Every finding on record at Westmoreland Rehabilitation & Healthcare Center

Based on staff interviews, clinical record review, and review of facility documents, the facility staff failed to prevent abuse for 1 of 34 residents (Resident #38), in the survey sample.The findings included: The facility staff failed to prevent Resident #15 from abusing Resident #38 by striking her on the chin.1. Resident #15 was admitted to the facility 7/12/19. The diagnoses included vascular dementia, muscle spasms, hemiplegia and hemiparesis, and major depressive disorder.The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/20/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 06 out of a possible 15. This indicated Resident #15's cognitive abilities for daily decision making were severely impaired.2. Resident #38 was admitted to the facility 4/26/22. The diagnoses included dementia, history of falls, acute kidney failure, and bipolar disorder.The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/6/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 00 out of a possible 15. This indicated Resident #38's cognitive abilities for daily decision making were severely impaired.On 8/20/26 at 1:05 PM an interview was conducted with the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services (RDCS). The DON stated that on 6/2/26, Resident #15 and Resident #38 were in a physical alteration. The DON also stated that Resident #38 placed her hand on Resident #15's arm. The DON further stated that as Resident #38 released her grip on Resident #15's arm, Resident #15 struck Resident #38 on the chin. The DON lastly stated that both residents were assessed and monitored for injuries and no injuries were sustained.A review of Resident #15's nursing progress notes dated 6/2/26 at 9:37 PM read: At 7:25p I was notified that (resident name redacted) was involved in an altercation with (resident name redacted). (CNA name redacted) reported observing (resident name redacted) strike (resident name redacted) on her left cheek after (resident name redacted) was observed holding onto (resident name redacted) arm in the living room. I did not witness the incident. Upon assessment, (resident name redacted) was A/O and responsive. Vitals: Temp. 98.6, O2 99%, P 84, BP 124/82 R19. Resident denied injury and exhibited no visible signs of distress. RP (responsible party), DON, and NP (nurse practitioner) notified. Residents were separated and monitoring initiated. Statement obtained from staff who witnessed the event.On 8/20/26 at 1:28 PM an interview was conducted with the RDCS. The RDCS stated that she cannot put her hand on the 15 minute checks. The RDCS also stated that the facility does not have the documentation to validate past noncompliance regarding the allegation of abuse.On 8/20/26 at approximately 4:15 p.m., a final interview was conducted with the Administrator, Director of Nursing, Regional Director of Clinical Services, and Regional Director of Operations. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on clinical record review, staff, and family interviews, the facility failed to provide the necessary foot care and treatment to avoid complications from conditions such as diabetes, including referral and treatment by a qualified professional, for one (1) (Resident #5) of five (5) residents in the survey sample, which resulted in harm. The findings included: Resident #5 was admitted to the facility on [DATE] with a diagnosis of diabetes, cerebrovascular accident, dysphagia, aphasia, hypertension, cognitive communication deficiency, chronic ischemic heart disease, adult failure to thrive, malnutrition, hepatitis, and difficulty walking. Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE], scored the resident on the Brief Interview for Mental Status (BIMS) as a 4 out of 15, indicating severe cognitive impairment, but able to complete the BIMS assessment. The resident was not assessed to resist care, including ADL assistance, taking medications, and receiving the care necessary to achieve the resident's goals. The resident was not assessed to have behaviors that would deter receiving care and services. Resident #5 had a care plan dated 7/19/2023 for diabetes mellitus that included proper foot care daily. Avoid tight, pinching shoes. Report any redness, blistering, or open areas promptly to the physician or designee. Check nail length and trim and clean on bath day and as necessary. Provide skin inspection daily during care. Observe for redness, open areas, scratches, cuts, bruises, etc., and report changes to the nurse. Report any changes to the nurse. Review of Resident #5's medical records dated 12/25/2023 at 5:07 PM documented that Resident#5 was transported to the emergency room (ER) by a family member (FM #2) to be assessed for a fall and weight loss. The emergency room physician's assessment documentation indicated, Left foot noted with bleeding about the big toenail. Generally speaking, bilateral feet, the patient has significantly overgrown toenails, will need podiatry to evaluate further. Resident #5 was treated and released from the emergency department and returned to the facility on [DATE]. Resident #5's medical record, dated 12/29/2023 at 11:32 PM, documented that the facility's staff obtained a culture of the resident's left toe drainage, but the courier was unable to transport the specimen. The residents' medical records did not indicate why the courier was unable to transport specimens at that time. Resident #5's medical record, dated 12/30/2023 at 11:56 AM, documented that the resident was diagnosed with a cutaneous abscess of the left great toe: We will attempt a culture of the drainage, and I will place the patient on Keflex 500 mg every 12 hours for 10 days. We will attempt to get him into a podiatrist as soon as possible. A review of Resident #5's medical records dated 01/03/2024 at 03:03 AM documented that facility staff again obtained a culture of the resident's left toe and sent it to the lab for examination due to inability to be sent out on 12/29/2023 Resident #5's medical record, dated 01/05/2024 at 8:09 AM, documented that the facility staff received the results from the resident's left toe drainage culture, which was *gram positive; We are trying to get him to see a podiatrist. *Gram-positive is an essential diagnostic tool/staining, helping to identify the type of bacteria causing an infection and guide appropriate antibiotic treatmenthttps://www.merckmanuals.com/home/infections/bacterial-infections-gram-positive-bacteria/overview-of-gram-positive-bacteria. Resident #5's medical record, dated 01/08/2024 at 12:00 AM, documented the resident on Doxycycline (an antibiotic) and a Podiatry consult pending. Resident #5's medical record, dated 01/09/2024, 05:30 AM, documented that the resident remained on antibiotics for the left great toe; The resident is on contact precautions due to Methicillin-resistant Staphylococcus aureus (MRSA), (a type of staph bacteria that's resistant to many antibiotics used to treat regular staph infections https://www.mayoclinic.org/diseases-conditions/mrsa/symptoms-causes/syc-20375336). Resident #5's medical records, dated 01/15/2024 at 1:25 PM, documented that the resident's left toenail was falling off; No drainage was noted at this time. Resident #5's medical records, dated 01/19/2024 at 03:25 AM, documented that the resident underwent a procedure by the facility's wound nurse to remove the left great toenail. The facility's wound nurse noted that the Patient nonverbally expressed too much discomfort to debride. Resident #5's medical record revealed that on 02/02/2024, at 12:00 AM, the facility's Nurse Practitioner (NP) documented the resident's left toe as healed. Resident #5's medical record entry revealed that the facility's wound care nurse was still treating the resident for a great left toe infection after 02/02/2024. Resident #5's medical records entry dated 2/25/2024 at 12:13 PM documented, Resident c/o (complaining of) pain of left great toe, removed shoe, and resident indicated relief of pain. Resident #5's medical record entry was dated 02/26/2024 at 12:00 AM. The facility's NP documented the resident's left great toe cutaneous abscess as resolved. Resident #5's medical record dated 3/02/2024 at 02:54 AM documented that the resident felt warm to the touch, and vital signs were obtained. The residents' temperature was 102.2 Fahrenheit (F) (Normal temperature for adults is in the range of 97 to 99 (https://www.mayoclinic.org/first-aid/first-aid-fever/basics/art-20056685). The resident was administered a standing order for Acetaminophen 650 milligram (mg) orally. Resident #5's medical record dated 3/02/2024 at 09:01 AM documented the resident's temperature as 102.3 (F). Resident #5's medical record, dated 03/06/2024 at 12:00 AM, documented that the facility's NP assessed the resident for spiking low-grade fever of 100.2 this morning. Resident # 5 has been complaining of foot pain. Resident #5 was observed with an additional left great toe site where a previous subcutaneous cyst was infected but had been resolved. The medical record of Resident #5, dated 03/08/2024 at 9:24 PM, documented Resident noted to have fever during feeding, 102.3, Tylenol given. The facility staff contacted Resident #5's family member regarding the resident's change in condition. FM requested that the resident be transported to the hospital. Emergency medical service (EMS) transported Resident #5 to the hospital on 3/8/24 at 9:45 PM. Resident #5's emergency room record dated 3/08/2024 documented the Resident arrived from a nursing facility, transported by EMS with a fever of 102 (F), as per the patient's sister, he was able to ambulate with a walker 3 months ago, but now is bedridden and has lost lots of weight in the last 3 months. Resident #5 was admitted to the hospital intensive care unit with diagnoses of Sepsis, Gangrene, Osteomyelitis of the left great toe, and pressure ulcer of the left great toe. Resident #5 was immediately scheduled for surgery to amputate his left great toe by the hospital. An interview was conducted on 4/07/25 at 1:15 PM with Resident #5's Family Member (FM #2) regarding the residents' care in the nursing facility. FM#2 stated the resident had a stroke but was making progress after being hospitalized for several months. FM #2 stated she scheduled and attended all the medical appointments of Resident #5 during his admission. She said she would usually pick up the resident from the nursing facility and transport him to wherever he needed. FM #5 stated she would often speak with the facility's NP regarding Resident #5's condition, including the resident's toenails, which needed clipping. During the above interview with FM #2, she stated the NP told her the facility staff would often skip cutting Resident #5 when the Podiatrist arrived. FM #2 said the NP indicated Resident #5 to be rescheduled to be evaluated by the Podiatrist. FM #2 stated that Resident #5 kept having fevers over the course of weeks, and on 12/25/2023, she transported the resident to the emergency department. FM #2 said she observed Resident #5 while waiting to be seen in the emergency department as he continuously shuffled his left foot back and forth. She said the emergency room nurse removed the resident's shoe and observed a bloody sock filled with pus. FM #2 stated Resident #5's left foot big toenail was partially torn off. FM #2 said once the resident returned to the facility, she once again requested to have the resident assessed by a podiatrist. She stated that the facility staff would always say, (Resident #5's name) would be seen soon by podiatry, which never happened. FM #2 requested that Resident #5 be transported again to the emergency room on 3/8/2024. She said Resident #5 still had high fevers, and his health declined. FM #2 stated, (Resident's name) was diagnosed with Sepsis and Gangrene of the left big toe. The hospital doctor told (Resident #5's name) and me that, because of complications and infection in his foot, amputation would be the only recourse. The procedure was scheduled, and I made sure he did not return to (Name of nursing facility). The reviewed hospital medical records supported the information shared during the interview by FM#2. An interview was conducted on 4/22/2024 at 12:00 PM with the facility's Podiatrist (POD #6) regarding Resident #5's treatment provided during his admission. POD#6 stated that the resident was never assessed during his admission. She said Resident #5 was scheduled to be seen on 12/12/2023, but the resident appeared agitated when she approached him. POD#6 said Resident #5's appointment was documented as a refusal. POD#6 stated she was never informed or contacted by the facility later regarding Resident #5's foot condition. POD #6 stated that the facility staff was responsible for creating the list of residents needing to be assessed during their visits. She said Resident #5 could have been scheduled to be seen by a local Podiatrist if needed. A review of Resident #5's medical records did not indicate the resident refused any podiatry treatments during the admission. A meeting was conducted on 4/22/2025 at 12:30 PM with the facility Administrator and Director of Nursing (DON). The DON stated that Resident #5 was scheduled to see the Podiatrist on 12/12/2023, and the resident refused treatment. The DON said the facility staff had no control over who the Podiatrist saw during their visits. It was not explained who prepared the list for the podiatrist visit or why the resident was never evaluated by a qualified professional, who would have been the podiatrist. The facility's administrator stated that the facility did not have podiatry coverage for a while during this timeframe. The facility administrator emailed a copy of a memorandum from the facility's Podiatry vendor regarding the facility's lack of coverage for the following months: July 2023-November 2023, we did not have a provider available for Westmoreland. The facility's Podiatrist was on maternity leave from 12/23/2024 through 4/19/2024. No additional information was presented regarding this incident.

F600 AFTER F689 Based on clinical record review, staff, and resident interviews, the facility staff failed to ensure adequate assistance was implemented for bed mobility, which the facility had control over to prevent accidents for one (1) of five (5) residents in the survey sample, Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis of Multiple Sclerosis, hemiplegia, and hemiparesis following a stroke affecting the right dominant side, muscle wasting and atrophy at multiple sites, lymphedema, spinal stenosis in the lumbar region without neurogenic claudication, and pulmonary embolism. Resident #1's Other Payment Assessment Minimum Data Set (MDS) with an assessment reference date of 3/25/25 coded for bed mobility (how the resident moves to and from lying position, turns side to side, and positions their body while in bed) as needing extensive assistance and support from 2 or more persons (s), physical assistance. Resident #1 Brief Interview for Mental Status (BIMS) scored 15 out of 15, indicating no cognitive impairment. Resident had a revised care plan dated 3/3/25 as having an ADL (Activity of Daily Living) self-care performance deficit related to weakness, Stroke, deconditioned status post hospitalization, Hemiparesis/Hemiplegia, muscle wasting and atrophy, and sequelae of the stroke. The care plan failed to address bed mobility needs, including two staff members for assistance. Review of Resident #1's progress notes dated 3/26/25 at 2:41 PM indicated that at approximately 10:40 AM, CNA #1 reported that Resident #1 had fallen out of bed and was lying on the floor. Facility staff documented that Resident #1 was immediately assessed and observed positioned on the right side of the bed on the floor. Resident #1 was alert, responded WNL (Within Normal Limits), and had no pain. ROM (Range of Motion) was WNL. Resident #1 was administered PRN (as needed) Tylenol as a pain preventative. The facility's staff immediately installed bed rails to the upper portion of the resident's bed to assist with bed mobility during turning and repositioning. An interview was conducted on 4/1/25 at 12:10 PM with Resident #1 regarding the incident. Resident #1 was just readmitted to the facility after being hospitalized from [DATE] to 3/31/25, for a condition determined to be unrelated to the fall. Resident #1 was eating in the facility's TV room. Resident #1 observed CNA #1 walking with the surveyor into the facility's TV room, at which time she stated, That's the nurse who dropped me! Resident #1 expressed that CNA #1 was bathing her and attempted to turn her to the right side. The resident said there were usually two or more nurses helping when repositioning her in bed. Resident #1 said she believed the facility is short of staff. Resident #1 stated, I remember being turned to the right side of the bed and continuously rolling straight towards the floor. I could hear the CNA repeatedly saying I'm Sorry! I'm sorry! She rushed out of the room to get help, leaving me on the floor alone. Resident #1 said the facility Administrator and Director of Nursing entered the room after the fall. Resident #1 stated she experienced pain in her back, and both legs were swollen. The resident remembered being transferred back into bed after the incident. Resident #1 stated she was having difficulty staying awake and told the facility staff, Just sit me in a chair. Resident #1 said that since the fall, she felt apprehensive about the staff assisting with bathing or showering. On 4/1/25 at 12:53 PM with CNA #1, an interview was conducted regarding the residents' fall. CNA said, I normally don't provide care for this resident, but I did it. I was bathing Resident #1, and I turned the resident onto her side using a drawsheet (a flat sheet, often smaller than a regular bed sheet, used in a healthcare setting to assist in repositioning or transferring patients in bed). I pulled too hard on the drawsheet, and Resident #1 rolled towards the right side of the bed. I observed the resident attempting to reach outward with her only functional left arm as she fell onto the floor on the opposite side of the bed, away from me. I heard (Resident #1's name) moaning on the floor. I immediately left the resident's room to get assistance. CNA said that LPN #2 entered the room, assessed the resident, and stayed with the resident on the floor. CNA #1 stated that the Director of Nursing (DON) and nurse practitioner (NP) came into Resident #1's room and assisted with getting the resident back into bed by utilizing the full mechanical lift. CNA #1 said she told everyone present how the incident occurred and that she dropped Resident #1 by accident. A meeting was conducted on 4/1/25 at 2:28 PM with the Facility's Nurse Practitioner (NP #6), who arrived in Resident #1's room after the fall. NP #6 stated he was called to assist with getting the resident back in bed after the fall. NP #6 said the resident was on the floor when he arrived in the room. NP #6 stated Resident #1 had no broken bones, but he was concerned about her legs swelling. He said the resident had no complaints of pain. NP #6 stated the facility usually waits a couple of hours before calling emergency medical services for residents who fall, if there is no obvious evidence of broken bones or immediate neurological changes. A review of the facility's residents' fall investigations for January 2025 through March 2025. The facility Director of Nursing (DON) presented the fall investigations binder, but the binder did not include information regarding Resident #1's fall investigation. The investigation binder was returned to the DON, and the fall investigation binder was asked if it was complete. The DON later returned the investigation binder, and Resident #1's information regarding the resident's fall was included. The DON did not explain why Resident #1's fall investigation was not initially included in the binder. A meeting with the DON was conducted on 4/1/25 at 2:45 PM regarding Resident #1. The DON stated CNA #1 came to her office for help when Resident #1 fell. The DON said NP 6 and the facility Administrator were in the room. Resident #1 was lying on the floor, lying on her back, and said she was not in pain. The DON stated Resident #1 was assessed, and the resident wanted to get up. She said Neuro checks were within normal limits, and Resident #1 denied hitting her head, which was corroborated by the CNA. DON stated CNA #1 provided morning care to Resident #1, while CNA #1 turned the resident on her side, the resident continued to roll off the mattress to the floor. The final exit meeting was conducted on 4/22/25 at 12:30 PM with the facility Administrator and Director of Nursing. No additional information was presented regarding this incident.

Based on staff interview and facility documentation review, the facility staff failed to maintain an infection control and prevention program to help prevent the development and transmission of infections, which has the ability to affect all Residents residing at the facility. The findings included: 1. The facility staff failed to develop and implement a water management plan for Legionella with regards to a risk assessment to identify where Legionella and other waterborne bacteria could grow. On 6/7/23, during review of the facility water management program the facility Maintenance Director of [NAME] President of Plant Operations were present. When asked for their facility risk assessment with regards to water management, which used to identify where Legionella and other waterborne bacteria could grow and spread in the facility water system, the facility had nothing to provide. On the morning of 6/8/23, the Corporate VP of Plant Operations (VPPO) stated they had been unable to locate any type of risk assessment with regards to water management and had nothing to submit. The facility Administrator was made aware of the lack of a water management program on 6/8/23, during the end of day meeting. No further information was provided. 2. The facility staff failed to maintain an infection control program that included a system of infection surveillance. On the afternoon of 6/8/23, Surveyor E met with the Director of Nursing (DON) and Infection Preventionist (IP) to review documents. The IP had a line listing of facility staff who displayed signs of infections from March and April 2023. The IP had no evidence of any infection surveillance/tracking, etc. for facility staff prior to March 2023 to submit. Review of the surveillance of Resident infections was reviewed and revealed that the tracking and trending was inaccurate and incomplete. The evidence included: a. For the month of June 2022, the facility noted 15 Resident infections. Of the 15 infections, 6 were UTI's (urinary tract infections). On the facility floor plan where they monitor for trends of infections, no UTI's were noted. b. For the month of January 2023, the facility noted 2 UTI infections, 5 COVID infections and 2 with pneumonia. Of these, only the pneumonia infections were noted on the facility floor plan, which is used to monitor for trending and potential spread of infection. c. For the month of February 2023, the facility noted 2 infections with pneumonia, either of which were noted on the floor plan for trending. None of the infection control documents submitted had any evidence of the evaluation of the data or any trends noted and the facility's response. On 6/8/23, the DON and IP were present for the above review and noted the same findings. When a discussion was held, both said they understood and agreed that the current infection control program was inadequate and missing a lot of information. The DON said, the reason infection surveillance is important is, To monitor for any best practices and to monitor for patterns or issues, where we are causing the infection through breaches in infection control and tracking it room to room. It allows us to take the best care of our residents. especially with flu and cold seasons. Review of the facility's infection control policy was conducted. The policy titled, Surveillance for Infections read, 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent further infections. Another excerpt read, .3. Infections that will be included in routine surveillance include those with: a. evidence of transmissibility in a healthcare environment; . c. clinically significant morbidity or mortality associated with infection (e.g., pneumonia, UTIs, C. Difficile) During the end of day meeting held on 6/8/23, with the facility administrator, director of nursing and corporate staff, they were made aware of the above findings. No further information was provided.

Based on interview, and facility documentation the facility staff failed to maintain Registered Nurse coverage 7 days a week. This has the potential to affect Residents who need the services of a Registered Nurse (RN). The findings included: The facility staff failed to maintain RN coverage for at least 8 consecutive hours a day on 10/15/22. On 6/7/23 during entrance conference, the facility was asked if they had any kind of waivers and they stated that they did not. On 6/7/23, a review of Payroll Based Journal reports revealed that the facility lacked RN coverage on 10/8/22, 10/15/22, 10/22/22 and 10/23/22. On 6/7/23, the Human Resource director ran a report of the nursing staff scheduled for the months of September and October of 2022. A staffing schedule showed that on 10/8/22, 10/22/22, and 10/23/22, there appeared to be a Registered Nurse scheduled. However, on 10/15/22 the schedule appeared to be missing RN coverage. A request was made for timecard punches for 10/8/22, 10/15/22, 10/22/22, and 10/23/22 as credible evidence that the facility was staffed properly for those days. There was no time punch for an RN on 10/15/22. An interview with Employee H who stated that staffing the facility had been a challenging job at that time. She stated that they had been doing their best to ensure Registered Nurse coverage as well as floor staffing needs. She stated that they have finally gotten their staffing to where they are no longer using agency staff and going forward RN coverage should not be an issue. On 6/8/23 during the end of day meeting, the Administrator was made aware of the concerns and no further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to maintain an ongoing antibiotic stewardship program to monitor the use of antibiotics which had the ability to impact numerous Residents throughout the facility on all nursing units/resident care units. The findings included: On 6/8/23 at 11:42 AM, an interview was conducted with the facility's Infection Preventionist (IP)/Employee J, and the Director of Nursing. Review of the infection surveillance revealed that the facility uses an electronic form to review antibiotic usage to determine if McGreer criteria was met. Several Residents were noted to be prescribed and receiving antibiotics and the assessment indicated antibiotic use was not warranted. The assessment read, Does not meet criteria and Does not meet requirements. The Director of Nursing stated when this happens the facility staff are to talk with the physician and document the conversation about antibiotic use not being warranted and note any new orders received. In each of the instances reviewed where the Resident was noted to not meet criteria for antibiotic usage, the facility had no evidence of a conversation being held with the prescriber/physician to see if they wanted to discontinue the antibiotic. Each of the Resident's completed a full course of antibiotics. During the above interview, the Director of Nursing discussed that the risk of antibiotic use when it was not warranted leads to antibiotic resistance. Review of the facility policy titled, Antibiotic Stewardship, was conducted. This policy read, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. 1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. 2. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community . On 6/8/23, the facility Administrator, Director of Nursing and Corporate staff were made aware that the facility had failed to provide evidence of an ongoing antibiotic stewardship program. No further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to 1) mitigate hazards for Residents that use slings, for 1 Resident (#33) in a survey sample of 26 Residents and 2) the facility staff failed to maintain water temperatures in a range to mitigate burns, scalding and other injuries. The findings included: 1) For Resident #33, the facility staff used a mechanical lift without the safety clips being on the hook to prevent the sling from backing out. On 6/7/23 at approximately 11:45 AM CNA's C and D were observed as they prepared to transfer Resident #33 from the bed to the shower stretcher. One CNA was on either side of the bed as they carefully rolled the Resident side to side to get the lift sling positioned under her correctly. The CNAs began explaining everything to the Resident who was responding and following directions. At that time, the Resident requested to be weighed and the CNA's stated that would be no problem as the lift has a weight scale on it. As the CNA's were getting the pad clipped onto the lift, it was noted that 2 of the hooks did not have clips on them. When asked what the clips were for CNA D stated that they were to prevent the lift sling from backing out and slipping off of the hook. CNA D stated that they had notified the former DON and she was supposed to have maintenance fix it. She stated she was told the facility had only lift with a scale, so they had to continue to use it. CNA C started we have another lift, but it does not have a scale on it. We also have 2 different lifts, but we were told we could not use them as they belong to a sister facility. CNA C told the surveyor where the lifts were located. There were 4 lifts on the back hall 1 without a scale and 2 that appeared to be new. On 6/7/23, an interview was conducted with the acting DON at approximately 1PM, who stated that she was unaware of the condition of the lift, and it has been taken out of service until the maintenance director could repair it. The sister facility's lifts were being used in the meantime. A review of the manufacturer's instructions read: After the first year of use, the hooks of the hanger bar and the mounting brackets of the boom should be inspected every three months to determine the extent of wear. If these parts become worn, replacement must be made. Casters and axle bolts require inspections every six months to check for tightness and wear. After the first twelve months of operation, inspect the hanger bar and the eye of the boom (to which it attaches) for wear. If the metal is worn, the parts MUST be replaced. Make this inspection every six months thereafter. Regular maintenance of patient lifts and accessories is necessary to assure proper operation. On 6/7/23 during the end of day meeting the Administrator was made aware of the finding and no further information was provided 41449 2. The facility staff failed to maintain water temperatures in a range to mitigate burns, scalding and other injuries. On the afternoon of 6/6/23, an interview was conducted with the maintenance director/Employee C. The maintenance director was asked if he checks water temperatures and the maintenance director stated, he checks temperatures weekly. Review of his water temperature logs revealed that temperatures are checked resident rooms routinely. The maintenance director was asked to obtain his thermometer used to check water temperatures. When asked how often he calibrates the thermometer he uses to check temperatures, the maintenance director stated, I haven't ever calibrated it. The maintenance director then went and borrowed a digital thermometer from the kitchen as well. The maintenance director accompanied Surveyor E to the room of Resident #4. The maintenance director used his thermometer to measure the water temperature and it was 118 degrees. The maintenance director then used the thermometer from the kitchen and the water measured 120.7 degrees. Both Surveyor E and the maintenance director did the same in 2 additional resident rooms and both measured 120.7-120.8 degrees on the digital thermometer. The maintenance director confirmed that this was too hot, and someone could get burned. On the morning of 6/7/23, the maintenance director and vice president of plant operations (VPPO) confirmed that they had purchased a new thermometer and made adjustments to the water mixing valve to decrease the water temperature to safe range in Resident rooms. The maintenance director and VPPO accompanied Surveyor E to several rooms on each resident care hallway and verified water temperatures to be between 103-111 degrees. Both again confirmed that the temperature reading of 120 degrees the day prior, was too hot and could be a potential hazard to Residents. On 6/7/23, the facility's corporate staff confirmed they were unable to pull a report of incident tracking via the electronic system used for incidents and would have to make a list manually. They further confirmed that no Residents had any incidents of burns within the past 3 months. Review of the facility policy titled water temperatures, safety of was conducted. This policy read, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit or the maximum allowable temperature per state regulation .4. If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor . Access to water at 120 degrees in 5 minutes can cause 3rd degree burns, according to [NAME], A.R., [NAME] F.C. Jr. (1947). Studies of Thermal Injury: 11. The Relative Importance of Time and Surface temperatures in the Causation of Cutaneous Burns. Am J Pathology, 23, 695-720. On 6/7/23 and again on 6/8/23, during an end of day meeting, the facility Administrator, Director of Nursing and Corporate Staff were made aware of the above findings. No further information was provided.

Based on observation, interview, clinical record review, and facility documentation the facility staff failed to 1) ensure controlled substances were disposed of correctly and 2) failed to provide routine medications for 2 Residents (#28 and 16). The findings included: 1. The facility staff failed to ensure proper disposal of 24 controlled substances for Residents who no longer reside in the facility or who no longer use the controlled medication. On 6/7/23 at approximately 8 AM, during the medication pass it was discovered that there were 24 controlled substances, in various bottles and cards, to include liquid morphine, liquid Ativan, oxycodone, hydrocodone, gabapentin, Vimpat, morphine ER, and Ambien for Residents who no longer reside in the facility or who no longer use the medication. A review of the facility's Policy entitled Discarding and Destroying Medications, read: Medications will be disposed of in accordance with federal, state and local regulations governing the management of nonhazardous pharmaceuticals, hazardous waste and controlled substances. 1. All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of. On 6/8/23 at approximately 11 AM, an interview was conducted with the Assistant Director of Nursing (ADON) who stated that the policy was to destroy controlled substances with 2 RN's and since the Director of Nursing (DON) quit, she was the only Registered Nurse (RN). On 6/8/23 at approximately 1 PM, an interview was conducted with the Acting DON who stated she had only been in the facility since 6/5/23 and was unaware of the number of controlled substances being stored in the carts and in the refrigerator. When asked what the process was for disposal of controlled substances, she stated that 2 nurses had to waste controlled substances, but she was pretty sure the DON was responsible for disposal of controlled substances when the Residents were discharged or otherwise not using the medication. She further stated that going forward the disposal will happen weekly to rid the carts and refrigerators of any discontinued controlled substances. On 6/8/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 41449 2. During the medication administration observation, the facility staff did not have available medications ordered by the physician for Resident #28 and Resident #16. On 6/7/23 at 8:18 AM, Licensed Practical Nurse C (LPN C) and LPN D were observed during the medication administration of Resident #28. LPN C mentioned that they did not have the MiraLax (Polyethylene Glycol 3350) to administer. LPN C said, it [Polyethylene Glycol 3350] has been out for several days- we have had hard time getting it from the pharmacy, it is out of stock. Since it is OTC [over the counter], supply has to order it. The clinical record review revealed Resident #28 had an order for GlycoLax Powder 17 GM/Scoop (Polyethylene Glycol 3350) Give 1 scoop by mouth one time a day for constipation, which was scheduled for a 9 am administration. On 06/07/23 at 08:21 AM, LPN C and LPN D were observed during medication administration for Resident #16. Following the observation, Surveyor E reviewed the physician orders. This review revealed that Resident #16 had an order for Refresh Tears Solution (Carboxymethylcellulose Sodium). Instill 2 drops in both eyes four times a day for dry eyes two drops in each eye four times per day. The eye drops had been signed off for the 9 am, administration, however they were not observed to be given. The facility policy titled, Unavailable Medication was received and reviewed. This policy read, . 2. In the event that a medication ordered for a resident is noted to be unavailable near or at the time it is to be dispensed [administered], nursing staff shall: a. Contact the pharmacy regarding the unavailable medication. b. Attempt to obtain the medication from the facility's automated medication dispensing system or emergency kit. c. Notify the physician of the unavailable medication . On 6/7/23, during an end of day meeting, the facility administrator, Director of Nursing (DON) and corporate staff were made aware of the above observations and medications not available for administration to Residents. The Regional [NAME] President stated that the concerns of the pharmacy had been brought to his attention and they had a meeting scheduled with their pharmacy. No further information was provided/received.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to determine the Resident's immunization status and offer influenza and pneumonia vaccines for 2 Residents (Resident #255 & #48) in a survey sample of 5 residents reviewed for immunizations. The findings include: 1. The facility staff failed to determine Resident #255's current immunization information and offer any immunizations the Resident was eligible. A clinical record review was performed on 6/7/23. Resident #255's clinical record revealed, under the immunization tab, that the flu vaccine and pneumococcal immunizations were, historical. The record had no information to support where the facility obtained this data. On 6/8/23, an interview was conducted with the facility's Director of Nursing (DON) who accessed the clinical record for Resident #255 and verified the findings. The DON further confirmed there was no Virginia Immunization Information System (VIIS) uploaded into the record as evidence that the facility had attempted to obtain the Resident's current immunization status. 2. The facility staff failed to identify/assess Resident #48's current immunization status so that they could offer any immunizations the Resident was eligible for. A clinical record review was performed on 6/7/23. Resident #48's clinical record revealed, under the immunization tab, that there was no information with regards to flu vaccine and pneumococcal immunizations. Nor was there any evidence that facility staff had offered education or the vaccines to Resident #48. On 6/9/23, an interview was conducted with the facility's Director of Nursing (DON) who accessed the clinical record for Resident #48 and confirmed the above findings. The DON further confirmed there was no Virginia Immunization Information System (VIIS) uploaded into the record as evidence that the facility had attempted to obtain the Resident's current immunization status. The DON stated that the facility's process is for admissions to check the VIIS and upload it into the clinical record and then nursing will educate and offer any immunizations the Resident is eligible to receive. She said the importance of immunization is, we are trying to help the community be healthier and safer. Following the above interview, the DON advised Surveyor E that no one in the facility has access to the VIIS system. Review of the facility policy entitled, Pneumococcal Vaccinations, was conducted. This policy read, 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine within (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated . The facility policy titled, Influenza, Prevention and Control of Seasonal was reviewed. An excerpt from this policy read, .Vaccination: 1. The infection preventionist organizes and oversees an annual influenza campaign. 2. All residents and staff are offered the vaccine at or before the onset of the influenza season. 3. All residents and staff are encouraged to receive the vaccine unless there is a medical contraindication . On 6/8/23 during the end of day meeting, the Facility Administrator, DON, and corporate staff were made aware of the findings. No further information was provided.

Based on observations, interview, clinical record review and facility documentation the facility staff failed to ensure the medical record was accurate for 1 Resident (#32) in a survey sample of 26 Residents. The findings included: For Resident #32 the facility staff failed to ensure that his clinical record contained only his information. On 6/8/23 when the electronic medical record was accessed for Resident #32 to view the Pre-Admission Screening And Resident Review (PASARR) screening, a tab that said PASARR was clicked and what opened up was a document containing 33 PASARR's. Resident #32's PASARR was among the 33 PASARRs. On 6/8/23 at approximately 2PM, an interview was conducted with Employee N who was asked how assessments and records get put in the EHR (electronic health record), she stated that they are scanned and uploaded into the system. When asked if they do one chart at a time, she indicated that they did. When asked if a document is scanned into the wrong person's chart what happens, she stated that when they are aware of it, they immediately correct it. When asked why this is important, she stated because it's a Health Information Portability and Accountability Act violation. On 6/8/23 at approximately 4:15 PM, an interview was conducted with the DON, Corporate VP and Administrator who were made aware of the finding of 33 PASARR's in Resident #32's chart. The Corporate VP stated that it must have been when medical records scanned it in incorrectly and attached the entire file instead of only Resident #32's. On 6/8/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, staff interview, clinical record review and facility documentation the facility staff failed to properly store medications for 1 of 2 medication carts inspected. The findings included: On [DATE] at 8:33 AM, while completing the medication storage tasks Surveyor E made the following observations of the medication cart for the 200 hall in the presence of LPN C and LPN D: 1. Resident #32 had a Lispro insulin pen that had an open date of [DATE], that was on the cart and available for use. Resident #32 also had a multi-use vial of Lantus, which had no date opened. 2. Resident #206, had an aspart insulin pen and a Degludec insulin pen that had no labeling for the date opened. 3. Resident #32 had a Basaglar Kwik pen in the cart, which did not have an open date. A Novolog insulin pen which had an open date of [DATE], remained in the cart and available for use. LPN C confirmed all of the above findings and confirmed the date opened on the ones that had a date and commented, They are only good for 28 days. LPN C also confirmed that she could not find a date opened on the other ones noted above. LPN C further added that, He [Resident #32] isn't here anymore, he is deceased . A review of the facility policy titled; Administering Medications was reviewed. It read, .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container . The facility policy regarding the storage of medications did not address the labeling of insulin or multi-use vials. An excerpt from the policy did read, . Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . On the afternoon of [DATE], the director of nursing was asked about the storage of and labeling of insulin. The DON stated insulin is to be labeled when opened because it is only good for 28 days after being opened/accessed. The DON also confirmed that medications that are not in use or if the resident is no longer at the facility should be removed from the cart. On [DATE] during the end of day meeting the Administrator was made aware and no further information was provided.

Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to ensure the medication error rate was less than 5%. There were 3 medication errors in 35 opportunities, resulting in an 8.57% error rate. The findings included: On 6/7/23 at 8:18 AM, Licensed Practical Nurse C (LPN C) and LPN D were observed during the medication administration of Resident #28. LPN C pulled Resident #28's medications which were a total of 10 pills (tablets and capsules). LPN C mentioned that they did not have the MiraLax to administer. LPN C said, it [MiraLax] has been out for several days- we have had hard time getting it from the pharmacy, it is out of stock. Since it is OTC [over the counter], supply has to order it. Following the medication administration, LPN C continued with her medication pass and did not make any attempts to clarify that a supply had/had not come in, notify the physician, or take any other actions. On 06/07/23 at 08:21 AM, LPN C and LPN D were observed during medication administration. LPN C entered the room and administered Resident #16's medications, which included 10 pills and 1 inhaler. LPN D had obtained the Diclofenac gel, and waited until LPN C administered the medications and then she applied the Diclofenac gel to both of Resident #16's knees. Following the observation of medication administration, Surveyor E conducted a clinical record review of Resident #28 and #16's medication orders and medication administration record. This review revealed the following: a. Resident #28 had an order for GlycoLax Powder 17 GM/Scoop (Polyethylene Glycol 3350) [MiraLax] Give 1 scoop by mouth one time a day for constipation, which was scheduled for a 9 am administration. b. Resident #16's order for the Diclofenac gel read, Apply to left knee, right shoulder topically two times a day related to unilateral primary osteoarthritis left knee, apply 2 gm (grams). This administration was not signed off as having been administered. c. Resident #16 had an order for the following: Refresh Tears Solution (Carboxymethylcellulose Sodium). Instill 2 drop in both eyes four times a day for dry eyes two drops in each eye four times per day. The eye drops had been signed off for the 9 am, but were not given. Surveyor E then returned to the floor and interviewed LPN C. LPN C was asked about the administration of the Diclofenac gel being applied to both knees when the order was for the left knee and right shoulder. Surveyor E also notified LPN C the administration was not signed off. LPN C did not respond. Surveyor E then questioned the Refresh Tears eye drops that had been signed off and were not administered. LPN C confirmed the eye drops were not in-house and not available for administration. During the above interview, LPN C further confirmed that medications are to be signed off at the time of administration and only if they are administered. Review of the facility policy titled; Administering Medications was conducted. This policy read, .4. Medications are administered in accordance with prescriber orders, including any required time frame .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . The facility policy titled, Unavailable Medication was received and reviewed. This policy read, . 2. In the event that a medication ordered for a resident is noted to be unavailable near or at the time it is to be dispensed [administered], nursing staff shall: a. Contact the pharmacy regarding the unavailable medication. b. Attempt to obtain the medication from the facility's automated medication dispensing system or emergency kit. c. Notify the physician of the unavailable medication . No further information was provided/received.

Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed to ensure 1 resident (Resident # 1) in a survey sample of 26 residents received oxygen care in a manner to prevent the spread of infection. Findings included: 1. For Resident # 1, the facility staff failed to label and date the oxygen tubing. Resident # 1's clinical record was reviewed on 6/6/2023 and 6/7/2023. During the initial tour on 6/6/2023 at 11:40 AM, Surveyor C observed Resident # 1 lying in bed with oxygen, via nasal cannula, delivered by an oxygen concentrator located on the right side of the bed. The oxygen tubing was not labeled and dated. On 6/6/2023 at 12:45 p.m., Resident #3's oxygen tubing was observed again and noted to be without label or date. An interview was conducted with LPN (Licensed Practical Nurse) C who stated oxygen tubing should be labeled and dated. LPN C observed the tubing and stated there was no label on the tubing. LPN C stated she knew the tubing had been changed on the night shift on Sunday 6/4/2023 because she was the nurse who worked that night. LPN C stated she forgot to put the label and date on the tubing. LPN C stated it was important to change, label and date the tubing weekly to decrease the risk of infection. During the end of day debriefing on 6/6/2023, an interview was conducted with the Interim Director of Nursing (DON) who stated, Oxygen tubing should be labeled and dated and also changed weekly in order to prevent infections. LPN B stated the facility staff should change the oxygen tubing weekly and staff should check the date on the tubing prior to using it to make sure it is not longer than a week due to potential for infection control problems. Review of the Physicians Orders revealed the following orders for oxygen therapy: for Oxygen at 2 Liters per minute via nasal cannula every shift. There was an order revised on 5/10/2023 for Oxygen Tubing, cannula / mask every _Sunday_______ and as needed when soiled. (every Sunday night shift) Review of the facility policy entitled Oxygen Therapy revealed no documentation of the policy on the frequency of changing oxygen tubing and humidifier or of labeling and dating the tubing. The policy did not state how often the tubing should be changed. During the end of day debriefing on 6/6/2023, the Regional Administrative Consultant, Corporate Nurse Consultant and interim Director of Nursing were informed of the failure of the staff to change, label and date the oxygen tubing weekly. The Corporate Nurse Consultant stated the oxygen tubing should be changed weekly, labeled and dated. No further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide care that meets professional standards of care for 1 Residents (#5) in a survey sample of 26 Residents. The findings included: 1. For Resident #5, the facility staff administered 2 doses of Rosuvastatin 80 mg when the order stated Rosuvastatin 40 mg. On 6/7/23 during the medication administration pass for Resident #5, the nurse pulled up the Resident #5's record and began pulling medications. When she came to Resident #5's Rosuvastatin, she read the dosage out loud (Rosuvastatin 40 mg) and then read the card containing 28 pills and it said Rosuvastatin 80 mg. She stopped and said the amounts are not the same. When asked what her next step is, she stated that she would finish pulling the rest of the meds, give them, and notify the Nurse Practitioner (NP) of the pharmacy error. She stated she would also notify her Unit Manager and document the medication that was found and let the NP know that the wrong dose had been pulled and given on the 2 previous days. On 6/8/23 at approximately 245 PM, an interview was conducted with LPN E who was asked if she had administered medications the previous 2 days and she stated that she had. When asked, did she sign off for the medication Rosuvastatin, she indicated that she did. When asked if she was aware of the dose, she stated that she had been told when she came to work it was an error from pharmacy. The acting DON forwarded an email to this surveyor where she had been in communication with the pharmacy since the error was discovered. The pharmacy was to send the correct medication dose on the next run. According to the [NAME] website: https://www.nursingcenter.com/ncblog/may-2011/8-rights-of-medication-administration Rights of Medication Administration 1. Right patient -Check the name on the order and the patient. Use 2 identifiers. Ask patient to identify himself/herself. When available, use technology (for example, bar-code system). 2. Right medication -Check the medication label Check the order. 3. Right dose -Check the order. Confirm appropriateness of the dose using a current drug reference. If necessary, calculate the dose and have another nurse calculate the dose as well. 4. Right route-Again, check the order and appropriateness of the route ordered. Confirm that the patient can take or receive the medication by the ordered route. 5. Right time -Check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given. 6. Right documentation - Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug. 7. Right reason -Confirm the rationale for the ordered medication. What is the patient's history? Why is he/she taking this medication? Revisit the reasons for long-term medication use. 8. Right response -Make sure that the drug led to the desired effect. If an antihypertensive was given, has his/her blood pressure improved? Does the patient verbalize improvement in depression while on an antidepressant? Be sure to document your monitoring of the patient and any other nursing interventions that are applicable. On 6/8/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to develop and implement a baseline care plan that included instructions to provide person-centered care for one resident (Resident #255) in a sample of 26 residents. The findings included: For Resident #255, the facility staff failed to develop a baseline care plan to address the care needs of the Resident which would include the use of a 1) CPAP (continuous positive airway pressure) machine when sleeping, 2) wounds on his right foot, and 3) a PICC (peripherally inserted central catheter), that were present on admission and required facility staff management. Resident #255 was admitted to the facility on [DATE]. Physician orders on admission included order for the treatment of wounds and care of a PICC line. On 6/6/23, Resident #255 was visited in his room. Upon initial interaction it was noted that Resident #255 had a bandage on his right foot/ankle. Resident #255 was unable to give any details as to what was wrong. Surveyor E also noticed that Resident #255 had a PICC line to the right side and a CPAP machine was noted at the bedside. On the afternoon of 6/6/26, Employee L, the unit manager, told Surveyor E that Resident #255 had been in the facility previously and they had healed his foot wounds. She went on to say Resident #255 discharged home but has now been back about 2 weeks and has wounds again that require treatment. On 6/7/23, during the morning, Resident #255 was visited in his room and observed to be asleep with his CPAP in use. On the afternoon of 06/8/23, the facility management staff provided Surveyor E with Resident #255's care plan and indicated that items initiated on admission were part of the baseline care plan. This review revealed that the baseline care plan for Resident #255 did not address the use of a CPAP machine, PICC line or wounds to the Resident's right foot. On 06/8/23, during an end of day meeting, the administrator, director of nursing (DON), and corporate staff were made aware of the above findings. No further information was provided.

Based on observations, staff interview, resident interview and clinical record review, the facility staff failed to ensure reasonable accommodation of needs for one Resident (Resident #35) in a survey sample of 26 residents. The findings include: For Resident #35, the facility staff failed to ensure the large clock on the bedroom wall was working. Resident #35's most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 5/19/2023. Resident # 35's BIMS (Brief Interview for Mental Status) Score was a 8 out of 15 indicating severe cognitive impairment. Review of the clinical record was conducted on 6/6/2023-6/7/2023. During the initial tour on 6/6/2023 11:45 a.m., the clock in Resident # 35's room had the time of 3:24. Resident 35 was in the room, sitting in the bed and watching television. On 6/6/2023 at 2:40 p.m., the clock had the time of 3:24. The second hand was not moving. Resident # 26 was observed sitting in his wheelchair and propelling himself in the hallway. He stated he was going back to his room after participating in an activity. On 6/6/2023 at 3:00 p.m., the clock had the time of 3:24. Resident # 35 was sitting on his bed watching TV. On 6/7/2023 at 9:30 a.m., the clock had the time of 3:24. Resident # 35 was sitting in the wheelchair in the room. When asked if he could tell time, he replied yes. When asked what time it was, Resident # 35 looked and the clock and stated the clock was wrong. He stated the Activities personnel lets him know when it is time to go to Activities. On 6/7/2023 at 12:10 p.m., the clock had the time of 3:24. On 6/7/2023 at 4:40 p.m., the clock had the time of 3:24. During the end of day debriefing on 6/7/2023 at 5:45 p.m., the Regional [NAME] President, Director of Nursing and Corporate Nurse Consultants were informed of the issue. They all stated the clocks should be accurate. During an interview with the Director of Nursing, she stated it was important for clocks to be accurate because they would help with orientation of the residents. The Corporate consultants stated they would check all of the clocks for accuracy. They stated the Maintenance Director would be informed of the need to replace batteries where needed. No further information was provided.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to offer COVID-19 immunizations for 2 Residents (Resident #255 and 48) in a survey sample of 5 Residents reviewed for COVID-19 immunizations. The findings include: 1. The facility staff failed to determine Resident #255's current immunization status and offer any COVID-19 immunizations the Resident was eligible for. A clinical record review was performed on 6/7/23. Resident #255's clinical record revealed, under the immunization tab, that the Resident had only received a primary vaccination series for COVID-19 and had not received any booster doses. Therefore, the Resident was eligible to receive the bivalent COVID-19 booster. On 6/8/23, an interview was conducted with the facility's Director of Nursing (DON) who accessed the clinical record for Resident #255 and verified the above findings. The DON further confirmed there was no evidence that Resident #255 had received education or been offered the COVID-19 bivalent booster. 2. The facility staff failed to identify/assess Resident #48's current COVID-19 immunization status so that they could offer any COVID-19 immunizations for which the Resident was eligible. A clinical record review was performed on 6/7/23. Resident #48's clinical record revealed, under the immunization tab, that there was no information with regards to COVID-19 immunizations. Nor was there any evidence that facility staff had offered education or been offered any COVID-19 vaccines to Resident #48. On 6/9/23, an interview was conducted with the facility's Director of Nursing (DON) who accessed the clinical record for Resident #48 and confirmed the above findings. The DON further confirmed there was no evidence that Resident #48 had been educated on or been offered any COVID-19 immunizations. The DON stated that the facility's process is for admissions to check the Virginia Immunization Information System (VIIS) and upload it into the clinical record and then nursing will educate and offer any immunizations the Resident is eligible to receive. She said the importance of immunization is, we are trying to help the community be healthier and safer. Following the above interview, the DON advised Surveyor E that no one in the facility has access to the VIIS system. Review of the facility policy entitled; COVID-19 Vaccination was conducted. This policy read, Eligible staff members and residents who meet eligibility criteria will be offered the COVID-19 vaccine . 2. Prior to offering the vaccine, individuals will be screened for prior immunization, medical precautions, and contraindications to determine if they are appropriate candidates for vaccination .Documentation: 1. The facility will document the following in the resident's medical record: a. That the resident (or representative) was provided education regarding the benefits and potential side effects of the COVID-19 vaccine, including the date the education, and offering took place . On 6/8/23 during the end of day meeting, the Facility Administrator, DON, and corporate staff were made aware of the findings. No further information was provided.

Based on staff interview, employee record review and facility documentation review, the facility staff failed to operationalize policies and procedures on screening for 12 of 25 new employees in the Employee Records Check Sample. The findings include: 1. For Employees # 8, # 11, # 14, # 19 and # 24, the facility staff failed to ensure a criminal background check was obtained within 30 days of hire. On 2/17/2022 at 8:40 a.m., review of the employee files selected for Employee Records Check was conducted with the Human Resources Manager (Employee F) in her office. Review revealed the following: Employee # 8-Registered Nurse, Director of Nursing- hired 1/15/2020- Criminal Background Check on 7/8/2020 Employee # 11-Certified Nursing Assistant-hired 3/18/2020-Criminal Background Check on 7/8/2020 Employee # 14- Licensed Practical Nurse-hired 1/22/2020-Criminal Background Check on 7/8/2020 Employee # 19- Certified Nursing Assistant-hired 7/3/2019- No Criminal Background Check in employee file Employee # 24- Certified Nursing Assistant-hired 2/15/2020-No Criminal Background Check in employee file On 2/17/2022, an interview was conducted with the Human Resources Manager who stated the corporate office usually obtained all of the required information during the hiring process. The Human Resources Manager stated the Corporate office conducted Criminal Background Checks upon hire but she later learned that those did not meet the requirements. The Human Resources Manager stated she would be sure all future new hires would have Criminal Background Checks within 30 days of hire. On 2/17/2022 at 11:32 a.m., an interview was conducted with the Administrator who stated the Human Resources Manager was hired in 2019. The Administrator stated that audits were done on employee files after they were informed about Sworn Statements being signed before or on the day of hire. The Administrator stated she explained to the Human Resources Manager that criminal background checks must be obtained within 30 days of hire. Review of the Abuse Policy entitled Abuse Prevention Program, Revised May 2017, revealed the following: Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: 2. Conduct employee background checks and will not knowingly employ or otherwise engage any who has: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law On 2/27/2022 at 3:59 p.m. during the end of day debriefing, the facility Administrator was again informed of the findings. The Administrator stated Criminal Background Checks should be conducted on all new hires. The Administrator stated she had no questions about the findings. No further information was provided. 2. The facility staff failed to verify licensure on 2 (Employees # 7 and # 8) of 3 Registered Nurses upon hire and failed to verify licensure for 3 (Employees # 6, # 14, and # 17 ) of 3 Licensed Practical Nurses and failed to verify certification for 3 (Employees # 11, 19, and # 20) of 12 Certified Nursing Assistants. On 2/17/2022 at 8:40 a.m., review of the employee files selected for Employee Records Check was conducted with the Human Resources Manager (Employee F) in her office. Review revealed the following: Employee # 7-Registered Nurse, Assistant Director of Nursing- hired 7/1/2021- No License Verification- no license look up date. There was a copy of a Maryland License which would expire on 8/28/2022. The Maryland License was a Compact State license that had been renewed on 6/23/2020. There was no date indicating the date of look up. Employee # 8-Registered Nurse, Director of Nursing- hired 1/15/2020- License Verification on 12/3/2021 Employee # 11-Certified Nursing Assistant-hired 3/18/2020-License Verification on on 7/8/2020 Employee # 14- Licensed Practical Nurse-hired 1/22/2020-License Verification on 10/6/2021. Employee # 17-Licensed Practical Nurse- hired-12/27/2019- License Verification on 1/7/2020, 2/6/2020 and 6/8/2020. Employee # 19- Certified Nursing Assistant-hired 7/3/2019- License Verification on 2/3/2020. Employee # 20-Certified Nursing Assistant-hired 8/25/2020-License Verification on 7/22/2021. Employee # 8-Registered Nurse, Director of Nursing- hired 1/15/2020- License verification on 12/3/2021. On 2/17/2022 at 10:44 a.m., an interview was conducted with the Human Resources Manager. The Human Resources Manager stated she audited the personnel files and found there were missing License Verification for some employees. The Human Resources Manager stated she had thrown the original license verifications away when the updated or renewed licenses were submitted. The Human Resources Manager stated she did not realize that was not the correct procedure until this surveyor requested the files along with a list of required documents on 2/16/2022. On 2/17/2022 at 11:32 a.m., the Business Office Manager stated Now I understand that the original Licenses cannot be thrown away when the new one is updated. I didn't know that at first. On 2/17/2022 at 11:32 a.m., an interview was conducted with the Administrator who stated the Human Resources Manager was hired in 2019. The Administrator stated she explained to the Human Resources Manager that original licenses must be verified prior to hire or care and maintained in the personnel files. She also stated that copies of verification of renewed licenses must be maintained in the files also. Review of the Abuse Policy entitled Abuse Prevention Program, Revised May 2017, revealed the following: Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: 2. Conduct employee background checks and will not knowingly employ or otherwise engage any who has: . c. Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of abuse, neglect, exploitation, misappropriation of property. On 2/17/2022 at 3:59 p.m. during the end of day debriefing, the facility Administrator was again informed of the findings. The Administrator stated she had no questions about the findings. No further information was provided.

Based on observation, Resident interview, staff interview, and facility documentation review, the facility staff failed to prepare the meal in accordance with the menu, which affected 52 of the 57 Residents, residing at the facility during survey. The findings included: On 2/15/22 at approximately 10:30 AM, a tour of the kitchen was conducted. This tour included an interview with the cook, Employee F. Employee F confirmed that he was preparing baked ziti as per the menu. On 2/15/22, the menu was reviewed which indicated the following items were to be served: Baked Ziti with meat sauce, broccoli florets, garlic breadstick, and cinnamon brown sugar blondie. The alternate meal was listed as: smothered turkey patty, Caesar salad, and mashed potatoes. On 2/15/22 at approximately 1:00 PM, the lunch meal tray line was observed by Surveyor D. Employee F, the cook, identified the items prepared as: baked ziti, broccoli florets, brownie and the alternate as a chicken patty and mashed potatoes. The preparation of trays was observed and no Residents were served a garlic break stick nor cinnamon brown sugar blondie. The chicken patty was served without being smothered. Employee F, the cook confirmed that these items had not been prepared as per the menu. On 2/15/22 at approximately 1:30 PM, Surveyor D and the Registered Dietician received and evaluated a test tray the kitchen had prepared. Review of the test tray revealed the garlic breadstick and cinnamon brown sugar blondie were not provided as per the menu. The Registered Dietician confirmed she was not made aware of, nor did she approve, any menu substitutions. Review of the Resident Council meeting minutes from the meeting held January 31, 2022, revealed Residents reported they were not getting items they were supposed to. Included in documents provided to the survey team was a document titled, Action Plan that was signed off on 12/30/21. This document read, Review all orders with the district manager before submitting any order. In the event that any items that have been ordered are currently out of stock, the Manager In Training will need to call the supplier to find a substitution. If at any time there is an item missing from the menu for the daily meal, it needs to be reflected on the tray ticket and on the menu boards through the facility. You will also be required to inform your ED (executive director) during the morning meeting and have a copy of the changes present for them to review. All changes need to be recorded on the Meal Substitution Log A review of the facility policy titled, Menus was conducted. This policy read, .6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or special meal. On 2/16/22, during an end of day meeting the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided.

Based on observation, Resident interview, staff interview, and in the course of a complaint investigation, the facility staff failed to provide Residents with food at an appetizing temperature for 3 Residents (Resident #21, #33, and #41) in a survey sample of 28 Residents. The findings included: On 2/15/22, during Resident interviews, Residents #41, #33 and #21 reported their hot foods are served cold frequently. On 2/15/22, Surveyor D requested a test tray be prepared during the lunch meal service. On 2/15/22 at 1:58 PM, the last Resident meal tray was delivered to a Resident. Administrative Employee D, the Registered Dietician, then retrieved the test tray from the meal cart and accompanied Surveyor D to a nutrition room on the unit to review the test tray. Both Administrative Employee D and Surveyor D tasted each food item on the tray and both confirmed that the baked ziti was room temperature and was not at an appetizing temperature. On 2/15/22, following the test tray observation, Administrative Employee D stated that she expect foods to be delivered in a manner so that cold foods are cold and hot foods are hot. Review of the Resident Council meeting minutes from the meeting held January 31, 2022, revealed that Resident's reported to facility staff that their food was cold at times. Included in the documents provided to the survey team was a document titled, Action Plan that was signed off on 12/30/21. This document read, .Food Quality (Temperatures). Test trays need to be performed twice a day during. [sic] Check all temperatures for food and beverages before each meal service. Review of the facility policy titled, Meal Distribution: Infection Control Considerations was conducted. This policy read, .3. All food items will be transported promptly for appropriate temperature maintenance. On 2/15/22, during an end of day meeting the facility Administrator was made aware of the findings. No further information was received. Complaint related deficiency.