Every finding on record at White Sulphur Springs Center

Based on record review, resident representative interview, and staff interview, the facility failed to implement their grievance policy procedure to locate lost clothing and follow-up with resident/resident representative in a timely fashion. Resident identifier: #31. Facility census: 65.Findings included: a) Resident #31 On 11/18/25 at 7:30 PM, an electronic medical record review was completed. The record review revealed RN #68 had documented resident's sister had reported she had brought in twelve (12) pairs of socks but resident no longer had any in his room. RN #68 checked with laundry and the laundry staff member stated he had not seen them. This was documented on 09/27/25 at 10:32 AM. There was no further documentation in the electronic medical record related to the allegation of missing socks. Review of the facility grievance log, which was completed on 11/18/25 at 7:50 PM, found there had not been a written grievance completed for the allegation of missing socks for Resident #31. During a telephone interview on 11/19/25 at 12:15 PM, Resident #31's representative stated she had not been contacted since reporting resident's socks had gone missing. During an interview on 11/19/25 at 1:00 PM, Unit Manager #9 reported if a resident reported missing clothing she would check with laundry and if it was not found that she would report the allegation of missing laundry to the social worker who would handle everything from there. During an interview on 11/19/25 at 1:10 PM, LPN #10 stated if a resident reported missing clothing she would first check with laundry to see if it could be located. If that did not work, LPN reported she would report the allegation of missing clothing to upper management. When questioned who upper management would be, LPN #10 stated she would report directly to the Administrator who would handle the paperwork and follow-up. During an interview on 11/19/25 at 1:16 PM, LPN #68 reported she remembered documenting the allegation of Resident #31 missing twelve (12) pairs of socks. She also stated she recalled checking with laundry and then reporting to her Unit Manager for further follow-up when laundry did not have socks. During an interview on 11/19/25 at 1:21 PM, the Social Worker stated she did not recall ever being told that Resident #31 had socks that were missing and had not returned to his room. Review of the facility's Grievance/Concern policy revealed the following expectations:-Concerns may be registered by telephone, mail, office visit, or direct outreach to staff-Upon receipt of the grievance/concern, the Grievance/Concern Form will be initiated by the staff member receiving the concern-Upon receipt of the Grivance/Concern Form, the Administrator or designee will document the grievance/concern on the grievance/concern log-When the grievance/concern is logged, the Administrator and appropriate department manager will be notified-The department manager will contact the person filing the grievance to acknowledge receipt and notify the person filing the grievance of resolution in a timely manner The Administrator, during an interview on 11/19/25 at approximately 2:00 PM, acknowledged the facility was unable to produce evidence that the allegation of Resident #31 missing twelve (12) pairs of socks had been investigated as per the facility's grievance/concern policy process.

Based on record review, staff interview and observations, the facility failed to ensure residents were served food in the correct consistency according to the facility's diet description for puree consistency solids. It was determined that this failed practice placed all (5) five residents currently on a puree diet in an immediate jeopardy situation. Providing a resident with the wrong consistency of food could result in choking, and/or aspiration pneumonia which can lead to serious harm and/or death. This failed practice was found to be true for five (5) of five (5) residents reviewed for diet consistency during the Long-Term Care Survey Process. Resident Identifiers: #12, #21, #33, #38, and #53. Facility Census: 65.Findings Include: a) Puree diets A record review on 09/08/25 at 11:00 AM, revealed a diet order for Resident #38 that read as follows:Regular/Liberalized-Dys Puree. Thick Liquids-Nectar. Resident #38 had a diagnosis of Dysphagia, Oropharyngeal Phase. An observation of the lunch meal on 09/08/25 at 12:30 PM, revealed Resident #38 being served a tray that included puree bread, puree cinnamonapples, puree peas, and a puree chicken fillet that appeared to be ground instead of pureed. The Regulatory compliance advisor (RCA) confirmed that the breaded chicken fillet was in fact ground, and not pureed as the diet order indicated. During an interview and observation on 09/08/2025 at 12:45 PM, The Corporate Dietary Manager (CDM) scooped up a scoop of puree breaded chicken, onto a plate. The State Agency (SA) asked, Was this the right consistency? The CDM stated, No, it's supposed to be a pudding consistency. SA then asked, Was all residents on a pureed diet served the ground consistency meat today CDM stated, All of them were served out of this. I feel like the liquid dried up.Further review of the medical record revealed that Resident #38 did have an against medical advice (AMA) signed by his Medical Power of Attorney (MPOA). The following nurses note dated 08/21/25 was found in the medial record regarding the AMA: Care plan meeting completed with family at bedside today. Sister, MPOA, brought food for resident that goes against his current diet regiment (dysphagia pureed w/nectar thickened liquids). I and the entire management team explained to sister the risks of resident having any food that does not follow current diet orders. MPOA said that she did not care what recommendations are, she will give him whatever he wants and our staff may do the same if he asks. She verbalized understanding of the risk of aspiration and all other risks. She did sign informed refusal and Acknowledgement for Diet Regimen and verbalized the meaning of thatrefusal form. Provider is aware. Further review of the medical record showed that the facility had (5) five residents currently on a puree diet, Residents #12, #21, #33, #38, and #53. None ofthe other (4) four residents on Puree has an AMA for the diet texture and according to the Regional Dietary Manager all were served the chicken that was ground texture, rather than puree. The facilities diet description for puree consistency solids reads as follows: All pureed foods must be the consistency of moist mashed potatoes or pudding. During an interview on 09/08/25 at 3:46 PM, The Speech Therapist (ST) stated,When I had (Resident #38 name) on caseload, it took a while to get him in for a modified barium swallow. When he did have the test there were some pretty significant deficits and they recommended him to be NPO and put in a peg tube. The family said no. So the best I could do was the puree diet and thickened liquid. The ST further stated, Getting the wrong consistency of diet can lead to a lot of things like choking and aspiration pneumonia. The facility was notified of the immeditate jeopardy on 09/08/25 at 4:00 PM. The facility's plan of correction was accepted on 09/08/25 at 5:00 PM. b) Facility Corrective Action Residents with a pureed diet did not receive proper consistency for pureed meats. The diet try was removed form the residents room and a fresh tray was provided with the correct texture. All residents on mechanically altered diets have the potential to be affected. The DON/designee conducted an audit on or before 09/08/25 for all residents to ensure diet orders are correct and accurate and attached to the Kardex with any corrective action immediately upon discovery. Re-education was provided by the DON/designee to all staff beginning on 09/08/25 to ensure diet orders are followed and the correct diet is being served with post-test to validate understanding any staff not available during this time frame will be provided re-education, including post-test during orientation by the DON/designee. Meal service will be audited to ensure correct consistency per diet order daily for 2 weeks including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a week for 4 week then randomly thereafter. Results of monitors will be reported by the DON/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC. c) Education Education provided to all staff reads as follows: If a resident is ordered a pureed diet, all food should be a pudding-like consistency. There should be no chunks throughout any of the food. If the food is found to be incorrect then the employee should immediately take the incorrect items back to the kitchen to be fixed. d) Follow-up of POC A review was completed of the signed education of all staff, to ensure all staff that are working has been provided the education. This correction has been completed. Post test for the education ask the following questions:Puree texture food should of a pudding type consistency. True of FalseIf a resident is served a diet that does not match their tray ticket what should you do?All post test were answered correctly. Staff interviews were conducted on O9/09/25 at approximately 10:30 PM. All staff interviewed answered the questions appropriately. Observation of the lunch meal pass on 09/09/25 beginning at 11:45 AM, revealed that all (5) five residents currently on a puree diet were served the correct consistency of diet. The IJ was abated on 09/09/25 at 12:30 PM.

Based on observation and staff interview, the facility failed to ensure it had a clean, comfortable, homelike environment. This deficient practice was a random opportunity for discovery. Resident identifiers: #18, #3, #32. Facility census: 65. Findings included: a) Resident's #18 and #3 On 09/03/25 at 2:27 PM found Resident #18's bathroom corner commode had a hole through the drywall to allow the toilet handle to function. The base of the commode was stained yellow and had a black substance around the base. An observation of the toilet room in Resident #3's room found a black substance around the base of the commode with a white caulking substance erratically applied over the black substance. On 09/10/25 at 11:30 AM an observation with the Nursing Home Administrator (NHA) of Resident's #18 and #3's toilet room confirmed Resident #18 and #3's toilet rooms were in disrepair. b) Laundry On 09/09/2025 2:45 PM an observation was conducted of the laundry with Regulatory Compliance Advisor (RCO) and the Laundry Director. A fan covered with a gray fuzzy substance was sitting on the floor on the clean side. It was not in use at this time. The RCO stated that he had asked staff to dispose of the fan yesterday. The Laundry Director #70 stated the fan was not in use and should have been removed. The vent in the clean laundry was darkened in color (gray) and LD #70 explained there was a washer fire (the washer had been replaced) and the gray ceiling and vent was from the smoke. He stated maintenance had attempted to clean the vent and ceiling, but it really needed to be painted. In the soiled laundry there were 3-4 bags of soiled laundry on the floor. [NAME] stated that he had put those there as they needed an empty barrel on the unit. There were broken and missing floor tiles in the clean laundry. The RCO confirmed all the findings. c) Resident #32 During the initial interview and observation on 09/02/25 at 3:10 PM, Resident #32 stated, It is really hard to see in my bathroom. I have told them, but nobody has fixed it. The observation revealed that there are 2 light bulbs over the sink, one of them is out and that the light over the stand-up shower is very dim. An observation on 09/09/25 at 3:56 PM, revealed that Resident #32's light over the bathroom sink is still out and the light over the stand-up shower is very dim. 09/09/2025 4:06 PM During an observation and interview with Licensed Practical Nurse (LPN) #37, the LPN turned on the light switch, one light bulb came on, after approximately 30 seconds the other light bulb blinked and then came on. The light bulb over the shower came on as well but was very dim. The LPN confirmed that the lights in Resident #32's bathroom were not working properly and stated, I will put in a work order for that.

Based on observation and staff interview, the facility failed to ensure it notified the Ombudsman of discharges/transfers. This was true for three (3) of seven (7) residents.Resident Identifiers: #72, #71,and #68. Facility Census: 65. a) Resident #72 09/10/2025 8:54 AM record review revealed Resident #72 was discharged to another skilled nursing facility on 08/02/24. The review of this discharge revealed no evidence that the Ombudsman was not notified of Resident #72's discharge. This was discussed with Employee #89. b) Resident #71 On 09/09/25 at 9:10 PM Resident #71 a review of the discharge record found no evidence that the Ombudsman had been notified of the discharge. c) Resident #68 A review of the discharge record on 09/04/25 at 11:21 AM found Resident #68 had been transferred to a local hospital and was discharged from the facility on 08/04/25. The family requested the discharge so that Resident #68 could be closer to family. There was no evidence that the Ombudsman had been notified. An interview with the Nursing Home Administrator (NHA) and the Social Worker (SW) on 09/04/25 at 12:12 PM, revealed they were not aware that the Ombudsman was to be notified of discharges/transfers. The Ombudsman had not been notified of any discharges/transfers. The facility was now going to send a monthly list to the Ombudsman.

Based on observation, record review and staff interview, the facility failed follow the menus by not serving the correct serving sizes per the dietary guide sheet, not serving the residents large portions as ordered by the physician and serving items listed on the tray card not to serve. Resident Identifiers: #36, #61, #53, #4 and #21. Facility Census: 65. Findings included: a) On 09/03/2025 at 11:50 AM, [NAME] #59 was serving/plating the lunch meal. The menu consisted of Chicken and Cheese Quesadillas, Gelatin Cubes, Cilantro [NAME] 1/2 cup and Fiesta Corn 1/2 cup. Mashed Potatoes and Fajita Vegetable Miz - 1/2 cup were confirmed by Dining Director # 67. The following items were served with less than full scoops and then were not emptied all the way onto the plate. Serving sizes were less than stated on facility's Diet Guide Sheet for meal service for corn, mashed potatoes, rice and fajita mix. Whole scoops were not utilized, which was confirmed by the Regulatory Compliance Officer and Administrator # 90. The Regulatory Compliance Officer instructed the staff to make sure scoops are filled all the way and emptied all the way. Further observation during the dining service process revealed, pureed rice and pureed meat scoops were not filled. No consistent scoop size with -1//2 scoops or two (2) scoops used at times. At 12:02 PM, the state surveyor consulted with Administrator #90 and the Regulatory Compliance Officer and confirmed the inconsistent scoops sizes and stated , She's still not filling them. At 12:14 PM , Administer #90 attempted to re-direct/educate [NAME] #59 [NAME] to make sure the scoops were filled to the top prior to serving. b) Resident #36 On 9/20 2025, during the initial interview process, Resident #36 was observed receiving his dinner tray. permission was given to review the resident's tray card. The resident's tray card listed the following items: Large Portions Herb Roasted chicken 2 each Dinner Roll - 2 each Banana pudding w/ Whipped Topping Squash Medley - 3/4 cup 2% milk - 8 Oz The resident received the following items: One (1) piece of Herb Roasted Chicken One (1) Dinner Roll No whipped topping on banana pudding Three half pieces of squash medley No milk on tray On 09/02/2025 at 05:35 PM, Nursing Assistant (NA) #12 confirmed the resident did not receive large portions and stated, I'll let the kitchen know he didn't get double portions. Resident #36's diet order stated, Regular/Liberalized diet Regular Texture, Standard Thin Liquids consistency, large portions all meals. On 09/08/2025, the following residents were ordered to have large portions and their tray cards stated Large Portions : Residents # 61, #53 and #4. c) Resident #61 Resident #61 did not receive 1 and 1/2 chicken sandwiches on a bun per tray card. Registered Nurse (RN) #9 confirmed the resident did not receive his large portion and stated, We noticed that. and we are getting him a second one. d) Resident #4 Resident #4 did not receive 1 and 1/2 chicken sandwiches on a bun per tray card. RN #9 confirmed the resident did not receive his large portion. e) Resident #53 Resident #53's tray card stated, Large Portions, x2 mash, L&D (lunch and dinner). The resident did not receive 1 and 1/2 chicken sandwiches or two (2) portions of mashed potatoes which was confirmed by Nursing Assistant (NA) #41. f) Resident #21 An observation on 09/02/2025 at 12:40 PM, revealed Resident #21 eating lunch in the dining area. Resident had an empty carton of milk sitting in front of her. Resident had a meal ticket that read, No Milk in bold letters at the top. During an interview 09/02/25 at12:42 PM, Nursing Assistant (NA) #28 confirmed that Resident #21 had drank the carton of milk and that the meal ticket read, No milk. NA #28 further stated, She likes it, she always drinks it all. A record review on 09/02/25 at 2:40 PM, revealed a diet order for Resident #21 that reads as follows: Regular/Liberalized-puree, No Milk.

Based on observations, staff interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 65. Findings included: a) The facility's policy and procedure for dry food storage stated, 2.3 Food stock is dated on the day of receipt. Items that are removed from the original box are individually dated. 2.6 Open packages are stored in closed containers, tightly secured with ties or in a food quality storage bags and include the use by date. The facility's policy and procedure for Refrigerated/Frozen Storage stated, 1.4 All foods are labeled with the name of the product and the date received and use by date once opened. Manufacturer use by dates are used until opened. 1.5 Prepared foods are labeled and dated with the name of the product, date opened, and use by date. Dining District Manager #74 stated for food storage, Typically seven (7) days. Drinks on the floor - three (3) days. Sandwiches - three (3) days. The kitchen investigation was initiated on 09/02/2025 at 11:15 AM. The following items were found: 1. Tortilla Strips - opened and not dated. Dining District Manager #74 stated, I'll go ahead and get rid of those.2. A carton of United whole milk - not dated.3. Hard boiled eggs - opened not labeled. On 09/03/2025 at 03:30 PM, the Nourishment Center for 100-300 Halls was investigated with the following items found: 1. Gold 'N Sweet whipped spread - No open date and no use by date - four (4) individual containers in a plastic cup.2 Thirty-six (36) [NAME] individual cups/containers of apple juice - No open or use by dates. These items were confirmed by Nurse Practice Educator (NPE) #33 at 03:40 PM. NPE #33 stated, I don't know why they're in here. - referring to the plastic cup of butter. On 09/03/2025 at 03:42 PM, the Nourishment Center for 200-400 Halls was investigated with the following items found: 1. Loaf of bread - opened, not sealed and not labeled.2. Eighteen (18) individual cups/containers of apple juice - No open or use by date. These items were confirmed by Licensed Practical Nurse (LPN) #329 at 03:46 PM. On 09/03/2025 at 11:25 AM, Dining Director #72 was preparing/cooking quesadillas for the lunch meal with no beard covering. Dining District Manager #74 confirmed Dining Director #72 did not have a beard covering on and instructed the staff member to put one on. Dining Director #72 wore a mask for the rest of the cooking, preparation and meal service.

Based on observation, staff interview and record review the facility failed to maintain an infection prevention program to provide a safe, sanitary and comfortable environment to help prevent the transmission of infections. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifier #43. Facility Census 65.a) Laundry On 09/09/25 at 2:45 PM a tour of the facility laundry was conducted with the Regulatory Compliance Advisor (RCO) and the Laundry Supervisor. A basket full of clean socks was found stored on the floor in the clean laundry. The Laundry Supervisor was asked if the clean socks were stored to prevent contamination, he responded No. In the soiled laundry, there were three (3) open bags of soiled laundry on the floor. The Laundry Supervisor stated he had put those there as they needed an empty barrel on the unit. When asked if the bags were stored properly, he stated No. b) Resident #43 An observation on 09/09/25 at 12:08 PM, revealed a sign on Resident #43's door for contact precautions that stated the resident could not come out of the room. The sign also stated the following: Wash hands with soap and water before and after patient contact, contact with environment and after removal of PPE. Wear gloves upon entering this room; remove prior to exiting and discard. Wear gowns upon entering this room; remove prior to exiting and bag before leaving this room. Please do not remove dedicated or single use disposable equipment from this room. When dedicated equipment is not possible, disinfect shared patient equipment with EPA approved sporicidal. Further observation showed A Nursing Assistant (NA) delivering Resident #43 his lunch tray. The NA went into the room and set up residents tray without putting on Personal Protective Equipment (PPE). During an interview 09/09/25 at 12:09 PM, The Director of Nursing (DON) stated, He is on contact precautions for C-Diff. The DON confirmed that Resident #43 is on Contact Precautions for Clostridium Difficile (C-Diff) and that the NA went into his room without following the precautions. A record review on 09/09/25 at 1:45 PM, confirmed the C- DIFF diagnosis and the Contact Precautions for Resident #43.

Based on observation and staff interview, the facility failed to ensure a updated Pre-admission Screening and Resident Review (PASARR) was completed for a resident with a new diagnosis of Bipolar Disorder. Resident Identifier: #11. Facility Census: 65. Findings included: On 09/03/2025 at 12:41 PM, Resident #11's PASARR was reviewed. The resident's PASRR was completed on 02/19/2025 and did not include Bipolar Disorder. The diagnosis of Bipolar Disorder was added to the resident's diagnosis list on 03/12/2025. The resident's PASARR was not updated to reflect the new diagnosis. On 09/09/2025 at 01:26 PM, the Director of Nursing (DON) confirmed their was no diagnosis of Bipolar Disorder on the resident's PASARR and and stated, I will get a new one started.

Based on observation, resident interview and staff interview, the facility failed to ensure a resident with limited Activities of Daily Living (ADL) ability was provided the necessary services to maintain grooming by assisting with facial hair removal. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #36. Facility Census: 65. a) Resident #36On 09/02/25 at 5:42 PM, the state surveyor observed facial hair on Resident # 36 during the initial survey interview process. The patient reported he did not want the facial hair and stated, I want it shaved. and They need to do it. Nursing Assistant #12 confirmed the resident's facial hair growth and stated she would get it shaved.09/09/25 at 8:45 AM, the resident was observed to still have facial hair. The state surveyor asked the resident if they had shaved him and the resident replied, A long time ago. and You can see it. Licensed Practical Nurse #37 confirmed the resident's facial hair.

Based on observation, record review, and staff interview the facility failed to provide care and services in accordance with professional standards of practice by not putting in physician orders timely related to skin issues. This failed practice was found true for (1) one (3) residents reviewed for general skin issues during the Long-Term Care Survey Process. Resident identifier #8. Facility Census 65. Findings include: a) Resident #8The initial observation on 09/02/25 at 2:00 PM, revealed a bandage to Resident #8's right arm dated 09/01.Further observation on 09/03/25 at 2:00 PM, revealed a bandage to Resident #8's right arm dated 09/01.An observation on 09/04/25 at 10:00 AM, revealed a bandage to Resident #8's right arm dated 09/01.A record review on 09/04/25 at 10:30 AM, found no mention of the bandage to right arm in the medical record for Resident #8. During an interview, on 09/04/2025 at 10:40 AM, the Director of Nursing (DON) stated, So the nurse on Monday discovered skin tears. I just talked to him, and he said that he got a skin tear from scratching his arm on the bed. He called the doctor and got an order but forgot to put it in. We are getting it assessed right now and getting pictures.A record review on 09/04/25 at 11:00 AM, revealed a nurse's note dated 09/04/25 at 10:45 AM that reads as follows:Reviewed with nurse for 9/1. Resident had scratched himself on his right forearm and obtained an order to cleanse an apply an Opti foam dressing for one time only. Nurse failed order entry. SHTL in for revaluation. Verified with Provider. Wife present at facility and aware.

Based on record review, resident interview and staff interview, the facility failed to ensure its residents were not abused. The facility failed to provide services to residents that were necessary to avoid mental or emotional harm. In addition, the facility failed to protect residents when verbal and physical threats were made. This was true for 1 (one) of 1 (one) resident reviewed during the Long-Term Survey Process. Facility census: 64. Resident identifier #42, and #61. This created an immediate jeopardy situation. Findings include: a) Resident #42 On 07/08/24 at 1:30 PM an interview was conducted with Resident #42. At that time, Resident #42 stated, I don't sleep much at night due to Resident #61 coming into my room at night. I nap during the day, so I don't wake up to find him in my room. It scares me. That's why I had the staff put up the stop sign in my door. On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed several notes in the documentation related to physical and verbal aggression towards staff and other residents. During the review, a progress note dated 07/06/24 at 6:05 PM read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts to talk with resident and offer food drinks and to go to the bathroom were unsuccessful. Resident was attempting to hit at staff and the residents of the room he had entered. Resident eventually left this residents room and was shown to his own room. Around lunch this resident was very tearful and stated he wanted to go home. He walked with me to the courtyard and we sat outside for awhile. This seemed to help calm him. He has been up wondering[SIC] in the hallways since dinner was completed. No noted further behaviors. Physician is aware. At this time, Resident #61's care plan was also reviewed, no documentation was revealed related to Resident #61's verbal or physical aggression. On 07/09/24 at 01:48 PM, the Policy and Procedure titled, Behaviors: Management of Symptoms was reviewed. This policy stated that patients exhibiting behavioral symptoms would be individually evaluated to determine the behavior and that the Interdisciplinary Team (IDT) would identify the underlying cause of the behavior. The policy also stated that residents who display or who are diagnosed with mental or psychosocial adjustment difficulty would receive appropriate treatment and services to correct the problem or to attain the highest practicable mental and psychosocial well-being. In addition, at this time, the Policy and Procedure titled, Abuse Prohibition was reviewed. This policy stated that verbal abuse was the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients or their families, within their hearing distance, regardless of their age, ability to comprehend or disability. This policy and procedure further stated that examples of abuse include but were not limited to threats of harm and saying things to frighten a patient. The Policy and Procedure titled; Abuse Prohibition also stated that if the suspected abuse if patient to patient the Center will do the following: * The patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. * The Center will provide adequate supervision when the risk of patient to patient altercation is suspected. * The Center will be responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit behaviors that make them more likely to be involved in an altercation. * The patient representative and physician will be notified and any follow up recommended will be completed (e.g., psychiatric evaluation). * The Center should seek alternative placement for the patient exhibiting the abusive behavior, if warranted. * Immediately upon receiving information concerning a report of suspected or alleged abuse the allegation will be entered into the PCC Risk Management Portal. * Allegations involving abuse will be reported not later than 2 (two) hours after the allegation is made. * The Center will protect other patients from further harm. * The Center will provide the patient with a safe environment. * The Center will assign a representative from Social Services or designee to monitor the patients feelings concerning the incident, as well as the patients involvement in the investigation. On 07/09/24 at 2:13 PM, an interview was conducted with the Director of Nursing (DON). During the interview, the DON acknowledged the following: - Knowledge of Resident #61's wandering behaviors. - Knowledge of Resident #61's verbal and aggressive behaviors. - No knowledge of any incident occurring between Resident #42 and Resident #61. - The residents in the room Resident #61 had entered on 07/06/24 and verbally and physically threatened had not been identified. - No assessment had been performed on the unidentified residents. - No follow up related to potential adverse outcomes from Resident #61's verbal and aggressive behavior had been completed for any resident this occurred with. - No follow-up was made by Social Services for any of the incidents. - The incident from 07/06/24 had not been reported and should have been. - Resident #61 was not placed on one-on-one observation following the incident occurring on 07/06/24 and was not. - Nothing had been done at this time to ensure other residents residing in the facility felt safe. - The IDT (interdisciplinary team) had not assessed Resident #61 for underlying causes which could contribute to Resident #61's verbal and aggressive behavior. - Resident #61's verbal and aggressive behavior have not been discussed in the IDT meetings. - Resident #61's verbal and aggressive behavior had not been taken to or reviewed in Quality Assurance and Performance Improvement (QAPI) committee meetings. On 07/09/24 at 3:35 PM, an additional interview was conducted with Resident #42 who stated, I don't remember who I told about the fact that Resident #61 scared me when Resident #61 comes into my room at night, it was a staff member and that staff member placed the stop sign on my door, but it doesn't stop Resident #61, Resident #61 just ducks under it. I hate to close my eyes. On 07/09/24 at 3:40 PM, an additional interview was conducted with the DON. At that time, the Social Worker (SW) and Assistant Director of Nursing (ADON) were present. When this Surveyor asked the DON if a psychological appointment had been made for Resident #61, and if not, why not, the DON responded, I don't have an answer for that. We can certainly try it, it can't hurt. The facility was notified of the Immediate Jeopardy (IJ) on 07/09/24 at 4:38 PM. The abatement plan of correction (POC) was submitted and accepted by the state agency on 07/09/24 at 6:11 PM. The POC read as follows: The Director of Nursing (DON) initiated one to one supervision for Resident #61 on 7/9/24 at 5pm. The Registered Nurse conducted a change in condition assessment with medical provider notification for Resident #42 on 7/9/24. All residents of the facility have the potential to be affected. The Director of Nursing (DON)/designee interviewed all residents with BIMS scores of 8 and above for potential emotional and mental distress on 7/9/24 with any corrective action immediately upon discovery. Re-education was provided by the Director of Nursing (DON)/designee to all employees on 7/9/24 to ensure that allegations of emotional and mental distress are identified, immediate intervention put in place to prevent reoccurrence, immediately reported to the appropriate state agencies, and thoroughly investigated. A Post-test to validate understanding. Any employee not available during this time frame will be provided re-education, including post-test upon the beginning of next shift to work. New employees will be provided education, including post-test during orientation by the DON/designee. Re-education was provided by the DON to the Unit Managers on 7/9/24 regarding reviewing progress notes of assigned units to ensure allegations of emotional, mental distress, and any resident behaviors that may have negative effects on other resident have been correctly identified, reported in a timely manner, and appropriate intervention put in place to prevent reoccurrence daily. A posttest to validate understanding. New Unit Managers will be povided education, including post-test during orientation by the DON/designee. The Unit Mangers of assigned units will monitor progress notes starting on 7/9/24 to ensure that allegations of emotional, mental distress, and any resident behaviors that may have negative effects on other resident have been correctly identified, reported in a timely manner, and appropriate intervention put in place to prevent reoccurrence daily. The Director of Nursing (DON) will monitor progress notes starting on 7/9/24 to ensure that allegations of emotional, mental distress, and any resident behaviors that may have negative effects on other resident have been correctly identified, reported in a timely manner, and appropriate intervention put in place to prevent reoccurrence daily across all shifts for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter. Results of monitors will be reported by the Director of Nursing (DON)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. On 07/11/24 at 03:05 PM, after staff interviews of the implementation of the POC, the IJ was abated. The IJ began on 07/09/24 and ended on 07/11/24.

]Based on medical record review, and staff interview, the facility failed to follow up on physician's recommendations for a biopsy of Resident #29 thyroid nodules upon readmission to the facility on [DATE]. This was true for one (1) of nineteen (19) residents care reviewed during the long-term care survey process. This created a situation of immediate jeopardy. Resident identifier: Resident #29. Census: 64. Finding included: a) Resident #29 No documentation in the chart of surrogate being notified of the hospitals recommendations to refer to and ENT (Ear Nose and Throat) for a possible biopsy of thyroid nodules. On [DATE] at 11:43 PM during an interview with the DON and NP confirmed the health care surrogate had not been contacted about the referral to the ENT because the resident made it clear upon her admission in 2022 that she did not want treatments. Therefore, they did not contact the surrogate. The NP further stated she believed that the resident would not want this done because she didn't want her gallbladder removed. The NP further stated that the resident had a hard time with the anesthesia from her hip surgery and she did not feel she would do well with a follow up with the ENT for the nodule. The DON and LPN further stated they were not aware that Resident #29's grandson was the residents appointed surrogate and they had not made effort to contact him to follow up on the referral for the nodule biopsy. On [DATE] at 10:30 AM a review of the capacity for Resident #29 identified three (capacity forms completed. The capacity form completed by the attending physician dated [DATE] was identified to give the resident capacity. This capacity form was signed by the physician but not dated to identify the date of completion. A further review of the physician notes identified the physician note was completed on [DATE] and stated the patient was alert and oriented x1 with no acute distress and that Resident #29 does not have capacity at this time. The capacity form completed by the attending physician on [DATE] identified Resident #29 to be incapacitated. This capacity form was signed by the physician but not dated to identify the date of completion. A further review of the physician's notes did not identify a note for the physician's visit. The capacity form completed by the attending physician on [DATE] identified Resident #29 to be incapacitated and Resident #29 sister was appointed to be her surrogate. This capacity form was signed by the physician but not dated to identify the date of completion. A further review of the physician's notes did not identify a note for the physician's visit. A review of Resident #29's Physician Orders for Scope of Treatment (POST) identified 3 POST forms on file. Post form is dated [DATE] with the Licensed Practical Nurse (LPN) #03 identified to have assisted Resident #29 to complete the form. Resident #29 had identified yes to cardiopulmonary resuscitation (CPR) with full treatments with additional orders for IV fluids for six (6) weeks. Authorization was initiated to allow changes if decision making capacities, is loss. Resident #29's grandson was marked to be her emergency contact. The primary care provider name and phone number are not listed. No participants are marked to have participated in the discussion. This form was signed by the Nurse Practitioner and dated [DATE]. b) Post form is dated [DATE] with the Nurse Practitioner identified to have assisted Resident #29 to complete the form. Resident #29 had identified at this time to no cardiopulmonary resuscitation (CPR) with comfort-focused treatments and not artificial means of nutrition. Additional orders for no IV fluids, no weights and no labs with exceptions. Authorization was not initiated to allow changes if decision making capacities, is loss. The participants noted to attend the discussion is marked the patient with decision making capacity. This form did not identify the Residents social security number, the residents address/zip code or the residents preferred name. This form identifies Resident #29s grandson as the Residents emergency contact. This form was signed by the Nurse Practitioner and dated [DATE]. The Nurse Practitioner phone number and license/certification number is not identified on this form. c) Post form was dated [DATE] with the Nurse Practitioner identified to have assisted Resident #29 to complete the form. Resident #29 had identified at this time to no cardiopulmonary resuscitation (CPR) with comfort-focused treatments and not artificial means of nutrition. Additional orders for no IV fluids, no weights and no labs with exceptions. Authorization was not initiated to allow changes if decision making capacities, is loss. The participants noted to attend the discussion is marked the patient with decision making capacity. This form does identify the Residents social security number, the residents address/zip code. This form identifies that the Resident #29s grandson name is marked off and the Residents sisters' information is written over top of the grandson's emergency contact information. Resident #29's sister is marked to be the MPOA Representative/surrogate. This form was signed by the Nurse Practitioner and dated [DATE]. The Nurse Practitioner phone number and license/certification number is identified on this form. Post form was dated [DATE] with the Nurse Practitioner identified to have assisted Resident #29 to complete the form. Resident #29 had identified at this time to no cardiopulmonary resuscitation (CPR) with comfort-focused treatments and not artificial means of nutrition. Additional orders for no IV fluids, no weights and no labs with exceptions. Authorization was not initialed to allow changes if decision making capacities, were loss. The participants noted to attend the discussion is marked the patient with decision making capacity. This form does identify the Residents social security number, the residents address/zip code. This form identifies that the Resident #29s grandson name is marked off and the Residents sister's information is written over top of the grandson's emergency contact information. Resident #29's sister is marked to be the MPOA Representative/surrogate. This form was signed by the Nurse Practitioner and dated [DATE]. The Nurse Practitioner phone number and license/certification number is identified on this form. During an interview with the NP on [DATE] at 10:38 AM the NP stated that she does her own capacity determination prior to completing the post forms. She further stated she had contacted the grandson on [DATE] and that the grandson is considering treatment for his grandmother. The facility was notified of the Immediate Jeopardy (IJ) on [DATE] at 01:30 PM. The abatement plan of correction (POC) was submitted and accepted by the state agency on [DATE] at 05:15 PM. The POC read as follows: The Nurse Practitioner (NP) called resident #29 health care surrogate (HCS) on [DATE] at 12: 35 pm regarding thyroid mass on Computed Tomography (CT) scan and the HCS stated he wanted to talk with a friend of his who is a doctor and let us know in ,d+[DATE] days how to proceed. The Director of Nursing contacted the HCS on [DATE] to follow up. All residents of the facility have the potential to be affected. The Director of Nursing (DON)/designee conducted an audit on [DATE] for all current residents admissions/readmissions since [DATE] discharge summary/orders to ensure physician recommendations are followed up with the resident/ responsible party with any corrective action immediately upon discovery. The Director of Nursing (DON)/designee conducted an audit on [DATE] for all current residents to ensure that the most recent physician visit matches the capacity form completed by the physician with any corrective action immediately upon discovery. The Director of Nursing (DON)/designee conducted an audit on [DATE] for all current residents to ensure that the correct responsible party has signed the Physician Order Scope of Treatment (POST) form with any corrective action immediately upon discovery. Re-education was provided by the Director of Nursing(DON)/Designee on [DATE] to all licensed nurses regarding new admissions/readmissions to ensure discharge summary/orders with physician recommendations are followed up with the responsible party. A Post-test to validate understanding. Any licensed nurses not available during this time frame will be provided re-education, including post-test upon the beginning of the next shift to work. New licensed nurses will be provided education, including post-test during orientation by the DON/designee. Re-education was provided by the Director of Nursing(DON)/Designee on [DATE] to the Nurse Practitioner and Medical Director regarding documentation that the capacity of the resident matches the capacity form and when completing a POST form with the responsible party ensure the form is signed by the correct responsible party. A Post-test to validate understanding. Any Nurse Practitioner (NP) and Medical Director not available during this time frame will be provided re-education, including post-test upon the beginning of the next shift to work. The Unit Managers (UM)/designee will monitor starting on or before [DATE] new admissions and readmissions to ensure discharge summary/orders with physician recommendations are followed up with the responsible party daily for 2 weeks including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a week for 4 weeks then randomly thereafter. The Unit Managers (UM)/designee will monitor medical provider notes starting on or before [DATE] to ensure the resident capacity matches the resident capacity form daily for 2 weeks including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a week for 4 weeks then randomly thereafter. The Unit Managers (UM)/designee will monitor new admissions/readmissions and residents with a change in advance directives starting on or before [DATE] to ensure the POST form is signed by the correct responsible party daily for 2 weeks including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a week for 4 weeks then randomly thereafter. Results of monitors will be reported by the Director of Nursing (DON) /designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. On [DATE] at 08:25 PM, after staff interviews of the implementation of the POC, the IJ was abated. The IJ began on [DATE] and ended on [DATE].

Based on Record review and family and staff interview, the facility failed to ensure residents were provided with a safe environment to prevent elopement, resulting in Resident #120 leaving the facility and being found outside the facility, deceased . The facility ' s failure to ensure residents did not exit the facility unattended on [DATE] placed all at risk residents who could have exited the facility in an Immediate Jeopardy (IJ) situation.This will be cited at past noncompliance because the facility corrected the failure as of [DATE], prior to this survey. This was true for one (1) of six (6) residents reviewed for accidents and one (1) of three (3) reviewed for elopement during the survey process.Resident Identifier: 120. Facility census: 64 Findings include: A) Facility report/investigation According to the facility ' s report: At approximately 12:35 PM on [DATE], Resident #120 was found outside the facility, face down, unresponsive. Preliminary investigation by the facility revealed a nurse had checked Resident #120's vital signs at approximately 12:00 PM. the patient allegedly exited on foot through the 400 hall door located adjacent to the hallway containing her room. At approximately 12:35 PM a staff member returning to the facility from lunch witnessed the resident face down in a grassy area adjacent to the sidewalk located to the rear of the center. The initial staff member entered the center alerting others of the patient's location. Licensed nursing staff exited the center, arrived on scene, assessed the resident, and determined her decision maker had selected a do not resuscitate (DNR) status. Law enforcement and EMS were notified at approximately 12:35 PM. Foul play was ruled out at this time. Initial investigation revealed the staff were not aware of Resident #120 exiting the facility. There was an elopement assessment completed for Resident #120 on [DATE], which revealed she was not an elopement risk. B) Family interview At approximately 1:13 PM on [DATE], an interview was conducted with a family member of Resident #120. During the interview, the family member stated Resident #120 came to the facility for therapy, due to losing strength, following gallbladder surgery. The family member stated they were notified by the facility on [DATE] that Resident #120 was found outside the facility and had passed away. The family member states the family was told in a meeting with administrative staff the facility was unaware of how Resident #120 exited the facility. The family member states Resident #120 was not a wanderer and did not leave her room unless family was there or she was attending therapy. The family member states the facility was in possession of video footage of the incident. C) Staff interview At approximately 10:50 AM on [DATE], an interview was conducted with the Administrator and Director of Nursing (DON) concerning the incident involving Resident #120. During the interview, the DON stated the morning of the incident was very uncharacteristic for Resident #120, as she was up and dressed before 5:30 AM. The DON states Resident #120 usually slept in, stayed in her bed to eat breakfast, and would get up and get dressed much later in the morning. The DON states Resident #120 had complained of feeling nauseated and being extremely fatigued throughout the day. The administrator stated no one heard alarms going off that morning, and when they arrived at the facility, the alarms were checked, and all functioned. When asked about the video footage, the administrator stated the facility was not in possession of it, but the senior administrator, who oversees multiple facilities in the region, and assisted with the investigation, would be able to obtain the footage. The administrator and DON states, to their knowledge, no alarms were disabled in the facility. At approximately 11:30 AM on [DATE], an interview was conducted with the Senior Administrator (SA) regarding the incident. During the interview, the SA stated the facility did not know exactly how Resident #120 was able to leave the facility. The SA stated, to their knowledge, no one turned off any alarms in the facility and, upon their arrival to the facility to assist with the investigation, all doors and alarms functioned. The SA states they are not in possession of video footage, but could obtain it. The SA then informed this surveyor they would arrive at the facility on [DATE] with the video footage of the incident. At approximately 12:09 PM on [DATE], an interview was conducted with Unit Manager (UM) #36 regarding this incident. During the interview, UM #36 stated they were in the facility that day to cover a call in and was working on the 400 hall. UM #36 stated Resident #120 got up early that morning, which was uncharacteristic for her. UM #36 states Resident #120 complained of being tired throughout the day but they did not think anything of it because she had gotten up so early. UM#36 states they did not hear any alarms throughout the day and did not know anything was wrong until they heard someone saying they needed help outside, at which point, they walked outside and realized it was Resident #120. At approximately 12:20 PM on [DATE] an interview was conducted with the Assistant Director of Nursing (ADON). The ADON states they were in the facility that day to split a shift with UM #36. The ADON states they arrived at the facility around 12:30 and never heard an alarm going off. The ADON states they went to their office and was there for about five (5) minutes and heard a housekeeper yelling for help. At this time, the ADON states they went outside and saw a nurse attending to Resident #120. The ADON states they returned to the facility to obtain the code status for the resident and the crash cart, if needed. At approximately 12:30 PM on [DATE], an interview was conducted with Licensed Practical Nurse (LPN) #34 concerning the incident for Resident #120. LPN #34 states they work on the 100 and 300 units and was not familiar with Resident #120 due to her residing on the 400 hall. LPN #34 states they heard someone screaming they needed help at the back laundry door. When LPN #34 walked out the door, they saw Resident #120 lying face down in the grass. LPN #120 states I immediately got down and rolled her over. She was blue in the face and had blood on her where she had fallen. I didn't know who she was because I had never worked with her before, I don't work on that unit. LPN #34 stated they did not hear any alarms going off at that time. A copy of the work order for the facility's alarm system revealed the alarms were checked on the doors upon their arrival on [DATE] and that upon their inspection, all doors and alarms were operational. D) Video Footage At approximately 9:30 AM on [DATE], the SA arrived at the facility and the video footage was viewed. The video footage viewed was from cameras from another building, with cameras facing the back of the facility. The footage was grainy and unclear. A figure, wearing clothes matching the description of Resident #120's, was observed exiting the facility and walking towards the location where Resident #120 was found. The figure in the video walked out of the frame of view before falling. E) Education UM #36, the ADON, LPN #34, Nurse Aide (NA) #20, and Registered Nurse (RN) #35 all acknowledged understanding for education on elopement, door alarms, and elopement drills. The Immediate Jeopardy Template was presented to the facility administration on [DATE] at 2:26 PM. F) Plan of Correction Staff interviews were immediately taken by everyone present and working at the time of the incident by the Administrator and Senior Administrator on [DATE]. Interviews were then conducted with all other staff over the phone or in person. All doors and door alarms were assessed for proper functionality by the Senior Maintenance Director on [DATE]. All windows were assessed to have stop gaps and screens in them by the Senior Maintenance Director Secondary door alarms were placed on all exit doors by the Senior Maintenance Director on [DATE]. Fifteen minute checks were started on [DATE] to ensure functionality of all doors and door alarms. Staff educations with post tests were initiated on [DATE] related to elopement process and door alarms by the Unit Manager. Staff educations continue to occur until all staff have been educated by the Director of Nursing/Designee. NewTech Systems assessed all exit doors and door alarms for functionality with the Senior Maintenance Director on [DATE]. All residents were re-assessed for elopement by the Unit Manager on [DATE]. An elopement/fire alarm drill was completed by the facility on [DATE] that included all staff on all shifts. Mock elopement/fire drills will continue weekly across all shift x 4 weeks and monthly across all shifts x 2 months, then as determined by the QAPI committee. On [DATE] while performing checks on all doors, the 400 hall door in the egress was noted not to alarm or release the mag lock. Door was addressed with readjustment of the mag lock by the Maintenance Director and is in working order. (Surveyors verified the functionality of the door during survey process.) All doors are audited twice daily to ensure alarms are functioning and that they open after 15 seconds. All alarm batteries are dated and will be monitored and changed every 30 days. Pulled Risk Management System for past 90 days for elopements. On [DATE] while checking alarms on evening shift, it was noted the perimeter alarm did not sound on the 300 hall door. Both the mag lock and the secondary alarm functioned properly. Doors and alarms without concerns, monitoring will change from every 15 minutes to every hour. Doors will be checked to ensure the alarm sounds and that it opens after 15 seconds every hour beginning on [DATE].

Based on observation and staff interview, the facility failed to dispose of refuse in a manner to prevent attracting vermin. This has the potential to affect all residents residing in the facility. Facility census: 64. Findings include: a) At approximately 2:00 PM on 07/10/2024, a tour was conducted of the rear of the facility where the facility kept their dumpsters. Upon arriving at the dumpsters, an empty potato chip bag, multiple clear gloves, pieces of food, and clear plastic garbage bags were scattered around and underneath the dumpsters. Three (3) of the four (4) dumpsters had the lids opened, with one missing a lead entirely. One dumpster was leaking a white substance out of the bottom, onto the pavement. At approximately 2:09 PM on 07/10/2024, the Dining Services District Manager acknowledged the trash on the ground and the state of the dumpsters.

Based on observation and staff interview, the facility failed to store and prepare food in a sanitary manner, due to having items that were out of date and not dated in the refrigerators, items exposed to the elements, having dirty equipment, and failing to monitor refrigerator temperatures of personal refrigerators in resident rooms. This has the potential to affect all residents receiving food from the kitchen and all residents with personal refrigerators in their rooms. Facility census: 64. Findings include: A) Outdated, undated, and exposed items At approximately 11:20 AM on 07/08/2024 a tour of the kitchen in the facility was conducted. During the tour, the following were found in the walk-in refrigerator: Three (3) trays of cake with no date. A plastic container of beef based with no lid on it. A plastic container of strawberries with no date on it. A cardboard box containing squash with a discard date of 07/01/2024. Twenty (20) individual cookies placed in plastic sleeves were in the dry stock room with no date. Dietary Aide/Cook #59 stated Those were made yesterday (Sunday) for today. The following items were found in the walk-in freezer: Chicken breasts with no date. A box containing a bag of frozen corn. The bag was open, exposing the corn to the elements. A box containing a plastic bag of frozen biscuits. The bag was open, exposing the biscuits to the elements. The following items were found in the reach in refrigerator: Barbeque Sauce with manufacturers discard date of 05/28/2024. A pitcher of pink lemonade without a date on it. A large container of tea without a date on it. A box of peeled hard cooked eggs with a discard date of 07/03/2024. Dietary Aide/Cook #59 confirmed the items found during the tour were out of date, not dated, or exposed to the elements in the freezer. Dietary Aide/Cook #59 stated, You will probably find all kinds of stuff in there that doesn't have dates because we have people coming to work here from other centers and they don't care, they will throw stuff in there without dates on it and everything else. B) Oven At approximately 11:30 AM on 07/08/2024, during a tour of the kitchen, [NAME] #66 opened the oven to take the temperature of French fries that were being prepared for lunch. When the oven was opened, burnt food was found lying at the bottom along with four (4) large globs of black debris. What appeared to be pieces of burned shredded cheese were observed scattered throughout the oven. [NAME] #66 was asked how often the oven was cleaned, to which they replied, We should have already cleaned it, it needs cleaned, but we haven't had a chance to clean it because we haven't had staff here to do it. C) Nourishment room microwaves At approximately 3:00 PM on 07/08/2024, a tour of the nourishment rooms was conducted with the Dining Services Account Manager (DSAM). Upon entering the nourishment room for the 100 and 300 units of the facility, the microwave was noted to have rust throughout the inside. The DSAM stated We have been trying to get new ones for a while because we can't get these cleaned. The DSAM was asked if the facility prepared food for residents in the microwave, to which they stated, Yes. Upon entering the nourishment room for the 200 and 400 units of the facility, the microwave was noted to have rust through the inside and was missing the turntable. The DSAM stated We have been trying to get a new one here also. We can't get either of them clean, and this one is missing the turntable on the inside. The DSAM confirmed resident food was prepared and heated in the microwave. 49650 d) Resident refrigerator temperatures The following was identified during a review of the facility Policy and Procedure OPS192 refrigerators:. Patient In-Room that states the PROCESS (documented as written) Maintenance will provide calibrated refrigerator thermometers and placed within each unit for both refrigerator and freezer, if applicable. 4.1 A refrigerator/freezer temperature log will be maintained for every patient refrigerator. .2 Nursing will observe and record temperatures of the refrigerator on a daily basis using the refrigerator/freezer temperature log. 4.3 If temperature falls outside of the acceptable range, notify the Maintenance Department immediately. During a tour of the facility on 07/08/24 at approximately 3:23 PM it was identified that the residents with their personal refrigerators in their rooms did not have a visible temperature log being maintained. During an interview with Registered Nurse Skin Health Team Lead (RN TLSH) #36, she identified Unit Clerk (UC) #08 to be the one who completed the temperature logs for each resident refrigerator daily. A request of the temperatures logs was made at this time. During an interview with the UC #08 on 07/08/24 at approximately 04:00 PM, UC #08 apologized for taking so long to get the documents that she was still completing the form for a newly admitted resident. She further stated if she was not in the facility, someone else would obtain the temperatures for her and she would document them when she returned to the facility. A review of the refrigerator temperatures UC #08 provided identified a distinct pattern for each refrigerator with the same exact times and/or the same exact temperatures noted for each day for the refrigerator and the freezer. During a review with the Administrator of the June 2024 and July 2024 resident refrigerator temperature logs on 07/08/24 at 4:10 PM the Administrator completed a random observation of three (3) of the 19 resident temperature logs provided. The log completed for each resident identifies the acceptable temperature ranges for the refrigerator to be 32-40 degrees Fahrenheit and the freezer to be 0-10 degrees Fahrenheit. The following discrepancies were identified: room [ROOM NUMBER]B The refrigerator temperature logs for the entire month of June was documented to be checked at exactly 9:05 AM every day and each day the refrigerator was documented to be at 35 degrees Fahrenheit and the freezer was documented to be at 10 degrees Fahrenheit. The July temperatures were documented to be checked at exactly 09:05 AM every day from 07/01/24 through 07/04/24 and then exactly at 9:00 AM each day from 07/05/24 through 07/08/24. The July temperatures were also documented to be at 35 degrees Fahrenheit for the refrigerator every day and 10 degrees Fahrenheit for the freezer consistently each day. During the random observation of 108 B refrigerator temperatures the Administrator made at 4:13 PM on 07/08/24 the refrigerator did not have a thermometer inside to obtain a temperature with. The freezer temperature was 10 degrees Fahrenheit. The Administrator agreed with the identified concern of the distinct pattern and the accuracy of the documentation when there was not a thermostat located in the refrigerator to obtain the temperature with. room [ROOM NUMBER] The refrigerator temperature logs for the entire month of June was documented to be checked at exactly 9:10 AM every day and each day the refrigerator was documented to be at 32 degrees Fahrenheit and the freezer was documented to be at 10 degrees Fahrenheit. The July temperatures were checked at exactly 9:10 AM every day from 07/01/24 through 07/04/24 and at exactly 9:05 AM every day from 07/05/24 through 07/08/24. The July temperatures were also documented to be at 32 degrees Fahrenheit every day for the refrigerator and 10 degrees Fahrenheit for the freezer consistently each day. During the random observation of 109 A refrigerator temperatures the Administrator made at 4:15 PM on 07/08/24 the refrigerator temperature was 35 degrees Fahrenheit and the freezer temperature was -5 degrees Fahrenheit. The Administrator agreed that the temperatures were not consistent with the monthly documentation being completed and that the freezer temperature was outside the acceptable temperature range. room [ROOM NUMBER] B The refrigerator temperature logs for the entire month of June was documented to be checked at exactly 9:15 AM every day and each day the refrigerator was documented to be at 35 degrees Fahrenheit and the freezer were documented to be at 10 degrees Fahrenheit. The July temperatures were checked at exactly 9:15 AM every day from 07/01/24 through 07/04/24 and exactly at 09:10 AM from 07/05/24 through 07/08/24. The July temperatures were also documented to be at 35 degrees Fahrenheit every day for the refrigerator and 10 degrees Fahrenheit for the freezer consistently each day. During the random observation of room [ROOM NUMBER] B refrigerator temperatures the Administrator made at 4:15 PM on 07/08/24 the refrigerator temperature was 38/40 degrees Fahrenheit and the freezer temperature was 10 degrees Fahrenheit. The Administrator agreed that the temperatures were not consistent with the monthly documentation being completed.

Based on record review and staff interview, the facility failed to employ qualified dietary staff, due to letting employees work in the dietary department before obtaining food handler permits. This had the potential to affect all residents residing in the facility. Facility census: 64. Findings include: a) At approximately 10:00 AM on 07/09/2024, food handler permits were requested from the Dining Services Account Manager (DSAM). The DSAM made copies of the ones on file in the dietary office and stated, I'll have to find the others. At approximately 1:30 PM the DSAM stated they were still waiting on a couple food handlers cards. On 07/10/2024, the DSAM supplied a copy of a food handler permit for [NAME] #59, with an issue date of 07/10/2024. Upon review of the employee list provided by the facility, [NAME] #59 has been employed at the facility and working without a food handler permit since 10/17/2023. On 07/11/2024, the DSAM supplied copies of food handler permits for Dietary Aide/Cook #64 and Dietary Aide/Cook #58, both with an issued date of 07/11/2024. Upon review of the employee list proved by the facility, it was determined Dietary Aide/Cook #64 had been employed at the facility and working without a food handler permit since 04/30/2024. It was determined Dietary Aide/Cook #58 had been employed at the facility and working with a food handler permit since 05/30/2024 All three instances were acknowledged by the DSAM and Dining Services District Manager.

Based on observation and staff interview, the facility failed to practice proper infection control to prevent the spread of communicable diseases during lunch service. This was a random opportunity for discovery. This has the potential to affect all residents residing in the facility. Facility census: 64. Findings included: At approximately 12:12 PM on 07/08/2024, an observation was made during lunch service in the 400 hallway of the facility. Nurse Aide (NA) #10 took a tray off the delivery cart, took it to room [ROOM NUMBER] and brought it back to the cart upon realizing the resident was out of the facility. Upon returning to the delivery cart, NA #10 placed the tray back onto the cart with the clean, undelivered trays. NA #10 acknowledged they should not have placed the tray back onto the cart and stated I ' m not sure why I did.

Based on record review and staff interview, the facility failed to accurately document medication administration times on the Medication Administration Record (MAR) and medication sign out and administration times on the narcotic count sheet for Resident #28 ' s Morphine Sulphate. This was a random opportunity for discovery. Facility census: 64. Findings include: A) Resident #28 Resident #28 was admitted to the facility with the diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Liver Cell Carcinoma. He had a Brief Interview for Mental Status (BIMS) score of 14, suggesting he was cognitively intact, and was determined to have capacity. Upon review of the resident matrix after arrival to the facility at approximately 11:00 AM on 07/08/2024, it was noted Resident #28 was marked for end of life/palliative care/comfort measures along with 25 other residents in the facility. At approximately 2:15 PM on 07/08/2024, Resident #28 was observed sitting on the side of his bed, bent over at the waist, with his hands almost touching the floor. Staff members then came into the room to help Resident #28 back into his bed. At this time an interview was attempted with Resident #28, however, he was not interviewable due to him being unable to hold his eyes open, slurred speech, and his head bobbing up and down as he was unable to stay awake. At approximately 2:30 PM on 07/09/2024, a review of Resident #28 ' s medication orders were reviewed. The following orders were found in Resident #28 ' s electronic health record (EHR: Ativan Oral Tablet 1 MG- Give one tablet by mouth two times a day for anxiety r/t (related to) restlessness. Gabapentin - Give 300 mg by mouth two times a day for neuropathy in feet. Morphine Sulfate (Concentrate) Solution 20 MG/ML- GIve 1 ml sublingually every 4 hours for pain/sob (shortness of breath). Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulphate) - Give 1 ml by mouth one time only for agitation and S.O.B. (shortness of breath) for 1 day. Oxycodone HCI Oral tablet 30 MG (Oxycodone HCI) - Give 1 tablet by mouth every 4 hours for pain. Morphine Sulphate (Concentrate) Solution 20 MG/ML - Give 0.5 ml sublingually every 2 hours as needed for pain/sob 0.5 ml = 10 mg Morphine Sulphate (Concentrate) Solution 20 MG/ML - Give 0.5 ml sublingually every 2 hours as needed for pain/sob 0.5 ml = 10 mg At approximately 1:00 PM on 07/10/2024, a review of progress notes for Resident #28 revealed he had passed away at the facility that morning. At approximately 2:30 PM on 07/10/2024, a review of the narcotic count sheet and the MAR was completed for Resident #28. During the review of the narcotic sheet for Resident #28 ' s morphine sulphate 100 mg/5 ml concentrate solution, the following eight (8) discrepancies were noted: Registered Nurse (RN) #30 signed out 0.5 ml at 7:30 PM on 07/06/2024 but no documentation was found on the MAR to indicate the medication had been administered. RN #30 signed out 0.5 ml at 9:00 PM on 07/07/2024 but no documentation was found on the MAR to indicate the medication had been administered. The next sign out time on the narcotic medication count sheet was 0.5 ml by RN #30 at 1:00 AM on 07/07/2024. No documentation was found on the MAR to indicate the medication had been administered. The next sign out time on the narcotic medication count sheet was 0.5 ml by RN #30 at 5:00 AM on 07/07/2024. No documentation was found on the MAR to indicate the medication had been administered. RN #30 signed out 0.5 ml at 10:00 PM on 07/08/2024 and there was documentation found on the MAR to indicate the medication was administered RN #30 signed out 0.5 ml at 2:00 AM on 07/09/2024 and there was no documentation found on the MAR to indicate the medication was given. Two one (1) ml doses were signed out on the narcotic medication count sheet at 7:00 PM and 11:00 PM on 07/09/2024, without signatures.No documentation was found on the MAR to indicate the medications were given. RN #30 later confirmed via interview they logged the medications out and forgot to sign the sheet. The narcotic medication count sheet noted there was 7.5 ml of morphine remaining in the bottle. Licensed Practical Nurse (LPN) #46 counted the medication and stated there was between 7.5 and eight (8) ml remaining in the bottle. Two surveyors witnessed the count of the medication and confirmed the amount remaining. At approximately 3:45 PM on 07/10/2024, an interview was conducted with the Director of Nursing (DON) and the Unit Managers at the facility regarding the discrepancies in the narcotic count sheet and the MAR. LPN #6 stated RN #30 was having a lot of trouble with documentation and the facility had provided prior training and was continuing to work with RN #30. LPN #6 then provided documentation from the progress notes for Resident #28, showing RN #30 administered the medications at 10:00 PM on 07/08/2024 and 2:00 AM on 07/09/2024, however, had forgotten to log them in the MAR and entered the administration into the progress notes as a MAR error. Further review of the MAR for Resident #28 indicated RN #30 had documented the logged out medications from 7:00 PM and 11:00 PM on 07/09/2024 were given at 9:00 PM on 07/09/2024 and 1:00 AM on 07/10/2024. At approximately 5:00 PM on 07/10/2024 a phone interview was conducted with RN #30 concerning the discrepancies in the MAR and the narcotic count sheet. RN #30 stated they struggle with military time and the computer system the facility uses to document times for medication. RN #30 states education has been provided on a couple occasions and the staff at the facility are continuing to assist with documentation problems. RN #30 states the two logged medications that had no signature belonged to them. RN #30 stated I logged the medication out and had a resident that got sick and had to go assist with them. I just forgot to go back and sign. I struggle with military time and thought the times I wrote down were the correct times. I gave the medications at 9:00 PM on the 9th and 1:00 AM on the 10th. LPN #6 helped me with the missed times on the MAR from 10:00 PM on the 8th and 2:00 AM on the 9th. The following medication sign out times were still unaccounted for on the MAR: 0.5 ml at 7:30 PM on 07/06/2024 0.5 ml at 9:00 PM on 07/07/2024 0.5 ml at 1:00 AM on 07/07/2024 0.5 ml at 5:00 AM on 07/07/2024 RN #30 confirmed during the phone interview they had forgotten to log the times in the MAR. At approximately 9:30 AM on 07/11/2024, an interview was conducted with the DON. The DON stated RN #30 had been suspended pending investigation.

Based on record review, staff interview and resident interview, the facility failed to provide medically related social services for Resident #61 or residents that suffered abuse from Resident #61. This was true for 1 (one) of 3 (three) residents reviewed during the Long-Term Survey Process. Facility census: 64. Resident identifiers: Resident #61 and Resident #42. Findings include: a) Resident #61 On 07/08/24 at 1:30 PM an interview was conducted with Resident #42. At that time, Resident #42 stated, I don't sleep much at night due to Resident #61 coming into my room at night. I nap during the day so I don't wake up to find him in my room. It scares me. That's why I had the staff put up the stop sign in my door. On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to physical and verbal aggression towards staff and other residents. During the review, a progress note dated 07/06/24 at 6:05 PM read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts to talk with resident and offer food drinks and to go to the bathroom were unsuccessful. Resident was attempting to hit at staff and the residents of the room he had entered. Resident eventually left this residents room and was shown to his own room. Around lunch this resident was very tearful and stated he wanted to go home. He walked with me to the courtyard and we sat outside for awhile. This seemed to help calm him. He has been up wondering[SIC] in the hallways since dinner was completed. No noted further behaviors. Physician is aware. At this time, Resident #61's care plan was also reviewed, no documentation was revealed related to Resident #61's verbal or physical aggression. On 07/09/24 at 01:48 PM, the Policy and Procedure titled, Behaviors: Management of Symptoms was reviewed. This policy stated that patients exhibiting behavioral symptoms would be individually evaluated to determine the behavior and that the Interdisciplinary Team (IDT) would identify the underlying cause of the behavior. The policy also stated that residents who display or who are diagnosed with mental or psychosocial adjustment difficulty would receive appropriate treatment and services to correct the problem or to attain the highest practicable mental and psychosocial well-being. In addition, at this time, the Policy and Procedure titled, Abuse Prohibition was reviewed. This policy stated that verbal abuse was the use of oral, written or gestured language that willfully included disparaging and derogatory terms to patients or their families, within their hearing distance, regardless of their age, ability to comprehend or disability. This policy and procedure further stated that examples of abuse include but are not limited to threats of harm and saying things to frighten a patient. The Policy and Procedure titled; Abuse Prohibition also stated that if the suspected abuse if patient to patient the Center will do the following: * The patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. * The Center will provide adequate supervision when the risk of patient to patient altercation is suspected. * The Center will be responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit behaviors that make them more likely to be involved in an altercation. * The patient representative and physician will be notified and any follow up recommended will be completed (e.g., psychiatric evaluation). * The Center should seek alternative placement for the patient exhibiting the abusive behavior, if warranted. * Immediately upon receiving information concerning a report of suspected or alleged abuse the allegation will be entered into the PCC Risk Management Portal. * Allegations involving abuse will be reported not later than 2 (two) hours after the allegation is made. * The Center will protect other patients from further harm. * The Center will provide the patient with a safe environment. * The Center will assign a representative from Social Services or designee to monitor the patients feelings concerning the incident, as well as the patients involvement in the investigation. On 07/09/24 at 2:13 PM, an interview was conducted with the Director of Nursing (DON). During the interview, the DON acknowledged the following: * Knowledge of Resident #61's wandering behaviors. * Knowledge of Resident #61's verbal and aggressive behaviors. * No knowledge of any incident occurring between Resident #42 and Resident #61. * The residents in room Resident #61 had entered on 07/06/24 and verbally and physically threatened had not been identified. * No assessment has been carried out on the unidentified residents. * No follow up related to potential adverse outcomes from Resident #61's verbal and aggressive behavior had been completed for any resident this occurred with. * No follow-up was made by Social Services for any of the incidents. * The incident from 07/06/24 had not been reported and should have been. * Resident #61 should have been placed on one-on-one observation following the incident occurring on 07/06/24 and was not. * Nothing had been done at this time to ensure other residents residing in the facility feel safe. * The IDT had not assessed Resident #61 for underlying causes which could contribute to Resident #61's verbal and aggressive behavior. * Resident #61's verbal and aggressive behavior have not been discussed in the IDT meetings. * Resident #61's verbal and aggressive behavior had not been taken to or reviewed in Quality Assurance and Performance Improvement (QAPI) committee meetings. On 07/09/24 at 3:35 PM, an additional interview was conducted with Resident #42 who stated, I don't remember who I told about the fact that Resident #61 scares me when Resident #61 comes into my room at night, it was a staff member and that staff member placed the stop sign on my door, but it doesn't stop Resident #61, Resident #61 just ducks under it. I hate to close my eyes. On 07/09/24 at 3:40 PM, an additional interview was conducted with the DON. At that time, the Social Worker (SW) and Assistant Director of Nursing (ADON) were present. When this Surveyor asked the DON if a psychological appointment had been made for Resident #61, and if not, why not, the DON responded, I don't have an answer for that. We can certainly try it, it can't hurt.

Based on record review and staff interview the facility failed to review and revise the care plan for Resident #61's psychotropic medication, dementia, and behaviors. In addition the facility failed to revise the care plan to reflect weights no longer be obtained for Resident #59 and the care plan to reflect the surrogate for Resident #29. This was true for 3 (three) of 19 residents reviewed for the Long Term Care Survey process. Facility census: 64. Resident identifiers: #61,#59 and #29. Findings include: a) Resident #61 Psychotropic Medication On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to, refusal of care, physical and verbal aggression towards staff and other residents. During the review, a progress note dated 07/06/24 at 6:05 PM read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts to talk with resident and offer food drinks and to go to the bathroom were unsuccessful. Resident was attempting to hit at staff and the residents of the room he had entered. Resident eventually left this residents room and was shown to his own room. Around lunch this resident was very tearful and stated he wanted to go home. He walked with me to the courtyard and we sat outside for awhile. This seemed to help calm him. He has been up wondering[SIC] in the hallways since dinner was completed. No noted further behaviors. Physician is aware. In addition, review of Resident #61's medical record revealed on 05/19/24 at 11:15 PM the following progress note was entered into Resident #61's medical record: Resident continues to be very restless with poor safety awareness. Attempted again to contact provider at Vis a Vis. Vis a Vis provider's microphone not working. Contacted Dr. [NAME] and instructed to administer 10 milligram (mg) Zyprexa intramuscularly (IM). Medication administered as ordered and resident assisted back to bed. Resting in bed at this time with 0 (zero) complaints of (c/o) pain/discomfort. This note was revealed to be a follow up to a Change in Condition Evaluation with an effective date and time of 05/19/24 at 11:10 PM. During this review of the Change in Condition Evaluation, it revealed the change in condition signs and symptoms identified was documented as agitation and restlessness, with the most recent vitals signs documented dated and timed 05/19/24 at 05:16 AM. Further review of this Change in Condition evaluation revealed, under the section for Resident Representative Notification that the Department of Health and Human Resources representative was the name of the resident representative notified, however, the section for the date and time of that notification was left blank. A review was performed of Resident #61's Medication Administration Record (MAR), it revealed on 05/19/24 at 11:10 PM, documentation of administration of Zyprexa 10 mg IM, one time only for agitation. On 07/08/24 at 09:33 PM, Resident #61's physician's orders was reviewed. Resident #61 was noted to be prescribed the following medications: * Ativan oral tablet 0.5 milligrams (mg). Give 1 (one) tablet by mouth two times a day for anxiety related to restlessness. * Lexapro oral tablet 10 mg. Give 1 (one) tablet by mouth one time a day for depression. On 07/09/24 at 01:48 PM, the Policy and Procedure titled, Behaviors: Management of Symptoms was reviewed. It revealed that when administering a medication for behavioral symptoms, a consent should be obtained and that the form Psychotropic/Therapeutic Medication Use Evaluation should be completed when a patient is newly prescribed a psychotherapeutic medication. In addition, Resident #61's care plan was reviewed. It revealed a care plan with the focus of Resident is at risk for complications related to the use of psychotropic drugs: Ativan. No further care plan related to the use of psychotherapeutic drugs was found at that time. On 07/10/24 at 02:35 PM, a further review of Resident #61's medical record was performed. It revealed that Resident #61 had 2 (two) forms titled, Psychotropic Medication Administration Disclosure. Both of these forms revealed that Resident #61's representative had the risks and benefits of psychotropic medication verbally explained and provided in writing. It also revealed that the Resident #61's representative understood the right to refuse the administration of these medications and the right to withdraw consent of medication administration at any time. Under the signature section of both forms, it revealed that verbal consent had been obtained and both forms were dated as the verbal consent being obtained on 05/07/24. However, when reviewing the forms, it revealed that each form was different. One of the forms listed Aricept and Ativan as the medications verbal consent had been obtained for on 05/07/24. The next form listed Aricept, Ativan and Lexapro as the medication verbal consent had been obtained for 05/07/24. Lexapro had 06/13/24 written beside it. On 07/10/24 at 03:29 PM, an interview was conducted with the Director of Nursing (DON). At that time, the DON acknowledged that Resident #61's psychotherapeutic medication care plan had not been revised to reflect the use of Lexapro and the one time administration of Zyprexa. The DON further acknowledged that Resident #61 had not been monitored for adverse reactions following the one time dose of Zyprexa IM. b) Resident # 61 Dementia Care On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to, refusal of care, physical and verbal aggression towards staff and other residents. During the review, a progress note dated 07/06/24 at 6:05 PM read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts to talk with resident and offer food drinks and to go to the bathroom were unsuccessful. Resident was attempting to hit at staff and the residents of the room he had entered. Resident eventually left this residents room and was shown to his own room. Around lunch this resident was very tearful and stated he wanted to go home. He walked with me to the courtyard and we sat outside for awhile. This seemed to help calm him. He has been up wondering[SIC] in the hallways since dinner was completed. No noted further behaviors. Physician is aware. In addition, review of Resident #61's medical recorder revealed that on 05/19/24 at 11:15 PM the following progress note was entered into Resident #61's medical record: Resident continues to be very restless with poor safety awareness. Attempted again to contact provider at Vis a Vis. Vis a Vis provider's microphone not working. Contacted Dr. [NAME] and instructed to administer 10 milligram (mg) Zyprexa intramuscularly (IM). Medication administered as ordered and resident assisted back to bed. Resting in bed at this time with 0 (zero) complaints of (c/o) pain/discomfort. This note was revealed to be a follow up to a Change in Condition Evaluation with an effective date and time of 05/19/24 at 11:10 PM. During this review of the Change in Condition Evaluation, it revealed the change in condition signs and symptoms identified was documented as agitation and restlessness, with the most recent vitals signs documented dated and timed 05/19/24 at 05:16 AM. Further review of this Change in Condition evaluation revealed, under the section for Resident Representative Notification that the Department of Health and Human Resources representative was the name of the resident representative notified, however, the section for the date and time of that notification was left blank. On 07/09/24 at 09:33 AM, a review of Resident #61's diagnosis list was reviewed. Resident #61's diagnosis list revealed that Resident #61 had been diagnosed with Unspecified Dementia, unspecified severity, with other behavioral disturbance onset 05/21/24. Also at this time, Resident #61's care plan was reviewed, which revealed a care plan for Psychiatric Disorder Dementia and Parkinson's was noted. The care plan read as follows: Focus: * Resident #61 exhibit or is at risk for distressed/fluctuating mood symptoms related to : Psychiatric Disorder Dementia and Parkinson's. Goal: * Resident #61 will demonstrate improved mood state as evidenced by calmer appearance, happier demeanor by the next review date. Interventions: * Observe for signs of delirium, including delusions/hallucinations; notify physician/advance practice practitioner as needed. * Observe for signs/symptoms of worsening sadness/depression/anxiety/fear/anger/agitation. * Observe for worsening signs/symptoms of existing psychiatric disorder (e.g., mania, hypomania, frequent mood changes, etc.). Notify physician/advanced Practice Practitioner as needed. * Observe for signs/symptoms of new psychiatric disorder (e.g., mania, hypomania, frequent mood changes, etc.). Notify physician/advanced Practice Practitioner as needed. On 07/09/24 at 01:48 PM, the Policy and Procedure titled, Behaviors: Management of Symptoms was reviewed. This policy stated that patients exhibiting behavioral symptoms would be individually evaluated to determine the behavior and that the Interdisciplinary Team (IDT) would identify the underlying cause of the behavior. The policy also stated that residents who display or who are diagnosed with mental or psychosocial adjustment difficulty that the Center would implement individualized, person centered, non-pharmacological interventions as the initial behavior mitigation strategy and update the care plan accordingly. On 07/10/24 at 03:29 PM, an interview was conducted with the Director of Nursing (DON). At that time, the DON stated that the best thing for Resident #61 when he is exhibiting behaviors is to take him outside. That seems to work the best. When asked if Resident #61's behaviors had been taken to the IDT committee to review for a root cause with new behavioral interventions to be added to Resident #61's care plan, the DON acknowledged Resident #61's behaviors had not been reviewed by the IDT committee and that the care plan had not been revised. On 07/09/24 at 3:40 PM, an additional interview was conducted with the DON. At that time, the Social Worker (SW) and Assistant Director Of Nursing (ADON) were present. When this Surveyor asked the DON if a psychological appointment had been made for Resident #61, and if not, why not, the DON responded, I don't have an answer for that. We can certainly try it, it can't hurt. c) Resident #61 Behavior Care On 07/08/24 at 9:11 PM a review of Resident #61's medical record was performed. It revealed there were several notes in the documentation related to, refusal of care, physical and verbal aggression towards staff and other residents. During the review, a progress note dated 07/06/24 at 6:05 PM read as follows : This resident was wondering [SIC] in and out of other residents rooms this morning. He was sitting on another residents bed and refused to leave. Multiple attempts to talk with resident and offer food drinks and to go to the bathroom were unsuccessful. Resident was attempting to hit at staff and the residents of the room he had entered. Resident eventually left this residents room and was shown to his own room. Around lunch this resident was very tearful and stated he wanted to go home. He walked with me to the courtyard and we sat outside for awhile. This seemed to help calm him. He has been up wondering[SIC] in the hallways since dinner was completed. No noted further behaviors. Physician is aware. In addition, review of Resident #61's medical recorder revealed that on 05/19/24 at 11:15 PM the following progress note was entered into Resident #61's medical record: Resident continues to be very restless with poor safety awareness. Attempted again to contact provider at Vis a Vis. Vis a Vis provider's microphone not working. Contacted Dr. [NAME] and instructed to administer 10 milligram (mg) Zyprexa intramuscularly (IM). Medication administered as ordered and resident assisted back to bed. Resting in bed at this time with 0 (zero) complaints of (c/o) pain/discomfort. This note was revealed to be a follow up to a Change in Condition Evaluation with an effective date and time of 05/19/24 at 11:10 PM. During this review of the Change in Condition Evaluation, it revealed the change in condition signs and symptoms identified was documented as agitation and restlessness, with the most recent vitals signs documented dated and timed 05/19/24 at 05:16 AM. Further review of this Change in Condition evaluation revealed, under the section for Resident Representative Notification that the Department of Health and Human Resources representative was the name of the resident representative notified, however, the section for the date and time of that notification was left blank. Further review of Resident #61's documentation revealsed the following Medication Administration Record (MAR) Progress Notes (PN): 6/15/2024 21:21 eMAR PN Note Text: Ativan Oral Tablet 1 MG Give 1 tablet by mouth two times a day for anxiety r/t restlessness Resident refused medication. Spit medication into floor. Provider aware. 6/15/2024 06:04 eMAR PN Note Text: Sepsis Vitals three times a day Resident refused to allow vital signs to be obtained this AM. Provider aware On 07/09/24 at 09:33 AM, a review of Resident #61's diagnosis list was reviewed. Resident #61's diagnosis list revealed that Resident #61 had been diagnosed with the following conditions *Unspecified Dementia, unspecified severity, with other behavioral disturbance onset 05/21/24. * Altered Mental Status, unspecified, onset 05/17/24. * Generalized Anxiety Disorder, onset 06/25/24. * Major Depressive Disorder, Recurrent, Moderate, onset 06/13/24. At this time, Resident #61's care plan was also reviewed, which revealed that Resident #61 had a care plan entered with a focus of Resident/Patient is at risk for or exhibits symptoms of delirium related to dementia was present. In this care plan, that each intervention listed had a creation date of 06/05/24 with no revisions noted. In addition, no care plan addressing Resident #61's anxiety or depression diagnosis. Further review did not reveal a care plan related to Resident #61's behaviors such as wandering at night, tearfulness, refusal of care and physical and verbal aggression towards staff and other residents. On 07/10/24 at 03:29 PM, an interview was conducted with the Director of Nursing (DON). At that time, the DON stated that the best thing for Resident #61 when he is exhibiting behaviors is to take him outside. That seems to work the best. When asked if Resident #61's behaviors had been taken to the IDT committee to review for a root cause with new behavioral interventions to be added to Resident #61's care plan with each occurrence of behaviors, the DON acknowledged Resident #61's behaviors had not been reviewed by the IDT committee and that the care plan had not been revised. On 07/09/24 at 3:40 PM, an additional interview was conducted with the DON. At that time, the Social Worker (SW) and Assistant Director Of Nursing (ADON) were present. When this Surveyor asked the DON if a psychological appointment had been made for Resident #61, and if not, why not, the DON responded, I don't have an answer for that. We can certainly try it, it can't hurt. d) Resident #29 During a medical record review for Resident #29 on 07/08/24 at approximately 07:45 PM it is identified in the residents care plan that the resident has an established advanced directive, Health Care Surrogate appointing her sister. This focus was created and intiated on 04/20/22 and revised on 10/11/22. A further record review identified a State of [NAME] Virginia Checklist for Surrogate Selection completed that states that the sister was the previous Health Care Surrogate (HCS) but is no longer able to be reached or returns calls. This State of [NAME] Virginia Checklist for Surrogate Selection further identifies that the resident was notified on 06/06/24 that the residents grandson was now the appointed surrogate. During an interview with the Director of Nursing (DON) on 07/10/24 at approximately 02:46 PM, the DON agreed that the care plan had not been revised to reflect the change in the Surrogate. e) Resident #59 During a medical record review on 07/08/24 at approximately 08:22 PM, Resident #59 physician determination of capacity identified resident to be incapciated on 04/47/24. The attending physician completed the surrogate selection appointing Resident #59's sister as the health care surrogate. A further review of the medical record the physicians note dated 04/26/24 stated the Residents sister wantes Resident # 59 to be DNR/Comfort care, No Peg tube or weights. A review of the physicians orders Resident #59 identified a verbal order for no weights ordered on 06/06/24. A further review of the residents care plan identified the resident to be care planned for the risk of oral health and dental care problems as evidenced by dentures. An intervention created on and initiated on 05/10/24 is to monitor for changes in nutritional/hydration status (changes in intake, ability to feed self, unplanned weight loss or gain). No other care plan was identified regarding Resident #59 weight orders. During an interview with the Director of Nursing (DON) on 07/10/24 at approximately 02:46 PM, the DON agreed that the care had not been revised to reflect the Surrogate request and physicians orders for no weights. 49650 d) Resident #29 During a medical record review for Resident #29 on 07/08/24 at approximately 07:45 PM it is identified in the residents care plan that the resident has an established advanced directive, Health Care Surrogate appointing her sister. This focus was created and intiated on 04/20/22 and revised on 10/11/22. A further record review identified a State of [NAME] Virginia Checklist for Surrogate Selection completed that states that the sister was the previous Health Care Surrogate (HCS) but is no longer able to be reached or returns calls. This State of [NAME] Virginia Checklist for Surrogate Selection further identifies that the resident was notified on 06/06/24 that the residents grandson was now the appointed surrogate. During an interview with the Director of Nursing (DON) on 07/10/24 at approximately 02:46 PM, the DON agreed that the care plan had not been revised to reflect the change in the Surrogate. e) Resident #59 During a medical record review on 07/08/24 at approximately 08:22 PM, Resident #59 physician determination of capacity identified resident to be incapciated on 04/47/24. The attending physician completed the surrogate selection appointing Resident #59's sister as the health care surrogate. A further review of the medical record the physicians note dated 04/26/24 stated the Residents sister wantes Resident # 59 to be DNR/Comfort care, No Peg tube or weights. A review of the physicians orders Resident #59 identified a verbal order for no weights ordered on 06/06/24. A further review of the residents care plan identified the resident to be care planned for the risk of oral health and dental care problems as evidenced by dentures. An intervention created on and initiated on 05/10/24 is to monitor for changes in nutritional/hydration status (changes in intake, ability to feed self, unplanned weight loss or gain). No other care plan was identified regarding Resident #59 weight orders. During an interview with the Director of Nursing (DON) on 07/10/24 at approximately 02:46 PM, the DON agreed that the care had not been revised to reflect the Surrogate request and physicians orders for no weights.

Based on medical record review, policy review, resident interview, and staff interview, the facility failed to ensure Resident #7 received effective pain management, which led to Resident #7's refusal to attend hemodialysis treatments for [CONDITION(S)]. The resident refused hemodialysis on 09/07/20 and 09/16/20 due to pain. The physician was not notified on either occasion of pain and/or the refusal to attend hemodialysis. Additionally, on 09/07/20 the resident's ordered pain patch ([MEDICATION(S)]) was not administered as ordered. This was determined to constitute actual harm to the resident. As a result Resident #7 was experiencing pain without relief due to the lack of administration of prescribed pain medication, and the failure to notify the physician, caused a negative, adverse impact on the resident's hemodialysis treatments. This was true for one (1) of one (1) resident reviewed for [CONDITION(S)] during the Long-term Care Survey Process (LTCSP). Resident identifier: #7. Facility census: 65. Findings include: a) Resident #7 Medical record review, on 10/07/20 at 10:10 am, found Resident #7 had refused [CONDITION(S)] treatments on 09/07/20 and 09/16/20 due to the complaint of pain and unable to go to the [CONDITION(S)] treatment. The record did not indicate the physician and/or the nurse practitioner (NP) had not been notified of the complaints of pain and the resident's refusal to attend her [CONDITION(S)] treatments. No pain assessments were completed on 09/07/20 and 09/16/20. Resident #7's last pain assessment was completed on 07/09/20 with the annual Minimum Data Set (MDS) which indicated that she had frequent pain which was currently scored as a 6 out of 10 with 0 being no pain and a 10 being the worse pain possible. At this time Resident #7 indicated the pain level was acceptable and did not interfere with her to day to day activities. However, this changed in 09/07/20, when the residents pain became unmanageable and she had to miss [CONDITION(S)] treatments due to her pain. Further review of the MDS with an assessment reference date (ARD) of 07/09/20 indicated Resident #7 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact and able to be interviewed. An interview with Resident #7 on 10/07/20 at 3:00 p.m., found Resident #7 had a bad week and had refused [CONDITION(S)] a couple times and they had recently changed her pain management medication. The medical record review revealed the resident had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) transdermal patch to be applied every 72 hours. The medical record review verified the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] patch was not applied till 09/09/20. The medication was available on 09/07/20; no documentation as to why it was not administered. Additional medical record review found a progress note, dated 09/28/20, noting the physician was notified of the residents continued breakthrough pain and pain assessment was completed. A progress note by the NP dated 09/28/20, noted the resident had refused two (2) [CONDITION(S)] treatments due to pain. New order noted for Oxycodone 5 milligrams (mg) every six (6) hours around the clock for pain. Review of the facility's pain management policy found, if the patient has a change in pain status, complete a pain evaluation (electronic) or paper and the physician and/or NP will be notified of the pain. The Center Nurse Executive (CNE) was interviewed on 10/07/20 1:44 p.m., she said the medication ([MEDICATION(S)]) was available on 09/07/20 and she does not know why it was not administered. She confirmed no pain assessment had been completed on 09/07/20 and 09/16/20 and no documentation could be located the physician/NP had been notified of increased pain and refusal to go to [CONDITION(S)]. She confirmed the NP had been notified of the increased pain and a pain assessment was completed on 09/28/20.

Based on observation, record review, and staff interview, the facility failed to provide treatment and services to prevent potential complications, such as aspiration pneumonia, for a resident receiving enteral nutrition. Resident #111 had both a physician's orders [REDACTED]. A nurse aide (NA) was observed placing Resident #111 in a supine position (flat on back) in order to provide care while an enteral feeding was in progress. Further investigation found that the facility's clinical competency validation of nurse aide skills regarding aspiration precautions did not include residents receiving enteral nutrition. These findings were determined to pose immediate jeopardy to the health and well-being of Resident #111. The immediate jeopardy began on 12/05/16 at 3:45 p.m. when the NA placed the resident, who had enteral nutrition infusing, in the supine position without ensuring the feeding was stopped. The facility administrator and the Center Nurse Executive (CNE) were notified of the immediate jeopardy on 12/05/16 at 9:45 p.m. The facility provided a plan of correction on 12/05/16 at 11:02 p.m. The immediacy of this deficient practice was abated on 12/05/16 at 11:25 p.m. after surveyors verified all residents with tube feedings were assessed and the physician notified. The team also verified that the off going (afternoon) and the oncoming shifts were receiving education as they came to work. After the immediate jeopardy was removed, no deficient practice remained for this requirement. This identified failed practice had the potential to affect three (e) of three (3) residents who received enteral nutrition. Resident identifier: #111. Facility census: 63. Findings include: a) Resident #111 Upon entering Resident #111's room on 12/05/16 at 3:45 p.m. to observe NA #65 provide care to the resident found the resident lying on her back with the head of the bed elevated approximately 30 to 45 degrees. NA #65 lowered the head of the resident's bed so she lay flat on her back in order to check the resident's brief. The pump was infusing tube feeding formula into the resident's gastrostomy tube (G/T) was set at 60 cubic centimeters an hour (cc/hr). On 12/05/16 at 3:50 p.m., when asked whether the tube feeding was usually turned off when the resident was flat, NA #65 responded Yeah, but that's above my scope. She then began to provide incontinence care to the resident while the feeding continued to infuse. The nurse responsible for Resident #111 for that shift, Licensed Practical Nurse (LPN) #11, was immediately located and interviewed on 12/05/16 at 4:00 p.m. regarding positioning of residents while enteral nutrition was infusing. She stated We do not routinely stop tube feedings for care. When asked (for clarification), Even when the resident is lying flat? LPN #11 stated Yes. LPN #13, interviewed on 12/05/16 at 5:36 p.m., stated that staff were told never to lay a resident receiving a tube feeding flat. She said she did not turn off a tube feeding for NAs to provide care. A review of the resident's medical record on 12/05/16 at 5:27 p.m., found prior to her initial admission to the facility on [DATE], Resident #111 had experienced a [MEDICAL CONDITIONS] that resulted with dysphagia (difficulty swallowing). The resident underwent [REDACTED]. Upon admission, the resident had a secondary [DIAGNOSES REDACTED]. The resident's care plan for an enteral feeding tube included an intervention of, Head of bed elevated 45 degrees as ordered. This intervention specified that All staff were responsible for implementation. The Kardex, a care tool utilized by NAs, listed Head of bed elevated 45 degrees as ordered under the eating section of the document. A policy review and facility clinical competencies review on 12/05/16 at 5:27 p.m., found the facility's policy titled ENTERAL FEEDING: Administration by pump, last revised 11/28/16, instructed Position patient in semi- or high Fowler's position. Head of bed to remain elevated 30-45 degrees continuously during feeding on page 2, section 6. The Clinical Competency Validation Enteral Feeding: Administration by Pump for licensed nurses listed under critical elements, #6 Position patient in semi- or high Fowler's position. Head of bed to remain elevated 30-45 degrees continuously during feeding. LPN #11's competency on 11/16/15 indicated the LPN had met the requirements for tube feedings as did LPN #13's competency dated 04/02/16. The CLINICAL COMPETENCY VALIDATION ASPIRATION PRECAUTIONS for NAs did not address aspiration precautions for resident receiving tube feedings, it only applied to residents who took food orally. During an interview on 12/05/16 at 6:09 p.m., with the Center Nurse Executive (CNE) and the Nurse Practice Educator (NPE), the CNE stated that it was the expectation that any resident with a tube feeding infusing would have the feeding placed on hold by a licensed nurse while care was performed which required the resident to lie flat. The NPE said competencies on caring for residents receiving enteral nutrition were completed for all licensed nurses and for NA classes as well, annually. She also stated that staff would not get checked off on their competencies if they did not know the degrees for bed elevation. Both the CNE and the NPE stated they had not been aware of any problems regarding tube feedings left running during care or having residents lying flat with a tube feeding running. The CNE said Resident #111 had her PEG tube placed right before her admission to the facility and medical measures such as aspiration precautions were communicated through the Kardex. b) Immediate Jeopardy Determination The observation of Resident #111 lying supine while an enteral feeding was infusing was determined to pose a serious risk to the health and well-being of the resident and constituted an immediate jeopardy situation. This immediate jeopardy was first observed on 12/05/16 at 3:45 p.m. The administrator and CNE were notified of the immediate jeopardy 12/05/16 at 9:45 p.m. c) Removal of the Immediate Jeopardy The facility provided a plan of correction on 12/05/16 at 11:02 p.m. The immediacy of this deficient practice was abated on 12/05/16 at 11:25 p.m. after surveyors verified all residents with tube feedings were assessed and the physician notified. The team also verified that the off going (afternoon) and the oncoming shifts were receiving education as they came to work. d) Plan of Correction for the Immediate Jeopardy. The POC was as follows: (typed as written) Resident #111 on 12-5-2016 @10:00 pm was assessed by the RN lung sounds are clear in all fields, placement of tube checked via aspiration and tube is in place. Resident has not experienced any S/S of aspiration. Dr. (physician name) notified. No further orders received. Resident #111 has not experienced any negative outcome. All resident of the facility who receive enteral feeding have the potential to be affected. On 12-5-16 RN assessment has been completed on the other two residents in the facility that are receiving enteral feeding. Lung sounds are clear and placement of tube checked via aspiration with tubes in place. Dr. (physician name) was notified. No further orders. Residents have not experienced any negative outcomes. Immediate re-education will be provided to nursing staff on duty on 12-5-2016 and at the beginning of each shift prior to providing care to residents with enteral feeding staff will receive education with competency validation. Posttest will be completed to validate understanding. Staff not available during this time frame including new staff members will be provided re-education during orientation with posttest validation. CNE/designee with observe care of resident receiving enteral feeding daily across all shift x 2weeks including weekends then 3x weeks x 2 weeks then to be determined the QIC with corrective action upon discovery to ensure that HOB (head of bed) is elevated at least 30 degree and if resident is lying flat that the feeding is placed on hold by the licensed nurse. All findings will be reviewed monthly by the CNE/designee at the QIC for any additional follow up and or in-services need until the issue is resolved and randomly thereafter.

Based on resident interview, staff interview, medical record review, State and Federal guidelines, and policy review, the facility failed to implement policies and procedures to protect one (1) of thirty-five (35) Stage 2 residents from potential abuse. The hospital transfer information recorded the resident alleged rape by a male perpetrator; the physician identified a history of possible sexual abuse by the father; the resident had a history of [REDACTED]. On 12/05/16 the physician assessed the resident as incapacitated, and the father was recorded as the responsible party. The Clinical Admission Director (CAD) had noted on 12/01/16 she had been informed the resident became agitated after speaking with the father on the telephone. The father was noted as the only emergency contact, and the facility notified him of the resident's location on 12/05/16. On 12/07/16 at 6:15 p.m., the administrator was notified of an immediate jeopardy related to the facility's failure to identify and act upon Resident #128's allegation of a history of sexual abuse, an allegation of rape from an unknown male perpetrator, and fear of her father and to protect the resident from potential abuse, sexual and/or psychosocial, or another other resident who might have been at risk. The facility provided a plan of correction to the State agency which was reviewed and accepted at 10:55 p.m. The plan of correction was reviewed for implementation and the immediacy abated at 11:00 p.m. on 12/07/16. No deficient practice remained for this requirement after the immediate jeopardy was removed. Resident identifier: #128. Facility census: 63. Findings include: a) Resident #128 During a Stage 1 interview on 12/06/16 at 10:55 a.m., Resident #128 voiced she was scared of her father and that he was mean. The medical record, reviewed on 12/06/16, indicated the father was Resident #128's emergency contact and authorized Health Insurance Portability and Accountability Act (HIPAA) contact. A discussion with the administrator on 12/06/16 at 7:00 p.m. revealed he had no awareness Resident #128 was fearful of her father or had any other concerns, and called the social worker (SW) to the office. SW #72 said she had been notified by Unit Manager (UM) #5 of an issue of alleged sexual abuse by the father, about two (2) hours earlier. She indicated the physician had noted possible history of sexual abuse by the father. The social worker stated she had not yet completed a resident assessment, and that she had not discussed it with the administrator. During a follow-up interview on 12/07/16/16 at about 9:30 a.m., SW #72 stated she had not yet completed a social service assessment for Resident #128. Unit Manager (UM) #5, interviewed on 12/07/16 at 9:45 a.m., stated the facility had been informed on the morning of 12/05/16 by the director of the previous nursing home placement (prior to hospitalization ), that, As long as her father doesn't find her you'll be okay. The UM verbalized the facility had notified the father on 12/05/16 of the resident's location. Upon inquiry, UM #5 stated she was notified on the morning of 12/05/16 by the director of nursing, and was not aware of any action plan in place to protect the resident. A hospital behavioral health note, dated as faxed on 12/01/16, recorded Resident #128 verbalized an allegation of being raped him. A physician's history and physical dated 12/05/16 noted the chief complaint as a, History of [MEDICAL CONDITION] and was sexually abused by father as a child? The physician's plan of care included, No male attendants, and indicated the plan of care was discussed with staff and the resident. Additionally, on 12/05/16 at 12:09 p.m., a physician ordered, No male nurse aides (NA). A progress note dated 12/05/16 also noted male NA's were not to provide care. The physician's statement of capacity noted Resident #128 lacked capacity due to [MEDICAL CONDITION], cognitive loss, disoriented to person, place, and time, inappropriate answers to questions, and long-term care indicated. The form noted the resident was notified the father would be making health care decisions during the period of incapacity. Further review of the record on 12/07/16 revealed Resident #128 signed a consent for treatment and release of information on12/03/16. The form contained names allowing permission for the facility to discuss information with family members or friends about her condition. The Quick PAR (Patient Assessment Review) form, dated 12/01/16 and signed by the CAD, noted, the social worker had stated, Patient did get upset after her father called her. The care plan was silent related to the resident's history of alleged sexual abuse or relationship with her father. An interview with Licensed Practical Nurse (LPN) #15 on 12/07/16 at 4:21 p.m., revealed Resident #128's father called the facility on 12/06/16 requesting information about her care. Nurse Aide (NA) #51 stated she was not aware of any concerns related to visitation and nothing had been reported to her from other shifts. On 12/07/16 at 6:15 p.m., the facility was notified of an immediate jeopardy related to the facility's failure to identify and act upon Resident #128's allegation of a history of sexual abuse, an allegation of rape from an unknown male perpetrator, and fear of her father and to protect the resident from potential abuse, sexual and/or psychosocial, or another other resident who might have been at risk. The facility provided a plan of correction to the State agency which was reviewed and accepted at 10:55 p.m. The plan of correction was reviewed for implementation and the immediacy abated at 11:00 p.m. on 12/07/16. During a discussion with the administrator and Center Nurse Executive (CNE) on 12/07/16, between 8:10 p.m. and 8:43 p.m. regarding admission practices, the CNE said a hospital nurse determined Resident #128 was appropriate for admission to the facility. Upon inquiry, the director said the registered nurse was a corporate employee and referred to her as a CAD (Clinical Admission Director). Upon inquiry as to how the facility ensured services were in place for the resident, the CNE said the hospital called report to the floor nurse. The CNS did not know who took the report, and had just found out about twenty (20) minutes prior to the discussion related to the immediate jeopardy, that there was a concern related to an allegation of possible sexual abuse. She related no information was available to the facility to indicate the resident had expressed fear or an allegation of sexual abuse. The medical record, reviewed with the CNE, included the hospital note dated 11/30/16, which had been faxed to the facility on [DATE], prior to Resident #128's admission and recorded raped him. She further added, the CAD would notify the facility of any pertinent information and denied she had been informed of any concerns. The CNE stated the facility did not address the resident's mental/psychosocial issues prior to admission, and had not reviewed the information although she was being discharged from a psychiatric location. During clarification of the admission process, at 10:06 p.m. on 12/07/16, the CNE said the CAD determined if the resident was acceptable, the information was placed on the care line, passed to the center, and the admission director (AD) at the facility printed it from the care line. She said if the CAD told them they were getting an admission, the facility did not routinely review the information, as it came from the CAD. Upon inquiry as to what happened to the information once the AD received it, the nurse said it was given to the floor nurse at the time of admission and the nurse only reviewed medications. The CNE denied she had received the referral information. The admission director (AD), interviewed on the morning of 12/08/16, verbalized her responsibility with the admission process was to obtain the referral from the care line. Upon inquiry as to what she did with the information, the AD said she gave it to the CNE. The director acknowledged she had obtained Resident #128's referral on 12/01/16 and said she had given it to the CNE on 12/02/16. The resident was admitted on [DATE]. Upon request, the CNE joined the meeting. She related she only reviewed medications, and did not look at any additional information including behavioral health/psychiatric notes. The Admission Criteria: General policy with a revision date of 08/01/16, reviewed on 12/07/16, included, .the scope of service provided must meet the level of health care needs of the patient upon admission .The Clinical Admissions Director (CAD) or employee reviewed admission criteria, a medication watch list to discuss need, potential alternatives . and noted guardianship was subject to review by the regional office. The purpose was to ensure a center preparedness for admission. The form indicated that if a clinical condition was not on the Center Clinical Capabilities, the CAD would .discuss the referral with the Center Nurse Executive (CNE) or designee prior to acceptance . The administrator and CNE voiced they did not understand the facility's responsibility related to Resident #128's past history of alleged sexual abuse and her stay at the facility. They denied adult protective services had been contacted related to the physician's findings, to the history of allegation of rape voiced by the resident at the hospital, or the previous nursing facility's report that they would be fine as long as the father did not find her. They also said the physician's orders [REDACTED]. Both denied the information created a question of concern about the resident's safety or psychosocial and emotional well-being. Additionally, the staffing assignment sheets, reviewed on 12/08/16, recorded a male NA assigned to Resident #128's care for the dates of: 12/06/16 on 7:00 a.m. - 3:00 p.m. shift 12/06/16 on 2:00 p.m. - 10:00 p.m. shift 12/07/16 on 2:00 p.m. - 10:00 p.m. shift When asked about the visitation protocol, the administrator said visitors did not sign in or out, and the facility did not track who entered the building. The administrator called SW #72 to the room at 8:42 p.m. The social worker said she had contacted APS at 10:30 a.m. or so on 12/07/16 and was told they were Resident #128's representative for ten (10) days during an investigation in 2015, but it was not substantiated and representation was returned to the father. Further review of the medical record revealed social service notes, dated 12/07/16 recorded at: -- 8:52 a.m., Resident states she is afraid of her father due to some sexual issues. States that she does not want him coming to the facility. SW called (Nursing Facility), past facility .They also stated that when her father came to visit, she would become agitated and throw herself in the floor, hence causing her admission to the hospital -- 13:12 (1:12 p.m.) Spoke with SW at (previous Nursing Home) regarding her stay . and was informed Resident #128's father was verbally abusive on the phone, calling names and cursing. SW #72 recorded she had spoken with a case worker who reported the father had told them there was some sexual abuse and Resident #128 did not want to be around him. -- At 14:50 (2:50 p.m.) a social service note indicated the ombudsman said the facility should contact adult protective services due to the resident did not want her father as representative. When asked what the facility did to protect Resident #128, the administrator related he had called the father and directed him not to come to the facility. Upon inquiry as to the process for alerting staff, the administrator said he would alert staff to be aware of someone who was about [AGE] years old; may ask for identification if asked about the resident, but did not have a plan in place. The Checklist for Surrogate Selection form, completed 12/07/16 at 12:55 p.m., noted the resident was deemed incapacitated by the physician on 12/05/16, and did not have a court appointed guardian, or medical power of attorney (MPOA). The form noted the Resident does not wish father to be involved in her care due to alleged sexual abuse, and he was notified at 5:30 p.m. on 12/07/16. The physician signed the form on 12/08/16 indicating the Department of Health and Human Resources (DHHR) would be designated as the resident's representative due to Resident does not wish father to be involved. The WV Abuse Prohibition policy, with a revision date of 11/28/16 was reviewed on 12/07/16. It noted the facility would identify possible incidents or allegations which needed investigated, and protect the resident(s) during the investigative process. 7.1 noted the facility would Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe. 7.2 noted the facility would Assign a representative from social services or a designee to monitor the patient's feelings concerning the incident, as well as the patient's involvement in the investigation. The Reporting of Suspected Crimes under the Elder Justice Act (EJA) dated 08/08/11 noted, All covered individuals will be notified by the Corporate Law/Compliance of their reporting obligations under the EJA to report a suspicion of a crime to the state survey agency and local law enforcement for the political subdivision in which the Center is located. A covered individual was defined as anyone who was an owner, operator, employee, manager, agent, or contractor of the Long Term Care (LTC) Center. Serious bodily injury was noted as an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation. During the interview with the administrator on 12/07/16 at 8:10 p.m., he acknowledged both the physician and the CAD were required to report any allegation and/or suspicion of abuse and protect the resident from potential harm. b) On 12/07/16 at 6:15 p.m., the administrator was notified of an immediate jeopardy related to the facility's failure to identify and act upon Resident #128's allegation of a history of sexual abuse, an allegation of rape from an unknown male perpetrator, and fear of her father and to protect the resident from potential abuse, sexual and/or psychosocial, or another other resident who might have been at risk. The facility provided a plan of correction to the State agency which was reviewed and accepted at 10:55 p.m. The plan of correction was reviewed for implementation and the immediacy abated at 11:00 p.m. on 12/07/16. No deficient practice remained for this requirement after the immediate jeopardy was removed. c) Plan of Correction for the Immediate Jeopardy The Center Executive Director (CED) and Center Nurse Executive (CNE) reported the allegation related to the resident #126 expressed fear of her father to the appropriate state entities on 12/7/16. The police was notified by CED on 12/7/16 at 7:05 PM of the allegation and arrived at the center and is in process of interviewing the resident. APS at 8:52AM and the Ombudsman 2:50PM were made aware by phone of the allegation by the Social Services on 12/7/16. It was recommended that APS be made temporary guardian until an appropriate surrogate is identified. The APS worker to fax form for Medical Director to complete the required form requesting APS to act as surrogate until an appropriate surrogate is determined. SS interviewed the resident at 7:15 PM of the actions taken. All residents of the facility have the potential to be affected. The CED interviewed SS at 7:55PM regarding any other residents who have statement regarding fear of responsible party and none were identified. CED and CNE will immediately reeducate Assistant Director of Nurses of the Unit and Medical Director who on 12/5/16 and SS on 12/6/16 that were aware of the allegation regarding need to identify an allegation of abuse and protect the resident and to implement the policy and procedure for abuse and immediately report to the appropriate State agencies. The Clinical Admission Director who faxed the information to the center regarding the resident's course in the hospital on [DATE] will be provided reeducation by CED/designee on 12/8/16 regarding the need to notify the center in advance of an allegation of abuse, need to protect the resident and need to implement the policy and procedure for abuse. The CAD/RN will review records for any potential allegations of abuse and neglect prior to admission. Hospital paperwork will be reviewed by CNE/designee prior to admission. SS contacted the father 12/7/16 at 5:48 PM regarding SS had spoken with DHHR about being guardian for resident due to resident wishing father not to be involved and requested he not visit. Resident #126 will be placed on 15 minute checks for 7 days and then to be determined by QIC to ensure protection, will have supervised visits from any visitors, and arrangements will be made for the physician visit on 12/12/16 to have EMS provide female attendants to remain with the resident while out of the center. The CED/designee will begin immediate reeducation of staff regarding need to identify an allegation of abuse and protect the resident and to implement the policy and procedure for abuse staff on duty 12/7/16 and continue at beginning of each shift until all employees are reinserviced. A posttest will be completed to validate understanding. Staff not available during this timeframe will be provided reeducation including posttest the first shift upon return to work. All residents/legal representatives will be interviewed for alleged abuse by SS/designee by 12/8/16 to ensure no additional findings with corrective action upon discovery. Staff interviews regarding alleged abuse investigation will start 12/7/16 by Nurse Practice Educator/management designee and will be completed by 12/8/16 or on the next shift worked. Trends identified will be reviewed monthly at the Quality Improvement Committee by CED/designee for any additional follow up and/or inservicing needs until the issue is resolved and randomly thereafter.

Based on record review and staff interview, the facility failed to provide nutritional care and services to ensure one (1) of three (3) residents reviewed for the care area of nutrition maintained, to the extent possible, acceptable parameters of nutritional status. The facility did not recognize, evaluate, and address the needs of this resident who was at risk for impaired nutrition. Resident identifier: #13. Facility census: 63. Findings include: a) Resident #13 Review of the medical record, at 11:00 a.m. on 09/28/15, found this resident was not on a planned weight loss program. The resident's [DIAGNOSES REDACTED]. The resident's weight records for the past six (6) months revealed the resident experienced severe weight losses in that period of time. In three (3) months, between 05/06/15 and 08/04/15, the resident had a weight loss of 13 pounds. This represented a severe weight loss of 10% in that three (3) month period. Overall, in six (6) months, between 03/01/15 and 09/04/15, the resident lost 19 pounds, which represented a severe weight loss of 13.8% of the resident's total body weight. The recorded weights were: 03/01/15 137.5 (pounds) 04/14/15 123.9 04/21/15 126.3 05/01/15 128.0 05/06/15 128.7 08/04/15 115.5 09/04/15 118.5 Review of Registered Dietitian (RD) #94's last nutritional assessment, dated 07/15/15, found no nutritional concerns were identified. At the time of the RD's review on 07/15/15, the resident's weight records indicated the resident had experienced a weight loss of 8.8 pounds in two (2) months, between 03/01/15 and 05/06/15. This represented an unidentified severe weight loss of 6.4%. The resident's current care plan, revised on 07/15/15, by RD #94, found the problem: Resident is at nutritional risk: related to poor intake, dementia and weakness, falls. The goal associated with the problem was, Resident will consume 50-75% of at least 3 meals q (every) day x (times) 90 days. Interventions associated with the problem included: - supplements as ordered - weights to be obtained as per doctor's orders - encourage 100% consumption of all fluids provided - recognize and respect decision for no tube feeding or weight - monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake - offer alternate food choices if less than 50% consumed at mealtime. - provide diet as ordered with 8 ounces of whole milk. Review of the Medication Administration Record [REDACTED]. This left the facility unable to determine if the intervention was effective, how much supplement was consumed by the resident, and/or if a different type or flavor should be considered. At 1:00 p.m. on 09/29/15, the activities of daily living (ADL) flow sheet for September 2015, was reviewed for the daily meal percentage consumption. Sixteen (16) meals had been refused by the resident during the month of September. On 21 of the 29 days reviewed, the resident had either refused or consumed less than 50% of a least one (1) meal a day. On two (2) days during September, 09/26/15 and 09/27/15, the ADL flow sheet was not completed. There was no evidence the flow sheet was monitored to recognize and address the resident's poor meal consumption. In addition, there was no evidence alternate choices were offered, and no evidence the RD and physician were notified of the resident's poor meal consumption. At 1:31 p.m. on 09/29/15, the director of nursing (DON) stated the resident's daughter requested the facility stop weighing her mother in May 2015. She said the daughter, on 08/28/15, asked the facility to start weighing her mother again. The DON stated this was why the resident was not weighed during the months of June or July 2015. Review of the current physician's orders for September 2015, found no physician's orders regarding weighing or not weighing the resident. At 2:58 p.m. on 09/29/15, an interview was conducted with RD #94 and the DON. They were asked how the facility was monitoring the effectiveness of the interventions and how the facility knew if the resident was consuming the nutritional supplement. RD #94 stated, We don't know if she drinks it or not. The DON stated the facility added the house supplement and [MEDICATION NAME], on 04/30/15, to address the resident's weight loss. RD #94 was asked how she had addressed the resident's weight loss. She stated that information would be in her dietary notes. The dietary notes were reviewed with RD #94, who confirmed her last note was written on 07/15/15. At that time, the RD wrote: A nutrition assessment was completed today. The resident's nutrition concern (s) is: No concern (s) identified. On 09/29/15, she confirmed no dietary notes had been written since 07/15/15. RD #94 and the DON confirmed the facility did not document the percentage of daily fluids consumed; therefore, no evidence was present to verify the intervention on the care plan to consume 100% of fluids offered was being monitored. It was also unknown if the resident consumed the 8 ounces of whole milk added to her meals. As the facility did not document the percentage of the house supplements consumed, no information could be provided to verify the resident was consuming the supplements given. The percentage of the house supplement had not been documented since it was ordered on [DATE]. RD #94 could provide no evidence she addressed the resident's daily meal consumption, which was less than 50% at numerous meals in September 2015. At the close of the survey, on 09/30/15 at 6:30 p.m., no further information had been provided to substantiate the facility evaluated and monitored the effectiveness of the all the interventions addressing the resident's nutritional status.

Based on observation, resident interview, medical record review, and staff interview, the facility failed to assure that one (1) of twelve (12) Stage II sample residents received the necessary supervision and positioning to prevent choking / aspiration during oral consumption. Resident #14, a [AGE] year old male with [DIAGNOSES REDACTED]. The resident was discovered slumped sideways in his bed at 9:15 a.m. on 05/11/11, with his breakfast tray on an overbed table above his abdomen. His head, right arm, and right shoulder were pressed against the siderail of his bed, with the call bell wedged under his right side between the mattress and siderail. The resident was noted to have partially masticated eggs on his chin and on the front of his shirt. He complained of having choked on his eggs. The resident was unable to reposition himself away from the siderail when cued. Interviews with staff members revealed the resident had experienced an episode of choking earlier the same morning, with staff intervening and repositioning him in the bed. The resident was left unsupervised to continue to eat until discovered by this nurse surveyor. review of the resident's medical record revealed [REDACTED]. Staff was aware he would frequently refuse to get out of bed for meals, and he was evaluated by a speech language pathologist (SLP) to see what could be done to promote safe eating and drinking while in bed. A recommendation was made to have him sitting in an upright position in bed with "pillow positioning" under his right side to assist him in maintaining this upright position, but this recommendation was not incorporated into the resident's care plan. In fact, his care plan was not revised at all to address his frequent refusals to get out of bed for meals. With regard to the amount of supervision Resident #14 was to receive during meals, the SLP's recommendation for "distant supervision" was made based on the need to consider the availability of nursing staff. When asked what kind of supervision the SLP would have recommended if nursing staffing was not a consideration, the SLP stated she would have recommended Resident #14 be kept under "close supervision" which would have required him to be within eyesight of staff members at all times while consuming an oral diet or liquids. The administrator was informed at 10:45 a.m. on 05/11/11 that failing to provide for appropriate positioning and necessary supervision when the resident was eating in bed placed Resident #14 in immediate jeopardy of harm or death from choking / aspiration. The immediate jeopardy was removed at 12:20 p.m. on 05/11/11, following an assessment of the resident's condition and implementation of a plan to assure appropriate positioning and supervision during consumption of food or fluids by Resident #14. There was no deficient practice identified following the implementation of the facility's interventions to assure resident safety during oral consumption. Resident identifier: #14. Facility census: 61. Findings include: a) Resident #14 While standing in the corridor outside of Resident #14's room on 05/11/11 at 9:15 a.m., this nurse surveyor observed Resident #14 in his bed slumped toward the right with his head on the siderail. After entering his room, observation found an overbed table placed across his abdominal area with his breakfast tray on top. His head, right arm, and right shoulder were pressed against the siderail of his bed, two (2) pillows were noted on the left side of the resident, and the call bell was wedged under his right side between the air mattress and siderail. The resident had a lift pad beneath him, which did not offer resistance to sliding when in contact with the surface of the air mattress. The resident was noted to have partially masticated eggs on his chin and on the front of his shirt. He complained of having choked on his eggs. The resident was unable to reposition himself away from the siderail when cued. A nursing assistant (NA - Employee #70) responded to a request for assistance. She assisted the resident to move away from the siderail and retrieved the call bell from between the siderail and the air mattress. After repositioning Resident #14, Employee #70 brushed back his hair with her hand, revealing a rectangular reddened area in the shape of the top of the siderail above the resident's right ear. When asked, Employee #70 stated she would report this reddened area to his nurse. She stated the resident chokes easily but had refused to get up that morning. -- An interview with the licensed practical nurse (LPN) responsible for the resident (Employee #27) was conducted at 9:22 a.m. on 05/11/11. She stated the resident had "choked" earlier, and she and another NA had assisted him to reposition in the bed. She stated she stayed with him until the resident "cleared his throat", and then she left to continue her medication pass. Review of information collected by the facility on 05/11/11 found that Employee #1 was identified as the NA who assisted Employee #27 that morning. Review of the facility's documentation found the NA had delivered the resident's breakfast tray to his room at approximately 8:30 a.m. on 05/11/11. The NA returned to the resident's room approximately five (5) minutes later after hearing the resident cough. The resident was leaning to the left, so she pulled him to the middle of the bed and got Employee #27 to assist. -- Record review revealed the following nursing note, entered two (2) hours after Resident #14's second choking episode by a corporate nurse consultant at 11:30 a.m. on 05/11/11 (quoted as typed), "Resident was assessed following a choking episode during morning meal. ... No signs of distress. ... No reddened area to (r) side of head as indicated by the surveyor observation. ..." -- Record review revealed this [AGE] year old male was most recently readmitted from the hospital to the facility on [DATE] where he had been treated for [REDACTED]. His active [DIAGNOSES REDACTED]. Review of Resident #14's most recent assessment, a quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/06/11, found in Section G that he required the extensive physical assistance of two (2) or more persons for bed mobility, was totally dependent on two (2) or more persons for transferring, required the extensive physical assistance of one (1) person with eating, required human assistance to stabilize when transferring between surfaces, and had impaired functional limitation in range of motion of his upper extremity on one (1) side. Review of Section K found the resident displayed coughing or choking during meals or when swallowing medications. Review of his previous two (2) MDSs, a Medicare 5-Day MDS with an ARD of 03/21/11 and a Medicare 14-Day MDS with an ARD of 03/26/11, revealed in Section G that he required the extensive physical assistance of two (2) or more persons for bed mobility, was totally dependent on two (2) or more persons for transferring, required the extensive physical assistance of one (1) person with eating, required human assistance to stabilize when transferring between surfaces and when moving on and off the toilet, and had impaired functional limitation in range of motion of his upper and lower extremities on one (1) side. Review of Section K found the resident displayed coughing or choking during meals or when swallowing medications. -- Review of Page 3 of 24 of the current care plan found the following problem statement (Date Initiated: 11/12/10; Revision on: 04/13/11) (quoted as typed): "restorative program for up in w/c (wheelchair) for all meals per program plan." The goal associated with this problem statement was (quoted as typed): "Follow OOB (out of bed) schedule to be up in w/c for meals." The interventions developed to assist the resident in achieving this goal were (quoted as typed): "Assist patient in sitting upright in w/c for all meals. Explain task to resident prior to activity. Provide supervision with meals." Review of Page 16 of 24 of the current care plan found the following problem statement (Date Initiated: 08/16/08; Revision on: 04/13/11) (quoted as typed): "Resident has impaired swallowing due to dysphagia and is edentulous - Resident is at risk for aspiration, chokes easily." The goal associated with this problem statement was (quoted as typed): "The resident will be free from signs and symptoms of possible aspiration thru next review." The interventions developed to assist the resident in achieving this goal were (quoted as typed): "Honor food preferences within meal plan. Provide diet as ordered (family aware of choking,waiver was signed). Provide thickened consistency liquids as ordered. Place resident in 90 (symbol for 'degree') upright position / out of bed when swallowing food or drink. Encourage resident to take small sips / bites. Observe for signs / symptoms of aspiration. Place call light within reach at all times. Supervise / cue / assist as needed with meals." Elsewhere in the care plan, the following interventions were found in association with other problem statements: - On Page 2 of 24 - "Observer (sic) resident safety, his diet and watch for choking." - On Page 5 of 24 - "Provide supervision with meals after set up. Assist as needed." The care plan did not address how staff was to ensure Resident #14 maintained an upright position at 90 degrees while consuming food / fluids in bed, nor did it provide guidance as to how much "supervision" to provide the resident when consuming food / fluids. -- An interview was conducted on 05/11/11 at 10:10 a.m. with the registered nurse (RN - Employee #43) who authored the care plan. She stated the resident was in the restorative program to be up in his wheelchair for all meals so he could be supervised while eating. She conveyed that the resident refused to get up / out of bed for meals at times. When asked if a care plan had been developed to assure the resident's safety while eating in bed, she stated that no such plan had been developed. -- An interview with the individual identified by the facility as the occupational therapist (OT - Employee #91) was conducted at 10:48 a.m. on 05/11/11. Employee #91 stated the resident was "really a high aspiration risk" and the plan was for him to be supervised in the dining room for all his meals. -- Review of the 04/27/11 care plan meeting note written at 1:52 p.m. found the following: "...The resident continues to be very high risk for aspiration. At times, he refuses to get out of bed for meals. He expresses understanding of the importance of getting out of bed for meals, and he understands how he needs to be up to reduce the risk for aspiration. He still refuses at times to get up. He is to be supervised with eating / drinking. ..." Review of the physician determination of capacity form in the medical record found that the attending physician determined, on 02/21/11, that Resident #14 lacked sufficient mental or physical capacity to appreciate the nature and implications of health care decisions. -- Further review of the medical record found an evaluation by the speech language pathologist (SLP) for the treatment period from 12/28/10 through 01/26/11. The SLP identified [DIAGNOSES REDACTED]. Her assessment found the resident demonstrated impairment in the following areas: dry swallow, reflexive cough, reflexive throat clear, volitional throat clear, volitional cough, and gag reflex. The assessment recommended "distant supervision" during consumption of food / fluids for safety. Additionally, a progress note recorded by a SLP on 12/31/10 stated (quoted as typed): "... Swallowing Therapy ( ) to assess and modify positioning to enhance swallow function including repositioning the patient in bed, with head of bed elevation and pillow positioning under right sid eof body to increase ability to sustain midline position. ..." (Note: The SLP who recorded this progress note was not the same SLP who also served as the therapy program manager.) -- An interview was conducted with the therapy program manager / SLP (Employee #85) at 9:10 a.m. on 05/12/11, in the presence of two (2) other nurse surveyors. She stated Resident #14 was a chronic aspirator, his aspiration was significant, and he can aspirate on his own saliva. She stated the resident has a very large, weak tongue which affects his swallowing, and it was a significant danger to him to consume an oral diet, but the family refused PEG tube placement. She stated she tried to make the best out of a really difficult situation. She recommended safe swallowing strategies and education for the NAs. She stated occupational therapy (OT) had a long-standing restorative program to encourage him to get up for meals. He frequently refused meals and frequently refused to get up out of bed for meals. She stated she tried to make the best out of a really difficult situation. She relayed that, when taking staffing concerns into consideration, she recommended he be sitting upright at 90 degrees with "distant supervision". When asked what her recommendation would have been if she did not have to take staffing levels into consideration, she stated she would have recommended he be kept under "close supervision" which would have required him to be within eyesight of staff members at all times while consuming an oral diet or liquids. When asked, she stated that evidence of choking included obvious signs of distress during eating, such as coughing. -- Review of witness statements from staff, obtained by the facility after Resident #14's second choking incident on the morning of 05/11/11, found the following: Statement from Employee #1, obtained during a telephone interview conducted by the director of nursing (DON) at 3:45 p.m. on 05/11/11 and signed by the employee on 05/12/11 (quoted as written): "... (Employee #1) stated at about 8:30 a.m., she went in and set up residents tray for him. She asked him if that was OK and he said yes. States his call light was in his lap when she left. Approximately 5 minutes later she heard him cough & went back in to check on him. He was leaning to the left so she pulled him to the middle of the bed. She then got the nurse (Employee #27), LPN to help pull him up higher in the bed & put a pillow behind his head. H.O.B. (head of bed) was adjusted as high as it would go. Asked him again if he was OK and he nodded yes. His call light was in his reach when she left. She was unaware resident should have constant supervision." Statement written by Employee #27, signed and dated on 05/11/11 (quoted as written): "In hallway passing meds when CNA (certified nursing assistant) called for assist to pull resident further up in bed. BKF (breakfast) tray was on bedside table - resident was eating prior to entering room, coughing episode was in progress when I entered the room. CNA & I pulled resident to head of bed placed a pillow behind his back to sit him more forward to eat. Resident was able to clear his throat on his own while CNA & I were in the room. When resident was OK, CNA pulled BKF tray to resident. I asked resident 'Are you OK' resident nodded his head yes. CNA & myself left the room. I returned to hallway to do med pass, did not hear resident cough while on 300 hall. Call light within reach." Based on the above statements, there was no evidence Employees #1 and #27 were aware of the need to place pillows under the resident's right side to assist the resident in maintaining a midline position when sitting upright in bed. -- Staff was aware that Resident #14 was at high risk for choking / aspirating food and fluids and that he would frequently refuse to get out of bed and sit in an upright position in a wheelchair for meals. The interdisciplinary team failed to develop interventions for staff to follow when Resident #14 refused to get out of bed for meals (to eliminate safety hazards over which the facility had control to prevent choking while the resident consumed food / fluids in bed), to include the application of "pillow positioning" under the right side to increase the resident's ability to sustain a midline position when sitting upright in bed. Staff left Resident #14 unsupervised following an episode of the resident sliding in the bed and choking / coughing during his morning meal. The failure to assure the resident remained in an upright position with staff supervision during the remainder of the morning meal on 05/11/11 placed this resident at risk of harm or death from aspiration. .