Morgantown Heights of Journey

Inspectors wroteBased on record review and staff interview, the facility failed to notify residents and their representatives of room changes. This failed practice was found true for (2) two of (3) three residents reviewed for room change notifications during the complaint survey. Resident identifiers: #60, and #68. Facility Census: 89.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Medical Power of Attorney (MPOA) was notified regarding transfer to an acute care facility related to a change of condition. This failed practice has the potential to affect more than a minimal number of residents residing in the Long-Term Care Facility. Resident #100. Facility census 89. Based on staff interview and clinical chart review completed on 7/29/26 at approximately 1:30 PM, an interview was conducted with the Director of Nursing (DON) regarding the transfer of Resident #100 to the hospital on [DATE] The DON confirmed the resident was transferred to the hospital on that date and acknowledged that the resident's designated Medical Power of Attorney (MPOA) was not notified at the time of the transfer. [...]

Inspectors wroteBased on resident interview, record review, observation, and staff interview, the facility failed to ensure one resident (Resident #71) received timely incontinent care and was protected from neglect by allowing the resident to remain in urine-soaked clothing and bed linens for an extended period, failing to provide care even after staff were directed by the Director of Nursing (DON) to do so, and documenting care that had not been provided. This failed practice resulted in the resident remaining in saturated clothing and linens for an additional hour, causing emotional distress as evidenced by the resident crying during the survey. Resident identifier: #71 Facility census: 89During an interview with Resident #71 on 07/27/26 at approximately 10:15 AM, a strong odor of urine was noted upon entering the resident's room. [...]

Inspectors wroteBased on record review, resident representative interview, and staff interview, the facility failed to ensure residents are allowed to return to the facility after requests to be sent to an acute care facility were honored without requiring an Against Medical Advice (AMA) discharge. This was true for two (2) of five (5) residents reviewed under the care area of Discharge. Resident Identifiers: #92 & #93. Facility Census: 89. Findings Include: a) Resident #92 A record review was completed on 07/28/26 at 10:00 AM. The resident was ordered intravenous (IV) fluids and antibiotics for the refusal of medications, and meals as well as treatment for a urinary tract infection (UTI) on 05/14/26. The resident was noted to pull out her IV multiple times. A progress note dated 05/16/26 at 5:50 PM was reviewed. The progress note stated, resident's son was here and resident pulled out her IV again. [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. This failed practice has the potential to affect more than a minimal number of residents residing in the long term care facility. resident identifier:

Inspectors wroteBased on record review and interview, the facility failed to provide the necessary care and services to ensure a resident received treatment in accordance with identified clinical needs by failing to timely initiate physician-ordered wound care and prescribed medication for one (1) of one (1) resident reviewed for quality of care. Resident #100. Facility census 89. a) Resident #100Resident #100 was admitted to the facility on [DATE] and was subsequently transferred to the hospital on [DATE]. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain an infection control program regarding the storage of resident urinals and linen. These were random opportunities for discovery. Resident Identifiers: #17, #29, #84, #62 and #19. Facility Census: 89. Findings Include: a) Resident Urinals On 07/27/26 at 9:36 AM and at 12:55 PM, a tour of the facility was completed. During the tour, observations of urinals containing urine sitting on the over-the-bed tables were made. These observations were for the following residents: --Resident #17 --Resident #29 --Resident #84 --Resident #62 --Resident #19 The care plans were reviewed for each resident. The care plan did not include the resident's preference regarding the storage of the residents' urinals. [...]

Inspectors wroteThe facility failed to maintain an effective pest control program so that the facility is free of gnats in resident rooms and common areas. This was a random oppertunity for discovery and has the potential to affect all residents residing in the Long Term Care Facility. Facility census:89 During an interview on 07/27/26 at approximately 11:00 AM with Resident #71 who complained about gnats in the room,An observation made on 07/27/26 while interviewing resident #71 gnats were visible throughout the room and bed side trays. Further observations were made throughout the building and Gnats were observed in the dining area, nurses station and conference room. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to develop and/or implement the care plan regarding a diagnosis for Resident #43, include antipsychotic medications for Resident #80, and the use of adaptive utensils for Resident #5. This was true for three (3) of 31 residents reviewed during the survey process. Resident Identifiers: #43, #80, and #5. Facility Census: 72. Findings Include: a) Resident #43 On 09/08/25 at 11:30 AM, a record review was completed for Resident #43. The review found all diagnoses were not included in the care plan. The diagnosis, which was added to the medical record on 09/26/24, that was not included was obstructive and reflux uropathy. On 09/08/25 at 2:13 PM, Corporate Nurse (CN) #300 confirmed the care plan had not been developed regarding the diagnosis obstructive and reflux uropathy. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to revise a care plan regarding actual falls for Resident #12, amount of assistance needed for showering for Resident #20, and physical and verbal aggression for Resident #46. This was true for three (3) of 31 residents reviewed during the survey process. Resident Identifiers: #12, #20, and #46. Facility Census: 72. Findings Include: a) Resident #12 On 09/09/25 at approximately 1:00 PM, a record review was completed for Resident #12. The review found the care plan focus area was listed as fall risk r/t (related to) weakness, balance problem. The review, also, found the resident had two (2) actual falls on 04/24/25 and 06/21/25. On 09/09/25 at 2:15 PM, the Corporate Nurse #300 confirmed the care plan was not revised to include the two (2) actual falls. [...]

Inspectors wroteBased on interview, and record review, the facility failed to promote residents' right to self-determination and choices in the areas of medication administration and discharge planning. Resident Identifier: #52. Facility Census: 72. Findings Includea) Resident #52During an interview on 09/03/2025 at approximately 10:55 AM, the resident stated that on 08/30/25, she and her roommate had to wait until around 11:45 PM for their medications. Resident stated that she requests her prescribed PRN Oxycodone and Tizanidine when her arm spasms become uncontrollable. The resident further stated that she usually requests these medications before she goes to sleep. On 08/29/25 at approximately 9:30 PM, the resident stated that she asked a Nursing Aide (NA) to notify the nurse that she wanted her medications. The resident could not remember who the NA was. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to notify the representative / emergency family member of medical changes. This was true for one (1) of three (3) residents reviewed for the care area of hospitalization during the annual long-term care survey process. Resident identifier: #60. Facility census: 72.

Inspectors wroteBased on interview and record review, the facility failed to perform a thorough investigation after an instance of resident-to-resident abuse. This was a random opportunity for discovery. Resident Identifiers: Resident #46. Facility Census: 72. Findings Include:a) Resident #46On September 9, 2025, during an interview conducted at approximately 1:08 PM, Resident #5 expressed concern about the behavior of Resident #46 towards other residents in the dining room. Resident #5 reported that Resident #46, who is known for his temper, threw a cup at another male resident, narrowly missing him. Additionally, about a month ago, Resident #46 became irritated with Resident #74 when she approached and began touching items on his table. In that instance, Resident #46 reportedly hit Resident #74 and told her, Go sit down! Sit down, or I will put you down, and you will be down for the rest of the day. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence the resident or the resident's representative was provided a written Notice of Transfer/Discharge when a resident was discharged from the facility. This was true for two (2) of three (3) residents reviewed for discharges. Resident identifiers: #60 and #82. Facility census: 72.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessment included all diagnoses for Resident #43. This is true for one (1) of five (5) residents under the care area of unnecessary medications. Resident Identifier: #43. Facility Census: 72. Findings Include: a) Resident #43 On 09/08/25 at 12:30 PM, a record review was completed for Resident #43. The review found all diagnoses were not included on the MDS quarterly dated 07/28/25 section I. After reviewing all diagnoses, the diagnosis, which was added to the medical record on 09/26/24, was obstructive and reflux uropathy. On 09/08/25 at 2:15 PM, the Corporate Nurse #300 confirmed the diagnosis of obstructive and reflux uropathy was not included in the MDS dated [DATE].

Inspectors wroteBased on observation, record review and staff interview, the facility failed to assist with activities of daily living (ADLs) for a dependent resident. This was true for one (1) of one (1) residents reviewed under the care area of activities of daily living. Resident identifier: #20 Facility Census: 72. Findings Include: a) Resident #20 On 09/03/25 at 3:24 PM, the resident was observed in his room appearing unkempt with greasy hair. On 09/10/2025 at 9:00 AM, a record review was completed for Resident #20. The review, included showers and bed baths, between 08/01/25 through 09/04/25. The review found the resident did not have a shower or bed bath between 08/11/25 through 08/18/25, which was seven (7) days; 08/21/25 through 08/27/25, which was six days, and from 08/28/25 through 09/04/25, which is seven (7) days. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to post the daily staff posting in a readily accessible area for residents and/or visitors to view and failed to provide an accurate daily posting on six (6) of eight (8) days sampled. Facility Census: 72. Findings Include: a) Staff Posting Accessibility On 09/09/25 at 1:45 PM, a tour of the facility was completed. There was no daily staff posting at or near the north side nurses' station. On 09/09/25 at 2:00 PM, a tour of the facility was taken. The south side of the facility was noted with the daily staff posting on a glass panel behind the receptionist's desk near the administrative offices. This was not readily accessible to the residents and/or the visitors. On 09/09/25 at 2:05 PM, an interview was held with the [NAME] President of Operations (VPO) #19. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure medically related socail services were provided to one (1) resident. The facility failed to notify the resident that the Notice of Medicare Non-Coverage issued to him was deemed invalid, that Medicare would continue to pay for services, and that no specific date had been set for discharge. This was true for one (1) of thirty-one (31) residents surveyed. Resident Identifier: #62. Facility Census: 72.b) Resident #62During an interview with Resident #62 on 09/03/25 at approximately 11:35 AM Resident #62 stated that he was scheduled to be discharged from the facility on 09/04/25 because he had received a Notice of Medicare Non-Coverage (NOMNC). Resident #62 was concerned about the clutter in his house. He states that he would be unable to wheel his walker or wheelchair through the house because there is no clear path. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received necessary dental services, including routine dental care. Additionally, the facility failed to provide the assistance needed or requested by residents to obtain these services. This finding applied to one (1) of the thirty-one (31) residents surveyed Resident Identifier: #68. Facility Census:72.

Inspectors wroteBased on observation and record review the facility failed to provide resident with the appropriate assistive devices to maintain or improve their ability to eat or drink independently. This was true for one (1) of thirty-one (31) residents sampled. Resident #5. Facility Census: 72. Findings Includea) Resident #5On 09/03/25, at approximately 12:20 PM, during a dining observation, Resident #5 was seen in the dining room struggling with her utensils. After unwrapping them, she awkwardly attempted to use the fork to pick up her food. When asked why she was having trouble with her utensils, Resident #5 explained that she was supposed to have right-angled adaptive equipment for feeding herself. She added, But today, they gave me these!A review of the resident's tray ticket indicated specific instructions for right-angled utensils. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate medical record for two (2) of 31 sampled residents reviewed in the Long-Term Care Survey process. The facility failed to obtain a resident's signature on a Physician Orders for Scope of Treatment (POST) form and the facility failed to document an accurate weight for a resident. Resident identifiers: #60 and #20. Facility census: 72.

Inspectors wroteBased on record review, resident interview, and staff interview the facility failed to provide care in accordance with professional standards of care by not following physician 's orders for woundtreatments, and medication administration. This failed practice was found true for (5) five of (5) five residents reviewed for medication administration and wound care during the complaint survey. Resident identifiers: #80, #5, #40, #76 and #6. Facility Census:

Inspectors wroteBased on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. This is true for the facility kitchen and nourishmentpantry. This had the potential to affect all residents in the facility. Facility census: 84.residents in the facility. Facility census: 84.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a dignified experience while receiving an administration of insulin for Resident #44. This was a random opportunity fordiscovery. Resident Identifier: #44. Facility Census: 84. Findings Include: a) Resident #44On 07/08/25 at 12:08 PM, an observation of Licensed Practical Nurse (LPN) #45 administering Humalog insulin to Resident #44 in the hallway. On 07/0/25 at 12:09 PM, an interview was held with LPN #45. LPN #45 was asked, Did you administer an injection in the hallway? LPN #45stated, Yes, but I'm running behind, there is always an issue with obtaining the blood sugars in the morning, night shift won't do it. On 07/08/25 at 12:11 PM, the Corporate Registered Nurse (RN) was notified and confirmed the injection should not have been given in the hallway.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the call system was accessible to residents while in their bed or other sleeping accommodations within the resident'sroom. This was a random opportunity for discovery. Resident identifier: #12. Facility Census 84Findings include: a) Resident #12On 07/07/25 at 1:10 PM, Resident #12 was heard yelling for help and continued yelling until 1:35 PM. Upon checking on the resident and entering her room, Resident #12 was observed sitting in her wheel chair at the end of her bed. Her call bell was out of her reach on her bed near the pillow. On 07/07/25 at 1:35 PM, in and interview withLicensed Practical Nurse #17, she acknowledged the call button was not within reach of the resident and stated that she was unaware as a nurse aide was just with the resident.

Inspectors wroteBased on record review and staff interview, the facility failed to develop the a comprehensive personal care plan for Resident #80. This was true for one (1) of six (6) residents reviewedduring the survey process. Resident Identifier: #80. Facility Census: 84Findings Include: a) Resident #80On 07/08/25 at approximately 2:00 PM, the care plan was reviewed for Resident #80. The review found the care plan was blank under multiple focus areas. The following areas were included:--Focus area: The resident has or a potential for: (acute pain-less than 30 days/sub acute pain 30-90 days/Chronic pain greater than 90 days)Pain/Pain Potential is Related to: (Typed as written.) No further information was listed under the focus area. Under the interventions of this focus area lists the following: The resident prefered to have pain controlled by: (SPECIFY) medication, treatment). [...]

Inspectors wroteBased on record review and staff interview the facility failed to report an allegation of suspected abuse within (2) two hours after discovering the occurrence. This failed practice was found true for (1) of (3) residents reviewed for reportable allegations of abuse, neglect, and misappropriation of property. Resident identifier: #40. Facility Census: 68. Findings Included: a) Resident #40 A review of the facilities reportables, on 05/21/24 at 9:00 AM, revealed that Resident # 40 had a bruise of unknown origin on the posterior upper left arm described as large deep purple bruising according to the skin assessment completed on 04/25/24. The incident was reported on 04/26/24 at 3:45 PM, which was 16.5 hours post incident. A medical record review, on 05/21/24 at 9:15 AM, revealed a nurse's note written on 04/25/24 at 11:15 PM, that reads as follows: Called to room by aide. [...]

Inspectors wroteBased on record review, staff interviews, the facility failed to follow the physician's order for antibiotics. Resident #73 did not receive Zyvox as ordered by the attending physician. Resident identifier: #73. Facility census: 68.

Inspectors wroteBased on record review, staff interviews, the facility failed to provide pharmaceutical services to meet the needs of a resident. Resident #73 did not receive Zyvox as ordered by the attending physician. Resident identifier: #73. Facility census: 68.

Inspectors wroteBased on observation, record review, staff interview, and resident interview the facility failed to ensure residents were free from abuse and neglect. The survey team witnessed the failure of staff to provide timely incontinence care to Resident's #6 and #237. When the observations of the surveyors were presented to the facility, the facility reported the incident to the state agency as required. Immediate jeopardy (IJ) occurred when the facility failed to provide education and servicing to one of the witnessed perpetrators before allowing this staff person to return to work. This failure placed all residents currently residing in the facility at an immediate risk for serious harm and/or death. After the immediacy was removed a deficient practice remained for Resident #331 who was improperly lifted off the floor after 2 falls. [...]

Inspectors wroteBased on observation, resident interview, record review, and staff interview the facility failed to ensure potential allegations of neglect were thoroughly investigated and failed to provide a corrective action for an allegation that did happen prior to letting the Nursing Assistant (NA) #63 return to work. This placed resident #6 and #237 in an immediate jeopardy situation by not thoroughly investigating allegations of neglect, and letting the alleged perpetrator return to work without the required Abuse and Neglect training. This deficient practice had the potential to affect all residents currently residing in the facility and was a random opportunity for discovery. In addition, the facility failed to maintain accurate records and investigate medication distribution for controlled substances for Resident #64, and #65. [...]

Inspectors wroteBased on record review, resident and staff interview, and observation the facility failed to ensure pain management was provided in accordance with professional standards of practice for two (2) of seven (7) residents reviewed for pain. Resident #331 was not provided pain medication after continued presentation of pain. Resident #181 was not provided with adequate pain medication for pain control or prior to physical therapy to allow adequate participation. This failed practice resulted in Resident #331 and Resident #181 suffering actual harm becuase thier pain was not assessed and/or treated timely resulting in the pain lasting longer than needed. This failed practice had the potential to affect only a limited number of residents. Resident identifiers: #331, #181. Facility census: 82.

Inspectors wroteBased on observation and staff interviews the facility failed to ensure the activities program is directed by a qualified professional. This had a potential to affect all residents residing in the facility. Facility Census: 82. Findings Include: a) Qualified Activity Professional During an observation on 02/26/24 at 12:35 PM, the activity office was void of any documentation of a certification of an activity professional. During an interview on 02/26/24 at 12:35 PM, the Activity Director(AD) was asked to see her activity certification. The AD stated I do not have a certificate, I will start the class in March. The Occupational Therapist reviews my stuff. I was thrown into this position when the other person was let go. [...]

Inspectors wroteBased on observation, record review, resident interview, and staff interview, the facility failed to ensure nursing staff possessed the competencies and skill sets necessary to provide nursing and related services. This deficient practice had the potential to affect all residents residing in the facility. Facility census: 82.

Inspectors wroteBased on resident interview, record review and staff interview the facility failed to ensure, the binding arbitration agreement was explained to each resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. This failed practice has the potential to affect more than a limited number of residents. Resident Identifiers: #72, #8, and #500. Facility Census: 82. Findings Include: a) Resident #72 On 03/06/24 at 11:39 AM during an interview with Resident #72, the resident stated he knew the facility Alternative Dispute Resolution Agreement had to do with a dispute between him and this facility and there would be someone else to fix it. He stated he knew he didn't have to sign it but was not aware of being able to revoke it. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to provide residents with a safe, clean, comfortable, and homelike environment. A glove that appeared soiled was observed on the handrail; clean linens were not available; and dining room chairs were observed to be unclean. These failed practices were a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census:

Inspectors wroteBased on record review, staff interview, and resident interview the facility failed to develop and/or implement care plans related to dementia, pain, dialysis and Diabetes. This failed practice was found true for (4) four of 24 residents reviewed for care plans during the Long Term Care Survey Process. Resident identifiers #23, #181, #40, and #7. Facility Census 82.

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to revise the care plan regarding bathing preferences and refusals of showers for Resident #58, diagnosis for antibiotic therapy and end-of-life wishes for Resident #76, multiple diagnoses including the use of a foley catheter, Gastromy (G-tube) tube and supplemental oxygen for Resident #179, pain for Resident #19, a splint for Resident #68, actual pain for Resident #10, and a diagnosis of dementia and pain for Resident #23. This was true for seven (7) of 24 residents reviewed during the survey process. Resident Identifier: #58, #76, #179, #19, #68, #10 and #23. Facility Census: 82. Findings Included: a) Resident #58 On 03/05/24 at 9:25 AM, a record review was completed for Resident #58. Upon completion of the review, the resident does not have a bathing preference or refusals of showers noted. [...]

Inspectors wroteBased on record review, staff interview, and resident interview the facility failed to ensure residents were receiving the necessary services to maintain good personal hygiene. Resident #44, #58 and #234 were not receiving showers. This failed practice was found true for (3) three of (9) nine residents reviewed for Activities of Daily Living (ADL's) during the Long Term Care Survey Process. Resident identifiers #44, #58, and #234. Facility census 82.

Inspectors wroteBased on observation, record review, resident interview, and staff interview the facility failed to provide an ongoing program of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This failed practice was found true for (3) three of (4) four residents reviewed for the care of activities during the Long Term Care Survey Process. Resident identifiers #35, #6, and #233. Facility census 82.

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This deficient practice had the potential to affect five (5) of 24 residents reviewed in the long-term care survey sample. For residents #44, #40, and #7, physicians' orders were not followed. Additionally, Resident #19 was receiving a medication without an order. Resident #7's diagnoses were not complete in the electronic health records. Resident #179 did not have a physician's assessment for capacity to make medical decisions. Also, a random opportunity for discovery found Residents #331, #64, #330, #65, and #47 were given their evening medications late. Resident identifiers: #44, #40, #19, #7, #179, #331, and #64. Facility census: 82.

Inspectors wroteBased on observation, record review, staff and resident interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Medications were left in Resident #64's room unsupervised. Resident #236 and #72 were unknowingly smoking without supervision in an outside non-smoking recreation area. These failed practices were a random opportunity for discovery. Resident identifiers: #64, #236, and #72. Facility census: 82.

Inspectors wroteBased on resident interview, record review and staff interview, the facility failed to provide dialysis care and services in accordance with professional standards of practice. Resident #40 was erroneously monitored for a thrill and bruit. This deficient practice had the potential to affect one (1) of one (1) resident reviewed for dialysis. Resident identifier: #40. Facility census: 82.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. A syringe of injectable medication had been in use for longer than manufacturer's recommendations. This was a random opportunity for discovery. Resident identifier: #61. Facility census: 82.

Inspectors wroteBased on observation, resident interview and staff interview the facility failed to ensure food was served at a safe and palatable temperature. The failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Resident Identifiers: #61. Facility Census: 82. Findings Include: a) Resident #61 During an interview on 02/26/24 at 3:33 PM, Resident #61 states my food is often cold. The other day the Salisbury steak was so cold. I sent it back and got tomato soup. b) Noon Meal Temperatures During a dining observation on 03/05/24 at 12:25 PM, the noon meal trays arrived in the North 1 hall. This surveyor asked the Dietary Aide to ask the Dietary Manager (DM) to bring a noon meal tray for the resident and the facility thermometer. [...]

Inspectors wroteBased on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. The facility failed to keep the equipment clean and sanitary. The facility also failed to accurately document resident refrigerator temperature logs. The facility also failed to not store other food in the resident's refrigerator. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen and the Resident's refrigerator. Facility Census: 82 FIndings Include: a) Policy Review During a review of the facility policy titled Labeling and Dating with no date read as follows: Guidelines for Labeling and Dating: -All foods should be dated upon receipt before being stored. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain an accurate and complete medical record for Resident #58's oral assessment, did not obtain a physician's order for the gastrostomy (G-tube) flushes and a diagnosis for the urinary foley catheter for Resident #179, Resident #10's incomplete consent for psychoactive medication, Resident #236's the Physician's Orders for Scope of Treatment (POST) form, documentation of snacks that were not delivered for Resident #32, #57, and #7, a diagnosis of neuropathy for Resident #7, and correct dosage on the physician's orders for medication and documentation for medication side effects for Resident #47. This is true for eight (8) of 24 residents reviewed during the survey process. Resident Identifiers: #58, #179, #10, #236, #32, #57, #7 and #47. Facility Census: 82. Findings Included: [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections while serving a sandwich to Resident #25. The facility did not complete hand hygiene while administering wound care for Resident #7. Surveyors observing a soiled glove in Resident #235's room. The facility staff did not follow enhanced-barrier precautions for Resident #23. The nursing staff administered nasal spray to Resident #330 without donning gloves and placed a dirty dining tray on a clean dining cart. These were random opportunities for discovery that had the potential to affect more than an isolated number of residents. Resident identifiers: #25, #7, #235, #23 and #330.

Inspectors wroteThe facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area from the resident's bedside. Resident call light location was not identifiable on the call light annunciator panel. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #237. Census: 82.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to inform and provide written information to the resident on their right to formulate an advance directive. This was true for one (1) of four (4) residents reviewed for the care area of advance directives during the annual survey. Resident identifier: #179. Census: 82.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure privacy during administration of nasal spray for Resident #330. This was a random opportunity for discovery. Resident identifier: #330. Facility census: 82.

Inspectors wroteBased on record review, staff interview, and resident interview the facility failed to report alleged violations related to misappropriation of property and failed to report the results of all investigations to the proper authorities within required time frames. This failed practice was a random opportunity for discovery. Resident identifiers: #64, #65. Facility census: 82.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate discharge Minimum Data Set (MDS) Assessment for one (1) of one (1) residents reviewed for the care area of discharge. Resident Identifier: #77. Facility census: 82.

Inspectors wroteBased on medical record review, family interview, resident interview and staff interviews, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one (1) of 24 residents reviewed during the Long-Term Care Survey (LTCSP). The MDS's for Resident #233 did not accurately reflect the residents' status for communication deficit. Resident Identifiers: #233. Facility Census: 82 Findings Include: a) Resident #233 During the initial interview on 02/26/24 at 3:36 PM, Resident #233 and her daughter were present during the interview. Resident shook her hand to respond yes and no to some answer and looked at her daughter for other responses. The daughter stated she has some communication issues due speaking Spanish and having a stroke. She mostly understands others but has some issues communicating needs to others. She mostly responds by shaking her head. [...]

Inspectors wroteBased on medical record review, family interview, resident interview and staff interviews, the facility failed to complete a baseline care plan for Resident #233's communication deficit. This was true for one (1) of 24 residents reviewed during the Long-Term Care Survey (LTCSP). Resident Identifier: #233. Facility Census: 82. Findings Include: a) Resident #233 During the initial interview on 02/26/24 at 3:36 PM, Resident #233 and her daughter were present during the interview. Resident shook her hand to respond yes and no to some answer and looked at her daughter for other responses. The daughter stated she has some communication issues due to speaking Spanish and having a stroke. She mostly understands others but has some issues communicating needs to others. She mostly responds by shaking her head. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure residents with indwelling urinary catheters receive treatment and care in accordance with professional standards of practice. These were random opportunities for discovery. Resident Identifiers: #179 and #29. Facility Census: 82. Findings Include: a) Resident #179 On 03/03/24 at 11:08 PM, the resident was observed to have a urinary foley catheter. The urinary foley catheter drainage bag was touching the floor. On 03/03/24 at 11:12 PM, Licensed Practical Nurse (LPN) #126 was notified and confirmed the urinary foley catheter drainage bag should not be touching the floor. No further information was obtained during the survey process. b) Resident #29 On 02/26/24 at 3:30 PM observation was made of Bedside Urinary Drainage bag under the middle of Resident #29's bed. [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure residents receive necessary respiratory care and services in accordance with professional standards of practice, by not safely storing oxygen tanks. This was a random opportunity for discovery. Facility census 82.

Inspectors wroteBased on record review and staff interview the facility failed to account for controlled substances within professional standards of practice for Resident #65. This failed practice was a random opportunity for discovery. Resident identifier: #65. Facility census: 82.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the drug regimen of each resident was reviewed at least once a month by a licensed Pharmacist. This failed practice was found true for (1) one of (5) five residents reviewed for unnecessary medications during the Long Term Care Survey Process. Resident identifier #61. Facility census 82.

Inspectors wroteBased on record review and staff interview, the facility failed to monitor efficacy of psychotropic medications. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #47. Facility census: 82.

Inspectors wroteBased on review of facility's grievance/concerns, policy review, resident interviews and staff interviews, the staff failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility, and failed to demonstrate their response and rationale for such response. Resident identifiers: #52, #71, #12, #60, #56, #44, and #3. Facility census: 74.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End of Life Care. This is true for five (5) of 24 residents reviewed for advance directives. Resident Identifiers: Resident #49, #59, #74, #25 and #273. Facility Census: 74. Findings Included: a) Resident #49 On 07/18/22 at 2:33 PM Resident #49's POST form was reviewed. On the POST form in Section D, signed and dated by the physician on 08/24/21 revealed no date of resident #49's signature. During an interview on 07/19/22 at 9:36 AM the Medical Record Staff #38 acknowledged Resident #49's POST form was not dated when signed by Resident #49. b) Resident #59 On 07/19/22 at 8:30 AM Resident #59's POST form was reviewed. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to implement their policy regarding allegations of neglect and injuries of unknown origin, which were not reported within the appropriate time frames and to the appropriate state agencies. These failed practices to implement their abuse policy had the potential to affect more than a limited number of esidents currently residing in the facility. Resident Identifiers: #46, #81 and #177. Facility Census: 74.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure that all alleged violations involving abuse/ neglect and injuries of unknown source, were reported immediately, but no later than 2 hours after the allegation is made to the appropriate agencies. These were random opportunities for discovery and was true for three (3) residents. Resident identifiers: #46, #81, and #177. Facility Census: 74 Findings Included: a) Resident #46 Review of the Concern/Complaints found a concern form for Resident # 46, dated 06/02/22 and read as follows: Registered Nurse (RN) #93 reports she asked the Nursing Assistant (NA) #51 to assist the resident to bed at 7:30 pm NA #51 reported to the nurse he doesn't usually go to bed this early, and he is a high risk for falls. RN #93 then told the NA #51 the resident's pants are soaking wet. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure the receiving facility received all required paperwork to ensure a safe and orderly transfer from one facility to another. The facility failed to send physicians orders or Medication Administration Records (MAR) upon transfer. This was true for three (3) of the three (3) Residents reviewed during the long term care survey process. Resident Identifiers: # 75, # 177 and # 28. Facility Census: 74. Findings Included: a) Resident # 75 A review of Resident #75's medical record found the following dated entry: 5/24/22 at 8:18 PM, Nurses Note: [...]

Inspectors wroteBased on record review and staff interview the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. This was true for three (3) of three (3) Residents reviewed during the long term care survey process. Resident Identifiers: # 75, # 177 and # 28. Facility Census: 74 Findings Included: a) Resident # 75 A review of Resident #75's medical record found the following dated entry: 5/24/2022 at 8:18 PM, Nurses Note: Resident was transferred out to (Local Hospital Name) by EMS (Emergency Medical Services) resident was calm and all vitals were stable at the time of transfer, (Local Hospital Name) called to ask last application of fentanyl Patch and last meds (medication) given nurse reported transfer was completed to (Local Hospital Name). [...]

Inspectors wroteBased on observation, resident interview, medical record review and staff interview the facility failed to develop and/or implement a comprehensive person-centered care plan with measurable objectives, in the areas of fall prevention, Hospice, and Advance directives. This is true for three (3) out of 24 residents reviewed during the long-term care survey process. Resident Identifiers: Resident #177, # 74, and #71. Facility census: 74.

Inspectors wroteBased on observation, staff interview, and medical record review the facility failed to follow physician orders in regard to neuro checks after a fall, providing nutritional supplemental snacks, monitoring of blood sugars for diabetics, and administering antibiotics. Resident Identifiers: Resident #46, #70, #28, #1, #48, #40, #32, #18, #17, #30, #22, #6, #424, #7, #62, #36, #52, #68, #67, #28, and #273. Facility census 74.

Inspectors wroteBased on observation, record review and staff interview the facility failed to maintain an environment that was free of accidents and hazards. Medication was left unattended in Resident #68's room. A Medication cart was left unlocked and unattended for an extended period. Fall protocol was not followed for Resident #6. Resident #22 consumed a snack not permitted within his diet order. The facility failed to modify and monitor the effectiveness of fall interventions for Resident #273 and Resident #177.

Inspectors wroteBased on record review and staff interview, the facility failed to assure that all nursing staff possess the competencies and skill sets to provide care and services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. [...]

Inspectors wroteBased observation, policy, and staff interview, the facility failed ensure all multi-dose vials which have been opened or accessed (e.g., needle-punctured), and medications designed for multiple administrations (e.g., inhalers, eye drops) are dated with the initial date they were opened and accessed. This was a random opportunity for discovery and had the potential to affect more than a limited number of newly admitted residents. Resident identifiers: #49, #21, #18, #68, #39, #9, #29, #71, #424, #67, and #4. Facility census 74.

Inspectors wroteBased on record review, food temperature measurement, resident and staff interview the facility failed to provide food and drink that is palatable, attractive, and at a safe and appetizing temperature. This was true for seven (7) out of 10 residents reviewed for food. Resident identifiers: Resident #3, #60, #56, #44, #67, #29, and #71. Facility census 74.

Inspectors wroteBased on observation, and staff interview, the facility failed to properly store food in a sanitary manner in accordance with professional standards for food service safety. The facility also failed to correctly document the three compartment sink temperatures, the walk-in refrigerator and two freezer temperatures. This deficient practice has the potential to affect more than a limited number of residents. Facility Census: 74. Findings Included: a) Walk-In Refrigerator During an initial visit of the kitchen on 07/18/22 at 11:10 AM with Account Manager (AM) #92 the walker-in refrigerator revealed a plastic bin labeled employee drinks with: -one (1) two (2) liter bottle of opened mountain dew -one (1) two (2) liter bottle of unopened mountain dew -one (1) unopened can of sprite -one (1) unopened can of mountain dew -one (1)unopened can of coke. [...]

Inspectors wroteBased on record review, observation and staff interview the facility failed to implement and maintain visitor and employee surveillance for COVID-19 and to ensure and maintain an infection prevention control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to monitor employees entrance screening surveillance for COVID-19, Staff was not wearing PPE upon surveyor entry to the facility, Residents in Isolation for COVID-19 rooms had doors open and gowns hanging on outside of door, perform hand hygiene before meals, Hand wipe container taken into Resident rooms, staff coming out of Resident room without N95 mask on and staff wearing PPE (personal protective equipment) improperly. [...]

Inspectors wroteBased on record review and staff interview the facility failed to educate and obtain consent prior to administering their COVID-19 vaccinations. This was true for 4 (four) of 5 (five) residents reviewed for vaccinations. Resident Identifiers: #14, #32, #52, and #71 Facility Census: 74 Findings Included: On 7/20/22 while reviewing vaccinations records on 5 (five) randomly selected residents the following information was gathered. Consents and refusals were reviewed and correct for influenza, pneumonia, and Prevnar vaccinations. However, COVID vaccine education and consents could not be located for 4 (four) of the 5 (five) records reviewed. This was confirmed with the Interim Administrator #90 on 7/20/22 at 10:00 AM and again with the Staff Development Coordinator #29 on 7/21/22 at 10:40 AM. The following residents were found to be out of compliance: [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure the call light system used for communication was functioning properly throughout the facility. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 74. Findings Included: During an after-hour survey on 07/19/22 at 11:34 PM an observation was made of call lights constantly alarming (beeping) with no indicator lights on the panel box to specify what room. Licensed Practical Nurse (LPN) #5 stated That's the ghost light it does that. One of the bathroom lights may not be pushed up all the way, it beeps all the time. It has been doing it for a long time. On 07/20/22 at 8:12 AM Maintenance Director #21 stated that the call lights not working properly was nothing new. [...]

Inspectors wroteBased on observation, medical record review, resident interview and staff interview the facility failed to ensure Resident #71 was provided care in a manner which preserved her dignity. Resident #71 was wearing an adult disposable brief with adhesive tabs instead of a panty line which was her preference. This was an random opportunity of discovery. Resident Identifier: #71 Facility Census:

Inspectors wroteBased on observation, medical record review, resident interview and staff interview, the facility failed to promote and facilitate resident self-determination through support of resident choice in regard to having access and choosing their undergarment preference and the right to choose when and how often to shower. Residents' identifier: Resident #3, and #71. Facility Census: 74. a) Resident #3 During an interview with Resident #3 on 07/18/22 at 11:44 AM, Resident #3 stated he normally (before coming here) would shower daily. Since being here at the facility it has been three (3) to four (4) days before can get showers. A review of Resident #3 medical records in regards to shower documentation found, his shower days are scheduled for Mondays and Thursdays. [...]

Inspectors wroteBased on record review and staff interview the facility failed to notify a family member of a fall that occurred at the facility. This failed practice had the position to affect a limited number of residents. Resident identifiers: #177. Facility census 74.

Inspectors wroteBased on observation and staff interview the facility failed to maintain a sanitary and comfortable environment that includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care area clean and at a desirable temperature. The curtain in a Resident's room was dirty and the facility temperatures were not within a comfortable and safe temperature range. This had the potential to affect a limited number of residents residing in the facility. Resident Identifier # 34. Facility Census 74 Findings Included: a) Resident #34 On 07/18/22 at 1:28 PM, during the long term care survey process this surveyor noticed Resident # 34 room curtain was soiled with several brown smudged spots. A review of Resident #34's care plan focus found the following: --I occasionally smear and chew my feces. [...]

Inspectors wroteBased on review of facility's grievance/concerns, policy review, resident interviews and staff interviews, the staff failed to act promptly to resolve individual complaint/concerns voiced by the residents. Some of which remain problems during the Long Term Care Survey. Resident identifiers: #74, #52, #71, #60, #56, #44, #3 and #26. Facility census: 74.

Inspectors wroteBased on review of concerns/grievance reports, medical record review and staff interview, the facility failed to investigate all allegations of abuse and/or neglect. These were random opportunites of discovery. This was true for Resident #46 and #81. Resident identifier:s: #46 and #81. Facility census: 74.

Inspectors wroteBased on record review and staff interview the facility failed to provide a bed hold notice to the Resident at the time of transfer to an acute care facility. This failed practice was true for two (2) out of three (3) discharged residents reviewed during the long term care survey process. Resident identifiers: Resident #177, and #28. Facility census 74.

Inspectors wroteBased on record review and staff interview the facility failed to review and revise the care plan when Resident #273's Physicians Orders for Scope of Treatment (POST) status changed from Attempt Resuscitation (CPR) to Do Not Attempt Resuscitation (DNR) status. Resident Identifier: #273 Facility Census: 74. Findings Included: a) Resident #273 On [DATE] Resident #273's POST form was completed and signed by his daughter and the Physician to reflect a DNR status. The care plan still states the Resident is a full code (CPR).

Inspectors wroteBased on observation, record review and staff interview the facility failed to properly store a Nebulizer for Resident #26 and Resident #59.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the daily staff posting was accurate and included the actual hours worked for staff directly responsible for the resident's care per shift every day. This had the potential to affect all residents residing in the facility. Facility census: 74.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #66 and #67. Facility Census: 74.

Inspectors wroteBased on record review and staff interview the facility failed to conduct monthly drug regimen reviews for two (2) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #68, and #60. Facility census: 74.

Inspectors wroteBased on medical record review and staff interview, the facility failed to evaluate the as needed (PRN) psychotropic medication ordered for longer than 14 days, without a documented rationale for continued use and failure to implement person-centered, non-pharmacological approaches prior to the administration of the PRN psychotropic (Ativan) medication. Resident #66. Facility Census: 74.

Inspectors wroteBased on record review and staff interview the facility failed to maintain the medical record in a manner that reflected a resident's progress toward achieving their person-centered plan of care objectives and goals and the improvement and maintenance of their clinical, functional, mental and psychosocial status. The facility did maintain a Medical Regiment Review (MRR) in the Residents chart. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medicaitons. Resident #27. Facility census 74 Finding Included: A) Resident #27 A Review of Resident # 27 medical record failed to reveal a Medical Regiment Review (MRR) from pharmacy. On 07/20/22 at 1:20 PM, Corporate Nurse (CN) provided emails from the facility pharmacist regarding Resident # 27's MRR that read: 07/0722: [...]