pens may be stored at room temperature in a locked medication cart. Insulin pens and vials do not require refrigeration after opening. Open insulin vials and pens are to be disposed of after 28 days unless otherwise recommended by the pharmacy manufacturer. When insulin is opened, the open date and expiration date is documented on the bottle.

Based on observation, record review and staff interview, the facility failed to ensure the main kitchen was kept in clean, sanitary manner, following proper food storage to aid with prevention of food born illnesses. And ensuring items were allowed to completely air dry prior to being returned to storage. This was found during the annual survey process. This failed practice has the potential to affect more than a limited number of residents. Facility census 130. Findings:a) Review of Policy for Food Safety RequirementsThe policy states: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety.Policy explanation and compliance guidelines: Food safety practices must be followed throughout the facility's entire food handling process, from receipt to delivery. This includes:Storing food to prevent deterioration, contamination, or microorganism growth.Refrigerated storage: Foods requiring refrigeration must be stored immediately upon receipt or placed in the freezer. Practices include daily temperature monitoring, proper labeling, dating, and maintaining covered or tightly contained items.All opened food in coolers or refrigerators must be labeled with its common name and the date it was opened or prepared. Anything unlabeled or undated must be discarded immediately. Kitchen areas must be kept clean, free from litter and rubbish, and protected from pests.Sanitation solution buckets must be kept in each kitchen, filled with two quarts of water and 1.5 teaspoons of bleach, and changed after each meal. Sanitizing towels must be stored in these buckets, kept free of debris, and changed after each meal.b) Review of Procedures for Equipment CleaningRange operation and care: Remove grease from cracks and openings. Scrape burned particles and grease off the range after each use. Once cool, wash the range top and lids with hot, soapy water, rinse, and dry. Wipe the range top with an oiled cloth to prevent rusting. Wash roasting ovens with hot, soapy water and a quality cleaning powder, then rinse and dry. Remove and clean grates.Equipment must be cleaned immediately after use on a routine basis. Ensure refrigerators and freezers are clean and kept at proper temperatures. Breakfast cooks are responsible for recording temperatures every morning. Prevent grease splatter from accumulating on stoves, floors, or walls, as it attracts dirt. Kitchen Observation on 08/10/26 at 12:00 PM with Kitchen Manager (KM) #133 revealed the following:Yellow, flaky debris was observed on top of the dish machine and along its sides and door. The manager verified that these areas require cleaning and that mold needs to be removed from the backsplash and caulking.Reach-in refrigerator: Nine of nine carafes contained a yellow liquid labeled cranberry juice (dated 08/04/2026). The manager confirmed this was actually lemonade and noted the labels needed correction.Prep tables: On the second shelf, five of eight clean, empty pitchers had dried labels reading sweet tea (dated 08/06/2026). The manager confirmed these labels should be removed.Sanitization: Two cleaning rags were found on the prep table with no sanitizing bucket present. The manager confirmed these must be kept in a sanitizer bucket.Milk cooler: Dark, black, flaky debris was observed along the lid edge and rubber gasket, with dried white liquid on the exterior. The manager confirmed this needs cleaning to remove mold.Oven: A large amount of dark brown, sticky, greasy buildup was observed on the top, backsplash, door, edges, and gasket. The interior also had significant buildup on the bottom and sides. The manager acknowledged the need for cleaning.Hotel pans: Of twelve hotel pans, ten had wet nesting. The manager confirmed these must air dry completely before storage and educated the cook/dishwasher on this procedure.Freezer: Two bags of tater tots were open with no labels or dates. The manager confirmed these need to be sealed, labeled, and dated.Walk-in refrigerator: Several items were identified as expired (past the three-day policy):Gluten-free noodles (dated 08/04/26)Chicken salad (dated 08/06/26)Mashed potatoes (dated 08/04/26)Diced potatoes (dated 08/05/26)Whipped topping (open, undated, unenclosed)Baby carrots (open, undated)Pasta (dated 08/03/26) KM #133 stated, I will educate everyone, especially the new hires.On 08/12/2026, at approximately 1:30 PM, an interview was conducted with KM #133 regarding the facility's policy for labeling, dating, and monitoring refrigerated food. The policy states, in part, that staff are responsible for labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (where applicable), / discarded: and keeping foods covered or in tight containers. When asked if a reference sheet or form existed for staff to determine use-by dates for leftovers, KM #133 replied, No, we just know. If they are new, I ensure they understand. We don't usually add the use-by date.The interview also addressed the process for items removed from the freezer, such as sliced deli meats. KM #133 reported that staff, Should add the pull date and discard after 7 days. Regarding the specific storage duration for prepared meals and deli items, KM #133 clarified, For leftovers it is three (3) days, and for any deli meats or items moved from the freezer, we need a pulled date and then we know to discard after seven (7) days.

Based on observation and staff interview, the facility failed to maintain appropriate infection control practices by failing to provide individual wound care cleanser for residents. This failure was true for one (1) of three (3) residents the state agency surveyor observed during wound care throughout the Long-Term Care Survey Process. Resident Identifier #59. Facility Census: 130. Findings Include: a) Resident #59 On 08/12/26 at 11:00 AM, the state agency surveyor observed Nurse #211 provide wound care on Resident #59. When finished with the wound care, Nurse #211 brought the skin integrity wound care cleanser and betadine out of the Resident #211's room and down the hallway to the treatment cart where treatment supplies are stored. The surveyor observed the skin integrity wound care cleanser without a date or name and the betadine without the resident's name or form of identification attached. The surveyor observed medicated ointments and topical medications that were stored in the cart without bags. The surveyor interviewed Nurse #211 about how the items were stored, specifically the Betadine and Skin Integrity Wound Care Cleanser. Nurse #211 stated, We keep them in here (pointing to the treatment cart in the medication storage room). The surveyor asked if residents get individual bags, containers, or separators, and how to identify who's cleanser or medication is being used for wound care. Nurse #211 stated, Some come from pharmacy with their name on it. The surveyor asked how staff would identify skin integrity wound care cleanser and betadine due to both being house stock and the nurse stated, We use the same bottle. The surveyor inquired more about how the items were used and if the same cleanser was used on multiple residents, to which Nurse #211 replied, Yes, we usually use them on different people. The surveyor notified the Director of Nursing of Nurse #211's response. The surveyor interviewed the DON to inquire if each resident had their own individual wound cleanser, topical medication, and ointments, to which she acknowledged and responded, Yes, I will re-educate (Nurse #211 ) on this.

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to follow the parameters of a blood pressure medication order for Resident #11. This was a random opportunity for discovery. Resident identifier: #11. Facility census: 130. a) Resident #11A record review, completed on 08/12/26 at 11:51 AM, revealed the following physician order:-Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG (Metoprolol Succinate) Give 50 mg by mouth one time a day related to HYPERTENSIVE CHRONIC KIDNEY DISEASE WITH STAGE 1 THROUGH STAGE 4 CHRONIC KIDNEY DISEASE, OR UNSPECIFIED CHRONIC KIDNEY DISEASE (I12.9) HOLD IF SYSTOLIC BLOOD PRESSURE LESS THAN 120. The physician order had a start date of 06/08/23.A review of the Medication Administration Record (MAR) from February 2026 - August 2026 revealed the following dates that the medication was given when Resident #11's systolic blood pressure was less than 120:-On 02/16/26, Resident #11's blood pressure was documented as 106/69. However, the medication was still administered.- On05/21/26, Resident #11's blood pressure was documented as 110/60. However, the medication was still administered. During an interview on 08/12/26 at 2:50 PM, Unit Manager RN #210 confirmed that on the above-listed dates, the medication was administered outside the physician ordered parameters.

Based on record review, and resident and staff interviews, the facility failed to ensure Resident #139 was transferred in a safe manner to prevent an accident of the resident. After the incident with Resident #139, the facility identified the failures and took appropriate action to correct the failures prior to the state agency entering the facility to conduct this complaint investigation. Therefore this will be cited as past noncompliance. This was true for one (1) of three (3) sampled residents. Resident Identifier: #139. Facility Census: 130 Findings Included: a) Resident #139 Resident #139 was admitted post left femur fracture and surgery in May 2025. Based on record review of an incident report on 06/03/25, at 10:00 AM, after finishing therapy, Resident #139 was being transferred back to her room via wheelchair. While being pushed down the hall by Therapy Employee #126, the wheelchair went over a hump in the floor where her left foot got caught and was bent under the wheelchair. Resident #139 yelled out in pain. The facility assessed her and noted the left hip staples were intact and resident in visible distress yelling out about her left hip. She was transported to the local emergency department for X-rays. X-ray findings taken on 06/03/25 and on 06/11/25 produced results as stated below:06/03/25 Received X-ray results: impression of left knee-expected alignment of the left femur after internal fixation; impression of the left hip-postoperative changes of the proximal left femur as described, no postoperative comparisons prior to today; impression of left knee-osteoarthrosis of the left knee with a small joint effusion. 06/11/25 X-ray findings taken on 06/11/25 at 11:08 AM found no evidence of fracture. Resident currently non-weight bearing to left leg. Based on therapy record review on 08/14/26, limited range of motion was ordered for left lower extremities post-incident. In an interview with the Therapy Manager (TM), she verified Resident #139's therapy was extended post-incident to make sure she was non-weight bearing during the next two therapy appointments. 06/03/25 Progress Notes (r/t post incident pain):06/03/25 11:15 Nurse's Note Text: Dr (name) Rounded; Resident (complained of) pain to left knee, left upper leg, and left hip pain d/t (due to) left foot being caught under wheelchair; Start naproxen 375mg po (by mouth) bid (twice a day) x 5 days d/t (due to) pain; Tylenol 650 mg po tid (three times a day) x 7 days d/t pain; Obtain xray of left knee, left femur, left hip; Updated resident; Xray scheduled with (name) Mobile; This nurse informed resident if (name of mobile company) does not arrive, she may have to be transported to (name of hospital) for xray-resident agreed 06/03/25 1:15 PM Nurse's Note Text: Resident requested to go to bed; this nurse x 2 staff members assisted resident to bed via hoyer; hoyer used to resident having increased pain06/03/25 1:32 PM Orders:Tylenol oral tablet 325 mg (milligram)Give 650 mg by mouth every 6 hours as needed for general discomfort/pain of 1-4 *not to exceed 3 gm (gram) tylenol daily.PRN Administration was: Ineffective A review of the facility's investigation found a starred (*) handwritten recommendation: use of leg rests correctly. Therapy Employee #126 on 08/26/26 stated that Resident #139 had self-propelled in her wheelchair down to the therapy room for her therapy appointment. She noted that the resident self-propelled in her wheelchair most of the time, but after therapy she was tired. At that point, she began pushing the wheelchair. She stated they were within 20 feet of reaching her room when they went over a hump and the resident's foot fell and was bent underneath the wheelchair. She also stated that she completed training on putting the leg rests back into position when pushing residents in their wheelchairs.On 08/13/26 at 2:45 PM, during an interview with the DON, she acknowledged the leg rests were not in place when Resident #139's incident occurred and verified the Performance Improvement Plan (PIP) was implemented, a facility audit was completed, staff re-education/training was started and completed before the survey team entered the facility. On 08/13/26 at 11:00 AM during an interview with the Administrator, he acknowledged that Resident #139's leg rests were not in place during the incident on 06/03/25. He also reported the facility audit and staff re-education/training and the implementation of the PIP. During an interview on 08/12/26 at 3:30 PM, Resident #77, who has the capacity to interview, stated that he has consistently observed staff using leg rests when pushing residents in wheelchairs throughout the facility and during activities. Resident #55 was interviewed on 08/14/26 at 1:10 PM while in the community room. She noted that while she occasionally self-propels, staff always ensure her leg rests are in place when they assist with her transport. On 08/12/26 at 1:45 PM, Resident #7 stated that she typically self-propels her wheelchair to the smoking area. When asked about facility-wide practices, she reported that she has not observed staff pushing other residents without the use of leg rests. Corrections:Following the incident, the facility addressed wheelchair safety through its Quality Assurance and Performance Improvement (QAPI) process. On 08/13/26, RN #218 reviewed the results of a year-long Performance Improvement Plan (PIP) and a facility-wide audit. The audit identified specific instances where leg rests were not consistently utilized during transfers. To mitigate this risk, the facility implemented comprehensive staff retraining and education on wheelchair safety, which is now integrated into new-hire orientation and annual educational fairs. This nursing staff education initiative began on 06/13/25 and was completed by 08/21/25. The facility continues to conduct scheduled monitoring to ensure ongoing compliance, successfully correcting the identified failures before the state agency's complaint investigation. The facility wheelchair policy was developed on 08/05/25 after the 06/03/25 incident involving Resident #139 as part of the facility's Quality Assurance and Performance Improvement (QAPI) process to improve safety. Key provisions of the policy included:Leg rests should remain available on each resident's wheelchair.When a resident is being transported or pushed over long distances, staff must ensure the resident's feet and legs are safely positioned with the leg rests in place to prevent feet from dragging or becoming caught.Residents who can safely self-propel using their feet may have leg rests swung to the side, footplates raised, or leg rests removed as appropriate. However, leg rests must not be used as a restraint or in a way that prevents a resident from safely self-propelling.Leg rests may be moved or removed as necessary for safe transfers or if they create a resident-specific safety concern.If a resident refuses to use leg rests, or if staff believe they interfere with the resident's mobility, positioning, or safety, this must be reported to the nurse or unit manager so the issue can be assessed and addressed in the resident's care plan.

Based on observation and interview, the facility failed to maintain a care plan that reflects resident #16's wishes per the Physician's Orders for Scope of Treatment (POST) Form. This failure was true for one (1) of six (6) residents reviewed. Resident Identifier: #16. Facility Census: 130. Findings Include: a) Resident #16 On 08/11/26 at 10:00 AM, a record review was completed on Resident #16's Physician's Orders for Scope of Treatment (POST) form, advance directives, physician orders, and care plan. Resident #16 had a code status of Do Not Resuscitate (DNR). Resident #16's POST form was not scanned into the electronic medical record. To review the details of the POST form, it was necessary to retrieve it from a locked room behind the nurses station. The POST Form indicated that Resident #16 chose Do Not Resuscitate (DNR), Limited Intervention (Includes medical treatment, IV fluids and cardiac monitoring as indicated, transfer to hospital if indicated, avoid intensive care units, and do not use intubation or mechanical ventilation. In the medically administered fluids and nutrition section, the POST Form stated, IV Fluids for a trial period until family and doctor deems not effective. Also, this section stated, Feeding tube long term. The directive sheet for the resident stated, I wish to have a Do Not Resuscitate Order. The physician order for the resident stated, DNR (Do Not Resuscitate) SEE POST FORM. The resident's care plan stated, The following Advance Directives are on record: Do Not Resuscitate (02-18-22) Medical/Durable Power of Attorney Mental Incapacity POST FORM (Signed by physician 02-21-22) Hospice (08-25-24). The State Agency Surveyor did not observe any other instructions in the care plan. On 08/11/26 at approximately 10:25 AM, the surveyor asked the Director of Nursing (DON) how staff would ensure the resident's treatment wishes were displayed and followed. The DON stated, We usually don't get a lot of POST Forms, but if we do, we would have that specifically in the order and the care plan to follow. The DON was asked how staff would identify the resident's (Resident #16) wishes if the order stated, DNR, without further instructions, to which the Director of Nursing stated, In their chart and care plan.

Based on observations, and resident and staff interviews, the facility failed to ensure resident's call lights was within reach. This failed practice had the potential to affect a limited number of residents. Resident Identifier: # 115 Facility Census: 130 Findings included: a) Resident #115 During an interview with Resident #115 on 08/11/26 at 9:00 AM, it was observed that her call bell was hanging over her footboard almost into the floor and her lifeline lanyard was on the outer side of her bedside table. When asked if she could reach her call bell, she stated only if you get it for me. surveyor went to get CNA Employee # 93 to verify both the call lights were not within residnet's reach. CNA # 93 verified that Resident # 115 could not reach either call light and moved them with in reach. In an interview with the DON on 08/11/26 at 1:35 PM, she acknowledged she had been made aware the call light was not within reach of resident #115. She also stated that when she spoke to the nurse, the nurse said she had just been in the room and did not realize the call bell wasn't within the resident's reach.

Based on observation, staff interview and review of facility policy, the facility failed to ensure waste was properly contained in dumpsters/compactors and were covered with lids. Facility Census 121. Findings included: a) On 04/23/25 at 01:43 PM an observation of dumpster/compactor below kitchen, was observed with lids removed and kitchen trash (plastic lid, plastic food cup, towels, mustard packet, pepper packet, paper etc.) surrounding the dumpster and on top of it. b)During an interview on 04/23/25 at 1:46 PM with Maintenance Staff #172 stated that the dumpster used to have a shoot that the trash was dropped in from the kitchen. He reported that they had to cut the shoot off due to trash getting stuck and smelling in the facility. He reported that if they close the lids on the dumpster, the kitchen still throw trash in the hole where the shoot was and it falls on the ground and they have to pick it up. He then found the lids and placed them on the dumpster/compactor. c) On 04/23/25 at 1:50PM observed the second dumpster on the other side of the building with lid open and latex gloves, drink lid, and multiple cigarette butts surrounding the dumpster. Further observation around the grounds of the facility revealed medical trash (such as latex gloves and masks as well as various other debris) along the edge of the parking lot. d) On 04/24/25 at 9:37 AM, review of form titled Policy #F011 Section: Sanitation and Infection Prevention/Control, Subject: Solid Waste Disposal a bulletin under Procedures: heading stated Keep lids closed on all outside receptacles.

Based on staff interview and review of documentation the facility failed to develop and implement a comprehensive person-centered care plan to include trauma informed care for resident who had diagnosis of Post Traumatic Stress Disorder (PTSD). This is true for resident #59. Facility Census 121. Findings included: a) On 04/22/25 at 10:23 AM a reviewed resident's diagnosis list included: F43.10 Post-Traumatic Stress Disorder, Unspecified with an onset date of 08/26/24. b) On 04/22/25 at 10:30 AM review of resident's care plan and there was no evidence that Post Traumatic Stress Disorder was addressed on Resident #59's care plan. c) On 04/23/24 at 3:12 PM during an interview with social worker #97 who reported that she was not aware that resident had a diagnosis of Post Traumatic Stress Disorder (PTSD). She acknowledged that resident had a behavior management program and was not receiving trauma-informed care. She also acknowledged that PTSD was not addresses in resident's care plan.

Based on observation, staff interview and review of documentation the facility failed to ensure the right to personal privacy and confidentiality of personal and medical records by leaving Resident #34's electronic chart open and unattended on medication cart in hallway. This was a random opportunity for discovery. Facility Census 121. Findings included: On 04/21/25 at 4:12 PM observed Licensed Practical Nurse (LPN) #54 was administering medication in resident #34's room and her computer screen was open at the medication cart in the hallway. Resident's chart was open on the computer, unattended. On 04/21/25 at 4:15 PM an interview with LPN #54 she acknowledged that resident's chart was left open and unattended on the medication cart in the hallway. On 04/24/25 at 9:19AM a review of facility document titled Maintenance of Electronic Clinical Records stated the following: - Policy: This facility will maintain electronic clinical records for each resident in accordance with acceptable standards of practice. -7. The facility shall not release resident-identifiable information to the public. Information that is resident-identifiable may be release only in accordance with a contract under which the agent agrees to disclose information except to the extent the facility itself is permitted to do so. -8. Unauthorized persons are permitted to review records only with the signed permission of the resident or a legal document allowing such access.

Based on record review and staff interview, the facility failed to ensure the resident's Pre-Admission Screening (PAS) reflected a pre-admission diagnosis for Resident #101 during the annual long-term care survey. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #101. Facility Census: 121. Findings Included: a) On 04/23/2025, a record review was completed for Resident #101's PAS submitted 11/21/23. Sections III (MI/MR Assessment) and V (Supplemental Questions for Major Mental Illness or suspected MI) of the PAS indicated no diagnoses. Resident #101 had an admission diagnosis of Bipolar Disorder, Unspecified. b) On 04/23/2025 at 3:31, the Director of Nursing confirmed there was no bipolar diagnosis on the initital PAS and stated, it was an oversight on our part.

Based on observation, inspection, and record review, the facility failed to follow a physician's order for the administration of oxygen. This was a random opportunity for discovery. Resident Identifier: #108. Facility Census: 121. Findings Include: a) Resident #108 During an interview with Resident #108 on 04/21/25 at approximately 2:37 PM, it was noted that the resident was receiving oxygen therapy. An inspection of the oxygen concentrator showed that it was set to deliver 3.0 liters per minute. The resident mentioned that she had just finished her breakfast and expressed that she was comfortable. Record review on 04/22/25 at 9:12 AM revealed a physician's order that stated: OXYGEN AT 2 LPM CONTINUOUS VIA NC D/T COPD Ongoing observation during the course of the survey revealed the following readings: On 04/22/25 at approximately 8:37 AM, the oxygen concentrator was observed to be set at 3.0 liters per minute. On 04/23/25 at approximately 11:29 AM the oxygen concentrator was observed to be set at 2.5 liters per minute. On 04/23/25, at approximately 11:31 AM, RN #73 was informed that the oxygen concentrator was not set to the prescribed dosage. The prescribed dose was 2.0 liters per minute, and RN #73 adjusted the concentrator to the correct setting. 04/24/25 at approximately 9:16 AM, the Director of Nursing (DON) stated that the oxygen concentrator in Resident #108's room had been tagged, and removed from service.

Based on record review and staff interview the facility failed to provide Trauma informed care for resident with a diagnosis of Post Traumatic Stress Disorder (PTSD). This is true for resident #59. Facility Census #121. Findings Included: a) On 04/22/25 at 10:23 AM a reviewed resident's diagnosis list included: F43.10 Post-Traumatic Stress Disorder, Unspecified with an onset date of 08/26/24. b) On 04/22/25 at 10:30 AM review of resident's care plan and there was no evidence that Post Traumatic Stress Disorder was addressed on Resident #59's care plan. c) On 04/23/24 at 3:12 PM during an interview with social worker #97 who reported that she was not aware that resident had a diagnosis of Post Traumatic Stress Disorder (PTSD). She acknowledged that resident had a behavior management program and was not receiving trauma-informed care. She also acknowledged that PTSD was not addresses in resident's care plan.

Based on record review and staff interview, the facility failed to ensure four (4) of seven (7) residents were not abused or neglected. Resident #89 did not have incontinence care in a timely manner. This is Past Non Compliance (PNC). Resident #57 was physically abusive towards Resident #89. This was PNC. Resident #11 was physically abusive towards Resident #3. This was PNC. Resident #69 was sexually abusive towards Resident #105. The sexual abuse involved Resident #69 and Resident #105 was PNC. The facility failed to ensure This was true for one (1) of seven (7) records reviewed during a facility reported incidents (FRIs) survey. Resident identifier: #89, #57, #11, #3, #69, and #105. Facility census: 121. Findings included: a) Resident #89 The above-mentioned deficient practice began on 04/24/24 when the facility failed to complete two (2) hour checks on Resident #89 to assess for incontinence. On 04/25/24 at 9:20 AM, Nurse Aide #140 reported to LPN #311 that resident was soaked all over and had fecal matter all over herself and on the floor mat and the floor itself. The facility had implemented corrective action to prevent recurrence by 05/01/24, prior to the start of the survey. Therefore, the deficiency was cited as past noncompliance. Social Worker #45 interviewed Resident #89 on 04/25/24. Resident was alert, oriented, and pleasant. She was noted to be following her usual routine. The resident could not recall the event in question. Social Worker #45 also contacted the evening staff that worked the previous night. Nurse Aide #81 had been assigned to work with Resident #89. Nurse Aide #81 stated she visited the resident at 6:00 PM when the resident's son was in the room. There was no identified issue at that time and her son had reported she had recently been changed. Nurse Aide #81 stated she conducted a bed check at midnight and that resident was OK. Nurse Aide #81 stated her last check was done at approximately 5:30 AM and that resident was sleeping so she did not enter the room, but she did not detect an odor and resident did not appear wet. Social Worker #45 spoke to all Nurse Aide staff working the morning shift of 04/25/24 and all denied entering Resident #89's room early morning. Nurse Aide #140 reported she presented Resident #81with a breakfast tray at about 7:15 AM but did not report the resident was wet or that resident needed changed. Resident was first found to be incontinent when Nurse Aide #140 had re-entered the resident's room at 9:20 AM. The facility was unable to determine what time Resident #89 urinated or had bowel movement. The resident had a history of not asking for assistance and timely bed checks had not been completed. Resident #81's care plan reflected she had a history of refusing bed checks and being combative with care. The facility completed a root cause analysis and determined it was necessary to complete an in-service regarding the facility's expectation for two-hour bed checks to be completed. The facility completed an in-service regarding bed checks on 05/07/24. Social Worker #45 provided the following information regarding the details of the in-service: - Per policy, bed checks are to be done every two (2) hours. There have been recent claims that bed checks are not always being done. During recent investigations, many statements from staff indicated that a few residents are resistant to care and can be aggressive when awakened during a bed check, and therefore may be 'skipped'. This is not acceptable. - Additionally, the following tips were shared with staff in the hopes they would assist staff when dealing with more difficult residents: -- Take a deep breath -- Remain calm -- Do not show anger, fear, alarm, or anxiety -- Speak using a calm, reassuring voice -- Acknowledge the resident's feelings -- Maintain eye contact -- Distract -- Reapproach -- Ask for help There have been no further issues with the two-hour bed checks and provision of incontinent care on a timely basis. 50795 b) Resident #57 On 04/07/24 at approximately 7:30 PM, Resident #89 was near the nurse's station, at the table where books were laid out for the resident's use. She was selecting some books from the table when Resident #57 took exception to it. Resident #57 beckoned her over, grabbed her fingers and twisted hard, yelling Give me the books. Put them back! Resident #89 was a [AGE] year-old female diagnosed with dementia, short term memory loss, inability to process information, and a lack of capacity to make medical decisions. Resident has resided at the facility since March 2024. Her Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 07/12/24 showed the resident had a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. On 04/07/24 at approximately 7:30 PM, Resident #89 was near the nurse's station, at the table where books were laid out for the resident's use. She was selecting some books from the table when Resident #57 took exception to it. Resident #57 beckoned her over, grabbed her fingers and twisted hard, yelling Give me the books. Put them back! Resident #89 was a [AGE] year-old female diagnosed with dementia, short term memory loss, inability to process information, and a lack of capacity to make medical decisions. The resident had resided at the facility since March 2024. Her Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 07/12/24 showed the resident had a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. Resident #57 was an [AGE] year-old female diagnosed with bipolar disorder, cognitive communication disorder, and anxiety disorder. The resident had resided at the facility since 03/08/24. Her Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 07/16/24 showed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Per the physician's capacity determination, the resident did not have capacity to make medical decisions. Investigation revealed an eyewitness report by Nursing Assistant (NA) #14, on 04/07/24 at approximately 7:30 PM, which stated that Resident #89 was by the nurse's station, in the living room area at around 7:30 PM on 04/07/24, looking at books on the table to read. Resident #57 started yelling, those aren't her books; she needs to put them back! NA #14 intervened and separated the two residents. She explained to Resident #57 that the books belonged to the facility, and that it was okay if Resident #89 wanted to take them and return them later. NA #14 walked away but continued to observe them. A few seconds later Resident #57 beckoned Resident #89 to come closer. She had then grabbed Resident #57's index and middle fingers and twisted hard yelling, Give me the books. Put the books back! NA #14 had rushed over and separated them, and stated to Resident #57 that she could not place her hands on other residents. When NA #14 had asked Resident #57 why this happened, the resident had stated, Those aren't her books. NA #14 had then reported the incident to RN #43, and LPN #132, while NA #191 watched the residents. During an assessment of Resident #89's right hand on 04/07/24 at 8:27 PM by RN #43, she documented that resident had stated that her right hand hurt, but that she would be okay. RN noted that no swelling was visible, but the resident experienced slight pain upon movement of the hand. Resident #89's Medical Power of Attorney (MPOA) had arrived a few minutes later and had been notified of the incident. He had then accompanied Resident #89 to her room. MPOA later stated that Resident #57 had apologized to his mother. He further stated, things like this happen. The physician had been notified of the incident on 04/07/2024 at 8:36 PM. He had ordered an x-ray of the right hand for the next morning, and ice packs for swelling if needed. Review of the X-ray on 04/09/24 revealed no acute fractures, or other injuries. A note by RN #127 on 04/08/24 at 11:17 AM stated that Resident #57's urine had been tested to rule out a urinary tract infection. She documented that the test was negative for nitrates, leucocytes, and blood. Record review on 08/27/24 at 2:18 PM revealed that Resident #57 had demonstrated multiple episodes of aggressive behavior, anxiety and cognitive communication disorder. She had been care planned for aggressive behavior. Her care plan, initiated on 6/12/23 states: Intervene as needed to protect the rights and safety of others. Approach/speak in a calm manner, divert attention. Remove from the situation and take to another location as needed. Facility had implemented a behavior management plan for Resident #57 on 06/12/23. This plan was updated on 04/10/24 to include close supervision, encouraging resident to sit near nurses' station so that she could be observed, encouraging her to join activities, and taking her meals in the dining room. Care plan notes that the resident seeks constant attention from staff. Resident's husband visits almost daily. Facility staff were in-serviced on aggressive behavior when dealing with dementia residents. This in-service had been previously conducted on 08/228/23 by Social Worker (SW) #45. c) Resident #3 Resident #3 was noted with blood on her upper lip at the doorway to the solarium. She stated that Resident #11 had smacked her in the face. Activities Staff Member (ASM) #2 noted that Resident # 3's walker was beside a table where Resident #11 was sitting. Resident #3 is an [AGE] year-old female diagnosed with dementia, major depressive disorder, and anxiety disorder. The resident had resided at the facility since 11/28/2023. Her Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 08/13/24 showed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident could not complete the interview. Her physician's capacity determination revealed that the resident did not have capacity to make medical decisions. Resident #11 was a [AGE] year-old female diagnosed with dementia, major depressive disorder, insomnia and cognitive communication deficit. The resident had resided at the facility since 02/09/2021. Her Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 06/18/24 showed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Per the physician's capacity determination, the resident did not have capacity to make medical decisions. The resident had a long history of chest pain, resulting in placement of a neurostimulator for pain management with pre-installed settings. Care plan states that level of stimulation should be adjusted every shift based on the resident's physical, verbal or facial response to pain relief. This care plan was revised on 07/13/2023. Record review revealed the following: On 05/01/24 at approximately 5:20 PM, Resident #3 and Resident #11 were in the solarium. Licensed Practical Nurse (LPN) #207 was passing medications and had heard a noise coming from the end of the hall. She had asked Activities Staff Member (ASM) #2 to check the area. ASM #2 had noted Resident #3 walking up the hall, with blood on her upper lip. Resident #3 was tearful and had stated that Resident #11 had hit her. A nursing note by LPN # 207 on 05/01/24 at 5:20 PM stated that the cut on the resident's lip had been cleansed with soap and water and left open to air. LPN #207 had further noted that Resident #3 had calmed down quickly, and begun eating her dinner, showing no further signs or symptoms of distress. Upon being questioned, Resident #11 denied hitting Resident #3 and went back to her room to have dinner. Record review revealed that Social Worker (SW) #110 had been notified of the incident on 05/01/24 at 5:22 PM. SW #110 had interviewed Resident #3 at approximately 5:45 PM. She stated that the resident had stated That woman hit me. When questioned about what had happened, the resident had stated, I don't know, she just hit me. A social worker note dated 05/01/24 at 6:26 PM stated: . resident was showing no ill effects from the incident upon this social worker speaking to her. This social worker apologized to (Resident #3) that this happened. SW #110 had notified Resident #3's Medical Power of Attorney (MPOA) at 6:05 PM on 05/01/24 and explained that the incident would be reported and investigated. SW #110 revealed documentation that verified that the report to Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services, and the Ombudsman was faxed on 05/01/24 at 7:19 PM, and that the five (5) day follow up report was faxed on 05/07/24 at 4:08 PM. Record review further revealed a nurses notes dated for the following days which stated: 05/02/24 at 4:36 AM: Resident has been awake periodically throughout this shift. Noted with increased tearfulness at times yelling out I don't want to live anymore. Redirection lasts for short intervals before yelling out again. Area to top lip remains. No active bleeding noted at this time.VSS. 05/02/24 at 11:01 AM: Alert and verbal, denies pain or discomfort. Area remains to left upper lip. No active bleeding noted. No bruising observed. Detailed fax to send to physician to update on previous resident to resident occurrence. Awaiting response 05/02/24 at 12:19 PM: Physician responded to fax sent regarding resident to resident with no new orders 05/02/24 at 6:46 PM: area remains to left upper lip, denies pain or discomfort. No acute distress noted. MPOA in for visit. No concerns voiced. 05/02/24 at 9:15 PM: Walking halls no c/o pain or distress at this time. Record review on 08/27/24 at 12:28 PM revealed an in-service to facility staff on 05/01/24 by SW #110, with instructions which stated: Due to the recent altercation, please do not allow residents to be alone together in the solarium or other locations without staff supervision. During an interview with SW #45 on 08/27/24 at 1:49 PM, she stated that due to the recent resident to resident altercations, facility staff were further in-serviced on aggressive behavior when dealing with dementia residents that had been previously conducted on 08/228/23 by Social Worker (SW) #45. A signed statement by SW #110 on 05/06/24 stated: Upon review of the security cameras in the solarium, it was noted that Resident #3 stood up off pf the couch, started walking toward the door with her walker, and approached Resident #11 who was sitting at a table putting a puzzle together. At this time, Resident reached out and grabbed the clothing protector that Resident #3 was wearing. Resident #11 didn't remove the protector but then reached out again and pulled the clothing protector off Resident #3. At this time Resident #11 began hitting out and swatting at Resident #3 several times making contact with Resident #3's face at one point. Resident #11 continued to swat at Resident #3 causing her to leave her walker behind and walk toward the door without it. As she went to go through the doorway, she turned around and re-entered the solarium. At this time, staff came into the solarium and assisted Resident #3 by giving her the walker and escorting her out of the solarium. c) Resident #105 On 05/05/24 at approximately 1:30 AM, Resident #69 was found in Resident #105's room, kissing her, and touching her breast over her shirt. NA #17 immediately attempted to redirect Resident #69 and get him out of the room. Resident #69 became combative and began punching NA #17 as she tried to redirect him. Eventually Resident #89 was redirected out of the room and began to walk toward the lobby. Record review revealed that on 05/5/24 at 1:32 AM, LPN #152 immediately performed a Head-to-toe assessment (Including vaginal assessment) of Resident #105. No marks or bruising noted. The Resident's Medical Power of Attorney (MPOA) was contacted by LSW and notified of the incident. Record review also revealed and in-service that had been conducted by SW #110 immediately after the incident, which instructed all staff that: Due to the recent incident (Resident #69) is to be supervised at ALL TIMES and not to be kept in the lobby unless supervised by staff. A note on 05/05/24 at 3:49 AM by Social Worker (SW) #110 stated: Administrator #94 was notified of the incident at 2:35 am. A review of facility records on 08/28/24 at 9:14 AM revealed that the facility staff had faxed a report to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services, and the Ombudsman on 05/05/24 at 3:15 AM, which was within the required two (2) hour window for reporting allegations of sexual abuse. The five (5) day follow up report was submitted on 05/07/24 at 3:58 PM Record review revealed that the facility had conducted an investigation of the alleged sexual abuse on 05/05/24. The facility had substantiated the allegation through interviews with staff. Resident #105 was a [AGE] year-old female diagnosed with severe dementia, Parkinson's disease, Alzheimer's, and epileptic seizures. The resident has resided at the facility since December 2023. Her Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 03/21/24 showed the resident was non reviewable, and unable to answer the questions. Facility conducted a staff interview and questioned staff on whether the resident was able to answer questions or make requests. It was revealed that the resident is unable to make her needs known, indicating severe cognitive impairment. Physicians' determination was that the resident does not have capacity to make medical decisions. Resident #69 was an [AGE] year-old male diagnosed with dementia, and depression. The resident had resided at the facility since November 2023. His Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 05/01/24 showed the resident had a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. Based on the physician's capacity determination, the resident does not have capacity to make medical decisions. Record review revealed an eyewitness report by Nursing Assistant (NA) #17, on 05/05/24 which stated: Upon bed check me and another CNA were also passing linens. This CNA went into Resident #69's room to put linens in there, upon leaving and moving into the next room, me and said CNA were getting a two (2) assist up out of bed to the bathroom, when three (3) alarms started going off. The nurse was getting one on the other end of the hall, I had turned Resident #69's off because he was in the hallway already, then assisted other CNA with the assist off the toilet back into bed. This CNA came down the hallway to the other alarm, and upon coming down the hallway I found Resident #69 in a female resident's bed with her. He had his hand on her chest, on top of her shirt and was kissing female resident. This CNA tried to redirect Resident #69, and he became very combative with this CNA and was punching CNA as she continued to try to redirect him. Once resident was redirected out of female resident's bed and room he began to walk toward lobby. Once this CNA got Resident #69 redirected CNA went back to help with resident that had fallen out of bed, with the nurse and the second CNA. Resident #69 then made his way back down out of the lobby to the long hallway where this CNA tried to get him to turn back around into the lobby so he can be monitored by either CNA or nurse while bed check was completed. Resident #69 then began to swing on CNA balling his fists and saying Yeah, I got em Then he walked back into the lobby and sat in recliner chair and has since been calm Further record review revealed the following notes by facility staff: 05/05/24 at 01:30 AM a note by Licensed Practical Nurse (LPN) #152 which stated: During bed check resident alarm was going off, Resident #69 came out of room, started walking towards lobby, CNAs were getting up female peer to go to bathroom, who is a two assist. stopped in front of door of female peer. CNA told Resident #69 to keep going to lobby and he started walking towards lobby. CNAs were done in female peer room, a bed alarm was going off, CNA went to get it and saw Resident #69 in another female peer room, kissing her and touching breast on top of her shirt, CNA tried to redirect him out of room, Resident #69 got combative, started hitting CNA, he then tried going into another female peer room, he was brought out to lobby and is sitting in chair, Resident #69 has no bruising or marks on hands from hitting CNA. Social worker was called at this time. 05/05/24 at 3:45 AM a note by Social Worker (SW) #110 which stated: This social worker was informed by nursing at 1:58 am that Resident #69 was found kissing and fondling Resident #105's breasts while she was laying in bed. This social worker entered the building at 2:15 am and went to the dementia unit. This social worker spoke with nursing as well as the CNAs regarding the situation. Resident #69 was redirected to the lobby where he remains at this time. Staff instructed to provide 1:1 to him at this time to ensure the safety of his female peers. Incident was reported to APS Centralized Intake, APS local office, Ombudsman and OHFLAC as well as to Administrator #94 at 2:35 am. Weirton Police Department was called 3:15 am and arrived at the facility at 3:30 am. Report was filed- incident #2024050040. Resident #69's MPOA will be notified later this AM. (name of behavior health unit) and physician will be notified for further instruction/evaluation. 05/05/24 at 4:00 AM a note by SW #110 which stated: This social worker called and spoke with (name of behavior health unit) regarding a referral for admission. They requested a consent form be signed by Resident #69's MPOA. Form was faxed to this social worker (will obtain signature later this AM). They requested that the consent form and other documentation be sent (Face sheet, diagnosis list, physician order, covid and influenza vaccine records, MAR/TAR, H&P, nurse's notes, allergy list). They stated that once they receive the consent and information, their doctor will review everything to see if he will accept him as a patient. If he does, then Resident #69 will need to be sent to (name of hospital emergency department) for them to admit to behavioral health. 05/5/2024 at 08:30 AM a note by SW #110 which stated: This social worker placed a call to Resident #105's MPOA/husband 8:30 am to explain the situation that occurred regarding a male peer being sexual with resident. MPOA did not answer; message left to return the call at his earliest convenience. 05/05/24 8:15 AM a note by SW #110 which stated: This social worker called and spoke with Resident #69's MPOA regarding the incident. This social worker also explained that due to there being several incidents and an increase in aggressive behaviors and for the safety of his female peers, the facility would like to send him to the (name of behavior health unit). MPOA expressed many concerns about sending him to that facility and asked that his physician be notified. This social worker explained that physicians would be notified after ending the call with her. This social worker explained that a consent form would need to be signed by her. MPOA stated that she would need to speak with her children before making a decision. She stated she would call this social worker back. 05/05/24 at 9:00 AM a note by SW #110 which stated: This social worker received a call from Resident #69's daughter regarding the situation. This social worker explained everything to her. She expressed her concerns about the geri-psych facility as well as how long he might be there. All issues were addressed with her. Nursing paged physician and he returned call. This social worker and nurse on duty explained the situation of Resident #69 being sexual with a female peer The Physician stated to send the resident to (name of geriatric psychiatric unit). Nursing also paged physician with a return call. This social worker and nurse on duty spoke with the physician and explained the situation. He stated that prior to resident being admitted to Weirton Geriatric Center (WGC) he had seen him in the office and was very well aware of his aggressive behaviors and difficulty in being redirected and was concerned with his placement at that time but seems to have adjusted well although there has been an increase in sexual behaviors stating that he had his wife at home but now he doesn't and his behaviors are not acceptable in the current environment although he cannot control it due to his dementia. He stated that he was in agreement that resident be sent to a geri psych facility- either (name of towns). He stated that resident #69 requires 1:1 staff supervision at this time but stated that is not possible at Weirton Geriatric Center. This social worker asked if he would be willing to speak with resident's daughter, and he agreed. This social worker called resident's daughter and joined the calls. Physician spoke with resident's daughter and wife, who was also on the call, in length regarding the situation. He stated to them that it is in the best interest of all involved that resident be sent to the geri-psych facility. He reinforced that for the safety of the other residents that the transfer was necessary. He stated to them that if they needed anything at all to call him as he is available any time. Resident's daughter and wife thanked physician for speaking with them and physician ended the call on his end. This social worker continued to speak with resident's wife and daughter. Resident's daughter stated that she and her mom would come to the facility and sign the consent papers around 11 am. This social worker explained to them the process and that after the paperwork and consent would be signed and sent to the facility, their doctor would review it, and they would let this social worker/nursing know if they would accept him as a patient. They asked if WGC would transfer him, and this social worker stated yes. Resident's daughter and wife thanked this social worker for everything and ended the call. Administrator #94 updated. 05/05/24 at 10:41 AM a note by SW #110 which stated: Spoke with physician regarding the incident of male peer being sexual with Resident #105. No new orders received. 05/05/24 at 1:08 PM a note by SW #110 which stated: This social worker received a call back from Resident #105's MPOA/husband. This social worker explained to MPOA that a male peer was laying in bed with (name of Resident #105), kissing her and touching her breasts. This social worker informed him that the police were called, and a report was filed, that an investigation is being completed by this social worker, and that Resident #105 was assessed from head to toe including her vaginal area and no marks or bruising were noted. This social worker informed him that resident showed no ill effects from the incident. MPOA stated that he realizes that the male peer didn't know what he was doing and that he understands that things like this happen. He asked if resident seemed okay today, and this social worker stated she was in good spirits. He stated he understands that the residents have dementia and that they don't know what they are doing. MPOA stated that he would be visiting today and bringing Resident #105 some snacks. He thanked this social worker for calling to let him know what happened. This social worker stated that the staff will continue to ensure Resident #105's safety. 05/05/24 at 1:38 PM a note by SW #110 which stated: This social worker received a call from SW at East Liverpool Senior Behavioral Health Unit stating that they would accept Resident #69 as a patient. She stated that he could bring 3 outfits with no hoods or strings and 1 pair of shoes also without strings. She stated that they would provide everything else for him. She stated to take him first to (name of hospital emergency department) to be medically cleared. This social worker spoke with Resident #69's wife and daughter and informed them that the (name of behavior health unit) accepted him as a patient and relayed all the other information to them. They stated that they would transport resident to the hospital. This social worker and nurse on duty called (name of hospital emergency department) and gave report to their nurse. 05/05/24 at 2:48 PM a note by SW #100 stated: Resident #69 left the facility with his family at 2:36 pm in stable condition to be transferred to East Liverpool Hospital. Vitals obtained by nurse on duty and all vitals were within normal limits. Wander guard removed from left arm. No distress noted. Physician and Administrator #94 notified. 05/06/24 at 1:19 PM a note by SW #110 which stated: This social worker received a call from the discharge planner, from (name of behavior health unit). She asked if WGC would be taking resident back, and this social worker stated yes. Discharge planner then stated that they do not do the significant change PASSAR, and that WGC would need to complete that. This social worker stated that this would be communicated to our director of nursing. This social worker asked how Resident #69 was doing. She stated that he was very combative in the ER last night and was given Geodon. She stated that resident was up most of the night and is very sleepy today. She stated that physician at the facility started him on Celexa stating that it usually works for getting rid of sexual behavior. This social worker asked about a possible discharge time frame. She stated that on average, resident would be there for at least 5-7 days but that could vary. She stated that WGC would be notified 1 day before discharge. Discharge planner stated that she would be faxing updates and asked for the fax number which was provided by this social worker. She stated that she would be providing updates M-W-F. This social worker thanked her for calling with an update. Information was communicated to Director of Nursing (DON) #102, RN #183, and Administrator #94. 05/07/24 at 1:08 PM a note by SW 110 which stated: This social worker spoke with Resident #69's MPOA regarding how resident is doing. MPOA expressed her dissatisfaction of resident being in the (Name of behavior health unit) stating that she felt it was rushed and didn't understand why he had to go there. This social worker reiterated with MPOA that per resident's physicians, with whom MPOA spoke, they recommended that resident be sent to the behavioral health unit. MPOA stated that she has a lot of faith in physician, but that she is just still upset about the entire situation. She stated that she felt that resident #69 was being punished. This social worker explained that resident was not being punished in any way and reminded her that this wasn't the first incident as well as him masturbating frequently, and this social worker again reiterated to her that his physicians wanted resident sent to the behavioral health unit. MPOA then stated that the process of getting him there was not a good experience and that she felt they were forced to take him themselves. This social worker once again reiterated to MPOA that this social worker gave them the option of having WGC transport him there or her and her family could transport him, and they decided to transport him themselves. This social worker apologized to MPOA that it was such a bad experience. MPOA requested that WGC transport resident back once he is discharged from the behavioral health unit. This social worker stated that this would be discussed with Administration. MPOA stated that she and her family had to sit in the ER for 6 hours. This social worker apologized that they had to sit there that long; however, this was out of anyone's control. MPOA stated that she just wants him back at WGC as soon as p[TRUNCATED]

Based on record review and staff interview, the facility failed to ensure that all alleged violations involving abuse and the administration of physician ordered medication in excessive doses were reported in a timely fashion to all appropriate state agencies. This was true for two (2) out of seven (7) facility reported incidents (FRIs) reviewed. Resident identifier: #89. Facility census: 121. Findings included: a) On 07/17/24, RN #183 was notified of a rumor that LPN #406 may be administering extra melatonin to the residents on the dementia unit to help them sleep better. On 07/22/24, the Director of Nursing was notified by RN #183 of the rumor and was told that RN #183 believed it to be true. The facility reported the allegation on 07/25/24. During an interview on 08/27/24 at 11:25 AM, Assistant Administrator #130 reported that the facility had been so involved in investigating the validity of the allegation that it had been an oversight that the allegation had not been reported timely. 50795 b) Resident #89 On 04/07/24 at approximately 7:30 PM, Resident #89 was near the nurse's station, at the table where books were laid out for the resident's use. She was selecting some books from the table when Resident #57 took exception to it. Resident #57 beckoned her over, grabbed her fingers and twisted hard, yelling Give me the books. Put them back! During an assessment of Resident #89's, right hand on 04/07/24 at 8:27 PM, by RN #43, she documented that resident had stated that her right hand hurt, but that she would be okay. RN noted that no swelling was visible, but the resident experienced slight pain upon movement of the hand. Physician had been notified of the incident on 04/07/2024 at 8:36 PM. He had ordered an x-ray of the right hand for the next morning, and ice packs for swelling if needed. Review of the X-ray on 04/09/24 revealed no acute fractures, or other injuries. A review of facility records, on 08/28/24 at 9:42 AM, revealed that the facility staff had faxed an initial report to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman on 04/08/24 at 8:50 AM, which was not within the required two (2) hour window for reporting allegations of abuse with injury. During an interview with SW #45, on 08/28/24 at 9:13 AM, she confirmed that the report was not faxed out in a timely manner.

Based on observation, record review, and staff interview, the facility failed to ensure resident falls resulting in serious bodily injury were reported in a timely manner to the appropriate state agencies. The failure to make a timely report and to report to the appropriate state agencies was true for three (3) of three (3) sampled residents for falls resulting in serious bodily injury during the Long Term Care Survey Process. Resident identifiers: #57, #108, and #67. Facility census: 119. Findings included: a) Resident #57 A medical record review, completed on 03/28/23 at 08:10 PM, revealed the following details: -Resident #57 experienced a fall on 12/16/22. -An x-ray was obtained and on 12/17/22. -A nurses note on 12/17/22 at 2:15 PM noted, Received final x-ray report as follows: Acute fracture involving the femoral neck bone which indicated a hip fractured. -Resident #57 was then sent out to the hospital and admitted for surgical repair. -A review of the facility reportable's revealed the serious bodily injury was reported to the Office of Health Facilities Licensure and Certification (OHFLAC) on 12/17/22 at 8:18 PM, over 6 hours after the facility having knowledge of serious bodily injury. -There was no evidence the facility had reported the serious bodily injury to Adult Protective Services (APS). During an interview on 03/29/23 at 7:45 AM, Social Worker #42 reported she had never reported serious bodily injuries to APS. The Social Worker acknowledged this was an error on her part that she will correct. Social Worker #42 also acknowledged the facility's failure to report within 2 hours. b) Resident #108 A medical record review, completed on 03/28/23 at 7:16 PM, revealed the following details: -Resident #108 experienced a fall getting up from her bed on 03/20/23 at 5:05 PM. -A new physician order to send Resident #108 to the emergency room for evaluation was given on 03/20/23 at 5:45 PM. -On 03/20/23 at 8:30 PM, a family member called the facility and reported the following update, . has a fracture of right humerus. She is being admitted to hospital and will have a ortho [orthopedic consult] in morning. -A review of the facility reportable's revealed the serious bodily injury was reported to OHLFAC the following day on 03/21/23 at 9:06 AM, over 12 hours after the facility having knowledge of serious bodily injury. -There was no evidence the facility had reported the serious bodily injury to APS. During an interview on 03/29/23 at 8:00 AM, Social Worker #42 reported she had never reported serious bodily injuries to APS. The Social Worker acknowledged this was an error on her part that she will correct. Social Worker #42 also acknowledged the facility's failure to report within 2 hours. c) Resident #67 On 3/28/23 at 9:22 AM a record review found Resident #67 fell on [DATE] at 9:00 AM. She was sent to the local emergency room for evaluation. She returned to the facility at 12:00 PM. Discharge records from the local hospital shows she had a right humerus fracture. This was noted by the nurse on duty upon return on 11/20/22. Documentation shows this was reported to the appropriate state agencies twenty-two (22) hours after learning of a fractured humerus. The injury was reported on 11/21/22 at 10:11 AM (Adult Protective Services (APS) and 10:13 (Office of Health Facility Licensure and Certification (OHFLAC). On 3/29/23 at 9:46 AM it was confirmed with Social worker #170 the incident should have been reported within a two hour window frame once it was confirmed that this injury was a fracture. 45171

Based on record review and staff interview, the pharmacist failed to identify incomplete medication orders during their Medical Record Review (MRR). Resident identifiers: #42, #91 and #104. Facility Census: 119 Findings Included: a) Resident #42 Resident #42 has a diagnosis of anxiety and major depressive disorder. She has an order for Buspirone (anti anxiety medication) tablet 5 milligrams, oral, twice a day at 6:00 AM and 6:00 PM start date 11/09/22 with no end date. There was no diagnosis listed for this medication order. The pharmacist failed to identify this incomplete medication order during their MRR. This was confirmed with the Director of Nursing on 3/28/23 at 1:30 PM. b) Resident #91 Resident #91 has an order for Cipro (antibiotic) (Ciprofloxacin HCL) tablet; 250 milligrams; oral twice a day at 6:00 AM and 8:00 PM. Start date of 3/21/2023, ending on 3/28/2023. There was no diagnosis for this medication order. According to documentation provided, the resident presented confused on 3/16/23 at 9:00 AM. There was an order from the Physician on 3/16/23 at 11:30 AM for a urinalysis with culture and sensitivity (U/A & C&S). Results of this U/A C&S was faxed to the physician on 3/20/23 at 10:55 AM with a new order on 3/21/23 at 3:00 PM for the Cipro for a Urinary Tract Infection (UTI). The pharmacist failed to identify this incomplete medication order during their MRR. This was confirmed with the Director of Nursing on 3/28/23 at 1:30 PM. c) Resident #104 Resident #104 has a diagnosis of major depressive disorder. She has an order for Citalopram (anti depressant) tablet 20 milligrams, oral, once a day at 6:00 AM for a diagnosis of Acute embolism and thrombosis of unspecified deep veins of the right distal lower extremity). This is an inappropriate diagnosis for this medication. Citalopram is used for depression , not deep vein thrombosis (DVT). The pharmacist failed to identify this incorrect medication order during their MRR. This was confirmed with the Director of Nursing on 3/28/23 at 1:30 PM.

Based on observation and staff interview, the facility failed to ensure resident rooms were designed or equipped to assure full visual privacy for each resident. This was true for five (5) out of five (5) resident rooms during the long-term care survey process. Resident identifiers: #108, #57, #55, #12, and #103. Facility census: 119. Findings included: a) room [ROOM NUMBER] Observation, on 03/27/23 at 2:11 PM, revealed there was one (1) privacy curtain in the room that could extend in a straight line between the two (2) resident beds in the room. Resident #12 was placed in the A-bed, which is the bed closest to the door. During a second observation, on 03/28/23 at 10:17 AM, LPN #128 acknowledged there was nothing that would afford Resident #12 full privacy should her roommate enter the room in an attempt to get to the B-bed, which is the bed closest to the window. b) room [ROOM NUMBER] Observation, on 03/27/23 at 2:26 PM, revealed there was one (1) privacy curtain in the room that could extend in a straight line between the two (2) resident beds in the room. Resident #103 was placed in the A-bed, which is the bed closest to the door. During a second observation, on 03/28/23 at 10:14 AM, LPN #128 acknowledged there was nothing that would afford Resident #103 full privacy should his roommate enter the room in an attempt to get to the B-bed, which is the bed closest to the window. c) room [ROOM NUMBER] Observation, on 03/27/23 at 2:34 PM, revealed there was one (1) privacy curtain in the room that could extend in a straight line between the two (2) resident beds in the room. Resident #108 was placed in the A-bed, which is the bed closest to the door. Resident #55 was placed in the B-bed, which is the bed closeest to the window. During a second observation, on 03/28/23 at 10:15 AM, LPN #128 acknowledged there was nothing that would afford Resident #108 full privacy should her roommate enter the room in an attempt to get to the B-bed, which is the bed close to the window. Additionally, LPN #128 acknowledged there was nothing that would afford Resident #55 full privacy should her roommate attempt to look out of the window in the room. d) room [ROOM NUMBER] Observation, on 03/27/23 at 3:39 PM, revealed there was one (1) privacy curtain in the room that could extend in a straight line between the two (2) resident beds in the room. Resident #57 was placed in the A-bed, which is the bed closest to the door. During a second observation, on 03/28/23 at 10:17 AM, LPN #128 acknowledged there was nothing that would afford Resident #57 full privacy should his roommate enter the room in an attempt to get to the B-bed, which is the bed closest to the window.

Based on observation and staff interview, the facility failed to maintain a resident's room in a clean and homelike manner. Feeding tube supplies were in an open box on the floor and filling up the visitor chair in the room. This is true for one (1) of two (2) residents reviewed for feeding tubes. Resident identifier: #18. Facility census: 119. Findings included: a) Resident (R)#18 An observation on 03/27/23 at 10:23 AM, revealed an open box on the floor in R#18's room containing five unused feeding tube bags. In addition, the chair in the room contained two open and one closed case of Glucerna tube feeding bottles, leaving no place for a visitor to sit. At 10:25 AM on 03/27/23, Registered Nurse (RN) #26 confirmed these findings and immediately picked the feeding bags up off the floor and cleared the chair for visitors.

Based on record review, staff interview and observation, the facility failed to ensure Resident #71 who had a 12.11% weight loss in 6 months, received assistance with meals as required by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in actual harm to the resident. The facility failed to provide supplements, the necessary level of assistance with eating, clear intervention directives, and to update care plan to include the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was found for one (1) of six (6) residents reviewed for the care area of nutrition during the long-term care survey process. Resident identifier: #71. Facility census: 115. Findings included: a) Resident #71 - (weights) Review of a paper copy of the Resident's weight record, located in the Resident's chart, found the Resident weighted 144.5 pounds on 05/03/21. On 11/12/21, the most recent weight, was 127 pounds. This represents a 12.11% weight loss in 6 months. In the previous 3 months of 05/03/21, Resident #71 lost 35.5 pounds. This represented a 19.72% weight loss. The resident steadily lost weight over a 9 month period for a 29.44% weight loss. Further review found the Resident's recorded weights as follows: --180 pounds on 02/02/21 --166 pounds on 03/01/21 --149 pounds on 03/11/21 --159 pounds on 03/18/21 --149 pounds on 03/28/21 --152.8 pounds on 04/01/21 --165 pounds on 04/08/21 --144.5 pounds on 05/03/21 --127 pounds on 11/12/21 b) Observation of the noon meal on 11/16/21: On 11/16/21 at 12:10 PM, the resident was sitting at the dining room table just looking at her meal. Her tray was set up but she was not eating. At 12:32 PM, on 11/16/21, the Resident left the dining table and was propelling herself in her wheelchair around the dining room area. Her meal remained on the table. At 1:14 PM on 11/16/21, the resident continued to be observed roaming around the nurses station (located within the dining room area.) Staff did not attempt to get the Resident to return to the dining table to eat. On 11/16/21 at 1:39 PM, Registered Nurse (RN) #38 acknowledged the Residents meal was not eaten. She said, the Resident refused to eat. When asked about the supplement the resident was to receive if she did not eat more than 50% of her meal, she stated, I told the aide to get her one. The surveyor was present during the noon meal and did not see or hear RN #38 asking any nurse aide to get the Resident a supplement. When asked who provided the supplement, RN #38 said she would get her supplement. c) Record review Record review found the resident lacked capacity to make medical decisions. The resident achieved a score of 3 on the Brief Interview for Mental Status (BIMS) on the Minimum Data Set, dated dated [DATE]. A score of 3 indicates severe cognitive impairment. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Registered/Licensed Dietitian to Physician forms revealed on 07/29/21 the Registered Dietician (RD) provided a summary of nutritional concerns: --Related to poor meal intakes --To review if additional interventions may be needed. --The recommendation from the RD is as follows: --Two cal HN 3 ounces one time a day. --Prealbuman lab --Question for physician: Post form has feeding tube long term marked, would a feeding tube be a consideration at this time? --The physician replied with, Yes weight loss continues, on 08/02/21. The Resident's daughter was not contacted about the request until 09/15/21. The next recommendation from the RD was dated 09/16/21. The resident was seen for low meal intakes and weight loss. Recommendations included: --Discontinue 1/2 cup of pudding with Glucerna. --Add Ensure clear 120 ml one time a day. The new orders for Ensure were not implemented until 09/23/21. Seven (7) days after the request. On 09/30/21 the Speech Therapist saw the resident and recommended the following: Bedside swallow evaluation completed with rec (recommendation) for dysphagia treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Caregiver education provided to charge LPN (Licensed Practical Nurse) regarding: resident response to treatment ST diet change recs (recommendations) placed on this date (Pureed diet with ground meat/extra sauce or gravy, nector-thick liquids, no straws, and staff assistance for PO (by mouth) intake). Continue POC (plan of care.) Review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] --10/04/21 - Nutritional supplement 6 oz. If less than 50% of meal is consumed and snack time as needed, chart amount of supplement given, post meal as needed and snack time as needed breakfast, lunch, dinner, snack. --10/04/21 Pureed diet with ground meat/extra sauce or gravy, no straws and staff assist for PO (by mouth intake), nectar thick liquids with staff assist. --11/15/21 an order was written for weekly weights times 4 weeks. Review of the current care plan found a Problem, updated on 10/21/21: --Nutritional risk related to significant weight loss. The goal associated with the problem was: --Will achieve adequate nutrition status as evidenced by maintaining stable weight, no signs or symptoms of malnutrition by next review. Interventions included: --Consult (Name of physician) as needed for adjustments of dentures --Invite to activities that promote additional intake of food and fluids --Monitor consumption. Offer supplement if less than 50% of the meal is consumed. --Monitor weight pre protocol or as ordered and record. Notify registered dietician of significant weight changes pre dietary recommendations 5% in one month 7.5 % in three months 10% in six months follow up with recommendations to doctor. --Obtain labs as ordered to notify the doctor of results --Provide diet and supplements as ordered, offer substitutes and alternatives at meals and frequent snacks. The care plan did not include the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] --The type of diet or the amount of staff assistance needed to feed the Resident. --Weekly weights. --When the nutritional supplement would be provided and the type of nutritional supplement to be provided. Review of the Residents Food Intake form, completed by the nurse aides to document the amount of food eaten for breakfast (B), lunch (L) and dinner (D). The categories are coded as B- L- D. Between L and D is a category coded as S- which is for recording snack (S) consumption. Review of the food intake form from 11/1/21 through 11/17/21 noted there was no documentation to verify any snacks were ever offered between lunch and dinner. The only time snacks were recorded from 11/01/21 through 11/17/21 were under the category coded S, which was after D, (dinner). There was no evidence any snacks were offered after dinner on the following days: --11/03/21 --11/04/21 --11/09/21 --11/10/21 --11/11/21 --11/12/21 --11/16/21 In the upper right hand column of the percentage of meals eaten was a smaller box for staff to note if the supplement was offered for each meal when the Resident consumed less that 50% of her meals: --On 11/03/21 and 11/16/21 the document contained no documentation of the percentage of the (D) dinner meal consumption; therefore, is it unknown if a supplement was offered or not. Review of the interim plan of care, this is the handwritten document used by the nurse aides to provide care to the resident. Under the category entitled, Eating: --The form contained the categories for eating: Independent, by staff, supervise, assist, feed, and restorative. None of these categories had been checked to indicate the resident required assistance. --Hand written on the form for eating was: Set up by staff. --Diet: NAS (no added salt) puree nectar thick, extra sauce and gravy no straws. assist with intake. --Fluids were listed a thin consistency even though the above notation said nectar thick liquids. d) Interviews On 11/16/21 at 1:42 PM, Nurse Aide (NA) #140 said the Resident required set up help with her tray only. The interim plan of care was reviewed with NA #140 who reviewed the documentation and said, See it says set up by staff. NA #140 indicated that meant to set up the tray, open any cartons, get the silverware and the Resident eats by herself. She said the plan of care is confusing because it says nectar thick liquids in one place and thin liquids in another place. I don't know what that means. On 11/16/21 at 3:39 PM, Registered Nurse, Unit Manager (RN) #67 said she had talked to the daughter on several occasions about the feeding tube and the daughter is thinking about it. A nursing note dated 09/15/21 was provided by RN #67, noting the daughter, the resident's responsible party, was contacted regarding the feeding tube placement. The call to the daughter was over 1 month after the recommendation from the RD to the physician (08/02/21) requesting the feeding tube placement indicated on the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/16/21 at 3:49 PM, RN #67 said the orders were misplaced when the RD wanted to add Ensure and discontinue pudding and Glucerna on 09/16/21. She stated the orders came in and for some reason they didn't make it up here until 09/23/21. On 11/17/21 at 7:22 AM RN, #67 reviewed the interim plan of care. RN #67 said the Resident needed set up assistance for meals. You open the milk, cut up the meat and then she eats it by herself. She confirmed the resident is to have nectar thick liquids not thin liquids, I don't know why someone wrote that. (RN) #67 confirmed the care plan failed to address the Resident's current diet order for pureed diet with ground meat/extra sauce or gravy, no straws and staff assist for PO (by mouth) intake. On 11/17/21 at 10:02 AM, the Speech Therapist (ST) was interviewed to clarify the intention of the evaluation from 09/30/21. The ST provided the following information: --Assistance with PO intake means staff are to feed the resident, PO means any intake by mouth. She said the Licensed Practical Nurse (LPN) on duty on 09/30/21 was trained to follow the recommendations. She did not recall the specific LPN on duty that day. She said, You could look at the schedule to see which one was working. She said the resident is to be positioned upright, then follow the protocol for feeding. The resident has Dementia progression and she needs the cuing for task initiation. She would benefit from staff offering her bites of food. Sometimes the resident gets off task, like will talk during meal times, that's why I want her to be fed by a trained feeding assistant. On 11/17/21 at 2:16 PM, the RD was interviewed by telephone and was asked what kind of nutritional supplement Resident #71 receives. The RD said all residents have the same order to be offered a supplement if less than 50% of the meal is consumed. It's a house standing order. The RD said she is working with the Dietary Manager (DM) because it is not clear if the supplement is enough to cover the meal you are not eating. The RD would prefer the DM work with her team to refer Residents to them so the residents can get orders from the RD to cover what they need. On 11/17/21 at 2:48 PM, RN #67 was asked what supplements the resident receives when less than 50% of meals are consumed. RN #67 presented 2 supplements from the nourishment room. One was a mighty shake and one was a juice. It was noted the shake contained 330 calories with 9 grams of protein and the juice contained 200 calories with 6 grams of protein. RN #67 said the shake was nectar consistency but if thickener was required for the juice, nurse aides have been trained on adding the thickener. e) Observation of breakfast on 11/17/21. RN #67 delivered the residents tray to her room on 11/17/21 at 7:48 AM. The Resident was setting up in bed with the over the bed table in place. At 7:50 AM on 11/17/21, RN #67 left the Residents room after setting up the tray. Observation on 11/17/21 at 8:09 AM and again at 8:21 AM found the Residents tray still in her room with no staff assistance provided from 7:50 AM through 8:09 AM. Review of the Resident Food intake form on 11/17/21 found the Resident was coded as refusing lunch and refusing the supplement on 11/16/21. On 11/18/21 at 9:17 AM, the Dietary Manager and the Director of Nursing (DON) were interviewed. --The DM said he informs the RD when the Resident loses weight so the RD can evaluate. --The DM reviewed the interim plan of care for the resident and confirmed the plan currently says set up help which means staff set up the tray, cut up the residents food, open containers etc. The DM confirmed the plan did not include staff assistance is required to feed the resident. --The DM said he does not communicate to the nursing department the amount of staff assistance needed for feeding the resident. --The DM said he attends the care plan meetings but he doesn't write the care plan. --When asked about the order, nutritional supplement 6 oz. If less than 50% of meal is consumed, the DM said mighty shakes and juice are offered as nutritional supplements but said, Residents can request other food items for their supplement. When ask if Resident #71 could request a particular food item, he stated, I don't believe so. After review of the speech therapist evaluation, the DM and DON said the Resident should have been fed by the staff. The DON and DM confirmed this should have been communicated to the nursing staff via the care plan and the interim plan of care. -The observations made during the noon meal on 11/16/21 and breakfast on 11/17/21 were communicated to the DON and DM. The Resident did not receive assistance during meal times and documentation supported the fact there was no evidence staff were told the Resident required one on one assistance for eating.

Based on record review, staff interviews, resident interview, review of facility policy, and observation, the facility failed to ensure residents assessed at nutritional risk were provided adequate nutrition and services to prevent significant weight loss. This affected two (2) of four (4) residents reviewed for nutrition. One (1) resident sustained [REDACTED]. One resident experienced a 7.5 pound weight loss in a 40-day period. Resident identifier: #129 and #102. Facility census: 133. Findings include: a) Resident #129 Review of the Resident Admission Record for Resident #129, on 11/18/15 at 9:43 a.m., revealed an original admitted to the facility of 06/23/15, and readmission date of [DATE] following a hospitalization for [MEDICAL CONDITIONS]. The Resident Admission Record indicated Resident #129 had [DIAGNOSES REDACTED]. Review of the Weight Record, on 11/18/15 at 10:31 a.m., revealed Resident #129 weighed 189 pounds at the time of admission. On 11/18/15 at 9:50 a.m., review of Resident #129's Nutritional Assessment completed by Dietary Manager #20, dated 06/23/15, revealed the resident was to receive: -- A mechanical soft diet with nectar thick liquids, and -- Nutritional supplements if she consumed less than 50% of meal. On 11/18/15 at 9:51 a.m., review of the 06/25/15 Nutritional Progress Notes by the dietitian revealed Resident #129: -- Had poor oral intake and stated she was not hungry; -- Current body weight was 189 pounds; and -- Current body mass index (BMI) was 34.6, and indicated the resident was obese. Further review of the 06/25/15 Nutritional Progress Notes revealed the dietitian recommended Resident #129 receive two (2) ounces of a nutritional supplement, Med Pass 2.0, twice per day with medication administration due to the resident's poor oral intakes and the need to increase the resident's calories. On 11/18/15 at 10:44 a.m., review of Resident #129's Admission Minimum Data Set (MDS) assessment dated [DATE], found the resident was 62 inches tall, weighed 189 pounds and required the limited assistance of two (2) for eating. Record review, on 11/18/15 at 12:10 p.m., revealed a physician telephone order dated 07/07/15, for Resident #129 to receive two (2) ounces of Med Pass 2.0 twice a day with medication administration due to poor appetite per the dietitian's recommendation. Review of Resident #129's Weight Record, on 11/18/15 at 10:31 a.m., revealed: -- On 06/30/15 and 07/07/15 the resident weighed 187 pounds. -- On 07/14/15 and 08/08/15, the resident weighed 184 pounds. -- On 09/08/15, Resident #129 was readmitted to the facility following a hospitalization and her weight was 183 pounds. -- On 09/15/15 and 09/22/15, the resident's weight was 183 pounds. Review of Nutritional Progress Notes dated 09/10/15, on 11/18/15 at 9:54 a.m., revealed Resident #129 was readmitted to the facility from the hospital. Orders were given to complete weekly weights for four (4) weeks. Resident #129's diet order remained mechanical soft with nectar thickened liquids. Additional Nutritional Progress Notes dated 09/10/15, reviewed at 9:54 a.m. on 11/18/15, noted Resident #129's family requested the resident receive more sandwiches and a possible diet upgrade. Review of Resident #129's Quarterly Review Dietary Progress Notes dated 09/23/15 at 4:03 p.m., on 11/18/15 at 10:03 a.m., revealed Resident #129 had a speech therapy evaluation and treatment on 09/18/15 for a possible diet upgrade per family request, but the resident was pocketing food on trials of regular texture foods. Review of the resident's speech therapy documentation from 09/21/15 to 10/20/15, revealed an evaluation for possible diet texture upgrade. The documentation stated Resident #129 was previously seen by speech therapy and demonstrated pocketing and low oral intake. On 11/18/15 at 10:35 a.m., review of Resident #129's current care plan for the problem of potential for nutritional risk related to mechanically altered diet, last updated on 09/24/15, revealed the care plan goals included the resident would maintain weight and would maintain adequate intakes. The care plan interventions included to provide diet as ordered, provide supplements as ordered and monitor weights as per protocol and record. Further review of Resident #129's current care plan for the problem of resident over ideal body weight range of 100 - 120 last updated 09/24/15, revealed the goal for Resident #129 was to maintain adequate nutritional status as evidenced by maintaining stable weight. The care plan interventions included to provide diet as ordered, provide supplements as ordered, to monitor the resident's weight as per protocol and record, evaluate any weight changes, determine percentage and follow facility protocol for weight changes and monitor meal intake records. Review of Resident #129's Weight Record, on 11/18/25 at 10:31 a.m., revealed the resident's weight on 09/29/15 and on 10/05/15 was 184 pounds. On 11/18/15 at 10:44 a.m., review of Resident #129's Readmission MDS, dated [DATE], revealed the resident weighed 184 pounds and required supervision with set up for eating. Review of physician orders [REDACTED].#129's liquids to thin liquids and continue all other diet restrictions. Review of Resident #129's Weight Record, on 11/18/25 at 10:31 a.m., revealed the resident's weight on 11/05/15 was 154 pounds. The documentation indicated the resident was reweighed on 11/06/15 and weighed 159 pounds. Further review of Daily Skilled Nurse's Notes, Nutritional Progress Notes and physician orders [REDACTED]. weight loss. Review of Daily Skilled Nurse's Notes from 10/01/15 through 11/05/15 revealed no documentation of the resident having any change in condition that may have contributed to the significant weight loss. Review of Nutritional Progress Notes dated 11/17/15 for Resident #129, on 11/18/15 at 10:05 a.m., revealed Resident #129 triggered for significant one (1) month weight loss, a 13.5% weight loss, with a reweigh of 159 pounds, also a 13.5% weight loss in one (1) month. In addition, Resident #129 experienced a 3 month, 15.8% weight loss since admission. The Progress Notes stated Resident #129 was hospitalized [DATE] to 09/08/15 due to a [MEDICAL CONDITION]. The Progress Notes revealed: -- Oral intakes poor except supper which varies from poor to fair; -- Refusal of most snacks; -- Taking Med Pass 2.0 - 2 ounces twice a day; -- Complains of food and tired of scrambled eggs and ground meats; -- Limited to mechanical soft diet; -- Weight loss may be related to change in [MEDICATION NAME] and [MEDICAL CONDITION]; -- Recommend increase Med Pass to 3 ounces twice a day; and -- Will request cottage cheese with fruit one day per week in place of scrambled eggs. Review of physician orders [REDACTED].#129, on 11/18/15 at 10:21 a.m., revealed a physician's telephone order to change the resident's diet texture to regular and to continue all other diet restrictions, to start 3 ounces of Med Pass 2.0 twice a day due to weight loss. Observation of Resident #129, on 11/18/15 at 12:09 p.m., revealed her seated in her wheelchair in the third floor dining room at a table with other residents waiting to be served their lunch meal. At 12:22 p.m., the residents were served a pulled pork sandwich, coleslaw, tater tots, cherry tart, coffee, milk, and juice. Resident #129 began to slowly start feeding herself without difficulty. Observation, at 12:48 p.m. on 11/18/15, revealed she had eaten approximately 10% of her lunch meal. Interview with Registered Nurse (RN) Unit Manager #2, on 11/18/15 at 12:43 p.m., revealed she was aware of Resident #129's weight loss. RN #2 stated she was unsure of the reason for the resident's weight loss. RN #2 stated the resident had been hospitalized in September 2015 for [MEDICAL CONDITION] and returned from the hospital with an admission weight which was the same as prior to her hospitalization . RN #2 stated they notified the dietitian and reweighed the resident after the obtaining the 11/05/15 weight that indicated the weight loss. The reweigh still indicated Resident #129 had a significant weight loss in one month. RN #2 confirmed the Dietitian ordered an increase in the Med Pass nutritional supplement on 11/17/15. During further interview, on 11/18/15 at 1:37 p.m., RN #2 confirmed she could not explain the resident's weight loss. At that time, RN #2 provided the resident's meal intake sheets for 09/08/15 through 11/17/15. Review of the resident's meal intake sheets revealed the documentation indicated Resident #129's intakes for the time period reviewed included multiple refusals and multiple intakes of less than 50%. The documentation further indicated the resident always refused a nutritional supplement. Observation of Resident #129 on 11/18/15 at 6:00 p.m., revealed the resident in bed slowly eating independently without problems. The meal consisted of sliced turkey, bread dressing, chopped beets, pineapple, milk, coffee, and apple-cranberry nutritional supplement. Resident #129 denied problems with eating the meal. She stated she did not know what the dressing was as it did not look appetizing and that she did not like beets. Resident #129 stated she would continue to try to eat the meal. Interview with the Dietary Supervisor #20, on 11/19/15 at 10:15 a.m., confirmed she was responsible for reviewing the resident intake sheets and weights. Dietary Supervisor #20 stated if any issues were found, they were reported to the Dietitian who came to the facility three (3) times a month. Dietary Supervisor #20 verified she was aware of Resident #129's weight loss in November. She stated she requested the resident be reweighed, but she was not informed of the resident's reweigh. Review of the facility's 09/28/15 Weight Change Procedures, on 11/19/15 at 3:00 p.m., revealed the procedures required: -- All residents will be weighed at least monthly and more often if warranted. -- If resident shows a 5% weight loss/gain or greater, a second weight will be obtained to verify accuracy of previous weight. -- Once weight loss/gain has been determined, the cause of weight loss will be investigated. -- All residents that have weight loss of 5% or greater, will be addressed in resident's care plan.

Based on observation, record review, policy review, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to identify quality deficiencies - of which it should have been aware - related to the administration of medications brought from home, and failed to develop and implement plans of action to correct those quality deficiencies. One (1) of ten (10) residents observed during the medication pass (Resident #155) and one (1) randomly observed resident (Resident #156) received medications from medicine bottles brought from home. Staff interview and record review for Residents #155 and #156 found no evidence these home medications had been reviewed by a licensed pharmacist in accordance with facility policy, to verify the contents of the bottles (e.g., right drug at the right strength, etc.) and to the verify the labels on the bottles matched the current physician's orders [REDACTED]. (See citation at F309 for additional information regarding immediate jeopardy.) Review of the facility's policy regarding QAA processes revealed the QAA committee was to review the facility's pharmacy services annually. Interview with the administrator revealed there was no evidence of QAA committee activity relating to monitoring of the staff's implementation of the facility's policies and procedures with respect to review of medications brought from home prior to administering the medications to residents. Facility census: 134. Findings include: a) Failure of the facility to review medications brought from home before administering them to residents 1. Resident #155 Observation of medication pass on the Alzheimer's unit, at 8:20 a.m. on 07/20/11, found an LPN (Employee #184) administered to Resident #155 medications from two (2) bottles labeled by a pharmacy in the community with fill dates of 06/19/11. The resident was admitted to the facility on [DATE]. These bottles of medication ([MEDICATION NAME] 5 mg and [MEDICATION NAME] 0.5 mg) had been brought by the resident from home, and each bottle contained four (4) pills. Employee #184 said she thought the RN nurse manager (Employee #236) had checked the medications before they were given. - A review of the facility's policy titled "Medications Brought to Household by Resident / Family" (dated 2005), which was received from the facility on 07/20/11 at 2:00 p.m., found the following under the heading "Procedure" (quoted as typed): "1. Over the counter drugs (non-legend) ordered by the resident's physician maybe accepted from the resident, legal representative, family or friend if delivered in the original, unopened manufacturer's package. "2. A licensed nurse will place the name of the resident on the drug container and place the container in the resident's drug drawer or cabinet in their bedroom. "3. If over the counter drugs are removed from the original manufacturer's packaging, other than for administration, a pharmacist will label the drug as required for prescription drugs. "4. Legend medications will not be accepted for administration to a resident unless the medication has been identified by a pharmacist. "5. Any non legend medications brought to the facility that cannot be administered to the resident will be returned to family, friend or legal representative. "6. Legend drugs that cannot be administered to the resident will be destroyed by the consultant pharmacist at the next visit." There was no evidence to reflect this policy and procedure had been reviewed and approved by the medical director. - An interview with Employee #236, on 07/20/11 at 2:15 p.m., found the medications for Resident #155 should have been taken to the pharmacy by the nurse manager and checked by the pharmacist. Employee #236 stated, however, that she was on vacation at the time the resident was admitted to the facility, and she expected the admitting nurse to have taken the medications to the pharmacy for verification in her absence. - An interview with the DON, on 07/20/11 at 2:30 p.m., found the medications for Resident #155 had not been checked by the pharmacist. She said home medications are usually taken to the pharmacy by one (1) of the nurses to be checked; then either the labels are to be initialed or the medication bottles are to be relabeled. -- 2. Resident #156 During medication pass on Unit 2 on 07/20/11 at 8:00 a.m., Employee #175 administered two (2) different eye drops spaced several minutes apart to Resident #156. The medications were [MEDICATION NAME] 2% (1) drop to the right eye and [MEDICATION NAME] 0.2% Ophthalmic one (1) drop to the right eye. - On 07/20/11 at 5:00 p.m., observation of the medication cart for Resident #156's unit, in the company of Employee #234, found in the top drawer a plastic bag containing two (2) unlabeled bottles of ophthalmic solution ([MEDICATION NAME] and [MEDICATION NAME]) and a box labeled [MEDICATION NAME] Ophthalmic Solution 0.0005%. The [MEDICATION NAME] box was labeled with Resident #156's name and directions for its use and contained a bottle of ophthalmic solution. The date on the [MEDICATION NAME] box indicated the medication was dispensed on 07/15/11 - four (4) days prior to Resident #156's admission to the facility on [DATE]. When asked, Employee #234 stated all three (3) ophthalmic medications belonged to Resident #156 and were brought with her from home, even the two (2) unlabeled bottles. She further stated another RN (Employee #221) took all three (3) of the eye drops to the pharmacy for verification of the medications on 07/19/11. When questioned whether there was documentation from the pharmacy to verify that the contents of these medication bottles had been examined, Employee #234 said there was none. -- 3. Resident #13 During medication pass on Unit 2 on 07/20/11 at 8:09 a.m., Employee #175 administered to Resident #13 one (1) puff from an [MEDICATION NAME] inhaler. The inhaler had no pharmacy label on it and no resident name. Employee #175, when questioned about the labeling of the inhaler at this time, stated Resident #13 was the only resident on that unit who used [MEDICATION NAME]. - On 07/20/11 at 5:00 p.m., an observation of the unlabeled [MEDICATION NAME] inhaler was made in the company of Employee #234. Employee #234 suggested that a nurse may have inadvertently thrown away the box for the inhaler which contained the pharmacy label and resident's name. Inspection of the inhaler with Employee #234 revealed three (3) of sixty (60) doses had been used. -- 4. On 07/20/11 at approximately 08:30 a.m., the RN unit manager (Employee #233) for the Unit 3 "Old" said home medications are sent to their original pharmacy and then repackaged by the pharmacy before they are to be administered to the residents. This procedure was not implemented for Residents #155 and #156, whose home medications were not verified by a pharmacist prior to administration by the nursing facility, to ensure the medications in the bottles matched what was identified on the labels (for drug, dosage, frequency, route, etc.) and were in accordance with the orders written upon admission by the attending physician. -- 5. During an interview on 07/21/11 at 09:15 a.m., Employee #234 stated she was in the process of developing a log whereby the nurse would record the date / time the medications were transported to the pharmacy for review, the name of the nurse doing the transport, and any other pertinent information, so the facility would have documented proof that the pharmacy verified the home medications prior to administration of these meds to the residents by facility staff. -- 6. The survey team met with facility administration on at 9:30 a.m. on 07/21/11, at which time the administrator and director of nursing (DON) were informed that immediate jeopardy existed with respect to administering home medications to Resident #155 before having these medications reviewed by a pharmacist. Additional findings were related to the administrator and the DON on 07/21/11 at 10:00 a.m., regarding Residents #156 and #13. The DON said they currently had no written means to show that home medications were being verified from the pharmacy prior to administration to residents. According to the DON, the meds were to be taken to the original filling pharmacy, and the pharmacist was to initial the label to indicate the verification had occurred; however, the DON acknowledged that the facility's current policy on home medications did not include this procedure. She said the two (2) medications without pharmacy labels probably had labels on the boxes and the boxes did not come with the resident. --- b) The facility's policy and procedures titled "Quality Assurance Process" (not dated) stated: "1. The Quality Assurance will first identify an area to be assess. Identification can be based upon complaints, suggestions, quality indicators outside of the standards determined up periodic review, surveyors or questionnaires from the residents, families, or staff members. ..." An addendum titled "Areas To Be Reviewed Yearly" (not dated) identified sixteen (16) topics to be reviewed annually, including "7. Pharmacy". In the Pharmacy section, under the heading "Suggested Members of the Quality Action Team", found the consultant pharmacist, assistant director of nursing or DON, medical director, head nurse, and an LPN (or medication aide), with the facility's quality assurance coordinator serving as a resource to the action team. Under the heading of "Role of the Quality Action Team" was found: "3. The action team will devise a plan to complete the Pharmacy Service Review, Medication Station Review, and Review of Medications and Resident Self Medication. The plan should include specific activities, members responsible for those activities, and the time frame for completion. The plan should be recorded on the Action Team Work Plan ..." - During an interview with the administrator on 07/27/11 at 09:30 a.m., she reported she found no evidence of QAA committee activity relating to monitoring of the staff's implementation of the facility's policies and procedures with respect to review of medications brought from home prior to administering the medications to residents.

Part I -- Based on observation, staff interview, medical record review, and policy review, the facility failed to provide necessary care and services to attain or maintain each resident's highest practicable physical well-being. One (1) of ten (10) residents observed during the medication pass (Resident #155) and one (1) randomly observed resident (Resident #156) received medications from medicine bottles brought from home. Staff interview and record review for Residents #155 and #156 found no evidence these home medications had been reviewed by a licensed pharmacist in accordance with facility policy, to verify the contents of the bottles (e.g., right drug at the right strength, etc.) and to the verify the labels on the bottles matched the current physician's orders [REDACTED]. The facility also failed to ensure one (1) of ten (10) residents observed during the medication pass (Resident #13) received medication from a container that was properly labeled. The survey team met with facility administration on at 9:30 a.m. on 07/21/11, at which time the administrator and director of nursing (DON) were informed that immediate jeopardy existed. The facility submitted an action plan to remove the immediate jeopardy at 2:53 p.m. on 07/21/11. The action plan included removing from the nursing units all medications brought from home which had not yet been reviewed by the physician, obtaining doses of the medications for the affected residents until their home medications could be reviewed, removing from the units all medications that were not properly labeled, and instituting a procedure for documenting the pharmacist's review of home medications before they are made available for administration to residents. On the afternoon of 07/21/11, the survey team verified that all home medications in-house for current residents had been had been reviewed by a pharmacist in accordance with the new procedure and that all medication carts were free of unlabeled medications. At 3:15 p.m. on 07/21/11, the administrator was informed that immediate jeopardy was removed. After removal of the immediate jeopardy, a deficient practice with the potential for causing more than minimal harm to more than an isolated number of residents remained until the facility was able to inservice all nurses who were not present on 07/21/11 on the new policy and procedure. Resident identifiers: #155, #156, and #13. Facility census: 134. Findings include: a) Resident #155 Observation of medication pass on the Alzheimer's unit, at 8:20 a.m. on 07/20/11, found an LPN (Employee #184) administered to Resident #155 medications from two (2) bottles labeled by a pharmacy in the community with fill dates of 06/19/11. The resident was admitted to the facility on [DATE]. These bottles of medication ([MEDICATION NAME] 5 mg and [MEDICATION NAME] 0.5 mg) had been brought by the resident from home, and each bottle contained four (4) pills. Employee #184 said she thought the RN nurse manager (Employee #236) had checked the medications before they were given. - A review of the facility's policy titled "Medications Brought to Household by Resident / Family" (dated 2005), which was received from the facility on 07/20/11 at 2:00 p.m., found the following under the heading "Procedure" (quoted as typed): "1. Over the counter drugs (non-legend) ordered by the resident's physician maybe accepted from the resident, legal representative, family or friend if delivered in the original, unopened manufacturer's package. "2. A licensed nurse will place the name of the resident on the drug container and place the container in the resident's drug drawer or cabinet in their bedroom. "3. If over the counter drugs are removed from the original manufacturer's packaging, other than for administration, a pharmacist will label the drug as required for prescription drugs. "4. Legend medications will not be accepted for administration to a resident unless the medication has been identified by a pharmacist. "5. Any non legend medications brought to the facility that cannot be administered to the resident will be returned to family, friend or legal representative. "6. Legend drugs that cannot be administered to the resident will be destroyed by the consultant pharmacist at the next visit. " There was no evidence to reflect this policy and procedure had been reviewed and approved by the medical director. - An interview with Employee #236, on 07/20/11 at 2:15 p.m., found the medications for Resident #155 should have been taken to the pharmacy by the nurse manager and checked by the pharmacist. Employee #236 stated, however, that she was on vacation at the time the resident was admitted to the facility, and she expected the admitting nurse to have taken the medications to the pharmacy for verification in her absence. - An interview with the DON, on 07/20/11 at 2:30 p.m., found the medications for Resident #155 had not been checked by the pharmacist. She said home medications are usually taken to the pharmacy by one (1) of the nurses to be checked; then either the labels are to be initialed or the medication bottles are to be relabeled. -- b) Resident #156 During medication pass on Unit 2 on 07/20/11 at 8:00 a.m., Employee #175 administered two (2) different eye drops spaced several minutes apart to Resident #156. The medications were [MEDICATION NAME] 2% (1) drop to the right eye and [MEDICATION NAME] 0.2% Ophthalmic one (1) drop to the right eye. - On 07/20/11 at 5:00 p.m., observation of the medication cart for Resident #156's unit, in the company of Employee #234, found in the top drawer a plastic bag containing two (2) unlabeled bottles of ophthalmic solution ([MEDICATION NAME] and [MEDICATION NAME]) and a box labeled [MEDICATION NAME] Ophthalmic Solution 0.0005%. The [MEDICATION NAME] box was labeled with Resident #156's name and directions for its use and contained a bottle of ophthalmic solution. The date on the [MEDICATION NAME] box indicated the medication was dispensed on 07/15/11 - four (4) days prior to Resident #156's admission to the facility on [DATE]. When asked, Employee #234 stated all three (3) ophthalmic medications belonged to Resident #156 and were brought with her from home, even the two (2) unlabeled bottles. She further stated another RN (Employee #221) took all three (3) of the eye drops to the pharmacy for verification of the medications on 07/19/11. When questioned whether there was documentation from the pharmacy to verify that the contents of these medication bottles had been examined, Employee #234 said there was none. -- c) Resident #13 During medication pass on Unit 2 on 07/20/11 at 8:09 a.m., Employee #175 administered to Resident #13 one (1) puff from an [MEDICATION NAME] inhaler. The inhaler had no pharmacy label on it and no resident name. Employee #175, when questioned about the labeling of the inhaler at this time, stated Resident #13 was the only resident on that unit who used [MEDICATION NAME]. - On 07/20/11 at 5:00 p.m., an observation of the unlabeled [MEDICATION NAME] inhaler was made in the company of Employee #234. Employee #234 suggested that a nurse may have inadvertently thrown away the box for the inhaler which contained the pharmacy label and resident's name. Inspection of the inhaler with Employee #234 revealed three (3) of sixty (60) doses had been used. -- d) On 07/20/11 at approximately 08:30 a.m., the RN unit manager (Employee #233) for the Unit 3 "Old" said home medications are sent to their original pharmacy and then repackaged by the pharmacy before they are to be administered to the residents. This procedure was not implemented for Residents #155 and #156, whose home medications were not verified by a pharmacist prior to administration by the nursing facility, to ensure the medications in the bottles matched what was identified on the labels (for drug, dosage, frequency, route, etc.) and were in accordance with the orders written upon admission by the attending physician. -- e) On 07/21/11 at 07:37 a.m., the survey team initiated email communication with the Program Manager II at the State survey agency regarding the above findings. At 8:20 a.m. on 07/21/11, the survey team met and reviewed Appendix Q of the State Operations Manual issued by the Centers for Medicare & Medicaid Services (CMS) for Immediate Jeopardy. Based upon review and the definitions, principles, triggers, and procedures within Appendix Q, the survey team determined that immediate jeopardy existed with respect to administering home medications to residents without first having these medications verified by a licensed pharmacist. At 9:00 a.m., the Program Manager II concurred with the determination of immediate jeopardy in this situation. - During an interview on 07/21/11 at 09:15 a.m., Employee #234 stated she was in the process of developing a log whereby the nurse would record the date / time the medications were transported to the pharmacy for review, the name of the nurse doing the transport, and any other pertinent information, so the facility would have documented proof that the pharmacy verified the home medications prior to administration of these meds to the residents by facility staff. - The survey team met with facility administration on at 9:30 a.m. on 07/21/11, at which time the administrator and director of nursing (DON) were informed that immediate jeopardy existed with respect to administering home medications to Resident #155 before having these medications reviewed by a pharmacist. - Additional findings were related to the administrator and the DON on 07/21/11 at 10:00 a.m., regarding Residents #156 and #13. The DON said they currently had no written means to show that home medications were being verified from the pharmacy prior to administration to residents. According to the DON, the meds were to be taken to the original filling pharmacy, and the pharmacist was to initial the label to indicate the verification had occurred; however, the DON acknowledged that the facility's current policy on home medications did not include this procedure. She said the two (2) medications without pharmacy labels probably had labels on the boxes and the boxes did not come with the resident. -- f) The facility submitted an action plan to remove the immediate jeopardy at 2:53 p.m. on 07/21/11. The action plan, titled "Plan of Correction: In Response to Immediate Jeopardy Citation" and dated 07/21/11, stated (quoted as typed): "1. To correct the alleged deficient practice - (Resident #155's) medication that was brought in from home and allegedly not reviewed by pharmacist before administration were immediately removed from the residents neighborhood by the nurse manager. New medications were obtained. 7/20/2011 "2. To identify others that have the potential to be affected by those alleged deficient practice, the nurse managers on each neighborhood immediately reviewed all residents medications on site to insure that all other drugs that came from home were reviewed by a pharmacist prior to administration. If any found, they will be immediately sent for review or disposal of and new medications ordered. 7/21/2011 "3. To ensure that the alleged deficient practice does not re-cur, policies and procedures pertaining to medications brought from home were reviewed and revised. (See attached) In addition, a new form was developed to show proof of pharmacist review. (See attached) After completed, this form will be placed in MAR (medication administration record) to show proof of review. This will remain in place until home meds are used and any new medications are obtained from pharmacy. Also, review of medications brought in by families has been added to Admission Checklist for admission nurse and staff nurse to check to see that the review was done per policy. In addition, DON and Staff Development Director will in-service all nurse managers, staff nurses, admission and supervisory nurses to new policy changes and new forms by 7/29/0011. "4. The above corrective actions will be monitored to ensure the practice does not re-cur by nurse managers in each neighborhood. They will check to see that medications brought in from home were indeed reviewed by a pharmacist when doing their review of all new admissions. In addition, the DON wills spot check these meds randomly on a monthly basis to ensure that no meds have been missed. The Q.A. (Quality Assurance) Coordinator will also add review of home medications to her annual med review. 7/21/2011 " - Attached to the plan was a revised policy titled "Medications Brought to Household by Resident / Family" (with no revision date recorded), which included the following revised steps (quoted as typed): "4. Prescription medications will not be accepted for administration to a resident unless the medication has been identified by a pharmacist. "5. Admission Nurse or her designee is responsible for sending medications to pharmacist for review at time of admission along with Pharmacy Review & Identification Form. Form will then be placed in resident's MAR indicated [REDACTED]. "6. Staff Nurse must validate that meds have been reviewed prior to medication administration per Admission Checklist. "7. Any over the counter medications brought to the facility that cannot be administered to the resident will be returned to the family, friend or legal representative. "8. Prescription drugs that cannot be administered to the resident will be destroyed by the consultant pharmacist at the next visit." - The plan included a form on which to document the pharmacist's review, which was to be placed on the resident's MAR prior to administration of the home medications. This review was also added as an item to a checklist to be completed by the nurse for any new admission bringing medications from home. Plans were put in place for the education of all licensed nursing staff the new policy and procedure. -- g) On 07/21/11 at 2:45 p.m., observation of the Unit 2 medication cart found Resident #156's two (2) bottles of eye drops ([MEDICATION NAME] and [MEDICATION NAME]) were labeled appropriately. At this time, the DON and Employee #234 produced the new form where the pharmacist had initialed indicating he verified these ophthalmic solutions. When asked if the [MEDICATION NAME] eye drops Resident #156 brought from home had been initialed by the pharmacist, as there was no new label on it, Employee #234 said they had not taken that medication to the pharmacist, since the label was recently written on 07/15/11. Another RN (Employee #221), who was also present, said she would take the [MEDICATION NAME] back to the pharmacist and obtain the pharmacist's initials for verification. On 07/21/11 at 3:10 p.m., Employee #221 produced the [MEDICATION NAME] eye drops along with the pharmacist's signature for verification. Also at this time, the [MEDICATION NAME] Inhaler for Resident #13 was observed to be properly labeled. The surveyors completed an inspection of all medication carts for unlabeled prescription medications at3:00 p.m., and the administrator was notified at 3:15 p.m. on 07/21/11 that the circumstances giving rise to immediate jeopardy had been removed. --- Part II -- Based on record review and staff interview, the facility failed to assess / monitor one (1) of forty-six (46) Stage II sample residents who exhibited an acute change in condition and obtain timely medical intervention which resulted in a delay in treatment. Resident #101 had treatment orders to assess her skin every shift and note any problem areas in the nurses notes. Nursing staff documented, on 07/01/11, the presence of a red raised area with a yellow center on the resident's lower left abdomen, but no further documentation was recorded in the nursing notes regarding the status of this alteration in skin integrity until 07/04/11, when the area was noted to have thick yellow exudate. Although a licensed practical nurse (LPN) documented having faxed information about this area to the on-call physician on 07/04/11, there was no evidence in the facility's fax book of this communication with the on-call physician, there was no evidence that any nursing staff communicated this information to the registered nurse (RN) on-call or to nurses on subsequent shifts, and there was no evidence that any nursing staff followed up with the resident's attending physician when no response was received from the on-call physician. No further documentation was found in the nursing notes about the abdominal wound from 07/04/11 until 07/08/11, when the resident was transferred to the hospital and admitted for treatment including surgical excision of a large abdominal mass. Resident identifier: #101. Facility census: 134. Findings include: a) Resident #101 Review of the July 2011 treatment administration record (TAR) revealed an order, dated 05/05/11, to assess the resident's skin and circulation every shift and note any problem areas in nursing notes. Each block on the TAR for all three (3) shifts from 07/01/11 through 07/08/11 was initialed by a nurse, indicating that a skin assessment had been completed on each shift. Review of nursing notes found an entry, dated 07/01/11 at 8:00 p.m., describing a red raised area with a yellow center and no drainage on the resident's lower left abdomen. The resident was [MEDICATION NAME] this time for a urinary tract infection and had previously been treated with another antibiotic (Z-Pak) from 06/16/11 through 06/20/11. Review of nursing notes revealed no additional entries to indicate there was any monitoring of the left abdominal wound until 07/04/11 at 8:45 p.m., at which time an LPN (Employee #172) documented that she had faxed the on-call physician (who was covering during the absence of the attending physician) information regarding the presence of a "red raised area, resembling a boil on lower left abdomen ... with occasional thick yellow exudate noticed". Review of nursing notes revealed no additional entries to indicate there was any monitoring of the left abdominal wound until 07/08/11 at 8:45 p.m., when a nurse recorded, "See transfer sheet." Review of the nursing transfer / discharge note, dated 07/08/11 at 8:45 p.m., revealed Resident #101 was transferred to the emergency room and subsequently admitted to a local hospital because of increased confusion and a large, painful, red area to the left abdomen. This reddened area measured 3 cm x 2 cm with a white center. A "Body Check" form, dated 07/08/11, described the left abdominal wound as a red area with a white center, warm, hard, and painful to touch. Review of an operative report from the hospital revealed a preoperative and postoperative [DIAGNOSES REDACTED]. An excision of a large mass on the anterior abdominal wall was performed on 07/11/11. Review of nursing notes, dated 07/11/11 at 10:15 p.m., found the resident returned to the facility by ambulance, was prescribed an antibiotic, was ordered to have a wound vac the following morning, and was to attend a follow-up appointment at the wound clinic on 07/25/11. During an interview on 07/26/11 at 11:20 a.m., the ward clerk (Employee #241) said faxes were filed in the fax book to show, if asked, that staff had sent notifications to the physician. She looked through the fax book and said there was no fax filed in the book of any communication to the on-call physician caring for Resident #101 on 07/04/11. When asked if the physician's response or outcome was always written on the fax in the book, she said, "Not always." During an interview with an RN supervisor (Employee #234) on 07/26/11 at 2:40 p.m., she said she would have expected the nurses to document the resident's skin condition each day after the redness on the abdomen was first discovered on 07/01/11. She agreed there was no fax on file related to the nurse notifying the on-call physician of the resident's abdominal wound with exudate. She said filing of the faxes in the book was not a policy - rather, it was a nursing measure to show proof that a fax had been sent - and that the unit secretary was responsible for filing them. She stated the nurse on 07/04/11 should have communicated to the next shift about the status of the resident's abdomen, followed up with the physician, and notified the RN on-call of the exudate. She stated their infection control program specifies the RN supervisor is to be notified when there is a wound with drainage. It was she (Employee #234) who was the RN on-call that day, and she confirmed she was not notified of the wound. She said a culture and sensitivity should have been done on the exudate and treatment should have been initiated at that time. During an interview with the administrator on 07/27/11 at 7:30 a.m., she said the nurse should have spoken with the physician about the drainage and should have inquired whether he wanted to order a culture. No further information was presented related to the absence of the fax in the book regarding communication the nurse had with the on-call physician about the wound on Resident #101's abdomen on 07/04/11, and no further information was presented related to having no follow-up communication with the attending physician or other nursing staff about the wound. During an interview with an LPN (Employee #176) on 07/27/11 at 9:40 a.m., she clarified that Resident #101's physician called with new orders for lab tests for the resident on 07/07/11, and that he did not say anything about Resident #101's abdomen during that telephone call. She further stated she knew nothing about a fax by Employee #172 to the on-call physician regarding the resident's abdomen, and she verified that information about the abdominal wound was not passed along to nursing staff on the subsequent shift. .