Every finding on record at Weirton Medical Center

Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. The staff failed to don a hairnet while in the kitchen. Lastly, the facility failed to follow the proper sanitation practices for the kitchen and the food preparation equipment This practice had the potential to affect all of the residents. Facility census: 27.Initial walkthrough of the kitchen upon entry into the facility on 2/2/26 at 11:45 AM. Findings include: Found six (6) quarts of whole milk that were outdated with a use by date of 01/30/2026. Diced celery was outdated with a use by date of 01/30/2026. One (1) container of sugar free lime gelatin was outdated with a use by date of 01/27/2026. In the walk-in refrigerator that has the fresh produce, the covers located on the condenser / evaporator need to be taken off and cleaned due to rust and debris. In the walk-in freezer there were one (1) bag of chicken tenders, one (1) bag of hashbrowns and one (1) box of crab cakes that were opened and were not dated properly. There was one (1) outdated beef pot roast in the walk-in refrigerator with a use by date of 01/24/2026. There were two (2) containers of chicken salad without a proper label or date in walk-in refrigerator. There was one (1) bag of pre-cooked hamburger patties not labeled or dated properly in the walk-in refrigerator. There was two (2) bags of liquid eggs not labeled or dated properly in the walk-in refrigerator. One (1) container of boiled eggs did not have a use by date in the walk-in refrigerator. One (1) bag of leftover pancakes, french toast and english muffins were not labeled or dated properly in the walk-in refrigerator. One (1) package of apple cinnamon scones were not labeled or dated properly in the walk-in freezer. Two (2) packages of gluten free bread located in the walk-in freezer was not labeled or dated properly. One (1) package of crab cakes located in the walk-in freezer was without an open or use by date. One (1) of three (3) can openers were soiled with debris and needed to be cleaned. One (1) package of opened whipped topping located in the reach-in refrigerator was not dated properly. One (1) opened package of hotdogs were not sealed correctly and was open to air in the reach-in refrigerator. At 12:19 PM on 02/02/2026 employee #69 did not have a hair net on. The Director of Nutrition Services (DNS) was beside me when this was discovered. I asked the Director if employee #69 was supposed to have a hairnet on while in the kitchen, and she said yes and asked employee #69 to put one on. I then asked for a copy of the employee dress code for nutrition services. 02/04/2026 at 8:45 AM This surveyor completed a second visit to the kitchen. Findings include: One (1) employee beverage was located in the kitchen on a cart that had other food items on it. I brought it to the attention of the Lead Nutrition Services Manager (LNSM) and the Director of Nutrition Services. They both said that they thought it was ok just as long as it had a lid with a straw on it. The LNSM removed it, and said she would educate all nutrition staff on this concern. The same one (1) package of crab cakes that were in the freezer during the initial walkthrough on 02/02/2026 was found again, without an open or use by date. There were two (2) packages of diced red potatoes that were not labeled or dated properly located in the walk-in refrigerator. There was 0ne (1) container of lime gelatin that was not covered properly in the walk-in refrigerator. The walk-in freezer that held the ice cream had a lot of debris on the floor that needed to be swept up. The LNSM said she would do that next. 02/04/2026 at 9:15 AM The DNS gave me the following policies for the department. Proper labeling and dating of foods. Food storage. Food storage to prevent cross contamination. Dress code for food and nutrition services.

Based on observation and staff and resident interviews the facility failed to have an ongoing activities program that meets the needs of the residents. Census 28. PS and findings JS The facility failed to provide activities for the residents based on observation and interviews with residents and staff.02/02/2026 3:14 PM complaints that there are never any activities, stated that the girl never shows up Interview with activity director 2:40 pm on 2/4/26 when questioned about why there are only four days a week scheduled for activities, she replied that they are short on staffing. Based on observation there was only one group activity done out of four days Monday through Thursday.The only activity completed was bingo which was held 2/4/26 at 1:30 PM.The activity calendar was only completed for 4 days a week with no activities being held on the other 3 days.No Notes

Based on observation and interviews, the facility failed to ensure the resident environment over which they had control was as free from accident hazards as possible in regards to bed safety. This was a random opportunity for discovery. Room Identifiers: #1, #10, #15. Facility census: 27. Findings Include: a) Resident #10 During an initial tour of the facility an observation, completed on 02/09/26 at 3:16 PM, revealed Resident #10 was lying in bed with an approximate 12-inch gap between the mattress and foot board. b) Resident # 1During an initial tour of the facility an observation, completed on 02/09/26 at 3:30 PM, revealed Resident #1 was lying in bed with an approximate 12-inch gap between the mattress and foot board. c) Resident #15An observation on 02/09/26 at 3:45 PM was made of Resident # 15 sitting up in a chair by his bed. The bed was observed to have a large gap at the foot board and mattress. During an interview and tour on 02/09/26 at 4:10 PM, the Director of Nursing verified the gaps between the mattress and foot boards for Residents #1, #10 and #15. She stated that these are the beds that's always been on this unit. She also stated that they do not do a bed evaluation between residents. She continued to say that she would have the maintenance director look at them tomorrow, and that she would put bed stuffers / wedges in place for the night.

Based on records review and staff interviews, the facility failed to ensure a complete and accurate medical records. This failed practice was found true for one (1) of four (4) residents reviewed during the survey. Resident identifier: #5 Facility Census: 27 Findings Included:During an electronic medical record review of Resident #5's Physician designated code status on 02/05/26 at 8:20 AM, Resident #5 was listed as a full code, attempt to resuscitate.On 02/05/26 at 8:25AM, during a record review of Resident #5's Chart, an Advance Directive form was not in the chart. Registered Nurse Employee # 66 provided Resident #5's Kardex. The Kardex, it was marked comfort at which time, She acknowledged the Kardex did not match the electronic medical record. When asked what staff would go by for guidance of resident wishes, she stated the Kardex.On 02/05/26 at 8:30AM, In an interview with the MDS Coordinator with the DON present, she acknowledged the Kardex and the electronic record did not match but would look for the correct record On 2/06/26 at 8:55AM, the MDS Coordinator reported she could not find the previous hospital stay record and stated, depending on the nurse, some staff would follow the Kardex and others would follow the electronic chart.

Based on record review and staff interview, the facility failed to develop accurate written abuse and neglect policies and failed to implement procedures for reporting to prevent all types of abuse. The facility failed to report an incident of neglect/mistreatment with Resident #2. This practice affected one (1) of two residents reviewed using the abuse pathway in the survey process. This failed practice had the potential to affect more than a limited number of residents who reside at the facility. Resident identifier: #2. Facility census: 24. Findings included: a) Based on an interview of Resident #2 on 06/24/24 at 1:05 PM, resident stated that she had needed to use her bedside commode on 06/23/24 at around 6:00 AM. Resident stated that no one had responded to her call light for over two (2) hours. She further stated that she was sitting at the edge of her bed and could feel herself sliding off, so she had begun to shout out loudly for assistance. Her calls were responded to by a Nursing Assistant (NA) #15, who told her to stop shouting so loudly. Resident's family member, who was present, stated that her sister, had made a complaint to the nurse in charge on 06/23/24 at 10:35 AM. She stated that no one had responded to the complaint. Investigation, and record review, revealed that the nurse in charge, RN #16, had submitted an email to the Director of Nursing (DON) #23 on 06/23/24 at 11:32 AM. The email stated: room [ROOM NUMBER] Resident #12's daughter is very upset. She said that her mother was on the call light for over two (2) hours from 4am - 6am. She said that a girl came in the room and asked her if she needed help and left her without helping and acted like she didn't know what a bedside commode was and left her. Family is upset and would like to talk to you. b) Review on 06/26/24 at 11:33 AM, of the facility's policy Abuse, Neglect and Exploitation, with an initial date of September 1990, and review, and revision dates from 08/91 through 03/22, revealed that the purpose of the policy is to assure that patients are free from mistreatment, neglect or abuse, including injuries of unknown source. The facility prohibits abuse, neglect, and exploitation of resident property. A review of the policy definitions revealed the following: Willfil - means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Verbral Abuse - means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Physical Abuse - includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental Abuse - is non-consensual sexual contact of any type with a resident. Further review of the policy revealed that the policy states that: Suspicion of abuse/neglect/exploitation, or reports of abuse/neglect/exploitation are to be responded to immediately. 1. The licensed Registered Nurse will: a. Respond to the needs of the resident and protect him/ her from further incident. b. Remove the accused employee from the resident care areas. c. Notify the Director of Nursing Service and Administrator d. Notify the attending physician, resident's family/legal representative, and Medical Director. e. Monitor and document the resident's condition, including response to medical treatment or nursing interventions. f. Document actions taken in the medical record. g. Protect the individual from further injury or mental anguish. h. Complete an incident report and initiate an investigation. 2. The Director of Nursing Services, Administrator or designee will: a. Notify the appropriate agencies immediately: as soon as possible, but no later than twenty- four (24) hours after discovery of the incident. b. Obtain statements from direct care staff. c. Suspend the accused employee pending completion of the investigation. d. Follow up with the appropriate agencies . to confirm the report was received. e. Report to the state nurse aide registry or nursing board any knowledge of any actions which would indicate an employee is unfit for service. Further record review, and interviews, with DON #23 revealed that none of the actions mandated in the policy had been initiated or acted upon. A review of the facility reportables, on 06/25/24 at 11:45 AM, did not find a corresponding reportable to the appropriate state agencies. During an interview with the DON on 06/25/24 at 2:28 PM, she stated that she had pulled the call log response time, but she had not yet had the opportunity to talk to the resident's daughter, due to surveyors entering the facility.

The facility failed to provide an environment that was free from accident hazards over which the facility had control. Water temperatures were found to be above 120 degrees Fahrenheit (F). This deficient practice had the potential to affect more than a limited number of residents. Facility census: 24. Findings included: a) State Operations Manual Appendix PP Review of the State Operations Manual Appendix PP found in the interpretive guidelines for F689 the following concern regarding water temperatures: - Water temperature of 124 degrees Fahrenheit will cause a 3rd degree burn in 3 minutes. - Water temperature of 120 degrees Fahrenheit will cause a 3rd degree burn in 5 minutes. - Burns can occur even at water temperatures below those identified, depending on an individual's condition and the length of exposure. -Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-degree burns surrounding third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black. b) Water Temperatures On 06/24/24 at 2:30 PM, the water temperature of the sink in room [ROOM NUMBER] was tested by Maintenance Worker #26 under observation of the surveyor. The water temperature was tested by inserting the stem of the thermometer into the stream of running water, so that the sensor was fully immersed. A water temperature of 120.5 degrees Fahrenheit was reached. Maintenance Worker #26 stated he knew it was undesirable to have a water temperature at or above 120.0 degrees Fahrenheit. The following areas of the facility were also tested by Maintenance Worker #26 under observation of the surveyor and had temperatures greater than 110 degrees Fahrenheit. - The shower room sink had a water temperature of 124.0 degrees Fahrenheit. - The sink in room [ROOM NUMBER] had a water temperature of 123.2 degrees Fahrenheit. During an interview, on 06/24/24 at 3:55 PM, the Director of Nursing confirmed that plant maintenance staff would ensure all water temperatures were immediately addressed to ensure resident safety.

Based on observation, and staff interview, the facility failed to ensure the safe storage of medications in the medication room. The facility had made no provision to install the appropriate environmental controls, and monitoring devices, to preserve the integrity of the medications stored in the medication room. This was a random opportunity for discovery. This failed practice had the potential for more than minimal harm. Facility census: 24. Findings included: a) Medication Room During an inspection of the medication room on 06/25/24 at 08:11 AM, this surveyor noted that there was no temperature monitoring device in the medication room. Interview of LPN #12 at 08:14 AM revealed that the medication room temperature was not monitored or documented. The Director of Nursing (DON) # 23, on 06/26/24 at 11:38 AM, confirmed that the medication room temperature was not monitored. She stated she would have to consult with the pharmacy. The DON acknowledged that she did not have any knowledge of the need for the medication room to be temperature monitored. Manufacturers' recommendations specify the storage temperature range for medications, because many medications can be altered by exposure to improper temperature, light, or humidity, it is important the facility implement procedures that address and monitor the safe storage and handling of medications in accordance these recommendations.

Based on interview and investigation, the facility failed to ensure Resident #2's preferred sleeping and waking times were honored. This failed practice had the potential to affect more than a limited number of residents who reside at the facility. This was a random opportunity for discovery. Resident Identifier #2. Facility Census: 24 Findings included: a) Resident #2 During an interview with Resident #2, she stated she was woken up at around 4:30 AM on 06/26/24 by three (3) Nursing Assistants (NAs). Resident #2 stated they set about getting her things packed. She said that they stated that they were getting her ready for discharge. She stated that she was unable to identify the NAs because it was dark, and she had just woken up. Resident stated, I paid for this room, and I will decide when to wake up, and when to get ready. An interview with the resident's daughter at 1:08 PM on 06/26/24, revealed she had made a complaint to RN #17. She stated the RN said that staff had probably, attempted to get a jump on things. During an Interview with RN #17 at 1:17 PM on 06/26/24 she stated she had received a complaint from the resident, and the resident's daughter. She further stated she had forwarded the complaint to Director of Nursing (DON) #23. While being interviewed, on 06/26/24 at 1:38 PM, (DON) #23 stated she would review the previous night's staffing schedule and investigate the complaint. The DON agreed that residents had the right to choose their schedules, consistent with their interests, assessments, and care plans. This included, but was not limited to, choices about the schedules that were important to the resident, such as waking, eating, bathing, and going to bed at night.

Based on observation and staff interview, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. This deficient practice had the ability to affect more than a limited number of residents and/or family members. This was a random opportunity for discovery. Facility census: 24. Findings included: a) Survey Results During an observation, completed on 06/26/24 at 10:19 AM, it was determined the facility had signage by the elevator indicating that survey results were available in the three-ring binder kept in a clear, wall mounted bin by the signage. Further observation revealed the three-ring binder did not have the results of the most recent Long-Term Care Survey Process. During an interview on 06/26/24 10:25 AM, the current Director of Nursing (DON) confirmed the binder did not have the most recent Long-term Care Survey Process survey. At that time, the DON spoke to the former DON who was working on the floor in a different capacity. The former DON stated, It was there. Maybe it was taken and not replaced.

Based on medical record review and staff interview, the facility failed to ensure Advance Directive paperwork was part of the resident's medical record. This was true for one (1) of 13 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #139. Facility census: 24. Findings included: a) Resident #139 A medical record review, completed on 06/25/24 at 8:27 AM, indicated that Resident #139 was admitted to the facility on [DATE]. It also identified the following details: -Resident #139's profile page identified the fact that one of resident's family members was appointed as Medical Power of Attorney (MPOA). -A Advance Directive Acknowledgement form on file and indicated Resident #139 been informed of his right under the law to use an Advance Directive while at the facility. Resident #139 indicated that he did have an Advance Directive and wanted it included in his medical record. -There was no copy of the Advance Directive paperwork scanned into the electronic record. -There was no copy of the Advance Directive paperwork on Resident #139's hard chart at the nurses' station. During an interview, on 06/26/24 at 10:50 AM, the MDS Coordinator reported the facility could not produce resident's Advance Directive paperwork which meant there was no way of knowing if a Living Will was part of it and what the resident's wishes would be in a true medical emergency where he was very sick and unable to communicate his wishes for himself.

Based on record review, resident interview, and staff interviews, the facility failed to report allegations of neglect and verbal abuse for Resident #2. This was a random opportunity for discovery. This failed practice has the potential to affect more than a limited number of residents at the facility. Resident Identifier #2. Facility census:24 Findings: a) Resident #2 During an interview of Resident #2 on 06/24/24 at 1:05 PM, resident stated that she had needed to use her bedside commode on 06/23/24 at around 6:00 AM. Resident stated that no one had responded to her call light for over two (2) hours. She further stated that she was sitting on the edge of her bed and could feel herself sliding off, so she had begun to shout out loudly for assistance. Her calls were responded to by Nursing Assistant (NA) #15, who told her to stop shouting so loudly. Resident's family member, who was present, stated that her sister had made a complaint to the nurse in charge on 06/23/24 at 10:35 AM. She stated that no one had responded to the complaint. Investigation, and record review, revealed that the nurse in charge, RN #16, had submitted an email to the Director of Nursing (DON) #23 on 06/23/24 at 11:32 AM. The email stated: room [ROOM NUMBER] Resident #12's daughter is very upset. She said that her mother was on the call light for over two (2) hours from 4am - 6am. She said that a girl came in the room and asked her if she needed help and left her without helping and acted like she didn't know what a bedside commode was and left her. Family is upset and would like to talk to you. A review of the facility reportables, on 06/25/24 at 11:45 AM, did not find a corresponding reportable to the appropriate state agencies. During an interview with the DON on 06/25/24 at 2:28 PM, she stated that she had pulled the call log response time, but she had not yet had the opportunity to talk to the resident's daughter, due to surveyors entering the facility

This was a random opportunity for discovery. Based on record review and resident and staff interview, the facility failed to initiate an investigation of an alleged violation of neglect and verbal abuse for Resident #2. This failed practice had the potential to affect more than a limited number of residents at the facility. Resident Identifier #2. Facility Census:24. a) Resident #2 Based on an interview of Resident #2 on 06/24/24 at 1:05 PM, resident stated that she had needed to use her bedside commode on 06/23/24 at around 6:00 AM. Resident stated that no one had responded to her call light for over two (2) hours. She further stated that she was sitting on the edge of her bed and could feel herself sliding off, so she had begun to shout out loudly. Her calls were responded to by a Nursing Assistant (NA) #15, who told her to stop shouting so loudly. Resident's family member, who was present, stated that her sister had made a complaint to the nurse in charge on 06/23/24 at 10:35 AM. She stated that no one had responded to the complaint. Investigation, and record review, revealed that the nurse in charge, RN #16, had submitted an email to the Director of Nursing (DON) #23 on 06/23/24 at 11:32 AM. The email stated: room [ROOM NUMBER] Resident #12's daughter is very upset. She said that her mother was on the call light for over two (2) hours from 4am - 6am. She said that a girl came in the room and asked her if she needed help and left her without helping and acted like she didn't know what a bedside commode was and left her. Family is upset and would like to talk to you. During an interview with the DON on 06/25/24 at 2:28 PM, she stated that she had pulled the call log response time, but she had not had the opportunity to talk to the resident's daughter as yet, due to surveyors entering the facility. b) Facility Policy on Abuse, Neglect and Exploitation A review of the policy revealed that the policy states that: Suspicion of abuse/neglect/exploitation, or reports of abuse/neglect/exploitation are to be responded to immediately. The Director of Nursing Services, Administrator or designee will: a. Notify the appropriate agencies immediately: as soon as possible, but no later than twenty-four (24) hours after discovery of the incident. b. Obtain statements from direct care staff. c. Suspend the accused employee pending completion of the investigation. d. Follow up with the appropriate agencies . to confirm the report was received. e. Report to the state nurse aide registry or nursing board any knowledge of any actions which would indicate an employee is unfit for service. A review of the facility reportables, on 06/25/24 at 11:45 AM, did not find a corresponding reportable to the appropriate state agencies. Further record review, and interview with DON #23 on 06/25/24 at 2:28 PM revealed that none of the actions mandated in the policy had been initiated or acted upon.

Based on staff interview and medical record review the facility failed to ensure resident #92 received an adequate amount of nutrition. This was true for one (1) of (1) residents reviewed for nutrition. Resident identifier #92. Facility census 24. Findings included: a) Resident #92 An observation on 06/24/24 at 1:14 PM the lunch tray was sitting in front of resident, she was not eating, no assistance was offered or observed during meal. A second observation on 06/25/24 at 1:32 PM her lunch meal was not consumed and just sitting in front of resident. A medical record review revealed a physician's order for a diabetic regular diet. No weights or nutritional assessments were documented during her admission to the skilled unit. A subsequent review of meal intakes revealed the resident's percentages were 0-25 eaten during meals. During an interview on 06/26/24 at 12:23 PM the Director verified that no weight was obtained on admission or 7 days later. She also verified Resident #92 should have been assessed within the first week of admission for nutritional status.

Based on record review and staff interview, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice. Pain medication was not administered appropriately per the physician's order. This was true for one (1) of two (2) residents who were reviewed under the pain pathway in the Long-Term Care Survey Process. Resident #139. Facility census: 24 Findings included: a) Resident #139 During an interview, on 06/24/24 at 1:33 PM, Resident #139 mentioned he received medication for pain in his back and had arthritis in hand which necessitated pain medication as well. Resident #139 went on the say that he had requested for his doctor visit him today because his pain levels were not always under control. A record review, completed on 06/26/24 at 8:35 AM, revealed the resident was admitted to the facility on [DATE]. The following two (2) orders were for pain management: -A 06/06/24 Physician Order prescribing: Oxycodone 5 mg oral tablet every 6 hr., -A 06/22/24 Physician Order prescribing: Acetaminophen (Tylenol) - 650 mg =2 oral tablets, every 6 hours, PRN, mild - Pain 1-3. Review of the Medication Administration Record revealed the following dates that Acetaminophen/Tylenol was given to resident despite his pain being higher than three (3): -Acetaminophen/Tylenol was given on 06/22/24 at 11:14 AM for a pain of ten (10) -Acetaminophen/Tylenol was given on 06/24/24 at 5:43 PM for a pain of four (4) -Acetaminophen/Tylenol was given on 06/25/24 at 8:12 AM for a pain of six (6) During an interview on 06/26/24 at 11:34 AM, the Director of Nursing acknowledged the above-mentioned dates where pain levels where at the level that Oxycodone should have been administered instead of Acetaminophen/Tylenol.

Based on record review and staff interview, the facility failed to ensure the attending physician documented in the resident's medical record, that the pharmacist's monthly medication review with recommendations had been reviewed and what, if any, action has been taken to address it. This was true for one (1) of five (5) unnecessary medication reviews throughout the long-term care survey process. Resident identifier: #2. Facility census: 24. Findings include: a) Resident #2 Record review on 06/25/24 at 3:38 PM for Unnecessary Meds, and Med Regimen Review, revealed that drug regimen reviews were performed by the pharmacist on 05/29/24 at 8:57AM, and on 06/25/24 at 9:53 AM. The pharmacist had notified physician that there were no depression, anxiety, or other mental health diagnoses for the prescribed drugs Duloxetine, Mirtazapine, and Lorazepam. Record review 0n 06/26/24 at 10:17 AM revealed that physician had not acknowledged or responded to the consultant pharmacist's recommendation. Record review on 06/26/24 at 10:23 AM revealed the facility's Drug review policy stated: Recommendations of the consulting pharmacist are acted upon and documented by the attending physician. The attending physician must document in the resident's chart that the identified irregularity has been reviewed and what, if any, action has been taken to address it within seven (7) days (48 hours if urgent action is required) During an interview with the DON, on 06/26/24 at 10:50 AM, she confirmed the physician had not acted upon the pharmacist's recommendations dated 05/29/24.

Based on facility documentation and staff interview the facility failed to have required members sign in at the Quality Assessment and Assurance (QAA) meetings. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 24. Findings included: a) QAA Record review of the facility's documentation of QAA Meeting Agenda and Minutes revealed no meeting was conducted in the first quarter of 2024. During an Interview 06/26/24, at 2:23 PM the Director verified the first quarter required quarterly QAA meeting was not conducted. No other information was provided prior to the end of the survey on 06/26/24.

Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items that were opened. This failed practice had the potential to affect a limited number of residents who are served food from the kitchen. Facility census: 20. Findings included: a) Initial Tour of Kitchen Observations during the initial tour of the kitchen, on 08/30/22 at 9:10 AM, revealed: -One (1) clear, plastic bag containing approximately ten (10) unfrozen sausage patties. The bag was unlabeled and undated. -One (1) clear, plastic bag of frozen hashbrowns. The bag was unlabeled and undated. During an interview on 08/30/22 at 9:20 AM, the Dietary Administrator acknowledged this practice did not follow facility protocol of labeling and dating all opened food items in the kitchen and did not allow the staff to ensure the food is still safe for consumption.

Based on medical record review, and staff interview, the facility failed to ensure residents are offered the pneumococcal vaccines currently recommended by the Center for Disease Control (CDC), educated on the risks and benefits and receive the vaccine unless medically contraindicated or refused. This is true for four (4) of five (5) residents reviewed for immunizations. Resident identifiers: #75, #66, #76, #73. Facility census: 20. Findings included: a) Immunization Record Review Review of the immunization records on 08/30/22, revealed Residents #75, #66, #76, and #73 were not offered the pneumococcal conjugate vaccine (PCV) 15 or PCV 20 vaccine. R 75's record notes she has not had a pneumonia vaccine and is silent for information regarding education of the vaccine and the opportunity to accept or decline the immunization. Residents #66, #76, and #73's medical records lack any information related to the residents' pneumococcal vaccine history, education on the risks and benefits of the vaccine, and the opportunity to receive the pneumococcal vaccine unless medically contraindicated. During an interview on 08/30/22 at 12:19 PM, the Director of Nursing acknowledged the vaccine immunization policy is not up to date and does not reflect CDC's current recommendations for the PCV 15 and PCV 20. The DON reviewed the immunization records and confirmed the residents pneumonia vaccine history was incomplete and the records lack education regarding CDC's current Vaccine Information Statement dated 02/04/2022.

Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. This was true for one (1) of two (2) residents reviewed for hospitalization s/discharges during the long-term care survey process. Resident identifier: #11. Facility census: 20. Findings included: a) Resident #11 An electronic medical record review was completed on 08/30/22 at 12:24 PM. Resident #11 was discharged to the hospital on 07/29/22. There was no evidence a written Notice of Transfer/Discharge was provided to Resident #11 or her legal representative. During an interview on 08/30/22 at 2:00 PM, Registered Nurse (RN) #8 and RN #7 were unable to readily locate evidence from the electronic medical record that a Notice of Transfer/Discharge was given to Resident #11 or legal representative. On 08/31/22 at 12:00 PM, the Director of Nursing stated the hard copy of the closed medical record was also reviewed and the facility could not provide evidence the Notice of Transfer/Discharge was given.

Based on record review and staff interview, the facility failed to submit the initial comprehensive assessment within the 14 day time limit. This is true for one (1) of two (2) reviewed for admission Minimum Data Set (MDS) assessments. Resident identifier: 73. Facility census: 20. Findings included: a) Resident #73 Review of the medical record on 08/31/22, revealed Resident (R) #73 was admitted to the facility on [DATE]. The initial comprehensive MDS assessment was not completed and submitted to the state within 14 days of admission as required by the Centers for Medicare and Medicaid (CMS). During an interview on 08/31/22 at 10:15 AM, the MDS nurse #7 confirmed R#73's admission MDS assessment was not submitted by the 14 day requirement.

Based on observation, resident interview, record review, and staff interview, the facility failed to provide care and treatment to residents to promote healing of existing pressure ulcers and to prevent new sores from developing. There was no system in place to ensure skin assessments were completed timely and accurately and that interventions were implemented, monitored, and revised as appropriate. The skilled care skin assessment sheets lacked accurate descriptions of the pressure ulcers that included measurements for Residents #162, #30, and #93. Resident #30, who was admitted without a pressure ulcer, experienced actual harm when she developed an ulcer on her heel that was subsequently diagnosed as gangrene by the physician and required debridement. These findings affected three (3) of three (3) residents reviewed for pressure ulcers. Resident identifiers: #162, #30, and #93. Facility census: 23. Findings include: a) Resident #30 A review of the clinical record at 9:00 a.m. on 09/08/16, revealed this [AGE] year-old female, admitted on [DATE], had [DIAGNOSES REDACTED]. She developed a pressure ulcer on her right heel on 08/06/16, assessed as a Stage 2 on 08/09/16. The area on the right heel progressed to a DTI (deep tissue injury) on 08/16/16, and on 09/01/16. When assessed by the physician on 09/01/16, the wound was diagnosed as Gangrene right heel and Ulceration with eschar right heel from pressure Stage III (3). The pressure ulcer was debrided by the physician on 09/02/16. The development of a pressure ulcer, and the deterioration of the wound resulting in gangrene and debridement of the wound was determined to be actual harm. In an interview at 2:30 p.m. on 09/06/16, the resident said she did not have a pressure ulcer on her heel when she came to this unit from acute care, but started having problems within a week after admission. Resident #30 was an alert and oriented individual. She was educated, had been employed as a Social Worker, and was knowledgeable about health care. She stated the nurses changed her dressings daily and told her it was healing. The resident said she could tell it was healing because it was no longer black; was not draining; did not smell as it did in the beginning; and was not as painful when the dressing was changed. The dimensions, needed to assess and monitor the effectiveness of treatment toward healing and to plan interventions were taken only 4 times (08/06/16, 08/25/16, 08/28/16, and 09/07/16). The assessments that did include a description of the pressure ulcers were inconsistent. The dates and descriptions were: -- 08/06/16: R) (right) heel - soft, mushy, fluid-filled blister - broken skin with portion peeled back - dark redding noted. (6 X 6 cm (centimeters) in diameter) -- 08/10/16: R) heel - discolored - skin peeled back with black area noted - Charge made aware. -- 08/12/16: Wound Nurse #171 documented, (R) heel Stage 2 pressure ulcer red wound bed with [MEDICATION NAME]. Sm (small) amt (amount) of serosang. (serosanguinous) drainage surrounding heel DTI (deep tissue injury) purple. -- 08/16/16: Wound Nurse #171 documented, (R) heel DTI with necrotic scab and peeling skin. SM (small) stage II noted. SM amt. bloody drainage. Suggested to charge RN for consult for debridement. Charge RN to talk to attending. -- 08/17/16: Entire heel circular area with dried scabs and center is black with scant amount of serous drainage. -- 08/19/16: Wound Nurse #171 documented, Entire heel dry black, flaky sm open area noted_ -- 08/21/16: right heel DTI with necrotic scab. -- 08/24/16 R heel with necrotic scabbed peeling area. -- 08/25/16: R heel opened pink - no drainage. (0.3 X 0.3 X 0 cm) -- 08/28/16: R heel skin very dry, black necrotic area 4 X 4. -- 08/30/16: Wound Nurse #171 documented, R heel dry & necrotic with dry flaky skin small open area noted with red wound bed. hydrogel & dry drsg (dressing) applied. Encouraged to elevate. -- 08/31/16: heel dry black, flaky small open area with no drainage -- 09/01/16: Scant amt (amount) serous drainage black scabbed area intact_ -- 09/03/16: R heel 3/4 of wound pink granulated, the other 1/4 black. -- 09/06/16: R heel with dry flaky skin, wound bed red with [MEDICATION NAME]. -- 09/07/16: Wound bed pink with [MEDICATION NAME]. Surround with skin dry / flaky. (2.8 X 2.5 X 0.2 cm) During an interview with RN #18 (direct care nurse) at 10:45 a.m. on 09/06/16, she was asked to identify the stage of a pressure ulcer. She said she was new at the facility and had been instructed that her responsibility was only to do wound care and document in the nurses' notes what she did and her observation of the wound. She said the wound care nurse measured the wound weekly. She was not sure where in the record we could locate the stage and referred the question to the charge nurse. When interviewed at 11:15 a.m. on 09/06/16, LPN #32 (direct care nurse) explained she did the wound care on residents assigned to her as ordered except on Wednesdays when the wound care nurse saw them and did her weekly assessments. She said if nursing observed a new pressure area or identified one on admission the charge nurse was notified and she notified the physician and the wound nurse per the physician's orders [REDACTED]. She denied having been told what to document, but agreed the descriptions in the wound care sheets could be better. The nurse did not know what the stage of the pressure ulcer was. Follow-up interview with the charge nurse (RN #62) at 11:30 a.m. on 09/06/16, confirmed the information provided by the other nurses. She added the wound nurse (LPN #171) saw residents when referred by the physician, but was readily available whenever called. RN #62 said that LPN #171 documented her findings on the wound sheet located on the clipboard with the daily nurses ' notes at least once weekly. Either the wound care nurse or the MDS nurse (RN #34) assigned staging to each pressure ulcer, but was not sure which was actually 'responsible'. During an interview at 1:20 p.m. on 09/07/16, Wound Care Nurse #171 (LPN) said she only assessed and monitored residents by physician referral. She assessed each resident at least weekly and documented on the wound sheet found on the clipboard. If she had concerns, they were reported to the charge nurse or the physician. When questioned about the staging decision on Res #30, she said, The MDS nurse does the staging, then said the pressure ulcer was a healing Stage 2. When it was pointed out she had documented multiple times the presence of black eschar, she said at that point it was unstageable, but after debridement it was a Stage 2 again. When pointed out to her that the physician had staged the pressure ulcer at Stage 3, she expressed surprise, but agreed that it did meet the description of a Stage 3. (According to NPUAP, a Stage 2 pressure ulcer does not have eschar.) A review of the job descriptions provided on request at 4:30 p.m. on 09/07/16, revealed wound care nurse job descriptions indicated the position required a RN. The job descriptions included, .comprehensive wound evaluations .documents accurately and promptly patient assessments, care and response to treatment and education on approved forms . and Documents accurately reflect changes in patient status and appropriate actions. A review of the wound care sheets at 1:40 p.m. on 09/07/16, revealed entries by LPN #171 on week #1 (08/12/16), week #2 (08/1616), week #3 (0819/16), and week #4 (08/30/16). None of these entries included measurements of the wound, documentation of pain status, or actual location of the resident ' s wound. During an interview with RN #34 (MDS nurse) at 3:30 p.m. on 09/08/16, she acknowledged the daily assessments, when done, did not always identify the status of the dressing, the area surrounding the ulcer, the ulcer's characteristics, the presence of pain, and the measurements. She said the wound care nurse was to monitor the changing status of the wound and notify the charge nurse and/or the physician when necessary for care changes. This was meant to ensure a professional evaluation of the wound care being given. She acknowledged, after discussion and review of the wound care documentation, there was a need for better documentation of pressure ulcers, but said they hoped that when they got a new computer program it would help with the problem. . b) Resident #162 Review of the medical record on 09/07/16 at 3:00 p.m., revealed Resident #162 had nonblanchable red buttocks when admitted on [DATE]. He experienced a decline after admission, and became dependent on staff for assistance with all activities of daily living. The five-day minimum data set (MDS) assessment with a reference date of 08/22/16, identified Resident #162 had a Stage 1 pressure ulcer when admitted . The 14-day MDS with an assessment reference date of 08/27/16 identified the resident had two (2) Stage 2 pressure ulcers. The skilled care skin care flow sheet, dated 08/15/16, noted the resident had non blanchable red buttocks present on admission. (Normal skin will blanch, or lighten, when pressure is applied with a finger, then return to normal after the pressure is removed. Skin that does not blanch may be a forerunner of a pressure ulcer.) On 08/17/16 at 9:00 a.m., the skilled care skin care flow sheet stated, bil (bilateral) buttocks dk (dark) pink, blanchable, intact. On 08/21/16, the skin care flow sheet stated, buttocks red, intact, crack of buttocks increased red, non-blanchable. On 08/25/16, the skin care flow sheet noted the resident ' s red buttocks were barely blanchable and the right buttocks had superficial open areas with yellowish centers. On 08/28/16, the skin care flow sheet stated, buttocks red, right side has open areas with yellow centers. On 08/30/16 at 6:35 a.m., an order was written for a wound care consult for open area on buttocks. On 08/30/16, Wound Care Nurse (WCN) #171 wrote on the skilled care skin flow sheet: coccyx red and nonblanchable, open areas noted from frequent incontinence, aggravated by pressure. orders to be place. The record lacked any measurements or staging of the wound. On 08/30/16 at 10:30 a.m., an order was written for [MEDICATION NAME]/[MEDICATION NAME]/vaseline ointment twice a day. The skin care flow sheet stated on 09/04/16, inner buttocks red, excoriated, and on 09/06/16, the skin care flow sheet stated, Inner buttocks beefy red, excoriated with several linear ___ with yellow wound bed/appearance of friction sheer. Licensed Practical Nurse (LPN) #32 reported Resident #162's pressure ulcer had worsened since admission during an interview on 09/06/16 at 3:00 p.m. LPN #32 reported the wound now had a cheese grater appearance. She reviewed the skin care flow sheets and acknowledged the flow sheets did not describe his pressure ulcers accurately. An observation of the wound was made on 09/07/16 at 11:00 a.m. while Licensed Practical Nurse (LPN) #32 applied the [MEDICATION NAME]/[MEDICATION NAME]/vaseline ointment. Resident #162 cried out illegible sounds when staff turned him, cleaned his buttocks, and applied the ointment. The buttocks wounds contained multiple small holes on both sides with beefy red and yellow centers, and pale skin between. At the surveyor ' s request, the areas were measured. The right buttocks wound was 7.5 cm long by 4 cm wide and the left buttocks pressure ulcer was 7.5 cm long by 2.5 cm wide. Both wounds were approximately 0.1 centimeter (cm) to 0.2 cm in depth in various areas. Immediately after this observation LPN #32 acknowledged the resident appeared to be in pain during this procedure. WCN #171 was interviewed on 09/07/16 at 1:20 p.m. She reported she sees the residents twice a week when she is consulted. She does not measure the wounds and she does not stage the pressure ulcers. WCN #171 reviewed the record during this interview and acknowledged she only saw the resident once and documented this on 08/30/16 on the skin care flow sheet. When questioned why she had not seen the resident again, she stated she was on vacation last week and reported there was no one to cover for her. During an interview on 09/07/16 at 2:00 p.m., Registered Nurse (RN) #62 acknowledged Resident #162's pressure ulcer had worsened and stated she had notified the physician and requested the wound nurse reevaluate the wound on 09/06/16. She reviewed the medical record during this interview and agreed the wound documentation on the skin care flow sheets did not accurately describe Resident #162's pressure ulcers. There were no measurements or staging of the pressure ulcers. In addition, there were no records indicating the physician or the wound nurse were notified of this change or that either evaluated Resident #162's worsening pressure ulcers. Minimum Data Set (MDS) Nurse #54, during an interview on 09/07/16 at 2:30 p.m., reported the charge nurse completed the skin assessments on the day of admission and documented the findings on the skin care flow sheets. Additional assessments were conducted weekly on a pre-selected shift. She was unaware as to whether or not the charge nurse measured the wounds and added she thought WCN #171 measured and staged the pressure ulcers. There was no system in place to track and monitor the status of pressure ulcers. Staff were unaware as to who was responsible for measuring and staging the wounds. There were no changes in treatment ordered when Resident #162's pressure ulcer worsened and became painful. b) Resident #93 On 09/08/2016 at 8:15 a.m., medical record review revealed this [AGE] year-old male was admitted to the skilled unit on 04/08/16 and discharged on [DATE]. His [DIAGNOSES REDACTED]. Review of copies of Skilled Care Skin Care Flow Sheets on 09/08/16 at 8:25 a.m. found the resident had three (3) pressure ulcers when admitted to the facility. Those were: 1. An unstageable pressure ulcer to coccyx identified as #1 2. A Stage 2 to the right inner buttock identified as #2 3. An unstageable to left buttock identified as #3 According to the flow sheets documentation: Pressure ulcer #1 was measured on admission 04/08/16 and weekly thereafter. Pressure ulcer #2 was measured on admission 04/08/16 and lacked any further wound measurements during stay. Pressure ulcer #3 lacked any evidence of measurements except one (1) on 04/27/16. The resident was discharged with the same three (3) pressure ulcers as documented on admission. After reviewing the Skilled Care Skin Care Flow Sheets for Resident #93, Registered Nurse (RN) #54 agreed that according to the documentation, wound measurements were not completed and/or were inconsistent during the resident's stay. She stated, Yes, there had not been an assessment with measurements, and therefore how can we determine if the wound is healing or improving? Also a wound assessment should include weekly measurements by the wound Nurse.

Based on observation, family interview, staff interview, and a review of the facility's disaster plan and other records, the facility failed to provide a fully functional nurse call system (with both audible and visual signaling components of the system working as designed) and failed to provide an alternate means of communication to allow residents to summon nursing staff from their rooms, toilets, and bathing facilities when the facility disabled the audible signal component of the nurse call system due to a malfunction. This placed all of twenty-seven (27) residents on this skilled nursing unit (SNU) at in immediate jeopardy due to an inability to summon staff in the event of an emergency. Staff interview revealed the nurse call system went down during a power outage at 6:00 a.m. on 01/28/11. During this power outage, the unit director distributed tap bells to all residents on the SNU as an alternate means of summoning staff when the nurse call system. When the power was restored, these tap bells were collected from the residents after the power was restored at 6:30 a.m. on 01/28/11. After the power was restored on 01/28/11, the emergency nurse call system for two (2) bathrooms located on the SNU malfunctioned, causing the audible signal to the nurse call system for the SNU to sound continuously. The audible signal to the nurse call system was disabled due to its continuous ringing; however, tap bells were not redistributed to all residents as an alternate of summoning staff while the audible signal was disabled. The entire SNU was without a fully functioning nurse call system with an audible signal that would sound at the nurse's station (to alert staff of a resident's need for assistance) since 01/28/11, with no alternate means provided to residents to allow them to summon staff in the event of a resident need or an emergency. Family interview, staff interview, and direct observation, on 02/09/11, verified the audible signal component of the nurse call system was still disabled and no alternate means of communication was available for residents on the unit to summon staff assistance. At 3:15 p.m., the unit director was notified that immediate jeopardy existed due to the disabled nurse call system and the absence of an alternate means for residents to summon staff assistance. At 4:05 p.m. on 02/09/11, staff presented the facility's Emergency Management Plan (EMP) dated 02/09/11, which outlined steps to remove / mitigate the circumstances placing residents in immediate jeopardy. At 5:10 p.m. on 02/09/11, a staff member was assigned to monitor the visual signals in the hallway, tap bells were distributed to residents for summoning staff assistance, and signs were up in the resident rooms providing directions on how to contact staff at the nurse's station via telephone. At the time, the surveyor confirmed, by direct observation and staff interview, that the circumstances which created immediate jeopardy were removed. The unit director was notified of the removal of immediate jeopardy as of 5:10 p.m. A deficient practice remained after the removal of immediate jeopardy, as the audible signal component of the nurse call system was still not fully functional; this remaining deficient practice presented the potential for more than minimal harm to all residents on the SNU. Facility census: 27. Findings include: a) On 02/09/11 at 1:45 p.m., Resident #207's daughter was observed looking at the visual signal of the nurse call system located above the resident's door in the corridor. When asked if the resident needed someone, she stated her father needed a pain pill, and she reported she was checking to see if the call light was working. Further interview with the resident's family found the call light had been on for about five (5) minutes. Observations made in the hallways, during the mid-afternoon on 02/09/11, found continuous faint alarm sounds coming from the duty stations located at various points on the SNU. At 2:05 p.m. on 02/09/11, interviews with a licensed practical nurse (LPN), the social worker, and the unit secretary (Employees , # , and # , respectively), who were at the nurse's station, revealed the audible signal to the nurse call system was not functioning and had been broken for several days. -- b) At the nurse's station, observations made with the facility director of maintenance (Employee # ), at 2:10 p.m. on 02/09/11, found there was no audible signal to alert staff when a resident's call light was activated. Observations made at the nurse's station found the call system monitor at the nurse's station indicated the light to Resident #207's room was on, as were the lights to Rooms 621 and 623. The maintenance director verified the system was down and the keyboard was unplugged, because the monitor continuously beeped. Observation of the bathrooms in Rooms #623 and #621, with Employee # , confirmed the audible signals to the nurse call system serving these rooms were broken and were ringing constantly. At 2:20 p.m., this surveyor contacted the field manager with the State survey agency via telephone to discuss the nurse call system. -- c) An interview with Employee # , at 2:45 p.m. on 02/09/11, revealed the company that manufactured the nurse call system currently in use by the SNU went out of business, and another company was going to provide help in fixing the system; however, the repairs could not be accomplished until 02/16/11, when a representative from the second company was scheduled to come to the facility. This was confirmed by review of e-mail communication between the facility and that company. Further interviews conducted at this time with two (2) nursing assistants (Employees # and # ) confirmed the audible signal component of the nurse call system had not been working for a while. -- d) At 3:00 p.m. on 02/09/11, this surveyor contacted the program manager with the State survey agency via telephone to discuss her findings, and a determination was made that the facility's failure to distribute an alternate means for residents to summon staff assistance in an emergency, while the audible signal component of the nurse call nurse was disabled, placed all residents on the SNU in immediate jeopardy. At 3:15 p.m., the unit director was notified that immediate jeopardy existed due to the disabled nurse call system and the absence of an alternate means for residents to summon staff for assistance. -- e) In an interview at 3:35 p.m. on 02/09/11, the unit director reported she had distributed tap bells to all residents on the SNU as an alternate means of summoning staff when the nurse call system went down during a power outage at 6:00 a.m. on 01/28/11; when the power was restored, these tap bells were collected from the residents after the power was restored at 6:30 a.m. on 01/28/11. She did not know how much actual time elapsed before she picked up the bells, but she said, "Almost as soon as I got the bells put out and the signs up, the power came back on, and I took the bells up." After the power was restored on 01/28/11, the emergency nurse call system for two (2) bathrooms located on the SNU malfunctioned, causing the audible signal to the nurse call system for the SNU to sound continuously. The audible signal to the nurse call system was disabled due to its continuous ringing; however, tap bells were not redistributed to all residents as an alternate of summoning staff while the audible signal was disabled. During earlier interviews in the unit director's office, in the late afternoon on 02/08/11 and in the late morning on 02/09/11 in the late morning, observation had found a box of tap bells available for use in a box on the floor in the office. The entire SNU was without a fully functioning nurse call system with an audible signal that would sound at the nurse's station (to alert staff of a resident's need for assistance) since 01/28/11. -- f) At 3:37 p.m. on 02/09/11, the division director of performance improvement and risk management (Employee # ) and the chief nursing officer (CNO - Employee # ) were interviewed. The CNO stated that tap bells could be utilized for the residents, and a staff member could be stationed in the hallways to watch for activation of the visual signals to the call system to ensure residents' needs were being met. -- g) At 4:05 p.m. on 02/09/11, Employee # presented the facility's EMP dated 02/09/11. Review of the EMP found the following: "Response to citation: Failure of nurse call system. "Problem Identified: Nurse call system noted to have no audible sound associated with the light outside the patient room. "Immediate Action: "Initiate manual call bells and place in all patient rooms. - Completed. "Increase staffing by one with specific responsibility to ensure continuous rounding. - Completed. "Communicate with patient and/ or family emergency procedure: use manual bell and/or telephone at x 6188 as posted in patient room. "Actions will be ongoing until system repair (see below) "Corrective Action: "Repair system: We have located a company in California that is making arrangements to come in next week (February 16th). The company is (name of vendor) that have replacement parts and have the knowledge of the software." -- h) A list of current residents was requested from the unit director at 4:15 p.m. on 02/09/11. Rounds were made to determine which residents were able to use tap bells and/or access the nurse's station via phone. There were twenty-four (24) residents on the SNU at this time, and there were six (6) residents who were unable to use the tap bells. This was confirmed with the unit director by review of the census list at 4:30 p.m. At this time, Employee # provided a copy of the facility's Emergency Operating Plan, and the section titled "Electricity" was reviewed. It stated, "Emergency power is provided to maintain the essential hospital services during an outage. The back up generator is fuel powered. The generator holds 3500 gallons fuel. In addition to this, a 275 gallon day tank is available and there is also 30,000 gallons stored in an underground tank. The fuel usage noted in the 24 hour outage in September 2008, when the generator was on for a 24 hour period was 1050 gallons. Based on this experience there is a sufficient amount of fuel on hand to operate for an extended period of time." There was no discussion in the Emergency Operating Plan to address a failure of the nurse call system. -- i) At 5:10 p.m. on 02/09/11, the staff member assigned to monitor the visual signals in the hallway arrived at the SNU, the tap bells were being utilized, and signs were up in the resident rooms indicating how to access the nurse's station via phone. At the time, the surveyor confirmed, by direct observation and staff interview, that the circumstances which created immediate jeopardy were removed. The unit director was notified of the removal of immediate jeopardy as of 5:10 p.m. A deficient practice remained after the removal of immediate jeopardy, as the audible signal component of the nurse call system was still not fully functional; this remaining deficient practice presented the potential for more than minimal harm to all residents on the SNU. .

Based on observation, family interview, staff interview, and a review of the facility's disaster plan and other records, the facility's governing body failed to ensure the skilled nursing unit (SNU) was administered in an effective and efficient manner to maintain the highest practicable well-being of each resident. The facility failed to provide a fully functional nurse call system (with both audible and visual signaling components of the system working as designed) and failed to provide an alternate means of communication to allow residents to summon nursing staff from their rooms, toilets, and bathing facilities when the facility disabled the audible signal component of the nurse call system due to a malfunction. This placed all of twenty-seven (27) residents on this SNU at in immediate jeopardy due to an inability to summon staff in the event of an emergency. Staff interview revealed the nurse call system went down during a power outage at 6:00 a.m. on 01/28/11. During this power outage, the unit director distributed tap bells to all residents on the SNU as an alternate means of summoning staff when the nurse call system. When the power was restored, these tap bells were collected from the residents after the power was restored at 6:30 a.m. on 01/28/11. After the power was restored on 01/28/11, the emergency nurse call system for two (2) bathrooms located on the SNU malfunctioned, causing the audible signal to the nurse call system for the SNU to sound continuously. The audible signal to the nurse call system was disabled due to its continuous ringing; however, tap bells were not redistributed to all residents as an alternate of summoning staff while the audible signal was disabled. The entire SNU was without a fully functioning nurse call system with an audible signal that would sound at the nurse's station (to alert staff of a resident's need for assistance) since 01/28/11, with no alternate means provided to residents to allow them to summon staff in the event of a resident need or an emergency. The immediate jeopardy situation was removed at 5:10 p.m. on 02/09/11, after the surveyor verified the implementation of action steps taken by the facility (i.e., a staff member was assigned to monitor the visual signals in the hallway, tap bells were distributed to residents for summoning staff assistance, and signs were up in the resident rooms providing directions on how to contact staff at the nurse's station via telephone). Observations, on 02/08/11 and on 02/09/11, found a box of tab bells available for use in the unit director's office, but they were no re-distributed to residents when the facility disabled the audible signal component of the nurse call system when it malfunctioned on 01/28/11, even though representatives of the facility's governing body were aware of the nurse call system's malfunction. Interview with the unit director, on 02/15/11, found there had been no quality assurance activity by the unit's quality assessment and assurance (QAA) committee in response to the malfunction and subsequent disabling of the audible signal component of the nurse call system. Facility census: 27. Findings include: a) On 02/09/11 at 1:45 p.m., Resident #207's daughter was observed looking at the visual signal of the nurse call system located above the resident's door in the corridor. When asked if the resident needed someone, she stated her father needed a pain pill, and she reported she was checking to see if the call light was working. Further interview with the resident's family found the call light had been on for about five (5) minutes. Observations made in the hallways, during the mid-afternoon on 02/09/11, found continuous faint alarm sounds coming from the duty stations located at various points on the SNU. At 2:05 p.m. on 02/09/11, interviews with a licensed practical nurse (LPN), the social worker, and the unit secretary (Employees , # , and # , respectively), who were at the nurse's station, revealed the audible signal to the nurse call system was not functioning and had been broken for several days. - At the nurse's station, observations made with the facility director of maintenance (Employee # ), at 2:10 p.m. on 02/09/11, found there was no audible signal to alert staff when a resident's call light was activated. Observations made at the nurse's station found the call system monitor at the nurse's station indicated the light to Resident #207's room was on, as were the lights to rooms [ROOM NUMBERS]. The maintenance director verified the system was down and the keyboard was unplugged, because the monitor continuously beeped. Observation of the bathrooms in Rooms #623 and #621, with Employee # , confirmed the audible signals to the nurse call system serving these rooms were broken and were ringing constantly. At 2:20 p.m., this surveyor contacted the field manager with the State survey agency via telephone to discuss the nurse call system. - An interview with Employee # , at 2:45 p.m. on 02/09/11, revealed the company that manufactured the nurse call system currently in use by the SNU went out of business, and another company was going to provide help in fixing the system; however, the repairs could not be accomplished until 02/16/11, when a representative from the second company was scheduled to come to the facility. This was confirmed by review of e-mail communication between the facility and that company. Further interviews conducted at this time with two (2) nursing assistants (Employees # and # ) confirmed the audible signal component of the nurse call system had not been working for a while. - At 3:00 p.m. on 02/09/11, this surveyor contacted the program manager with the State survey agency via telephone to discuss her findings, and a determination was made that the facility's failure to distribute an alternate means for residents to summon staff assistance in an emergency, while the audible signal component of the nurse call nurse was disabled, placed all residents on the SNU in immediate jeopardy. At 3:15 p.m., the unit director was notified that immediate jeopardy existed due to the disabled nurse call system and the absence of an alternate means for residents to summon staff for assistance. - In an interview at 3:35 p.m. on 02/09/11, the unit director reported she had distributed tap bells to all residents on the SNU as an alternate means of summoning staff when the nurse call system went down during a power outage at 6:00 a.m. on 01/28/11; when the power was restored, these tap bells were collected from the residents after the power was restored at 6:30 a.m. on 01/28/11. She did not know how much actual time elapsed before she picked up the bells, but she said, "Almost as soon as I got the bells put out and the signs up, the power came back on, and I took the bells up." After the power was restored on 01/28/11, the emergency nurse call system for two (2) bathrooms located on the SNU malfunctioned, causing the audible signal to the nurse call system for the SNU to sound continuously. The audible signal to the nurse call system was disabled due to its continuous ringing; however, tap bells were not redistributed to all residents as an alternate of summoning staff while the audible signal was disabled. During earlier interviews in the unit director's office, in the late afternoon on 02/08/11 and in the late morning on 02/09/11 in the late morning, observation had found a box of tap bells available for use in a box on the floor in the office. The entire SNU was without a fully functioning nurse call system with an audible signal that would sound at the nurse's station (to alert staff of a resident's need for assistance) since 01/28/11. - At 3:37 p.m. on 02/09/11, the division director of performance improvement and risk management (Employee # ) and the chief nursing officer (CNO - Employee # ) were interviewed. The CNO stated that tap bells could be utilized for the residents, and a staff member could be stationed in the hallways to watch for activation of the visual signals to the call system to ensure residents' needs were being met. - At 4:05 p.m. on 02/09/11, Employee # presented the facility's EMP dated 02/09/11. Review of the EMP found the following: "Response to citation: Failure of nurse call system. "Problem Identified: Nurse call system noted to have no audible sound associated with the light outside the patient room. "Immediate Action: "Initiate manual call bells and place in all patient rooms. - Completed. "Increase staffing by one with specific responsibility to ensure continuous rounding. - Completed. "Communicate with patient and/ or family emergency procedure: use manual bell and/or telephone at x 6188 s posted in patient room. "Actions will be ongoing until system repair (see below) "Corrective Action: "Repair system: We have located a company in California that is making arrangements to come in next week (February 16th). The company is (name of vendor) that have replacement parts and have the knowledge of the software." - A list of current residents was requested from the unit director at 4:15 p.m. on 02/09/11. Rounds were made to determine which residents were able to use tap bells and/or access the nurse's station via phone. There were twenty-four (24) residents on the SNU at this time, and there were six (6) residents who were unable to use the tap bells. This was confirmed with the unit director by review of the census list at 4:30 p.m. At this time, Employee # provided a copy of the facility's Emergency Operating Plan, and the section titled "Electricity" was reviewed. It stated, "Emergency power is provided to maintain the essential hospital services during an outage. The back up generator is fuel powered. The generator holds 3500 gallons fuel. In addition to this, a 275 gallon day tank is available and there is also 30,000 gallons stored in an underground tank. The fuel usage noted in the 24 hour outage in September 2008, when the generator was on for a 24 hour period was 1050 gallons. Based on this experience there is a sufficient amount of fuel on hand to operate for an extended period of time." There was no discussion in the Emergency Operating Plan to address a failure of the nurse call system. - At 5:10 p.m. on 02/09/11, the staff member assigned to monitor the visual signals in the hallway arrived at the SNU, the tap bells were being utilized, and signs were up in the resident rooms indicating how to access the nurse's station via phone. At the time, the surveyor confirmed, by direct observation and staff interview, that the circumstances which created immediate jeopardy were removed. The unit director was notified of the removal of immediate jeopardy as of 5:10 p.m. A deficient practice remained after the removal of immediate jeopardy, as the audible signal component of the nurse call system was still not fully functional; this remaining deficient practice presented the potential for more than minimal harm to all residents on the SNU. (See also citation at F463.) -- b) During an interview at 9:40 a.m. on 02/15/11, the unit director reported there had been no quality assurance activity by the QAA committee in response to the malfunction and subsequent disabling of the audible signal component of the nurse call system on the SNU. The unit director provided a copy of the policy titled "Skilled Care Improvement Committee Policy" (dated 01/10), which stated: "Policy: The Skilled Care Improvement Committee will provide ongoing quality and assurance activities. The committee identifies quality deficiencies, develops, and implements plans of action to correct these quality deficiencies, including Monitoring and the effect of implemented changes and making needed revisions to the action plans. "Scope: This policy applies to the Skilled Care Unit. "Responsibilities: The Director of the Skilled Nursing Facility is responsible for the application, interpretation and the enforcement of this policy. "Procedures: "1. Members of the committee will include, but not limited to, the Director of Nursing , the medical director, and at least three other members of the facility's staff (i.e. Infection Control Coordinator, Activities, MDS Coordinator, Rehabilitation Services, Food and Nutritional Services, etc.) "2. The Director of Nursing will chair the committee. "3. The committee will meet at least quarterly: to identify issues, develop and implement appropriate plans of action, and evaluate effectiveness of actions taken. "4. Action plans may include, but not limited to, the revision of policies and procedures, training of staff, recommendation of equipment purchases, and standards for evaluating staff performance." -- c) As noted in the findings above, the unit director, director of maintenance, social worker, unit secretary, and various members of the SNU's nursing staff were aware of that the nurse call system was not functioning properly, but the SNU's QAA committee, which was chaired by the unit director, failed to take action to ensure an alternate means of communication was made available when the audible signal component of the nurse call system malfunctioned on 01/28/11 and was subsequently disabled by the facility. (See also citation at F520.) The governing body failed to ensure the SNU's QAA committee identified and took prompt action, using readily available resources (i.e., tap bells) to ensure residents had an alternate means of alerting staff to the needs and to summon staff in the event of an emergency. .

Based on observation, family interview, staff interview, and a review of the facility's disaster plan and other records, the facility's quality assessment and assurance (QAA) committee failed to identify quality deficiencies of which it should have been aware and failed to implement measures to remedy these quality deficiencies. The facility failed to provide a fully functional nurse call system (with both audible and visual signaling components of the system working as designed) and failed to provide an alternate means of communication to allow residents to summon nursing staff from their rooms, toilets, and bathing facilities when the facility disabled the audible signal component of the nurse call system due to a malfunction. This placed all of twenty-seven (27) residents on this skilled nursing unit (SNU) at in immediate jeopardy due to an inability to summon staff in the event of an emergency. Staff interview revealed the nurse call system went down during a power outage at 6:00 a.m. on 01/28/11. During this power outage, the unit director distributed tap bells to all residents on the SNU as an alternate means of summoning staff when the nurse call system. When the power was restored, these tap bells were collected from the residents after the power was restored at 6:30 a.m. on 01/28/11. After the power was restored on 01/28/11, the emergency nurse call system for two (2) bathrooms located on the SNU malfunctioned, causing the audible signal to the nurse call system for the SNU to sound continuously. The audible signal to the nurse call system was disabled due to its continuous ringing; however, tap bells were not redistributed to all residents as an alternate of summoning staff while the audible signal was disabled. The entire SNU was without a fully functioning nurse call system with an audible signal that would sound at the nurse's station (to alert staff of a resident's need for assistance) since 01/28/11, with no alternate means provided to residents to allow them to summon staff in the event of a resident need or an emergency. Observations, on 02/08/11 and on 02/09/11, found a box of tab bells available for use in the unit director's office, but they were no re-distributed to residents when the facility disabled the audible signal component of the nurse call system when it malfunctioned on 01/28/11. The immediate jeopardy situation was removed at 5:10 p.m. on 02/09/11, after the surveyor verified the implementation of action steps taken by the facility (i.e., a staff member was assigned to monitor the visual signals in the hallway, tap bells were distributed to residents for summoning staff assistance, and signs were up in the resident rooms providing directions on how to contact staff at the nurse's station via telephone). During an interview at 9:40 a.m. on 02/15/11, the unit director reported there had been no quality assurance activity by the QAA committee in response to the malfunction and subsequent disabling of the audible signal component of the nurse call system on the SNU. Facility census: 27. Findings include: a) On 02/09/11 at 1:45 p.m., Resident #207's daughter was observed looking at the visual signal of the nurse call system located above the resident's door in the corridor. When asked if the resident needed someone, she stated her father needed a pain pill, and she reported she was checking to see if the call light was working. Further interview with the resident's family found the call light had been on for about five (5) minutes. Observations made in the hallways, during the mid-afternoon on 02/09/11, found continuous faint alarm sounds coming from the duty stations located at various points on the SNU. At 2:05 p.m. on 02/09/11, interviews with a licensed practical nurse (LPN), the social worker, and the unit secretary (Employees , # , and # , respectively), who were at the nurse's station, revealed the audible signal to the nurse call system was not functioning and had been broken for several days. - At the nurse's station, observations made with the facility director of maintenance (Employee # ), at 2:10 p.m. on 02/09/11, found there was no audible signal to alert staff when a resident's call light was activated. Observations made at the nurse's station found the call system monitor at the nurse's station indicated the light to Resident #207's room was on, as were the lights to rooms [ROOM NUMBERS]. The maintenance director verified the system was down and the keyboard was unplugged, because the monitor continuously beeped. Observation of the bathrooms in Rooms #623 and #621, with Employee # , confirmed the audible signals to the nurse call system serving these rooms were broken and were ringing constantly. At 2:20 p.m., this surveyor contacted the field manager with the State survey agency via telephone to discuss the nurse call system. - An interview with Employee # , at 2:45 p.m. on 02/09/11, revealed the company that manufactured the nurse call system currently in use by the SNU went out of business, and another company was going to provide help in fixing the system; however, the repairs could not be accomplished until 02/16/11, when a representative from the second company was scheduled to come to the facility. This was confirmed by review of e-mail communication between the facility and that company. Further interviews conducted at this time with two (2) nursing assistants (Employees # and # ) confirmed the audible signal component of the nurse call system had not been working for a while. - At 3:00 p.m. on 02/09/11, this surveyor contacted the program manager with the State survey agency via telephone to discuss her findings, and a determination was made that the facility's failure to distribute an alternate means for residents to summon staff assistance in an emergency, while the audible signal component of the nurse call nurse was disabled, placed all residents on the SNU in immediate jeopardy. At 3:15 p.m., the unit director was notified that immediate jeopardy existed due to the disabled nurse call system and the absence of an alternate means for residents to summon staff for assistance. - In an interview at 3:35 p.m. on 02/09/11, the unit director reported she had distributed tap bells to all residents on the SNU as an alternate means of summoning staff when the nurse call system went down during a power outage at 6:00 a.m. on 01/28/11; when the power was restored, these tap bells were collected from the residents after the power was restored at 6:30 a.m. on 01/28/11. She did not know how much actual time elapsed before she picked up the bells, but she said, "Almost as soon as I got the bells put out and the signs up, the power came back on, and I took the bells up." After the power was restored on 01/28/11, the emergency nurse call system for two (2) bathrooms located on the SNU malfunctioned, causing the audible signal to the nurse call system for the SNU to sound continuously. The audible signal to the nurse call system was disabled due to its continuous ringing; however, tap bells were not redistributed to all residents as an alternate of summoning staff while the audible signal was disabled. During earlier interviews in the unit director's office, in the late afternoon on 02/08/11 and in the late morning on 02/09/11 in the late morning, observation had found a box of tap bells available for use in a box on the floor in the office. The entire SNU was without a fully functioning nurse call system with an audible signal that would sound at the nurse's station (to alert staff of a resident's need for assistance) since 01/28/11. - At 3:37 p.m. on 02/09/11, the division director of performance improvement and risk management (Employee # ) and the chief nursing officer (CNO - Employee # ) were interviewed. The CNO stated that tap bells could be utilized for the residents, and a staff member could be stationed in the hallways to watch for activation of the visual signals to the call system to ensure residents' needs were being met. - At 4:05 p.m. on 02/09/11, Employee # presented the facility's EMP dated 02/09/11. Review of the EMP found the following: "Response to citation: Failure of nurse call system. "Problem Identified: Nurse call system noted to have no audible sound associated with the light outside the patient room. "Immediate Action: "Initiate manual call bells and place in all patient rooms. - Completed. "Increase staffing by one with specific responsibility to ensure continuous rounding. - Completed. "Communicate with patient and/ or family emergency procedure: use manual bell and/or telephone at x 6188 s posted in patient room. "Actions will be ongoing until system repair (see below) "Corrective Action: "Repair system: We have located a company in California that is making arrangements to come in next week (February 16th). The company is (name of vendor) that have replacement parts and have the knowledge of the software." - A list of current residents was requested from the unit director at 4:15 p.m. on 02/09/11. Rounds were made to determine which residents were able to use tap bells and/or access the nurse's station via phone. There were twenty-four (24) residents on the SNU at this time, and there were six (6) residents who were unable to use the tap bells. This was confirmed with the unit director by review of the census list at 4:30 p.m. At this time, Employee # provided a copy of the facility's Emergency Operating Plan, and the section titled "Electricity" was reviewed. It stated, "Emergency power is provided to maintain the essential hospital services during an outage. The back up generator is fuel powered. The generator holds 3500 gallons fuel. In addition to this, a 275 gallon day tank is available and there is also 30,000 gallons stored in an underground tank. The fuel usage noted in the 24 hour outage in September 2008, when the generator was on for a 24 hour period was 1050 gallons. Based on this experience there is a sufficient amount of fuel on hand to operate for an extended period of time." There was no discussion in the Emergency Operating Plan to address a failure of the nurse call system. - At 5:10 p.m. on 02/09/11, the staff member assigned to monitor the visual signals in the hallway arrived at the SNU, the tap bells were being utilized, and signs were up in the resident rooms indicating how to access the nurse's station via phone. At the time, the surveyor confirmed, by direct observation and staff interview, that the circumstances which created immediate jeopardy were removed. The unit director was notified of the removal of immediate jeopardy as of 5:10 p.m. A deficient practice remained after the removal of immediate jeopardy, as the audible signal component of the nurse call system was still not fully functional; this remaining deficient practice presented the potential for more than minimal harm to all residents on the SNU. (See also citation at F463.) -- b) During an interview at 9:40 a.m. on 02/15/11, the unit director reported there had been no quality assurance activity by the QAA committee in response to the malfunction and subsequent disabling of the audible signal component of the nurse call system on the SNU. The unit director provided a copy of the policy titled "Skilled Care Improvement Committee Policy" (dated 01/10), which stated: "Policy: The Skilled Care Improvement Committee will provide ongoing quality and assurance activities. The committee identifies quality deficiencies, develops, and implements plans of action to correct these quality deficiencies, including Monitoring and the effect of implemented changes and making needed revisions to the action plans. "Scope: This policy applies to the Skilled Care Unit. "Responsibilities: The Director of the Skilled Nursing Facility is responsible for the application, interpretation and the enforcement of this policy. "Procedures: "1. Members of the committee will include, but not limited to, the Director of Nursing , the medical director, and at least three other members of the facility's staff (i.e. Infection Control Coordinator, Activities, MDS Coordinator, Rehabilitation Services, Food and Nutritional Services, etc.) "2. The Director of Nursing will chair the committee. "3. The committee will meet at least quarterly: to identify issues, develop and implement appropriate plans of action, and evaluate effectiveness of actions taken. "4. Action plans may include, but not limited to, the revision of policies and procedures, training of staff, recommendation of equipment purchases, and standards for evaluating staff performance." -- c) As noted in the findings above, the unit director, director of maintenance, social worker, unit secretary, and various members of the SNU's nursing staff were aware of that the nurse call system was not functioning properly, but the SNU's QAA committee, which was chaired by the unit director, failed to take action to ensure an alternate means of communication was made available when the audible signal component of the nurse call system malfunctioned on 01/28/11 and was subsequently disabled by the facility.