FACILITY LOOKUP

An unannounced complaint investigation survey was conducted at Hopemont Hospital from November 18 - 20, 2024. The deficiencies contained in this report are based on observations, review of residents' clinical records, resident interviews, family interviews, and staff interviews, and review of other facility documentation as indicated. The facility's census on the first day of the survey was 51 residents.

Complaint #33231 was substantiated
Complaint #33745 was unsubstantiated
Complaint #33353 was unsubstantiated
FRI #34522 was substantiated with no deficient practice
FRI #35186 was unsubstantiated
FRI #34901 was unsubstantiated
FRI #33786 was unsubstantiated
FRI #33663 was unsubstantiated
FRI #33306 was unsubstantiated

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Based on record review and staff interview, the facility failed to ensure that an alleged violation involving resident-to-resident sexual abuse was reported within two (2) hours of the event/allegation being brought to the facility's attention, to appropriate state agencies as required. This was a random opportunity for discovery throughout the facility reportable incident (FRI) investigative process. Resident identifier: #48. Facility census: 51.

Findings included:

a) Resident #48

During a record review, on 11/19/24 at 7:30 PM, it was noted there was a written reporting form outlining a resident-to-resident sexual altercation between Resident #48 and Resident #8. There was no evidence that the Office of Health Facility Licensure and Certification (OHFLAC) had been notified of this incident within the required two (2) hour time frame.

On 11/20/24 at 8:30 AM, a review of the facility's Abuse and Neglect policy revealed that an allegation must be reported within (2) hours if it involved abuse..

During an interview on 11/20/24 at approximately 9:00 AM, the Chief Operating Officer confirmed the allegation had not been reported to the appropriate state agencies as per the facility's policy. The allegation of resident-to-resident sexual abuse had not been reported until the following day to the OHFLAC office.

Due to the timing of the incident related to the time/date of survey correction of the incident related to resident #48 is not practical to achieve. The allegation of potential sexual abuse was reported to all required agencies on 07/14/2024, by unit charge nurse (Attachment A). On 7/13/2024, the unit charge nurse assessed resident #48 revealing no harm was caused to resident #48 by the alleged deficient practice. (Attachment B).

All residents have the potential to be affected by the alleged deficient practice. By 01/01/2025, the Quality Assurance Performance Improvement (QAPI) Nurse/designee will review all reportables submitted during calendar year 2024 to ensure all were reported within the required time frames (Attachment C).

By 01/01/2025, the Staff Development Nurse/designee will complete training with all facility staff on mandatory reporting of abuse or serious bodily injury no later than 2 hours of the allegation, or not later than 24 hours of the allegation if there is no abuse or serious bodily injury (Attachment D)

The QAPI nurse/designee will audit all mandatory reports of allegations of abuse twice monthly for two months, then monthly for 6 months, then quarterly thereafter to ensure all mandatory reports are completed timely (Attachment E). The QAPI nurse/designee will immediately inform the administrator/designee if concerns are discovered during the review process. All data will be presented by the QAPI Nurse/designee to the QAPI Committee at least quarterly for analysis and any further action

§483.60(d) Food and drink Each resident receives and the facility provides- §483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Based on observation, and staff interview, the facility failed to provide food at a palatable and appetizing temperature as determined by the type of food to ensure resident satisfaction. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 51.

Findingd included:

a) A tray on A-Hall was tested by DM #100 and temperatures were as follows:

Pureed Pork - 122 degrees
Mashed Potatoes - 126 degrees
Pureed Peas - 102 degrees
Pureed Bread - 100 degrees

b) Temperatures were confirmed by DM #100. DM #100 reported pork should have been at 130 degrees and the vegetable's temperature was low. DM #100 stated the bread could be served hot or cold.

The facility's Policy and Procedure stated, "Hot foods will be served at a temperature 120 degrees F or higher".

These findings confirmed by Dietary Manager (DM) #100 on 11/19/24 at 12:25 PM.

No residents were found to be affected by the alleged deficient practice.

All residents receiving a pureed diet had the potential to be affected by the alleged deficient practice.

On 11/22/2024, the Infection Preventionist reviewed the Infection Control Surveillance Report for the previous 96 hours with no findings of any residents showing Gastro-intestinal illness (Attachment F).

On 11/19/2024, the Chief Operating Officer and the Dietary Manager assessed the plate dispenser cart and corrected the setting to allow the puree plates to heat to a higher temperature (Attachment G).

The Dietary manager/designee will test the temperature of a puree meal test tray at each meal to ensure temperature compliance of 120 degrees (F) or higher and record temperatures and any necessary corrective actions taken (Attachment H).

The Quality Assurance Nurse/designee will audit the test tray temperature logs twice monthly for two months and then monthly for 6 months then quarterly thereafter for compliance of 120 degrees (F) or higher (Attachment I). The QAPI nurse/designee will immediately inform the administrator/designee if concerns are discovered with review of logs. All data will be presented by the QAPI Nurse to the QAPI Committee at least quarterly for analysis and any further action.

§483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Based on observation, record review and staff interview, the facility failed to store and label food 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: 51.

Findings included:

Findings confirmed by the Dietary Manager (DM) #100 and the Chief Operating Officer (COO) #35 on 11/18/24 during the investigation initiated at 11:42 AM included the following items in the pantry:

a) An opened can of Shasta.
b) Undated sandwiches in fold over bags.
c) Unlabeled and undated drink in a cup -tea.
d) Undated bowl of broth.
e) Opened and used container of Boost in the freezer.
f) Undated hamburger in the freezer.
g) Undated package of lasagna in freezer.

DM #100 asked, "Is that me?" and stated, "I'm going to throw it away."
COO #35 stated the refrigerators were the dietary department's responsibility.

According to the 2013 US Publilc Health Service Food and Durg Administration Food Code:

3-202.15 Package Integrity:

"Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants."

3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.

"Except when packagaing food using a reduced oxygen packaging method as specified under \'a7 3-502.12, and except as specified in \'b6\'b6 (E) and (F) of this section, refrigerated, Ready-to -eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5\'baC (41\'baF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1."

No residents were found to be harmed by the alleged deficient practice.

All residents had the potential to be affected by the alleged deficient practice. On 11/22/2024, the Infection Preventionist reviewed the Infection Control Surveillance Report for the previous 96 hours with no findings of any residents showing Gastro- intestinal illness (Attachment F).

On 11/18/2024, the Dietary Manager removed and disposed of the unlabeled food identified in the surveyor findings.(Attachment J)

On 12/3/2024, the Director of Nursing placed a Nutrition Station Refrigerator check sheet on each unit for Licensed Nurses to monitor proper labeling and storage of foods.

All foods that do not meet criteria will be discarded immediately (Attachment K). By 01/01/2025, The Staff Development Nurse/designee will educate all dietary and nursing staff that all food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded on the premises (Attachment L).

The QAPI nurse/designee will audit the Nutrition Station Refrigeration logs twice monthly for two months, then monthly for 6 months, then quarterly thereafter to ensure compliance of labeling and discarding of food (Attachment M).

The QAPI nurse/designee will immediately inform the Director of Nursing/designee if concerns are discovered with the review of the logs. All data will be presented by the QAPI Nurse to the QAPI Committee at least quarterly for analysis and any further action.

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Hopemont Hospital is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. A review of the plans of correction and credible evidence was accepted in lieu of an onsite revisit for the complaint survey concluding on 11/20/24. The facility is in substantial compliance with the previously cited deficient practices.
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§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

§483.60(d) Food and drink Each resident receives and the facility provides- §483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

§483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

An unannounced annual recertification, annual relicensure, and complaint investigation survey was conducted at Hopemont Hospital from May 28 - June 6 2024. The deficiencies contained in this report are based on observations, review of residents' clinical records, resident interviews, family interviews, and staff interviews, and review of other facility documentation as indicated. The facility's census on the first day of the survey was 49 residents.

--Complaint #32768 was unsubstantiated with no related or unrelated deficiciencies cited.
--Complaint #32845 Substantiated
--Complaint #29837 Unsubstantiated
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§483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Based on staff interviews and observation the facility failed to provide a dignified dining service. This failed practice was found true for (1) one random resident observed during the lunch dining in the Long-Term Care Survey Process. Resident identifier #44. Facility Census 49.

Findings Include:

a) Resident #44

During an observation on 05/29/24 at 12:15 PM, Resident #44 was sitting at a table with (3) three other residents. The other (3) three residents got their lunch tray at 12:15PM. (9) nine other residents at different tables were served before Resident #44 received her lunch tray at 12:25 PM.

Further observation showed that (1) one of the residents seated at the table with Resident #44 was finished eating when Resident # 44 got her lunch tray.

During an interview, on 05/29/24 at 12:25 PM, with Nurse aide (NA) #87 she stated, "We are supposed to pass them out in order, but they don't come out in order. We must find them. We have not come to [Resident # 44 name\ tray yet."

1. Resident #44 was interviewed on 6/26/24 by the Clinical Social Worker and found not to be affected by the alleged deficient practice (attachment 101). Due to the timing of the alleged deficient practice no corrective action could be taken.

2. All residents have the potential to be affected by the alleged deficient practice. On 6/26/2024, all residents were interviewed by the Assistant Director of Nursing (ADON) and found not to be affected by the alleged deficient practice.
(attachment 102).

3. On 6/26/2024 the ADON reviewed and revised the dining room seating chart and meal tray delivery with the Dietary Manager (attachment 103). By 7/30/2024, the Dietary Manager will educate dietary staff to appropriately load the dining carts according to the dining room tray chart (attachment 104). By 7/30/2024, the Director of Nursing (DON)/designee will provide education to all nursing staff regarding a dignified dining experience and proper requirements from Certified Medicare and Medicaid Services (CMS) guidelines (attachment 105). All new nursing staff will be provided education regarding a dignified dining experience and proper requirements from Certified Medicare and Medicaid Services (CMS) guidelines (attachment 105). All new dietary staff will be educated on appropriately loading the dining carts according to the dining room tray chart (attachment 104).

4. The DON/designee will audit meal tray passes weekly for 1 month, then monthly for 6 months, and then quarterly thereafter to ensure residents receive their meals per regulatory compliance (attachment 106). The Quality Assurance Performance Improvement (QAPI) Nurse/designee will audit the meal tray pass log monthly for six months, and then quarterly thereafter (attachment 107). All data will be presented by the QAPI Nurse/designee and presented to the QAPI Committee at least quarterly for analysis and any further action.

§483.10(c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: §483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. §483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. §483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Based on resident observation, record review and staff interview, the facility failed to ensure the resident and or representative was informed in advance by the physician, other practitioner or health professional of the risks and benefits of proposed care, of treatment alternatives or treatment options and to choose the alternative option preferred. This was true for 1 (one) of 18 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #36. Facility census: 49.

Findings include:

a) Resident #36

On 05/28/24 at 12:30 AM, a review of Resident #36's medical record was conducted. A fall care plan was noted with interventions stating, "Encourage resident to wear hipsters at all times for safety." and "Encourage resident to wear soft helmet while ambulating for safety."

On 05/28/24 at 01:07 PM an observation of Resident #36 was conducted. Resident #36 was noted to be in bed, no hipsters were noted to be on Resident #36 and no helmet was noted to be present.

On 5/29/24 at 11:25 AM an interview with Employee #72 was conducted. Employee #72 stated, "He refuses to wear the hipsters."

Further review of Resident #36's medical record on 5/29/24 at 08:00 PM was conducted. Resident #36's capacity form, fall care plan and the Interdisciplinary Team recommended interventions. It was then noted that several of the Interdisciplinary Team recommended interventions were "continue educating on fall interventions and encourage resident to use them, as he always refuses."

The documented dates for this intervention included the following: 04/04/24, 04/17/24, 04/19/24, 04/23/24 and 05/19/24. Review of Resident #36's capacity form indicated that Resident #36 had been "examined and found to be mentally incapable of granting informed consent or to have the capacity to consent to treatment" and that Resident #36's brother had been named as Health Care Surrogate.


On 5/30/24 at approx. 9:00 AM an interview with Employee #73 was conducted. Employee #73 stated, "He refuses to wear his helmet and hipsters. They are in his closet."

Further review of Resident #36's medical record on 5/29/24 at 08:00 PM noted a behavior care plan with an intervention stating, "Nurse may disguise medication in his food in the attempt to make sure he takes it due to sexual behaviors."

On 5/30/24 at approximately 9:30 AM, an interview was conducted with the Director of Nursing (DON). This Surveyor reviewed, with the DON, the behavior and fall care plan including the interventions. This Surveyor then asked the DON if Resident #36 had the right to refuse treatment or if education related to the risks of refusing treatment was provided to Resident #36 or his MPOA. The DON stated, "You are contradicting what you said yesterday about him not being able to be educated if you are saying he can refuse his medications. His MPOA says we can disguise it in his food and so does the doctor." This Surveyor then requested a copy of the facility resident rights and a copy of education provided to Resident #36 or his MPOA related to risks of refusal of his medications, helmet, and hipsters. This Surveyor also requested the DON provide education that was provided to Resident #36 or his MPOA related to alternative options of his refusal of medication, helmet, and hipsters.

On 5/30/24 at approximately 11:30 AM a copy of Policy and Procedure entitled, "Resident Rights Guidelines for all Nursing Procedures" was provided to this Surveyor which stated, "Prior to having direct care responsibilities, staff must have appropriate in-service training on resident rights, including, Resident right of refusal (medications and treatments)."

The DON did not provide further documentation related to the request for education provided to Resident #36 or his MPOA related to the risks of refusing medication, helmet and hipsters or alternative options related to the refusal of his medications, helmet, or hipsters.

1. On 6/26/2024 resident (436 was interviewed by the Assistant Director Of Nursing (ADON) and found not to be affected by the alleged deficient practice (attachment 108). Due to the timing of the alleged deficient practice no corrective action could be taken.

2. All residents have the potential to be affected by alleged deficient practice. By 7/30/2024, the Director Of Nursing (DON)/designee will review the treatment record for all residents with interventions for helmets and hipsters and education will be provided to resident and legal representatives by the DON/designee if needed (attachment 109). By 7/30/2024, education will be provided by the DON/designee to any resident and legal representatives found to be affected by the alleged deficient practice (attachment 109).

3. By 7/30/2024, the DON/designee will provide a copy of Resident Rights to all residents and legal decision makers and informed of the risk and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option he/she prefers (attachment 110).

4. The DON/designee will audit treatment weekly for 2 months, then monthly 6 months and quarterly thereafter to monitor compliance with care. (attachment 111). The Quality Assurance Performance Improvement Nurse/designee will audit the treatment compliance log monthly for six months, and then quarterly thereafter (attachment 112). All data will be presented by the QAPI Nurse to the QAPI Committee at least quarterly for analysis and any further action.

§483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Based on staff interview and facility documentation, the facility failed to provide reasonable accommodation in regard to activities of daily living (ADLs). This was true for one (1) of eighteen (18) residents reviewed under the ADL pathway. Resident identifier: #43. Facility Census: 49

Findings included:

a) Gas Leak Resulting in No Hot Water

Facility staff had reported signs of a gas leak on 05/26/24. The gas company technician had noted a positive test for gas in the kitchen area, and, as a precaution, recommended turning off the gas supply to the facility. As a result, no hot water had been available for the residents since 05/26/24.

a) Resident #43

During staff interviews on 05/30/24 at 11:03 AM, with Nurse Aide (NA) #29, Registered Nurse (RN) #83 and Licensed Practical Nurse (LPN) #73, stated the bath wipes used for bed baths were to be warmed for 20 seconds in a microwave before being used on residents. However, staff were unable to warm the bath wipes because the microwave ovens had been removed due to safety concerns. This resulted in residents being wiped down with cold bath wipes. NA #39 stated that residents who had capacity were refusing the bed baths.

During a review of Bath/Shower Temperature Logs at the nursing station on 05/30/24 at 11:17 AM, RN #83 and LPN #73 showed a shower being completed for Resident #43 on the evening of 05/26/24.

During an interview with Resident #43 on 05/30/24 at 11:47 AM, the resident, in the presence of NA #10, stated that he did not take cold showers.

Submission of a request for Bath/Shower Temperature Logs completed on 05/30/24 at 11:17 AM. These logs revealed no completed sheets. Upon interview with the Director of Nursing (DON) - on 05/30/24 at 12:47 PM, DON stated there were no log sheets available because no showers were offered due to the non-availability of hot water.

Record review of Health Services Worker (HSW) intervention logs produced by the DON revealed documentation of a shower for Resident #43 on 05/26/24. The HSW Interventions logs required entries specifying which type of bath was offered to the resident. (W) for whirlpool, (S) for shower, and (BB) for bed bath.

The MDS Coordinator provided the logs for Resident #43. The logs had a single letter entered for each day. When questioned about what the letters denoted, the MDS Coordinator stated that she would ask the DON. She returned, and stated the DON had informed her they were the initials of the staff person performing the bath. When questioned further as to why there was only one letter, and why there was no information to identify who the initials belonged to, the MDS coordinator stated that she didn't have any further information.

On 6/18/2024 the Assistant Director Of Nursing (ADON) spoke with resident #43 regarding the use of disposable bath cloths at;
room temperature. resident #43 was found not to be affected by the alleged deficient practice.
(attachment 113).

2. All residents have the potential to be affected by the alleged deficient practice. On 6/18/2024, the ADON asked all residents who;
were interviewable if they are ok with using disposable bath cloths at room temperatures for partial bathing in between showers. No residents verbalized negative responses (attachment 114).

3. On 6/7/2024 an electric hot water tank was installed by the Maintenance Department in the Gore 1 shower room providing hot water for resident showers and bed baths (attachment 115).

4. The Director of Nursing/designee will present the shower/bed bath temperatures to the weekly water temperature Performance Improvement Program (attachment 116). The Quality Assurance Nurse/designee will audit the shower/bed bath temperature monthly for six months, and then quarterly thereafter (attachment 117). All data will be presented by the Quality Assurance Performance Improvement (QAPI) Nurse to the QAPI Committee at least quarterly for analysis and any further action.

§483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

Based on observation, staff interview, and resident interview the facility failed to provide a homelike environment by not allowing Resident # 29 access to his personal belongings by his own freewill. Resident #33's room had personal health information taped on the bed and had cosmetic imperfections that could pose a safety hazzard in the bathroom. This failed practice was found true for two (2) of two (2) residents reviewed for environment during the Long-Term Care Survey Process. Resident identifiers: #29, #33. Facility Census: 49.

Findings Include:

a) Resident # 29

During the initial interview on 05/28/24 at 1:46 PM, Resident # 29 stated, " I want stuff out of my closet, and I can't get to it because there is a lock on it." When surveyor asked if he had a key to it Resident #29 stated, " No, the nurse or NA has it and I have to have them come and unlock. It takes them a long time."

A record review on 05/28/24 at 2:00 PM revealed that Resident # 29 has a Brief Interview of Mental Status (BIMS) score of 14.

During an interview, on 05/28/24 at 3:30 PM, the Administrator stated, " I'm sure there is a reason that the locks are on the closets, someone was probably getting into his closet, or something. It should be care planned."

A record review on 05/28/24 at 4:00PM, revealed Resident #29 does not have a care plan to have his closet pad locked. There is also no nurses' notes in the medical record to indicate why his closet would be pad locked.

During an interview, on 05/28/24 at 4:50 PM, the Administrator stated, "I know why his closet is locked, I feel like he was defecating in it." When the surveyor asked if there were notes to attest to that. The administrator said, "I don't know."
05/29/24 10:00 AM Observation of resident rooms revealed locks are off closet. 05/29/24 10:15 AM Resident stated, "Hey I was able to get in my closet today."

b) Resident #33

05/28/24 12:55 PM an observation revealed tape noted to bed on foam around head/foot board (says the foam is to protect my head).

In the bathroom towel rack was observed off the wall, hardware present.

05/30/24 02:55 PM during a staff interview the staff member said, "Oh God." The staff member confirmed the hardware on wall posed safety hazard and said a request would be sent to maintenance to fix it.

1. On 5/29/2024 locks were removed from resident #29 closet by the Maintenance Department. On 5/29/2024 resident #33's towel rack was removed in the bathroom by the Maintenance Department (attachment 118).On 5/292024 the note was removed from resident #33's bed by the Assistant Director of Nursing (ADON) (attachment 119).

2. All residents have the potential to be affected by the alleged deficient practice. On 5/29/2024 all resident closets were checked by the Maintenance Department for locks and removed if not in the resident's care plan (attachment 120)- By 7/30/2024, Maintenance/designee will check all resident bathrooms for properly secured towel racks and exposed hardware that could cause injury (attachment 121).

3. By 7/30/2024, the Maintenance Director/ designee will educate maintenance staff on performing checks of resident rooms, checking for locks on resident closet doors, bathroom towel racks, and exposed hardware. Any needed repairs will be made immediately, and any locks found will be immediately reported to the Administrator/ designee for review/removal (attachment 122).

4. Maintenance/designee will perform room safety checks consisting of locks on closet doors, bathroom towel racks and exposed for 6 months, and then quarterly thereafter to hardware weekly for 2 months, then monthly monitor compliance with care (attachment 123). The Quality Assurance Performance Improvement (QAPI) Nurse/designee will audit the lock/bathroom log monthly for six months, and then quarterly thereafter
(attachment 124).

All data will be presented by the QAPI Nurse to the QAPI Committee at least quarterly for analysis and any further action.

§483.10(j) Grievances. §483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. §483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. §483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident. §483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; (ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; (iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; (iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law; (v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; (vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and (vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Based on resident council meeting interviews, observation and staff interview the facility failed to ensure residents were able to submit grievances anonymously. This had the potential to affect more than an isolated number of residents. Facility census: 49.

Findings included:


a) 05/28/24 12:30 PM, Observed a sign in the front lobby stating there were grievance forms available at the front desk.

05/29/24 10:45 AM, During resident council meeting, Resident #24 stated in order to file a grievance residents and family must ask for a form at the front desk. She stated that staff will assist residents in filing out the paper. Resident #24 stated there was no place to get the forms anonymously or to submit them anonymously.

05/29/24 11:12 AM during an interview with Social Worker (SW) #9 the SW explained that the process of completing a grievance was to ask a staff member for a form and that she or other staff would assist in completing the form if asked. She stated there was no place to get a form anonymously and/or submit it anonymously.

1. On 6/24/2024, the Social Services Director/ Designee communicated to resident #24 that the Grievance forms are placed at the
Solarium and are now accessible to all residents whenever needed and can be completed and turned in anonymously into a locked box that has been installed on the wall in the solarium (attachment 125).

2. All residents have the potential to be affected by the alleged deficient practice. By 7/30/2024, the Social Services /designee will interview all residents to determine if they were affected by the affected by the alleged deficient practice (attachment 126).

3. By 7/30/2024, the Social Worker/Designee will inform all residents on where the Grievance forms are located and where the locked box for grievance forms are to be placed once completed (attachment 127). All new admissions will be shown a grievance form and
where they are located upon admission by Social Services /designee.

4. Social Worker/Designee will audit that Grievance forms are available for residents to have access twice weekly x 2 months, then weekly thereafter to ensure grievance forms are available as needed (attachment 128). The Quality Assurance Performance Improvement (QAPI) Nurse/designee will monitor Grievance forms twice a month for 6 months to ensure Grievance forms are available (attachment 129). Thereafter, monitoring will occur on a quarterly basis. All data will be presented by the QAPI Nurse to the' QAPI committee at least quarterly for analysis and any further action.

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Based on record review and staff interview, in response to allegations of abuse, the facility failed to have evidence that all alleged violations are thoroughly investigated. This was true for 1 (one) of 7 (seven) residents reviewed in the Long Term Care Survey Process. Resident identifier: Resident #25. Facility census: 49.Findings include:Resident #25On 05/29/24 at 09:00 PM, a review of Facility Reported Incident (FRI) dated 05/16/24, was conducted. It was reported on 05/16/24 that on 05/15/24 at 10:00 PM, while facility staff was providing care to Resident #25, a "10cm x 5cm bruise, right upper thigh" was noted and that it was estimated to be approximately "2-3 days old." A review of the facility ' s investigation noted that statements were obtained from 12 from staff members. However upon reviewing the statements obtained it was noted that 7 (seven) of the 12 statements were from employees not working on the unit at the time of the occurrence. At that time this Surveyor requested a copy of the schedule from the date and time of the occurrence. It was then noted that statements were not obtained from 3 (three) staff members working the date of the incident on the hallway of Resident #25. Further review of the schedules 4 (four) days prior to the date of the occurrence, also reveals statements were not obtained from the staff working on the hallway of Resident #25. On 05/30/24 at approximately 12:00 PM, a review of the facility policy entitled, Abuse, Neglect, Reporting/Investigation was reviewed and was noted to state the following:Investigation:The Resident Advocate/Grievance Official shall have access to all records and employees. The Resident Advocate/Grievance Official will gather all facts, conduct interviews of all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Failure to do so will result in disciplinary action and/or reporting to the employees licensing entity. 5. There will be a complete and thorough documentation of the investigation. On 05/30/24 at 12:55 PM, an interview was conducted with the facility Social Worker who acknowledged the above referenced policy, and that she failed to interview 8 (eight) employees who could have had knowledge of the occurrence. The facility Social Worker also acknowledged at that time she had not performed a thorough investigation.

1. By 6/26/2024, the Social Service Director / Clinical Social Worker has interviewed all employees who could have had knowledge
of the occurrence of a bruise to resident #25's right upper thigh (attachment 130).

2. All residents have the potential to be affected by the alleged deficient practice. All Self Reports from May 15, 2024 were reviewed by the Social Services Director, and all self reports were found within investigation regulatory compliance (attachment 131).

3. On 6/26/2024, the Administrator provided education to the Social Services Director and Clinical Social Worker on the policy Abuse, Neglect, and Reporting an Investigation (attachment 132).

4. The Performance Improvement Program Committee will review all allegations of abuse and neglect prior to submission of the five day follow up to ensure all the investigation processes were completed per policy (attachment 133). The Quality Assurance Performance Improvement (QAPI ) Nurse/ Designee will audit the logs of allegations of abuse weekly for two months, then monthly for 6 months,then quarterly thereafter to ensure investigations of incidents are completed (attachment 134) with corrective action immediately upon discovery. All data will be presented by the QAPI Nurse to the QAPI Committee at least quarterly for analysis and any further action.

§483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. §483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with: (i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services; or (ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission- (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability. §483.20(k)(2) Exceptions. For purposes of this section- (i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital. (ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual- (A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital, (B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and (C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services. §483.20(k)(3) Definition. For purposes of this section- (i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1). (ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter.

Based on record review and staff interview, the facility failed to ensure a complete and accurate Preadmission Screening and Resident Review (PASRR) and failed to complete a new PASRR when a PASRR expired. This deficient practice had the potential to affect two (2) of two (2) residents reviewed for the care area of PASRR. Resident identifiers: #27 and #41. Facility census: 49. Findings included:a) Resident #27 Review of Resident 27's medical records showed the resident was admitted on 08/31/23. The resident had a diagnosis of unspecified psychosis not due to a substance or known physiological condition at the time of admission to the facility. Resident #27 had been transferred from another long-term care facility who documented that the resident had a diagnosis of psychosis. Further review of Resident #27's medical records showed a PASSR completed 08/29/23. The PASSR did not indicate the resident had a diagnosis of psychotic disorder. On 05/29/24 at 2:00 PM, Social Worker #65 confirmed Resident #27's admission PASSR was incorrect and did not indicate the resident had a diagnosis of psychosis. No further information was provided through the completion of the survey process. Facility failed to ensure a complete an accurate admission PASSAR, and an expired PASSARTN-PS2 of 2 residents looked at for PASSARa) Resident # 27 TNB) Resident # 41 CRResident #27PASARR 05/28/24 04:39 PM unable to find PASSAR in file PASSAR dated 08/29/23 did indicate psychotic disorder - when was diagnosed? had diagnoses from transferring LTC 08/11/23 of unspecified psychosis not due to a substance or known physiological condition SW #65 confirmed admission MDS was incorrect; psychosis was not identified

Facility failed to ensure a complete an accurate admission PASSAR, and an expired PASSARTN-PS2 of 2 residents looked at for PASSARa) Resident # 27 TNB) Resident # 41 CRResident #41PASARR F-645 Facility failed to ensure residents PASSAR was accurate and correct. Resident # 4105/29/24 03:25 PM Interview with Director of Social Services, We are in the process of trying to get her out of the facility per her family. They want her in the Charleston area near them, but nooone has accepted her yet. Do you think I should do a new one.

1. Resident #41 no longer resides in the facility. By 07/30/2024, the Social Service Director/Clinical Social Worker will submit a corrected PASARR's for resident #27.

2. All residents have the potential to be affected by the alleged deficient practice. By 7/30/2024, the Social Services Director/Clinical Social Worker will review all PASARR's and update as required (attachment 135).

3. By 7/30/2024, the Administrator/designee will educate the Social Services Director/Clinical Social worker on complete and accurate PASARR's (attachment 136). All new admissions will have their PASARR reviewed to ensure the diagnosis listed and the expiration dates on the PASARR is correct.

4. Social Worker/Designee will audit resident PASARR's twice monthly x 2 months, then monthly x 6 months, then quarterly thereafter to ensure PASARR'S are updated as needed (attachment 137).The Quality Assurance Performance Improvement (QAPI ) Nurse/ designee will monitor resident PASARR'S twice a month for 6 months to ensure PASARR logs are being completed
(attachment 138). Thereafter, monitoring will occur on a quarterly basis. All data will be presented by the QAPI Nurse to the Quality Assurance Performance Improvement (QAPI ) committee at least quarterly for analysis and any further action.

§483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Based on record review, resident observation and staff interview the facility failed to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs.This was true for 3 (three) of 18 residents reviewed during the Long Term Care Survey Process. Resident identifiers: Resident #36, Resident #25 and Resident #45. Facility census: 49.Findings Include:Resident #36On 05/28/24 at 12:30 AM, a review of Resident #36 ' s medical record was conducted. A fall care plan was noted with interventions stating, "Encourage resident to wear hipsters at all times for safety." and "Encourage resident to wear soft helmet while ambulating for safety." On 05/28/24 at 01:07 PM an observation of Resident #36 was conducted. Resident #36 was noted to be in bed, no hipsters were noted to be on Resident #36 and no helmet was noted to be present.A further review of Resident #36 ' s medical record was conducted on 05/28/24 at approximately 01:25 PM, which noted Resident #36 had 19 documented falls from 01/01/24 through 05/26/24. The falls were as follows: 01/15/24, 01/22/24, 01/28/24, 02/13/24, 03/6/24, 03/0/247, 03/11/24, 03/14/24, 03/23/24, 04/01/24, 04/08/24, 04/09/24, 04/17/24, 04/19/24, 04/23/24, 05/19/24, 05/20/24, 05/21/24 and 05/26/24. It was also noted during this review that after a fall on 04/01/24 at 08:15 PM, Resident #36 was sent to the Emergency Room due to sustaining a laceration to the left elbow that was documented to be "deeper than first appeared." Then on 05/16/24, Resident #36 was sent to the hospital related to this laceration of the left elbow. During a review of Resident #36 ' s hospital record it was noted Resident #36 was diagnosed with septic left olecranon bursitis after a "failed outpatient antibiotic" series. On 05/29/24 at 11:20 AM a copy of the facility fall policy was requested from the Director of Nursing (DON).On 05/29/24 at 11:25 AM an interview with Employee #72 was conducted. Employee #72 states "He refuses to wear the hipsters." On 05/29/24 at approximately 12:30 PM, a review of the provided facility policy titled, "Falls Risk Assessment and Management Program was conducted and noted the following text:A multi-disciplinary team will meet monthly to review the resident ' s identified as being high risk for falls, to evaluate the interventions in place and to modify the Resident ' s Care Plan as needed. At these meetings, individual falls and/or residents are discussed and analyzed*Possible intrinsic and extrinsic factors*Evaluation of present interventions in place*Current or newly prescribed medications*Further preventative measures and interventions*Additional equipment/supply needsTherapy or Restorative Nursing evaluations/treatment - for decline in function, adaptive needs, seating assessment, etc.Special attention is paid to residents with any repeat occurrences.Following the Fall Management meeting, the DON, ADON and Unit Managers or charge nurse will implement individual changes recommended by the team; modify the resident ' s fall risk assessment plan of care and mini-in-service staff on the units of changes/updates.A copy of any Interdisciplinary Team notes, related to Resident #36 ' s falls that have occurred during the year of 2024 were requested.5/29/24 at 01:30 PM the Interdisciplinary Team notes were provided. The months provided were from 03/21/24 through 05/21/24. This Surveyor then requested a copy of Resident #36 ' s capacity form from the DON.Further review of Resident #36 ' s medical record on 5/29/24 at 08:00 PM was conducted. Resident #36 ' s capacity form, fall care plan and the Interdisciplinary Team recommended interventions. It was then noted that several of the Interdisciplinary Team recommended interventions were "continue educating on fall interventions and encourage resident to use them, as he always refuses." These dates this intervention was documented included the following: 04/04/24, 04/17/24, 04/19/24, 04/23/24 and 05/19/24. Review of Resident #36 ' s capacity for indicated that Resident #36 had been "examined and found to be mentally incapable of granting informed consent or to have the capacity to consent to treatment" and that Resident #36 ' s brother had been named as Health Care Surrogate. On 5/30/24 at approximately 09:00 AM an interview with Employee #73 was conducted. Employee #73 states, "He refuses to wear his helmet and hipsters. They are in his closet." On 5/30/24 at approximately 09:33 AM, an interview was conducted with the Director of Nursing (DON). This Surveyor reviewed, with the DON, Resident #36 ' s fall care plan.The DON acknowledged that from 12/19/23 until 04/02/24 Resident #36 ' s fall care plan had not been revised or updated with Interdisciplinary Team intervention recommendations then states, "I don ' t know why it wasn ' t updated with new interventions after each fall." Resident #25On 05/28/24 at 02:49 PM an observation of Resident #25 was made. Resident #25 was noted to be at the end of A Hall at the exit door attempting to open it when the alarm sounded. Resident #25 was then approached by a member of the facility staff. who was coming out of another resident room, easily redirected Resident #25. At this time, Resident #25, was observed to have a wander guard to his right ankle, was seated in a back wheelchair with a chair alarm attached to it. . On 05/29/24 at 07:50 AM a review of Resident #25 medical record was performed. It was noted that in Resident #25 ' s behavior care plan focus that Resident #25 had a "history of wandering and attempting to enter unsupervised areas." An intervention in this care plan was as follows: "15 minute checks for safety" was entered. This Surveyor then asked the Director of Nursing (DON) for documentation of the care planned 15 minute checks. On 5/29/24 at approx 12:30 PM a record review of the facility 15 minute check worksheet for Resident #25 noted that multiple areas of documentation were missing. On 5/29/24 at 01:15 PM an interview with the DON was conducted. The DON acknowledged the missing documentation should be present.c) Resident #45During a record review on 05/28/24 at 3:47 PM, of Resident #45 ' s fall care plan created on 12/08/23 reads as follows:Focus: \Effective date of 03/21/24\ FALL- (Resident #45 name) has the risk for injury related to falls, fragile skin, balance issues, and poor safety awareness secondary to impaired cognition from a number of factors that include : aging process, side effects from psychotropic medications, behavior issues, and Alzheimer ' s disease. Goals: \Effective date of 02/28/24\ - Areas of impaired skin will show no signs or symptoms of infection and resolve within 30 days. (Resident #45 name) will not have a significant injury from falls within the next 90 days.Interventions: -Provide assistance with transfer, ambulation and locomotion as needed.-Ensure that the call bell is within reach at all times.-Provide a safe, clutter free environment.-Ensure resident wears appropriate, well-fitting footwear to minimize the risk of slipping-Pad alarm to bed and wheelchair at all times for safety.-May use a wheelchair as needed due to weakness and unsteady gait.-15 minute checks for resident safety.-1:1 at all times due to resident safety.-Encourage periods of rest.-When staff witness (Resident #45 name) is sitting on the floor, stay with her and offer a chair to sit on.-Hipsters on at all times.Further record review of Resident #45 ' s orders showed that 1:1 at all times had been discontinued on 03/08/24.During an interview on 05/29/24 at 11:13 AM, The Director of Nursing (DON) stated, " The one to one ' s were discontinued in March. I don't know why it is still on her care plan, it should not be. That care plan is a social worker care plan and I guess she did not take it out."

1. By 6/5/2024, the Fall/Injury, Elopement, and Behavior/Trauma Care plans for residents *25, *36 and #45 were all reviewed, revised and corrected by the Minimum Data Set (MDS) Coordinator to reflect the current plan of care (attachment 139).

2. . All residents have the potential to be affected by this deficit practice. By 7/30/2024, the MDS Coordinator/designee will review all Resident's Fall/Injury, Elopement, and Behavior/Trauma Care plans to ensure the care plans include resident specific interventions appropriate to the care being provided
(attachment 140).

3. By 7/30/2024,The Director of Nursing/designee will provide education to the MDS Coordinator on ensuring that all Resident's Fall/Injury, Elopement, and Behavior/Trauma Care plans reflect their current plan of care (attachment 141). All incidents will be reviewed weekly x 2 months, then monthly x 6 months, then quarterly thereafter by the Performance Improvement Program (PIP) which includes members of IDT and interventions will be reviewed, revised and updated.

4. The Director of Nursing(DON)/designee will audit care plans weekly for 2 months, then monthly for 6 months, and then quarterly thereafter to ensure the care plans are updated to reflect the current plan of care (attachment 142). The Quality Assurance Performance Improvement (QAPI ) Nurse/designee will audit the care plan logs monthly for six months, and then quarterly thereafter (attachment 143). All data will be presented by the Quality Assurance Performance Improvement (QAPI ) Nurse to the QAPI Committee at least quarterly for analysis and any further action.

§ 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice which would allow the residents to achieve their highest practicable physical, mental, and psychosocial well-being. This was true for two (2) out of four (4) residents reviewed for restorative nursing services. Resident identifiers: #5 and #37. Facility census: 49.

Findings included:

a) Resident #5

Record review on 05/30/24 at 11:51 AM, revealed that Resident #5's physician had prescribed Range of Motion (ROM)/stretching protocol global 1 (one) time daily, up to 5 (five) times a week for contracture management on 12/15/21.

During an interview on 05/30/24 at 10:46 AM, Physical Therapist (PT) #15 and PT # 22 , and also confirmed by record review, revealed the resident received twelve (12) treatments out of a prescribed twenty-five (25) treatments, during the period 04/01/24 to 04/31/24.

b) Resident #37

Record review for Resident #37 revealed that his physician had prescribed Moist Heat to L LE (Left Lower Extremity) and low back 1x/daily for up to 5x a week for 20 minutes or less per treatment for pain management.

Treatment record review, and interview with PT #15 and PT #22 revealed that application of the moist heat pad required a nurse to be in attendance. Treatments were frequently canceled because the nurse was busy and unable to come to physical therapy. Treatment record review for Resident #5 revealed that resident received five (5) moist heat treatments out of the prescribed twenty-three (23) treatments, during the period 05/01/24 to 05/30/24.

1. Resident #5 no longer resides in the facility. On 6/26/2024, the Minimum Data Set (MDS) Nurse reviewed Resident #37 May 2024
Activity of Daily Living (ADL) sheets. ADL sheets reveal Resident #37 is independent for ADL's requiring set up of supplies only and is independent for mobility. ADL sheets were reviewed for the previous 6 months and found that Resident #37 has not had a decline in function related to alleged deficient practice (attachment 144).

2. All residents have the potential to be affected by the alleged deficient practice. By 7/30/2024, the Minimum Data Set (MDS) Nurse will review all resident MDS assessments for the previous 12 months for Significant Change related to decline in ADL'S. Any resident found to have a significant change in ADL's will be referred to the Physical Therapist for evaluation (attachment 145)

3. By 7/30/2024, the Minimum Data Set (MDS) Nurse/designee will provide education to the Restorative Therapy Assistants that residents must receive Restorative Therapy Services as ordered (attachment 146).

4. The Minimum Data Set (MDS)Nurse/ designee will audit Restorative Therapy documentation weekly for 2 months, then monthly for 6 months, and then quarterly thereafter to ensure residents are receiving Restorative Therapy as ordered (attachment 147).The Quality Assurance Performance Improvement (QAPI ) Nurse /designee will audit the Restorative Therapy logs monthly for six months, and then quarterly thereafter (attachment 148). All data will be presented by the Quality Assurance Performance Improvement (QAPI ) Nurse to the QAPI Committee at least quarterly for analysis and any further action.

§483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Based on record review, staff interview and resident observation the facility failed to provide supervision, implementation, monitoring and modifying of interventions to prevent avoidable accidents. This was true for 2 (two) of 7 (seven) residents reviewed during the Long-Term Care Survey Process. Resident identifiers: Resident #36 and Resident #25. Facility census: 49.

Findings include:

a) Resident #36

On 05/28/24 at 12:30 PM, a review of Resident #36 ' s medical record was conducted. A fall care plan was noted with interventions stating, "Encourage resident to wear hipsters at all times for safety." "Encourage resident to wear soft helmet while ambulating for safety."

On 05/28/24 at 1:07 PM an observation of Resident #36 was conducted. Resident #36 was noted to be in bed, no hipsters were noted to be on Resident #36 and no helmet was noted to be present.

A further review of Resident #36's medical record was conducted on 05/28/24 at approximately 1:25 PM, which noted Resident #36 had 19 documented falls from 01/01/24 through 05/26/24. The falls occurred on: 01/15/24, 01/22/24, 01/28/24, 02/13/24, 03/6/24, 03/0/247, 03/11/24, 03/14/24, 03/23/24, 04/01/24, 04/08/24, 04/09/24, 04/17/24, 04/19/24, 04/23/24, 05/19/24, 05/20/24, 05/21/24 and 05/26/24. It was also noted during this review that after a fall on 04/01/24 at 8:15 PM, Resident #36 was sent to the Emergency Room due to sustaining a laceration to the left elbow that was documented to be "deeper than first appeared."

Then on 05/16/24, Resident #36 was sent to the hospital related to this laceration of the left elbow. During a review of Resident #36 ' s hospital record it was noted Resident #36 was diagnosed with septic left olecranon bursitis after a "failed outpatient antibiotic" series.

On 05/29/24 at 11:20 AM a copy of the facility fall policy was requested from the Director of Nursing (DON).

On 05/29/24 at 11:25 AM an interview with Employee #72 was conducted. Employee #72 stated, "He refuses to wear the hipsters."


On 05/29/24 at approximately 12:30 PM, a review of the provided facility policy titled, "Falls Risk Assessment and Management Program was conducted and noted the following text:

A multi-disciplinary team will meet monthly to review the resident's identified as being high risk for falls, to evaluate the interventions in place and to modify the Resident's Care Plan as needed.

At these meetings, individual falls and/or residents are discussed and analyzed
*Possible intrinsic and extrinsic factors
*Evaluation of present interventions in place
*Current or newly prescribed medications
*Further preventative measures and interventions
*Additional equipment/supply needs
Therapy or Restorative Nursing evaluations/treatment - for decline in function, adaptive needs, seating assessment, etc.
Special attention is paid to residents with any repeat occurrences.
Following the Fall Management meeting, the DON, ADON and Unit Managers or charge nurse will implement individual changes recommended by the team; modify the resident's fall risk assessment plan of care and mini-in-service staff on the units of changes/updates.

A copy of any Interdisciplinary Team notes, related to Resident #36's falls that have occurred during the year of 2024 were requested.

On 05/29/24 at 01:30 PM the Interdisciplinary Team notes were provided. The months provided were from 03/21/24 through 05/21/24. This Surveyor then requested a copy of Resident #36's capacity form from the DON.

Further review of Resident #36 ' s medical record on 5/29/24 at 08:00 PM was conducted. Resident #36 ' s capacity form, fall care plan and the Interdisciplinary Team recommended interventions. It was then noted that several of the Interdisciplinary Team recommended interventions were "continue educating on fall interventions and encourage resident to use them, as he always refuses." The dates this intervention was documented included the following: 04/04/24, 04/17/24, 04/19/24, 04/23/24 and 05/19/24. Review of Resident #36 ' s capacity for indicated that Resident #36 had been "examined and found to be mentally incapable of granting informed consent or to have the capacity to consent to treatment" and that Resident #36 ' s brother had been named as Health Care Surrogate.

On 05/30/24 at approximately 9:00 AM an interview with Employee #73 was conducted. Employee #73 stated, "He refuses to wear his helmet and hipsters. They are in his closet."

On 05/30/24 at approximately 9:33 AM, an interview was conducted with the Director of Nursing (DON). This Surveyor reviewed, with the DON, Resident #36's fall care plan. The DON acknowledged that from 12/19/23 until 04/02/24 Resident #36's fall care plan had not been revised or updated with Interdisciplinary Team intervention recommendations then states, "I don't know why it wasn't updated with new interventions after each fall."

Resident #25

On 05/28/24 at 2:49 PM an observation of Resident #25 was made. Resident #25 was noted to be at the end of A Hall at the exit door attempting to open it when the alarm sounded.

Resident #25 was then approached by a member of the facility staff who was coming out of another resident room. This staff member easily redirected Resident #25. At this time, Resident #25, was observed to have a wander guard to his right ankle. The resident was seated in a back wheelchair with a chair alarm attached to it. .

On 05/29/24 at 07:50 AM a review of Resident #25's medical record was performed. It was noted that in Resident #25's behavior care plan focus that Resident #25 had a "history of wandering and attempting to enter unsupervised areas." An intervention in this care plan was 15-minute checks for safety. This Surveyor asked the Director of Nursing (DON) for documentation of the care planned 15-minute checks. It was also noted that in a separate social work care plan focus that Resident #25 was on a one to one as he wandered into rooms of others and was an elopement risk.

On 5/29/24 at 12:30 PM a record review of the facility 15-minute check worksheet for Resident #25 noted that multiple areas of documentation were missing.

On 5/29/24 at 01:15 PM, an interview with the DON was conducted. The DON acknowledged the missing documentation should be present.

On 5/30/34 at 11:18 AM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON acknowledged that the care plan was incorrect and should have been updated.

1. By 6/5/2024, the Fall/Injury, Elopement, and Behavior/Trauma Care plans for residents #25 and #26 were all reviewed, revised and corrected by the Minimum Data Set (MDS) Coordinator to reflect the current plan of care (attachment 139).

2. All residents have the potential to be affected by this deficit practice. By 7/30/2024, the MDS Coordinator/designee will review all Resident's Fall/Injury, Elopement, and Behavior/Trauma Care plans to ensure the care plans include resident specific interventions appropriate to the care being provided. (attachment 140).

3. By 7/30/2024,The Director of Nursing (DON)/designee will provide education to the MDS Coordinator on ensuring that all resident's Fall/Injury, Elopement, and Behavior/Trauma Care plans reflect their current plan of care (attachment 141). On 7/30/2024, all incidents will be reviewed weekly x 2 months, then monthly x 6 months, then quarterly thereafter by the Performance Improvement Program (PIP) and interventions will be reviewed, revised, and updated.

4. The Director of Nursing(DON)/designee will audit care plans weekly for 2 months, then monthly for 6 months, and then quarterly thereafter to ensure the care plans are updated to reflect the current plan of care (attachment 142). The Quality Assurance Performance Improvement (QAPI) Nurse/ designee will audit the care plan logs monthly for six months, and then quarterly thereafter (attachment 143). All data will be presented by the (Quality Assurance Performance Improvement (QAPI ) Nurse to the QAPI Committee at least quarterly for analysis and any further action.

§483.35(b) Registered nurse §483.35(b)(1) Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. §483.35(b)(2) Except when waived under paragraph (e) or (f) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis. §483.35(b)(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.

Based on facility record review and staff interview the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. This was true for two (2) of five (5) days identified during the long-term care survey process. This had the ability to affect all the residents. Facility census: 49.

Findings included:

a) 05/28/23

On 05/29/24 at approximately 11:00 AM during a review of the facilities payroll transaction report of all direct care hours for 05/28/23, no direct care Registered Nurse (RN) hours were identified for 05/28/23.

On 05/29/24 at approximately 11:05 AM during a further review of the facility Nursing Staff Information Sheet (also known as the Nursing Staffing Posting form), the total number of Registered Nurse staff for 05/28/23 was handwritten in at one (1) and the total number of hours for the Registered Nurse Staff hours was also handwritten in at eight (8).

During an interview with the Director of Nursing (DON) on 05/29/24 at approximately 12:15 PM, he stated he had found an agency Timesheet for Agency RN #95 and that he had hours marked for 05/28/23. The DON was asked to provide documentation of the facility or the agency payroll documentation to identify the hours marked and that they had actually been worked. No further information was provided by the DON.

b) 07/05/23

On 05/29/24 at approximately 11:00 AM during a review of the facilities payroll transaction report of all direct care hours for 07/05/23 revealed no direct care Registered Nurse (RN) hours were identified for 07/05/23.

On 05/29/24 at approximately 11:05 AM during a further review of the facility Nursing Staff Information Sheet (also known as the Nursing Staffing Posting form), the total number of Registered Nurse staff for 07/05/23 was handwritten in at zero (0) and the total number of hours for the Registered Nurse Staff hours was also handwritten in at zero (0).

During an interview with the Director of Nursing (DON) on 05/29/24 at approximately 12:15 PM, he stated they had numerous Registered Nurses (RN) with administrative duties in the facility that day and that he did not have to have an RN on duty.

During a review of the RN requirements in accordance with the Payroll Based Journal for direct care and administrative duties, the DON said he would have to read that information for himself. The information was then provided for the DON electronically on the computer screen and the DON stated he would have to check into who else was in the building at this time.

The DON acknowledged that no RN's were listed on the Nursing Staff Information for 07/05/24 and that there were no RNs with non-administrative duties payroll time captured in the facility transaction report for direct care hours on 07/05/24. No further information was provided by the DON.

1a. No residents were identified in the surveyor findings as being affected by the alleged deficient practice.

1b. No residents were identified in the surveyor findings as being affected by the alleged deficient practice.

2a. On 6/26/2024, the Director of Nursing (DON) reviewed the facilities 24 hour nursing report for 5/28/2024 no residents were found to be affected due to this alleged deficient practice (attachment 149).

2b. On 6/26/2024, the Director of Nursing (DON) reviewed the facilities 24 hour nursing report for 7/5/2023 and no resident's were found to lack the care of a Registered Nurse (RN) (attachment 149).

3a. On 6/26/2024, the DON put into place a process effective with payroll date ending on 6/29/24 where the Office Assistant 2 will provide a digital copy to the DON of all agency timesheets to ensure thorough record keeping of RN coverage (attachment 150).

3b. Beginning 6/27/24, the DON/designee will complete the nursing staffing posting form daily to ensure the number of Registered Nurses and Registered Nursing hours are recorded and meet regulatory compliance. The DON/designee; will review the previous day's nursing staffing posting form with the administrative team in the daily morning meeting to confirm RN coverage meets regulatory compliance. Data will be documented on the morning agenda
(attachment 151).

4a. The Quality Assurance Performance Improvement (QAPI) Nurse /Designee will monitor Digital Copies of agency timesheets weekly x 2 months, then monthly for 6 months to ensure RN coverage is accurate and completed, thereafter, monitoring will occur on a quarterly basis (attachment 152).

4b. The Quality Assurance Performance Improvement (QAPI) Nurse/Designee will monitor Staffing Sheets/Census sheets to ensure that Registered Nurse Hours are identified accurately weekly x 2 months, then monthly for 6 months, thereafter, monitoring will occur on a quarterly basis. All data will be presented by the QAPI (attachment 152).

§483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. §483.35(g)(2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. §483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. §483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Based on facility record review and staff interview the facility failed to provide the accurate data on the nurse staffing information form. The daily census was not accurate for 4 of 5 daily of the nurse staffing information forms reviewed during the long-term care process. This issue had the ability to affect more than a limited number of residents. Census: 49.

Findings included:

The facilities available and occupied beds report review on 05/29/24 at 11:00 AM revealed the following:

a) 05/28/23

On 05/28/23 the daily census was identified to be 46 and the staffing posting form was a handwritten census of 49.

b) 07/05/23

On 07/05/23 the daily census was identified to be 47 and the staffing posting form was a handwritten census of 48.

c) 01/01/24

On 01/01/24 the daily census was identified to be 43 and the staffing posting form was a handwritten census of 44.

d) 05/27/24

On 05/27/24 the daily census was identified to be 49 and the staffing posting form was a handwritten census of 50.

During an interview with the Director of Nursing (DON) on 05/29/24 at approximately 12:20 PM, he acknowledged that the forms were not accurate and stated that he could not explain why the census was not accurately documented on the nursing staffing information form. No further information was provided.

1. No residents were identified in the surveyor findings as being affected by the alleged deficient practice.

2. All residents have the potential to be affected by the alleged deficient practice. On 6/27/2024, all residents were interviewed by the Director of Nursing/designee and no residents were affected by the alleged deficient practice
(attachment 153).

2. Beginning 6/27/24, the Director of Nursing (DON)/designee will complete the nursing staffing posting form daily to ensure the facility posts the following information for total resident census. The DON/designee will review the previous days' nursing staffing posting form with the administrative team twice weekly in the morning meeting to confirm that the Resident Census is accurate. Data will be documented on the morning agenda (attachment 151).

4. The Quality Assurance Performance Improvement(QAPI) Nurse/Designee will monitor Staffing Sheets/Census sheets to ensure Resident. Census is identified accurately weekly x 2 months, then monthly for 6 months, thereafter, monitoring will occur on a quarterly basis. All data will be presented by the QAPI (attachment ).

§483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Based on record review and staff interview, the facility failed to ensure behavior monitoring and medication side effect monitoring was documented for a resident receiving psychotropic meds. This deficient practice affected one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #12. Facility census: 49.

Resident identifier:

a) Resident #12

Review of the facility's policy titled "Behavioral Assessment, Intervention, and Monitoring" with no implementation date specified, stated the following:

- If a resident was being treated for altered behavior and mood, the Interdisciplinary Team (IDT) would document any improvements or worsening in the resident's behavior, mood, and function.
- The IDT would monitor for side-effects related to psychoactive medications.

Review of Resident #12's medical records showed the resident had been admitted to the facility on 05/09/24. Resident #12 had diagnoses of anxiety, depression, and mood disorder. The resident was prescribed the psychotropic medications Buspar (buspirone) for anxiety, Zoloft (sertraline) for depression, and Seroquel (quetiapine) for mood disorder.

The resident had a physician order written on 05/09/24 to monitor for side effects of medication during administration and every shift.

Further review of Resident #12's medical records did not show any monitoring of the resident's symptoms of anxiety, depression, or mood disorder. Furthermore, review of Resident #12's medical records did not show any monitoring of medication side-effects for the resident.

The Director of Nursing (DON) and Minimum Data Set (MDS) Nurse #4 were interviewed on 05/30/24 at 11:20 AM. MDS Nurse #4 stated residents taking psychotropic medications (medications that affect the mind, emotions, and behavior) have their behaviors and side-effects monitored every shift on a handwritten documentation sheet. The DON stated Resident #12 had no behaviors or side-effects but confirmed this had not been documented on a behavior monitoring sheet.

No further information was provided through the completion of the survey.

1. On 05/29/2024, behavior monitoring and medication side effect sheets were initiated for Resident #12 by the Director of Nursing (DON) (attachment 154).

2. All residents have the potential to be affected by the alleged deficient practice. By 7/30/2024, the DON/designee will review all resident medications and behavior monitoring and medication side effect sheets for compliance (attachment 155).

3. By 7/30/2024, the DON/designee will educate all Licensed Nurses on initiating behavior monitoring and medication side affect sheet for any resident receiving psychotropic medications (attachment 156).

4. The DON/designee will audit behavior monitoring and medication side effect sheets weekly for 2 months, the monthly for 6 months, and then quarterly thereafter (attachment 157). The Quality Assurance Nurse/designee will audit behavior monitoring and medication side effect sheets log monthly for six months, and then quarterly thereafter (attachment 158). All data will be presented by the (Quality Assurance Performance Improvement (QAPI ) Nurse to the QAPI Committee at least quarterly for analysis and any further action.

§483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include: §483.70(e)(1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population; (iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and (v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. §483.70(e)(2) The facility's resources, including but not limited to, (i) All buildings and/or other physical structures and vehicles; (ii) Equipment (medical and non- medical); (iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies; (iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; (v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and (vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. §483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.

Based on facility record review and staff interview the facility failed to conduct and document a complete facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility did not assess the physical environment, equipment, services, and other physical plant considerations that are necessary to care for the resident population. This was a random opportunity for discovery during the long-term care survey. Census: 49.

Findings included:

a) Gas leak

On 05/29/24 at approximately 11:30 AM during a review of the facility assessment revealed on Page 14 under number 3.12 "to provide your facility-based and community-based risk assessment, utilizing an all-hazards approach (an integrated approach focusing on capacities and capabilities critical to preparedness for a full spectrum of emergencies and natural disasters)." It was further identified on Page 24 of the facility assessment that the following were the identified facility risks and or community risks/disasters listed that have the potential to affect the facility:

1. Fire
2. High wind/ tornado
3. Flood
4. Pandemic communicable diseases such as influenza, Ebola
5. Workplace security issue such as bomb threat, terrorism, active shooter
6. Loss of electrical power or water service
7. Hazardous material release
8. Loss of facility computer system
9. Severe Weather
10. Missing/ eloped resident.

During an interview with the Administrator on 05/30/24 at approximately 11:36 AM the Administrator explained the recent events of the gas services loss due to a gas leak and the potential evacuation of the residents and staff that the facility had faced.

The Administrator agreed that the facility assessment, when completed correctly, should identify the individual facility vulnerabilities to enable the facility to thoroughly assess the needs of its resident population and the required resources to provide the care and services the residents need.

The Administrator further agreed that the facility failed to complete the facility-based risk assessment, utilizing an all-hazards approach with the main source of hot water for residents bathing being the gas service and the ability to prepare the residents meals being solely dependent on the gas service.

The Administrator further commented since he has experienced this gas leak with an initial threat of a potential explosion and the possible need for an emergency evacuation of the residents and staff. And with the ongoing complete loss of their gas services which is affecting the means of providing the residents their baths and preparing their meals, it would be a definite vulnerability of the facility that was not identified in the facility assessment.

1. There were no residents identified in the surveyor findings as being affected by the alleged deficient practice.

2. The deficient practice has the potential to affect all residents. By 7/30/202, the Infection Preventionist Nurse/designee will interview all residents for adverse effects related to the alleged deficient practice of not having an updated Facility Assessment (attachment 159).

3. The Quality Assurance Performance Improvement (QAPI) Committee updated the Facility Assessment on 6/26/2024, to include I potential for loss of all utility resources (attachment 160).

4. By 7/30/2024, the Administrator/designee will review the Facility Assessment in the Safety meeting monthly x 6 months, then, then quarterly thereafter(attachment 161). The Quality Assurance Performance Improvement (QAPI) nurse/designee will audit for completion of Facility Assessment Log monthly for 6 months, then quarterly thereafter (attachment 162). All data will be presented by the Quality Assurance Performance Improvement (QAPI ) Nurse to the QAPI committee at least quarterly for analysis and any
further action.

§483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Based on staff interview and facility documentation, the facility failed to provide accurate and complete medical records in regard to activities of daily living (ADLs). This was true for one (1) of eighteen (18) residents reviewed under the ADL pathway. Resident identifier: #43. Facility Census: 49

Findings included:

a) Gas Leak Resulting in No Hot Water

Facility staff had reported signs of a gas leak on 05/26/24. The gas company technician had noted a positive test for gas in the kitchen area, and, as a precaution, recommended turning off the gas supply to the facility. As a result, no hot water had been available for the residents since 05/26/24.

a) Resident #43

During a review of Bath/Shower Temperature Logs at the nursing station on 05/30/24 at 11:17 AM, RN #83 and LPN #73 showed a shower being completed for Resident #43 on the evening of 05/26/24.

Submission of a request for Bath/Shower Temperature Logs completed on 05/30/24 at 11:17 AM. These logs revealed no completed sheets. Upon interview with the Director of Nursing (DON) - on 05/30/24 at 12:47 PM, DON stated there were no log sheets available because no showers were offered due to the non-availability of hot water.

Record review of Health Services Worker (HSW) intervention logs produced by the DON revealed documentation of a shower for Resident #43 on 05/26/24. The HSW Interventions logs required entries specifying which type of bath was offered to the resident. (W) for whirlpool, (S) for shower, and (BB) for bed bath.

The MDS Coordinator provided the logs for Resident #43. The logs had a single letter entered for each day. When questioned about what the letters denoted, the MDS Coordinator stated that she would ask the DON. She returned, and stated the DON had informed her they were the initials of the staff person performing the bath. When questioned further as to why there was only one letter, and why there was no information to identify who the initials belonged to, the MDS coordinator stated that she didn't have any further information.

1. On 6/26/2024, a statement was received from Certified Nursing Assistant (CNA) that the shower provided to Resident #43 on 5/26/2024 was given prior to the gas being turned off (attachment 183).

2. All residents have the potential to be affected by the alleged deficient practice. By 7/30/2024, all shower records will be reviewed to ensure no showers were given prior to the electric hot water tank being installed on 6/7/2024 (attachment 164).

3. On 6/7/2024, an electric hot water tank was placed in the Gore 1 shower providing hot water for resident showers until the main gas water heaters servicing the facility can be restored to service (attachment 115).

4. The Director of Nursing (DON)/designee will present the shower/bed bath temperatures to the weekly water temperature Performance Improvement Program (PIP) (attachment 116). The Quality Assurance Nurse/designee will audit the shower/bed bath temperature monthly for six months, and then quarterly thereafter (attachment 117). All data will be presented by the Quality Assurance Performance Improvement (QAPI ) Nurse to the QAPI Committee at least quarterly for analysis and any further action.

§483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Based on observation and staff interview the facility failed to provide hand washing to residents on B hall before their lunch meal. Resident #33 had a pool noodle type piped foam taped around the head and foot board of the bed. This foam could not be effectively cleaned. These practices were random opportunities for discovery during the Long-Term Care Survey Process. Facility Census: 49.

Findings included:

a) B-hall

An observation on 05/29/24 at 12:35 PM, revealed (7) seven lunch trays were passed on B hall with no hand hygiene provided.

During an interview on 05/29/24 at 12:35 PM, with Nurse Aide (NA) #29 she stated, " I'll be honest, we normally don't do it on the hallway. We do in the dining room but not on the hallway.."

During an interview on 05/29/24 at 1:30 PM, with The Director of Nursing (DON) he confirmed that handwashing should be completed with residents before they receive their tray.

b) Resident #33

05/29/24 at 1:38 PM during a tour of resident room the black pipe foam that resembled a pool noodle was seen to be tapped with black tape along the headboard and the foot board of the bed. Some of the tape was coming lose and the foam was tearing apart in several areas. Licensed Practical Nurse (LPN) #50 stated the cleaning and disinfecting of the foam was not the nursing responsibility and that the housekeepers clean it.

During an interview on 05/29/24 at 1:39 PM with Housekeeper #41 the housekeeper stated she would spray her disinfectant to the top surface and let is set on the pipe foam for about 30 seconds and then wipe it down. During an interview at on 05/29/24 1:41 PM with the DON and Material Data Set RN #05, the DON acknowledged the foam was torn in areas and the foam material was not able to be fully disinfectant. He stated it should had been changed out.

1a. There were no residents identified in the surveyor findings as being affected by the alleged deficient practice.

lb. On June 27, 2024, the Infection Preventionist reviewed the infection control surveillance report and no adverse effects were observed for resident #33. See statement from Infection Preventionist (attachment 165). An order was received on 5/29/2024 from the Physician to discontinue all Pool Noodles for resident #33's. All pool noodles were removed from resident #33's room on 5/29/2024 See copy of order (attachment 168).

2a. The deficient practice has the potential to affect all residents. On 6/27/2024, the Infection Preventionist reviewed the facility Infection Surveillance Report and determined No residents were found to have been affected by the alleged practice of not washing residents hands prior to meal (attachment 167).

2b. By 7/30/2024, the Infection Preventionist/ designee will check all resident rooms for pool noodles and will be removed (attachment 168).

3a. By 7/30/2024, the Director of Nursing (DON)/Designee will provide education to all Licensed Nursing staff and Certified Nursing Assistants on Hand Hygiene prior to meals (attachment 169).

3b. By 7/30/2024, the Director of Nursing (DON)/Designee will provide education to all Licensed Nursing staff and Certified Nursing Assistants on items that can not be placed in resident rooms that can not be cleaned per infection control regulations (attachment 169).

4a. The DON/designee will perform hand hygiene audits on nursing staff prior to meals (attachment) weekly times 2 months, then monthly for 6 months, then quarterly thereafter to ensure residents' hands are being washed prior to meals (attachment 170).

4b. The DON/designee will perform audits in resident rooms for items that cannot be placed in resident rooms that cannot be cleaned per infection control regulations weekly times 2 months, then monthly for 6 months, then quarterly thereafter to ensure residents' hands are being washed prior to meals (attachment 170).

4aa. The Quality Assurance Nurse/Designee will monitor completion of Hand Hygiene Logs prior to meals monthly for 6 months, thereafter monitoring will occur on a quarterly basis (attachment 171). All data will be presented by the Quality Assurance Performance Improvement (QAPI) Nurse to the QAPI committee at least quarterly for analysis and any further action.

4bb. The Quality Assurance Nurse/Designee will monitor completion of Infection Control Log for items in rooms that can not be cleaned monthly; thereafter, monitoring will occur on a quarterly basis (attachment 171). All data will be presented by the QAPI Nurse to the QAPI committee at least quarterly for analysis and any further action.

Hopemont Hospital is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. A review of the plans of correction and credible evidence was accepted in lieu of an onsite revisit for the investigation survey concluding on 06/06/24. The facility is in substantial compliance with the previously cited deficient practices.

§483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

§483.10(c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: §483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. §483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. §483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

§483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

§483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

§483.10(j) Grievances. §483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. §483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. §483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident. §483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; (ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; (iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; (iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law; (v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; (vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and (vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

§483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. §483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with: (i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services; or (ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission- (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability. §483.20(k)(2) Exceptions. For purposes of this section- (i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital. (ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual- (A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital, (B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and (C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services. §483.20(k)(3) Definition. For purposes of this section- (i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1). (ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter.

§483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

§ 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

§483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

§483.35(b) Registered nurse §483.35(b)(1) Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. §483.35(b)(2) Except when waived under paragraph (e) or (f) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis. §483.35(b)(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.

§483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. §483.35(g)(2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. §483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. §483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

§483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

§483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include: §483.70(e)(1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population; (iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and (v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. §483.70(e)(2) The facility's resources, including but not limited to, (i) All buildings and/or other physical structures and vehicles; (ii) Equipment (medical and non- medical); (iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies; (iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; (v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and (vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. §483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.

§483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

§483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

An unannounced complaint investigation survey was conducted at Hopemont Hospital from 05/06/24 to 05/07/24. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and/or 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. The facility's census on the first day of the survey was 48 residents.
Complaint #32739 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced complaint investigation survey was conducted at Hopemont Hospital from March 26-27, 2024. The deficiencies contained in this report are based on observations, review of residents' clinical records, resident interviews, family interviews, and staff interviews, and review of other facility documentation as indicated. The facility's census on the first day of the survey was 48 residents.

--Complaint #31365 was substantiated
.

§483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under §483.75. §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. §483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. §483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Based on reportable allegation review, staff interview and policy review the facility failed to ensure they implemented their abuse/neglect policy as it relates to thoroughly investigating allegations of abuse. Resident identifier: #34, #28. Facility census: 48.

Findings included:

a) Resident #34

The facility received allegations through a social media account that alleged that on night shift on hallway B1 the nurse aides were telling an obese patient that she needs to come to the desk to get water because she's "too fat."

The facility investigated an allegation of abuse/neglect involving Resident #34 on 01/08/24. During this investigation Social Worker #22 and Social Worker #40 both interviewed Resident #34. They both asked the resident how she got access to water for drinking. When Social Worker #40 asked this question the resident responded, "They don't bring me water in my bedroom. They tell me that I need to go to the bathroom and then get my water." When Social Worker #22 asked the question the resident said, "I ask for it and they bring it." The social workers did not interview staff only residents.

b) Resident #28

During the investigation of the allegations regarding Resident #34 the social workers interviewed Resident #28. During that interview the resident was asked, "Has anyone ever called you any names?" The resident responded, "They call me little brat but they only tease me. I just ignore them." The social workers did not interview any staff regarding the comments made by Resident #28.

A review of the abuse and neglect reporting, investigation policy dated 02/22/24 revealed the following regarding abuse/neglect investigations:

" 1. The Resident Advocate/Grievance Official shall have access to all records and employees. The Resident Advocate/Grievance Official will gather all facts, conduct interviews of all involved persons including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation, and review medical records as necessary to determine the circumstances surrounding the allegation(s).

5. There will be a complete and thorough documentation of the investigation."

On 03/26/24 at 6:15 PM the Director of Nursing (DoN) was asked about the investigation into the allegations above. He had no comments regarding the investigation. On 03/27/24 at 12:06 PM both social workers agreed they did not interview any staff during this investigation. They both said they normally let the assistant director of nursing interview staff. During the facility exit on 03/27/24 at 3:30 PM the Assistant Director of Nursing #8 said she did not interview any staff related to these allegations.

1. Resident #28 and resident #34 compliant investigated by the Social Services Director and Clinical Social Worker on 1/18/24, See resident #34 witness statement (attachment A), and #28 witness statement (attachment B).

2. All residents have the potential to be affected by the alleged deficit practice. All residents were interviewed on 4/12/24 by the
Social Services Director and Clinical Social Worker. No allegations of abuse were reported during the investigation (attachment N). An investigation with all Direct Care staff will be completed by the Social Services Director and the Clinical Social Worker by 4/16/2024 (attachment P). From March 26, 2024 all self reports and 5 day investigations will be reviewed by the Quality Assurance Performance Improvement (QAPI) committee to ensure investigations are compliant with facility policy.

3. By 4/412024, the facility administrator/designee will educate the Director of Social Services the abuse/neglect policy (attachment C), and Clinical Social Worker on the abuse/neglect policy (attachment D) as it is related to thoroughly investigating allegations of abuse. The Performance Improvement Program Committee will review all allegations of abuse and neglect prior to submission of the five day follow up to ensure all the investigation processes were completed per policy (attachment E).

4. The QAPI nurse/designee will audit the logs of allegations of abuse weekly for two months, then monthly for 6 months, then quarterly thereafter to ensure Investigations of incidents are completed with corrective action immediately upon discovery (attachment F). All data will be presented by the QAPI Nurse to the QAPI Committee at least quarterly for analysis and any further action.

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Based on reportable allegation review, staff interview and policy review the facility failed to ensure they thoroughly investigated allegations of abuse. Resident identifier: #34, #28. These were random opportunities for discovery. Facility census: 48.

Findings included:

a) Resident #34

The facility received allegations through a social media account that alleged that on night shift on hallway B1 the nurse aides were telling an obese patient that she needs to come to the desk to get water because she's "too fat."
The facility investigated an allegation of abuse/neglect involving Resident #34 on 01/08/24. During this investigation Social Worker #22 and Social Worker #40 both interviewed Resident #34. They both asked the resident how she got access to water for drinking. When Social Worker #40 asked this question the resident responded, "They don't bring me water in my bedroom. They tell me that I need to go to the bathroom and then get my water." When Social Worker #22 asked the question the resident said, "I ask for it and they bring it." The social workers did not interview staff only residents.

b) Resident #28

During the investigation of the allegations regarding Resident #34 the social workers interviewed Resident #28. During that interview the resident was asked, "Has anyone ever called you any names?" The resident responded, "They call me little brat but they only tease me. I just ignore them." The social workers did not interview any staff regarding the comments made by Resident #28.

A review of the abuse and neglect reporting, investigation policy dated 02/22/24 revealed the following regarding abuse/neglect investigations:

" 1. The Resident Advocate/Grievance Official shall have access to all records and employees. The Resident Advocate/Grievance Official will gather all facts, conduct interviews of all involved persons including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation, and review medical records as necessary to determine the circumstances surrounding the allegation(s).

5. There will be a complete and thorough documentation of the investigation."

On 03/26/24 at 6:15 PM the Director of Nursing (DoN) was asked about the investigation into the allegations above. He had no comments regarding the investigation. On 03/27/24 at 12:06 PM both social workers agreed they did not interview any staff during this investigation. They both said they normally let the assistant director of nursing interview staff. During the facility exit on 03/27/24 at 3:30 PM the Assistant Director of Nursing #8 said she did not interview any staff related to these allegations.

1. Resident #28 and resident #34 compliant investigated by the Social Services Director and Clinical Social Worker on 1/18/24, See resident #34 witness statement (attachment A), and #28 witness statement (attachment B).

2. All residents have the potential to be affected by the alleged deficit practice. All residents were interviewed on 4/12/24 by the Social Services Director and Clinical Social Worker. No allegations of abuse were reported during the investigation (attachment N). An investigation with all Direct Care staff will be completed by the Social Services Director and the Clinical Social Worker by 4/16/2024 (attachment P). From March 26, 2024 all self reports and 5 day investigations will be reviewed by the Quality Assurance Performance Improvement (QAPI) committee to ensure investigations are compliant with facility policy.

3. By 4/4/2024, the facility administrator/designee will educate the Director of Social Services the abuse/neglect policy(attachment C), and Clinical Social Worker on the abuse/neglect policy (attachment D) as it is related to thoroughly investigating allegations of abuse. The Performance Improvement Program Committee will review all allegations of abuse and neglect prior to submission of the five day follow up to ensure all the investigation processes were completed per policy (attachment E).

4. The QAPI nurse/designee will audit the logs of allegations of abuse weekly for two months, then monthly for 6 months, then quarterly thereafter to ensure investigations of Incidents are completed with corrective action immediately upon discovery (attachment F). All data will be presented by the QAPI Nurse to the QAPI Committee at least quarterly for analysis and any further action.

The facility must ensure that its- §483.45(f)(2) Residents are free of any significant medication errors.

Based on medical record review and staff interview the facility failed to ensure one (1) of three (3) residents were free from significant medication errors. Resident #54 received two (2) medications that were intended for his roommate. Resident #54 received a sulfonylureas (Glipizide) and an anticonvulsant (Dilantin). The resident did not have diagnoses that supported the need for these two (2) classes of medications. Resident identifier: #54. Facility census: 48.

Findings included:

a) Resident #54

A medication error report dated 12/27/23 regarding Resident #54 revealed the facility administered Glipizide 10 mg (milligram) po (by mouth) and Diazepam 5 mg po. These medications were both administered on 12/19/24 at 10:00 PM.

The medication error report revealed the medication belonged to Resident #54's roommate. Registered Nurse (RN) #29 administered the medication. The report revealed the physician was contacted and the resident was to be monitored, a snack given and glucose monitored every 3-4 hours. Further medical record review revealed this did not happen. There was no documentation to support that the resident received a snack, that glucose was monitored and that the residents ability to be aroused easily was monitored. There was also no evidence of a physician order requiring these things to be done. The medical record did not identify when the physician was notified.

On 03/27/24 at approximately 12:50 p.m., during an interview with Assistant Director of Nursing (ADON) #8 she was asked to provide documentation regarding the monitoring that was completed for Resident #54, and any subsequent orders that resulted form the call to the physician. Employee # 8 was unable to locate the information.

1. Identified resident #54 is no longer a resident at this facility. Resident #54 did not experience any adverse reactions that required medical intervention.

2. All residents have the potential to be affected by the alleged deficient practice. On 3/26/2024 the Director of Nursing (DON) reviewed all medication error reports for October 2023 - March 26, 2024.(attachment L). It was found that no other resident received the wrong medication.

3. The Director of Nursing provided documentation on 4/8/2024 that all Licensed Nurses had received education for the following policies:

Medication Administration, Change in Residents Condition or Status, and Adverse Reactions and Medication Errors policies (attachment H). On hire all Licensed Nurses will receive education by the Staff Development Nurse/designee on Medication administration, Change In residents' condition or status, and Adverse reactions and medication errors policies. The Director of Nursing/designee will observe Medication Administration weekly for 2 months then monthly for 6 months, thereafter, monitoring will occur on a quarterly basis for medication errors. (attachment I).

4. The Quality Assurance Nurse/designee will audit for Medication Administration compliance weekly times 2 months, then monthly times 6 months, thereafter, monitoring will occur on a quarterly basis (attachment 0) with any corrective action immediately upon discovery. All data will be presented by the QAPI Nurse to the QAPI Committee at least quarterly for analysis and any further action.

§483.75(a) Quality assurance and performance improvement (QAPI) program. Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must: §483.75(a)(1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities; §483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation; §483.75(a)(3) Present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request; and §483.75(a)(4) Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request. §483.75(b) Program design and scope. A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must: §483.75(b)(1) Address all systems of care and management practices; §483.75(b)(2) Include clinical care, quality of life, and resident choice; §483.75(b)(3) Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF. §483.75(b) (4) Reflect the complexities, unique care, and services that the facility provides. §483.75(f) Governance and leadership. The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that: §483.75(f)(1) An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities. §483.75(f)(2) The QAPI program is sustained during transitions in leadership and staffing; §483.75(f)(3) The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed; §483.75(f)(4) The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information. §483.75(f)(5) Corrective actions address gaps in systems, and are evaluated for effectiveness; and §483.75(f)(6) Clear expectations are set around safety, quality, rights, choice, and respect. §483.75(h) Disclosure of information. A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section. §483.75(i) Sanctions. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Based on medication error report review, policy review, medical record review and staff interview the facility failed to ensure their quality assurance committee analyses a significant medication errors to determine a root cause analysis and prevent the possible recurrence. Resident #54 received two (2) medications that were intended for his roommate. Resident #54 was one (1) of three (3) residents who were reviewed for significant medication errors. Resident #54 received a sulfonylureas (Glipizide) and an anticonvulsant (Dilantin). Resident identifier: #54. Facility census: 48.

Findings included:

a) Resident #54

On 03/27/24 at approximately 9:10 a.m., interview with Registered Nurse (RN)/QAPI (Quality Assurance and Performance Improvement) #47 she was asked to describe how medication administration errors are reported to the QAPI committee. RN/QAPI #47 replied " I get the med error numbers and report them out in the meeting. " RN/QAPI #47 was asked if a root cause analysis of medication administration errors are performed with each error. RN/QAPI #47 replied, " No, I do not do one each time. "

Review of the facility policy titled, "Adverse Reactions and Medication Errors" dated 02/20/24 revealed on page (3) of (5) the following: "The following information is documented in an incident report and in the resident's clinical record: Factual description of the error, name of physician and time notified, physician's subsequent orders, resident's condition for 24 to 72 hours or as directed. Each incident report is forwarded to: Director of Nursing, Quality Assurance Nurse, Medical Director and Consultant Pharmacist."

"The QAPI Committee will conduct a root cause analysis of the medication administration errors to determine the source of errors, implements process improvement steps, and compare results over time to determine that system improvements are effective in reduction errors."

1. Identified resident #54 is no longer 4/15/24 a resident at this facility.

2. Only residents who have a medication error have the potential to be affected by the alleged deficient practice. On 3/26/2024 the Director of Nursing (DON) reviewed all medication error reports for October 2023 - March 26, 2024. It was found that no other resident received the wrong medication.

3. A Root cause analysis form was implemented on 3/28/2024 by the Quality Assurance Performance Improvement Committee (QAPI) and will be completed with all medication errors (attachment J). On 3/29/24 the Quality Assurance Nurse educated nursing administration on the root cause analysis form (attachment M).

4. The Quality Assurance Nurse/designee will audit Medication Root Cause Analysis (RCA) records weekly for two months and then monthly for 6 months, thereafter monitoring will occur on a quarterly basis (attachment K).with any corrective action immediately upon discovery with review of Medications RCA's. All data will be presented by the QAPI Nurse to the QAPI Committee at least quarterly for analysis and any further action.

Hopemont Hospital is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. A review of the plans of correction and credible evidence was accepted in lieu of an onsite revisit for the investigation survey concluding on 03/27/24. The facility is in substantial compliance with the previously cited deficient practices

§483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under §483.75. §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. §483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. §483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

The facility must ensure that its- §483.45(f)(2) Residents are free of any significant medication errors.

§483.75(a) Quality assurance and performance improvement (QAPI) program. Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must: §483.75(a)(1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities; §483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation; §483.75(a)(3) Present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request; and §483.75(a)(4) Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request. §483.75(b) Program design and scope. A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must: §483.75(b)(1) Address all systems of care and management practices; §483.75(b)(2) Include clinical care, quality of life, and resident choice; §483.75(b)(3) Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF. §483.75(b) (4) Reflect the complexities, unique care, and services that the facility provides. §483.75(f) Governance and leadership. The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that: §483.75(f)(1) An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities. §483.75(f)(2) The QAPI program is sustained during transitions in leadership and staffing; §483.75(f)(3) The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed; §483.75(f)(4) The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information. §483.75(f)(5) Corrective actions address gaps in systems, and are evaluated for effectiveness; and §483.75(f)(6) Clear expectations are set around safety, quality, rights, choice, and respect. §483.75(h) Disclosure of information. A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section. §483.75(i) Sanctions. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

An unannounced complaint investigation survey was conducted at Hopemont Hospital from 001/09/24 to 01/12/24 defiencies cited are based on observations, interviews and record review as indicated. The facility's census on the first day of the survey was 44 residents.

An extended survey took place on 01/23/24 - 01/24/24 and on 02/09/24.

Complaint #30333 - substantiated with citations

§483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Based on observation, staff interviews, medical record review, temperature log review, and facility reportable incident (FRI) review, and hospital record review the facility neglected to ensure one (1) of six (6) residents was not subjected to hot water temperatures of 134 degrees Fahrenheit (F). This failure resulted in physical harm to Resident #19. Resident #19 sustained second degree burns to left hand, bilateral lower extremities and feet, bilateral buttocks and scrotum. This created an immediate jeopardy situation that began on 01/04/24 at 7:12 PM when the resident was placed in the tub and ended on 01/07/24 at 6:54 PM when all hot water was shut off in the facility. All residents had the potential to be affected by the hot water temperatures. Resident identifier: #19. Facility census: 44.

Findings included:

a) Facility Reportable Incident (FRI)

A facility reported incident was received at the state agency on 01/04/24. The report stated Nurse Aide (NA) #99 put Resident #19 into a whirlpool tub. She filled the tub to the knee level. The nurse aide realized the water was too warm. She had another aide try to adjust the water. The nurse aide admitted to not looking at the water temperature and this resulted in Resident #19 receiving severe burns to lower legs, feet, thighs, and left hand. The facility reported the immediate action taken was to suspend the nurse aide, take all tubs out of service and check for malfunction. Adult protective services were notified, as well as, the ombudsman, the local sheriff's department, and the nurse aide registry.

A second facility reported incident dated 01/04/24 related to Resident #19 was also received by the state agency. This incident stated the registered nurse did not assess or treat a resident with severe burns timely. The immediate action taken was a suspension of the registered nurse in addition to the nurse aide and a shutdown of the bathtubs.

A third facility reported incident dated 01/04/24 was sent to the state agency. This incident stated Maintenance Supervisor (MS) #76 had been monitoring water temperatures for over six (6) months which did not meet regulatory guidelines. MS #76 failed to report the temperatures or attempt to make any changes to meet regulatory compliance. The report revealed MS #76 said he was aware of the guidelines for water temperature and chose to keep it warmer per staff request.

The five (5) day follow up report obtained on 01/09/24 revealed the following:

"After reviewing camera and interviewing staff (Registered Nurse #100) was asked by CNA (certified nurse assistant) that was giving (Resident #19) his bath to assess him. Another CNA asked nurse to assess him. Finally at 7:36 she went to shower room and left at 7:37. At 8:44 she got order to send to ER (emergency room). No 1st aide administered by unit nurse until 9:05. Nurse (Registered Nurse #100) sent home until investigation over. (Registered Nurse #100) failed to assess (Resident #19) when asked 3 times by CNAs. Did not administer treatment in a timely manner. I find this report to be substantiated for neglect of resident. (Registered Nurse #100) will be removed from schedule and her agency will be notified of decision. Excessive delay in treatment."

This report was completed by social service supervisor.

A five day follow up to the immediate report for Certified Nurse Aide (NA) #41 revealed:
"After reviewing camera and interviewing NA #41 who was called to shower room and found the water too hot and adjusted water temperature. She was seen on camera leaving the shower room and going to nurses station but camera has no sound. I find this to be substantiated. NA #41 did adjust water but failed to assist in maintaining safety of resident. NA #41 sent home until investigation is done. I find this report to be substantiated for neglect of resident. NA #41 will be removed from schedule and her agency will be notified of decision." This report was completed by the social service supervisor.

b) Facility Entrance

During the entrance conference with the Assistant Nursing Home Administrator (ANHA) and the DON, on 01/09/24 at 12:25 PM, the DON stated Resident (#19) had received third degree burns to both lower extremities during a tub bath on the evening of 01/04/24. Resident #19 had been transferred to a local hospital and then transferred to an out of state burn unit.

c) Resident #19

Resident #19 was admitted to the facility 10/12/17. Medical diagnoses included dementia with behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, peripheral vascular disease (PVD), alcohol dependence in remission, Fabry's disease, and high blood pressure. No Brief Interview for Mental Status (BIMS) was able to be obtained as the only verbal response was grunting. The resident was incontinent of bowel and bladder and required total care. The state of West Virginia served as health care surrogate for this resident.

d) Timeline

A timeline provided by the facility revealed Resident #19 was taken to the "tub room" on 01/04/24 at 7:12 PM by Nurse Aide (NA) #99.

The following information is a review of the videotape of the hallway activity conducted by the Social Worker (SW) and the Minimum Data Set (MDS) Coordinator. This video was on 01/04/24 and reviewed on 01/05/24.

7:12 PM Resident #19 was taken to the tub room by Nurse Aide (NA) #99.
7:16 PM NA #99 out in the hall times two (2) and back to the tub room.
7:17 PM NA #99 out of the tub room-went to Resident #19's room and returned to the tub room.
7:20 PM NA #99 to Nurses Station (NS) then part way up hall got NA #41 and together they went to the tub room.
7:21 PM NA #41 leaves the tub room and goes to the NS back to the tub room and back to NS.
7:23 PM NA #41 in NS and leaves the NS at 7:24 PM.
7:26 PM NA #41 in the tub room then to NS at 7:27 PM.
7:29 PM NA #99 out in the hall to the linen cart and returns to the tub room.
7:33 PM NA #99 to NS and appears to be returning to the tub room. NA #99 gets NA #59 who is coming down the hall and they both go to the tub room together at 7:34.
7:35 PM NA #59 to NS.
7:36 PM NA #59 and RN #100 to tub room
7:36 PM NA #41 at NS
7:37 PM RN #100 returns to NS
7:52 PM NA #99 to NS and back to tub room
7:54 PM NA #99 to NS and back to tub room
8:00 PM RN #100 to tub room
8:02 PM RN #100 to NS
8:04 PM NA #63 arrives from Unit A1 to assist.
8:08 PM NA #41 leaves NS and goes to the tub room.
8:12 PM Resident #19 is taken back to his room.
8:15 PM NA #59 to NS and back to Resident #19's room
8:22 PM NA #41 to NS and then back to Resident #19's room
8:25 PM NA #63 leaves Resident #19's room, goes to the linen cart and returns to Resident #19's room.
8:28 PM NA #63 leaves Resident #19's room and returns with more linens.
8:33 PM NA #63 leaves Resident #19's room and returns with more linens.
8:38 PM NA #63 to NS and then to tub room
8:40 PM NA #59 to the tub room and then NS
8:41 PM NA #63 and #59 return to Resident #19's room.
8:42 PM NA #59 goes down B1 hall then returns to Resident #19's room.
8:43 PM NHA (nursing home administrator) on the unit and immediately goes to the tub room then NS and then to Resident #19's room.

A review of a nursing progress note by RN #100 revealed the resident was transferred on 01/04/24 at 9:15 PM to the local hospital. Resident #19 was documented to have blistering and peeling skin to bilateral feet and calves.

Vitals were documented from three (3) hours prior to transfer:
Temperature: 97.7 (36.5 C) (01/04/2024 17:53 (5:53 PM)
Pulse 55 (01/04/2024 17:53 (5:53 PM)
Respiration: 18 (01/04/2024 17:53 (5:53 PM)
Blood Pressure: 127/66 (01/04/2024 17:53 (5:53 PM)

e) Investigation Statements

-HSW (health service worker) #99

Statement dated 01/04/24 as follows:

"I was giving resident B110b (#19) a bath, as the last bit of water was draining out I noticed he had a blister on the back of his foot. I then went to the nurses station to tell the nurse (RN #100). she said she would come look at it shortly. I waited a few minutes and noticed more blisters were showing up so I went to get the other aide on the hall (name of aide) (HSW #59). She looked at it and also went to tell the nurse she needs to come look at it now. The nurse came to look at it and said she'd call the "on call nurse" to see what to do next. (see whether he'd need to be sent out or not.) HSW #99, #59 and #63 (identifiers used instead of names) transferred him to his wheelchair after letting some time go by to see what the nurse wanted us to do, then took him to his room, got him in bed, and laid cold compresses on his feet and legs to stop further blistering." Typed as written.

-HSW #41

Statement dated 01/04/24 as follows:

"I am floating unit to unit. I came over to B. As I was walking down the unit HSW #99 waved me down and asked me to lower the water temp. I walked in and put my hand in the water and said "that's hot." the [sic] looked at the temp gauge and it was 134. The water was past his knees but not running. I immediately turned the temp down and ran cold water in the bath. It cooled down and went out of the bath back to my task I was doing. Then when I walked back up the hall. I overheard he had blisters and recalled what happened. 1/4/24 9:01 pm I knew the bathtub would go to 140 but I didn't report it because the other staff told me it was normal and how to fix it." Typed as written.

-HSW #59 Statement

"(first name of HSW #59) came to get me to see if I could get the nurse to look at Resident #19 because she thought his feet looked bad and the nurse to her she would look at them when he got back into bed. So I went to the tub room to look at them and seen they were badly blistered on the top and sides and a blister on his shin (left). After I seen them I went to the nurses station to tell the nurse she needed to come look at him. She said "Why do they look bad?" I told her "no you want to come now." The nurse finally came into the tub room to see his feet when she saw the she asked if Resident #19 had edema? I told her yes, but that ' not the problem. The nurse then said she will go check the computer to see if day shift reported it. I told her it was from the water and those were burns because it looked like his skin was melting off. Resident #19 was left in the empty tub for awhile after and I decided he needed to be moved to his room via w/c (wheel chair) because he was ripping his skin off his legs by rubbing them together and ripping the skin off his feet by rubbing them on the drain. We put him to be and placed wet rags on his burns and stayed with him trying to keep him comfortable waiting to see what was going to happen. Stayed with him until EMS came. Signed by HSW #59 with date of 01/05/24."

-Nursing Home Administrator (NHA) statement on 01/09/24 at 10:04 AM.

"I arrived at Hopemont once being made aware of this issue of the burn. I went to the resident floor. Nurse (last name) RN #100 was at the nurses station. She said to me (Resident first name) #19 is in his room. I went to his room and CNA staff advised they repeatedly told (RN first name) RN #100 that resident (resident first name) #19 was burned and she needed to look at him. They said she only momentarily observed him while in the tub and left the bathroom. They got him out of the tub and took him to his room. I observed Resident #19 and stated he is in obvious discomfort and pain that needs to be addressed. They stated the nurse never came to his room. My involvement and goal was to see that appropriate steps regarding addressing this issue were implemented to identify, correct, process, and investigate the matter fully and thoroughly. I went to the nurses station after watching the resident writhing in pain. I advised RN #100 he needs pain management now. I asked if she had been to his room. She said no and asked if she should call the doctor. I told her something needs to be done now. Further I learned that the doctor ordered the resident sent out and that it was almost 30 minutes before RN #100 even called 911. She in no way assessed the resident and his care needs.
I helped interview her with the social worker. She excused her action on training and orientation. I explained as a long term RN and having worked here before she was well aware of the process, care responsibility, appropriate reaction to resident need and that emergency care is immediate paperwork second. She was removed from the schedule...."

-RN #100 Statement

"This nurse was at nurses desk when first CNA came out to desk from shower room and asked if resident's (Resident #19) feet normally peel. Told CNA I would check on it. Other CNA approached several minutes later and asked nurse to come and assess residents feet. This nurse went to assess feet. Lower part of legs about 1 inch red and feet were red, blistering and starting to peel. Attempted to contact A! to get phone numbers to try and contact on call. There was no answer. Attempted to message on call but reply not immediate. Got on call number from another staff and (unable to determine this word). Informed of situation. On call supposed to re-contact. Contacted MD for order to send out after second assessment with blisters large and redness moving up his legs. Delay in call back from on call. MD gave permission to send out. Contacted back by phone and several minutes later contacted by ADON. Started process to send out. Called 911 and gave report. Contacted MD back as ADON arrived and went to see resident to get order for pain med. Paper work put together and EMS arrived after giving pain med. Signed by RN #100." There was no date nor times when this statement was to when it was written and no times when calls were made or resident assessments completed.

A review of of nursing progress notes titled "Nursing transfer/Discharge Note" dated 01/04/24 at 20:27 (8:37 PM) found the following:

The resident left the facility on 01/04/24 at 9:00 PM. The transfer note described the resident as having blistering and peeling skin to bilateral feet and calves. The transfer note was electronically signed by Registered Nurse (RN) #100 on 01/04/24 at 8:49 PM.

Vitals at Time of Transfer:

Temperature: 97.7 (36.5 C) (01/04/2024 17:53 (5:53 PM)
Pulse: 55 (01/04/2024 17:53 (5:53 PM)
Respirations: 18 (01/04/2024 17:53 (5:53 PM)
Blood Pressure: 127/66 (01/04/2024 17:53 (5:53 PM)

These vitals were not taken at the time of transfer but approximately three (3) hours prior to transfer. At the time of transfer the resident was marked as confused.

A nursing note dated 01/05/24 at 1:02 AM stated that Resident (#19) was sent to (initials of local hospital) by MD order for evaluation and treatment for burns to bilateral lower extremities (BLE). The note stated the resident was in the bath and when water was let out it was reported that he had red skin and blisters to BLE. The note stated that the on call nurse was notified at 7:59 PM and the Medical Director (MD) was contacted and an order to send the resident out was obtained at 8:44 PM. Morphine 10 milligram (mg) was given by mouth previous to EMT arriving at 9:05 pm. The Emergency Medical Technicians (EMTs) left with the resident at 9:15 PM by ambulance on a stretcher. Electronic signature by RN #100 on 01/05/24 at 1:07 AM.

The resident's general condition was marked as confused, required total care and required total assistance for feeding. The resident moved all extremities. He had blisters on both lower extremities. He was incontinent of bowel and bladder with impairments of speech. RN #100 electronically signed the note on 01/04/24 at 8:40 PM.

In an interview with the Nursing Home Administrator (NHA), on 01/12/24 at 3:40 PM by phone, the NHA stated when he arrived in Resident #19's room, the resident was moving all over the bed and flailing his arms and legs. When the NHA went to the NS he said he told RN #100 that Resident #19 needed something for pain immediately.

A report from the local hospital where the resident was transferred revealed the resident had second degree burns to bilateral lower extremities and feet, left hand, bilateral buttocks and scrotum. The estimated surface area of the burns was 35%. At the local hospital the resident was given medications for pain including Morphine (injection 4 milligram) and Fentanyl (injection 100 microgram/2 milliliter). The resident was transported to a neighboring state burn center on 01/04/24 at 11:30 PM.

1. Resident #19 was transferred out of facility 1/4/2024 to Preston Memorial Hospital for emergency care, and no longer resides at Hopemont Hospital.

2. All residents had the potential to be affected by the alleged deficient practice. All residents received skin assessments on 1/5/2024 by the MDS Coordinator/designee, resulting in no other residents with evidence of burns.

3. On 1/4/2024, the Administrator directed the maintenance supervisor to disconnect the water and electric to the whirlpool tub disabling the tub from further use. On 1/4/2024, the Administrator and Assistant Director of Nursing (ADON)/designee instructed the Licensed Nurses and Certified Nursing Assistants (CNA's) who were on duty at that time to no longer use the whirlpool tub.

On 1/5/2024, the Quality Assurance Performance Improvement (QAPI) Nurse/designee informed the Licensed Nurses and CNAs who were on duty at that time not to use the showers for any resident care until further notice. On 1/5/2024, all Licensed Nurses and CNA's were informed by the Director of Nursing (DON)/designee to complete all resident baths via bed baths until further notice. On 1/7/2024, the facility hot water system was turned off as directed by the Administrator.

On 1/4/2024, the Administrator and ADON immediately reported Nursing Assistant (NA) # 99 to all required State agencies and law enforcement for allegations of abuse and neglect, and NA #99 was immediately suspended from work. On 1/4/202, the Administrator and ADON immediately reported Registered Nurse (RN) to all required State agencies and law enforcement for allegations of abuse and neglect and RN #100 was immediately suspended from work. On 1/5/2024, RN #00 was reported to the West Virginia Board of Registered Nurses (WVBRN). On 1/9/2024, the ADON followed up with the WVBRN and completed online reporting on RN #100.

An additional allegation of abuse/neglect was formulated on 1/5/24 regarding Maintenance Supervisor (MS) #76, resulting in immediate reporting of MS #76 by the Assistant Administrator to all required State agencies and law enforcement, and MS #76 was immediately suspended from work. During the course of the investigation an allegation of abuse/neglect was formulated on 1/8/2024 regarding NA #41, this resulted in the immediate reporting of NA #41 by the ADON o all required State agencies and law enforcement, and NA #41 was immediately suspended from work. Hopemont Hospital completed all investigations and reported the results to all State agencies within the required 5 day time frame. NA #99, NA #41, RN #100, and MS #76 are no longer employed at Hopemont Hospital.

On 1/11/2024, Hopement Hospital adopted a bathing policy which includes taking water temperatures prior to individual resident bathing to ensure a temperature of no higher than 110 degrees Fahrenheit, and supervision of residents during bathing to prevent harm. By 1/22/2024, the DON/ADON/designee educated all Licensed Nurses and Certificate Nursing Assistants on bathing policy, with return demonstration competencies that ensured understanding of resident bathing policy requirements.

Staff Development Coordinator/designee will review and document competency skills with all Licensed Nurses and Certified Nursing Assistants (CNA's) upon hire and annually on this bathing policy.

On 1/17/2024, the DON/designee educated maintenance staff on this bathing policy for monitoring, recording, maintaining, and reporting water temperatures to ensure hot water does not exceed 110 degrees Fahrenheit. Maintenance staff/designee have been following this bathing policy with monitoring temperatures daily or more frequently as needed. On 2/12/224, the QAPI committee held a meeting and updated this bathing policy to adjust the schedule of monitoring hot water temperatures to twice weekly or more frequently as needed. Staff Development Coordinator/designee will review and document competency skills with all Maintenance Staff upon hire and annually on this bathing policy.

4. Hot water temperatures measured above 110 degrees Fahrenheit during temperature monitoring, will be immediately reported by nursing/maintenance staff/designee to the administrator/designee. Hot water will not be used if it is measured to be higher than 110 degrees Fahrenheit.

Hot water temperature monitoring and any actions taken will be recorded on logs. Additionally, the QAPI nurse/designee will audit the logs of bathing and hot water temperatures and actions taken weekly for a period of six months, twice a month for six months and then monthly. The QAPI nurse/designee will immediately inform the administrator/designee when concerns are discovered with the review of the temperature logs. A report of findings will be presented by the QAPI nurse/designee to the QAPI committee at least quarterly for analysis and any further actions.

§483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Based on observation, staff interviews, medical record review, temperature log review, facility reportable incident (FRI) review, and hospital record review, the facility failed to ensure one (1) of six (6) residents had an environment which was as free of accident hazards as was possible. Nurse Aide (NA) #99 failed to monitor the water temperature when filling the tub. In addition NA #99 failed to supervise this resident during the bathing process. After Resident #19 was placed in the tub, water at 134 degrees (F) was used to fill the tub. Resident #19 sustained second degree burns to the left hand, bilateral lower extremities and feet, bilateral buttocks and scrotum. This created an immediate jeopardy situation that began on 01/04/24 at 7:12 PM when the resident was placed in the water and it ended on 01/07/24 at 6:54 PM when the hot water in the facility was turned off. When the immediate jeopardy was removed the result was harm to Resident #19. Resident identifier: #19. Facility census: 44.

Findings included:

a) Facility Reportable Incident (FRI)

A facility reported incident was received at the state agency on 01/04/24. The report stated Nurse Aide (NA) #99 put Resident #19 into a whirlpool tub. She filled the tub to the knee level. The nurse aide realized the water was too warm. She had another aide try to adjust the water. The nurse aide admitted to not looking at the water temperature and this resulted in Resident #19 receiving severe burns to lower legs, feet, thighs, and left hand. The facility reported the immediate action taken was to suspend the nurse aide, take all tubs out of service and check for malfunction. Adult protective services were notified, as well as, the ombudsman, the local sheriff's department, and the nurse aide registry.

A second facility reported incident dated 01/04/24 related to Resident #19 was also received by the state agency. This incident stated the registered nurse did not assess or treat a resident with severe burns timely. The immediate action taken was a suspension of the registered nurse in addition to the nurse aide and a shutdown of the bathtubs.

A third facility reported incident dated 01/04/24 was sent to the state agency. This incident stated MS #76 had been monitoring water temperatures for over six (6) months which did not meet regulatory guidelines. MS #76 failed to report the temperatures or attempt to make any changes to meet regulatory compliance. The report revealed MS #76 said he was aware of the guidelines for water temperature and chose to keep it warmer per staff request.

The five (5) day follow up report obtained on 01/09/24 revealed the following:

"After reviewing camera and interviewing staff (Registered Nurse #100) was asked by CNA (ceritfied nurse assistant) that was giving (Resident #19) his bath to assess him. Another CNA asked nurse to assess him. Finally at 7:36 she went to shower room and left at 7:37. At 8:44 she got order to send to ER (emergency room). No 1st aide administered by unit nurse until 9:05. Nurse (Registered Nurse #100) sent home until investigation over. (Registered Nurse #100) failed to assess (Resident #19) when asked 3 times by CNAs. Did not administer treatment in a timely manner. I find this report to be substantiated for neglect of resident. (Registered Nurse #100) will be removed from schedule and her agency will be notified of decision. Excessive delay in treatment."

This report was completed by the social service supervisor.

A five day follow up to the immediate report for Certified Nurse Aide (NA) #41 revealed:
"After reviewing camera and interviewing NA #41 who was called to shower room and found the water too hot and adjusted water temperature. She was seen on camera leaving the shower room and going to nurses station but camera has no sound. I find this to be substantiated. NA #41 did adjust water but failed to assist in maintaining safety of resident. NA #41 sent home until investigation is done. I find this report to be substantiated for neglect of resident. NA #41 will be removed from schedule and her agency will be notified of decision." This report was completed by the social service supervisor.

b) Facility Entrance

During the entrance conference with the Assistant Nursing Home Administrator (ANHA) and the DON, on 01/09/24 at 12:25 PM, the DON stated Resident (#19) had received third degree burns to both lower extremities during a tub bath on the evening of 01/04/24. Resident #19 had been transferred to a local hospital and then transferred to an out of state burn unit.

c) Resident #19

Resident #19 was admitted to the facility 10/12/17. Medical diagnoses included dementia with behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, peripheral vascular disease (PVD), alcohol dependence in remission, Fabry's disease, and high blood pressure. No Brief Interview for Mental Status (BIMS) was able to be obtained as the only verbal response was grunting. The resident was incontinent of bowel and bladder and required total care. The state of West Virginia served as health care surrogate for this resident.

d) Timeline

A timeline provided by the facility revealed Resident #19 was taken to the "tub room" on 01/04/24 at 7:12 PM by Nurse Aide (NA) #99.

The following information is a review of the videotape of the hallway activity conducted by the Social Worker (SW) and the Minimum Data Set (MDS) Coordinator. This video was on 01/04/24 and reviewed on 01/05/24.

7:12 PM Resident #19 was taken to the tub room by Nurse Aide (NA) #99.
7:16 PM NA #99 out in the hall times two (2) and back to the tub room.
7:17 PM NA #99 out of the tub room-went to Resident #19's room and returned to the tub room.
7:20 PM NA #99 to Nurses Station (NS) then part way up hall got NA #41 and together they went to the tub room.
7:21 PM NA #41 leaves the tub room and goes to the NS back to the tub room and back to NS.
7:23 PM NA #41 in NS and leaves the NS (nurses station) at 7:24 PM.
7:26 PM NA #41 in the tub room then to NS at 7:27 PM.
7:29 PM NA #99 out in the hall to the linen cart and returns to the tub room.
7:33 PM NA #99 to NS and appears to be returning to the tub room. NA #99 gets NA #59 who is coming down the hall and they both go to the tub room together at 7:34.
7:35 PM NA #59 to NS.
7:36 PM NA #59 and RN #100 to tub room
7:36 PM NA #41 at NS
7:37 PM RN #100 returns to NS
7:52 PM NA #99 to NS and back to tub room
7:54 PM NA #99 to NS and back to tub room
8:00 PM RN #100 to tub room
8:02 PM RN #100 to NS
8:04 PM NA #63 arrives from Unit A1 to assist.
8:08 PM NA #41 leaves NS and goes to the tub room.
8:12 PM Resident #19 is taken back to his room.
8:15 PM NA #59 to NS and back to Resident #19's room
8:22 PM NA #41 to NS and then back to Resident #19's room
8:25 PM NA #63 leaves Resident #19's room, goes to the linen cart and returns to Resident #19's room.
8:28 PM NA #63 leaves Resident #19's room and returns with more linens.
8:33 PM NA #63 leaves Resident #19's room and returns with more linens.
8:38 PM NA #63 to NS and then to tub room
8:40 PM NA #59 to the tub room and then NS
8:41 PM NA #63 and #59 return to Resident #19's room.
8:42 PM NA #59 goes down B1 hall then returns to Resident #19's room.
8:43 PM NHA (nursing home administrator) on the unit and immediately goes to the tub room then NS and then to Resident #19's room.

A review of a nursing progress note by RN #100 revealed the resident was transferred on 01/04/24 at 9:15 PM to the local hospital. Resident #19 was documented to have blistering and peeling skin to bilateral feet and calves.

Vitals were documented from three (3) hours prior to transfer:
Temperature: 97.7 (36.5 C) (01/04/24 17:53 (5:53 PM)
Pulse 55 (01/04/24 17:53 (5:53 PM)
Respiration: 18 (01/04/24 17:53 (5:53 PM)
Blood Pressure: 127/66 (01/04/24 17:53 (5:53 PM)

e) Investigation Statements

-HSW (health service worker) #99

Statement dated 01/04/24 as follows:

"I was giving resident B110b (#19) a bath, as the last bit of water was draining out I noticed he had a blister on the back of his foot. I then went to the nurses station to tell the nurse (RN #100). she said she would come look at it shortly. I waited a few minutes and noticed more blisters were showing up so I went to get the other aide on the hall (name of aide) (HSW #59). She looked at it and also went to tell the nurse she needs to come look at it now. The nurse came to look at it and said she'd call the "on call nurse" to see what to do next. (see whether he'd need to be sent out or not.) HSW #99, #59 and #63 (identifiers used instead of names) transferred him to his wheelchair after letting some time go by to see what the nurse wanted us to do, then took him to his room, got him in bed, and laid cold compresses on his feet and legs to stop further blistering." Typed as written.

-HSW #41

Statement dated 01/04/24 as follows:

"I am floating unit to unit. I came over to B. As I was walking down the unit HSW #99 waved me down and asked me to lower the water temp. I walked in and put my hand in the water and said "that's hot." the [sic] looked at the temp gauge and it was 134. The water was past his knees but not running. I immediately turned the temp down and ran cold water in the bath. It cooled down and went out of the bath back to my task I was doing. Then when I walked back up the hall. I overheard he had blisters and recalled what happened. 1/4/24 9:01 pm I knew the bathtub would go to 140 but I didn't report it because the other staff told me it was normal and how to fix it." Typed as written.

-HSW #59 Statement

"(first name of HSW #59) came to get me to see if I could get the nurse to look at Resident #19 because she thought his feet looked bad and the nurse to her she would look at them when he got back into bed. So I went to the tub room to look at them and seen they were badly blistered on the top and sides and a blister on his shin (left). After I seen them I went to the nurses station to tell the nurse she needed to come look at him. She said "Why do they look bad?" I told her "no you want to come now." The nurse finally came into the tub room to see his feet when she saw the she asked if Resident #19 had edema? I told her yes, but that ' not the problem. The nurse then said she will go check the computer to see if day shift reported it. I told her it was from the water and those were burns because it looked like his skin was melting off. Resident #19 was left in the empty tub for awhile after and I decided he needed to be moved to his room via w/c (wheel chair) because he was ripping his skin off his legs by rubbing them together and ripping the skin off his feet by rubbing them on the drain. We put him to be and placed wet rags on his burns and stayed with him trying to keep him comfortable waiting to see what was going to happen. Stayed with him until EMS came. Signed by HSW #59 with date of 01/05/24."

-Nursing Home Administrator (NHA) statement on 01/09/24 at 10:04 AM.

"I arrived at Hopemont once being made aware of this issue of the burn. I went to the resident floor. Nurse (last name) RN #100 was at the nurses station. She said to me (Resident first name) #19 is in his room. I went to his room and CNA staff advised they repeatedly told (RN first name) RN #100 that resident (resident first name) #19 was burned and she needed to look at him. They said she only momentarily observed him while in the tub and left the bathroom. They got him out of the tub and took him to his room. I observed Resident #19 and stated he is in obvious discomfort and pain that needs to be addressed. They stated the nurse never came to his room. My involvement and goal was to see that appropriate steps regarding addressing this issue were implemented to identify, correct, process, and investigate the matter fully and thoroughly. I went to the nurses station after watching the resident writhing in pain. I advised RN #100 he needs pain management now. I asked if she had been to his room. She said no and asked if she should call the doctor. I told her something needs to be done now. Further I learned that the doctor ordered the resident sent out and that it was almost 30 minutes before RN #100 even called 911. She in no way assessed the resident and his care needs.
I helped interview her with the social worker. She excused her action on training and orientation. I explained as a long term RN and having worked here before she was well aware of the process, care responsibility, appropriate reaction to resident need and that emergency care is immediate paperwork second. She was removed from the schedule...."

-RN #100 Statement

"This nurse was at nurses desk when first CNA came out to desk from shower room and asked if resident's (Resident #19) feet normally peel. Told CNA I would check on it. Other CNA approached several minutes later and asked nurse to come and assess residents feet. This nurse went to assess feet. Lower part of legs about 1 inch red and feet were red, blistering and starting to peel. Attempted to contact A! to get phone numbers to try and contact on call. There was no answer. Attempted to message on call but reply not immediate. Got on call number from another staff and (unable to determine this word). Informed of situation. On call supposed to re-contact. Contacted MD for order to send out after second assessment with blisters large and redness moving up his legs. Delay in call back from on call. MD gave permission to send out. Contacted back by phone and several minutes later contacted by ADON. Started process to send out. Called 911 and gave report. Contacted MD back as ADON arrived and went to see resident to get order for pain med. Paper work put together and EMS arrived after giving pain med. Signed by RN #100." There was no date nor times when this statement was to when it was written and no times when calls were made or resident assessments completed.

A review of of nursing progress notes titled "Nursing transfer/Discharge Note" dated 01/04/24 at 20:27 (8:37 PM) found the following:

The resident left the facility on 01/04/24 at 9:00 PM. The transfer note described the resident as having blistering and peeling skin to bilateral feet and calves. The transfer note was electronically signed by Registered Nurse (RN) #100 on 01/04/24 at 8:49 PM. The order from the physician to send the resident out of the facility was obtained by the RN at 8:44 PM. The reportable record showed the nurse aides (#41 and #99) first began asking RN #100 for assistance and to assess Resident #19 due to blisters from the hot water on 01/04/24 at 7:36 PM.

f) A review of the water temperature logs revealed the following:

Water Temperature Leaving Mixing Valve, located in the "Potato Room" i.e., boiler room, which supplies hot water to resident care areas as follows:

Water Temperatures:
January 2023

01/03/23 122 degrees (F), 01/04/23 120 degrees (F), 01/05/23 118 degrees (F), 01/06/23 124 degrees (F), 01/09/23 120 degrees (F), 01/10/23 126 degrees (F), 01/11/23 122 degrees (F), 01/12/23 120 degrees (F), 01/15/23 120 degrees 126 degrees (F), 01/18/23 124 degrees (F), 01/19/23 122 degrees (F), 01/20/23 120 degrees (F), , 01/24/23 126 degrees (F), 01/25/23 122 degrees (F), 01/26/23 126 degrees (F), 01/27/23 124 degrees (F), 01/30/23 126 degrees (F), 01/31/23 126 degrees (F),

February 2023

02/02/23 124 degrees (F), 02/03/23 124 degrees (F), 02/06/23 126 degrees (F), 02/07/23 124 degrees (F), 02/08/23 130 degrees (F),02/13/23 126 degrees (F), 02/14/23 124 degrees (F), 02/15/23 128 degrees (F), 02/16/23 126 degrees (F), 02/17/23 128 degrees (F), 02/21/23 124 degrees (F), 02/22/23 128 degrees (F), 02/23/23 126 degrees (F), 02/24/23 128 degrees (F), 02/27/23 120 degrees (F)

March 2023

03/01/23 126 degrees (F), 03/02/23 120 degrees (F), 03/03/23 124 degrees (F), 03/06/23 130 degrees (F), 03/07/23 124 degrees (F), 03/08/23 126 degrees (F), 03/09/23 126 degrees (F), 03/10/23 130 degrees (F), 03/16/23 120 degrees (F), 03/20/23 130 degrees (F), 03/21/23 130 degrees (F), 03/22/23 119 degrees (F), 03/23/23 124 degrees (F) 03/27/23 124 degrees (F), 03/28/23 128 degrees (F)

April 2023

04/03/23 120 degrees (F), 04/04/23 126 degrees (F), 04/05/23 124 degrees (F), 04/06/23 119 degrees (F), 04/07/23 121 degrees (F), 04/10/23 120 degrees (F), 04/11/23 124 degrees (F), 04/12/23 123 degrees (F), 04/13/23 121 degrees (F), 04/14/23 115 degrees (F), 04/17/23 125 degrees (F), 04/18/23 120 degrees (F), 04/19/23 119 degrees (F), 04/20/23 121 degrees (F), 04/21/21 122 degrees (F),
04/24/23 130 degrees (F), 04/25/23 128 degrees (F), 04/26/23 115 degrees (F), 04/28/23 120 degrees (F)

May 2023

05/01/23 120 degrees (F), 05/02/23 124 degrees (F), 05/03/23 122 degrees (F), 05/04/23 122 degrees (F), 05/05/23 118 degrees (F), 05/10/23 116 degrees (F), 05/11/23 124 degrees (F), 05/15/23 120 degrees (F), 05/16/23 126 degrees (F), 05/17/23 130 degrees (F), 05/18/23 120 degrees (F), 05/19/23 118 degrees (F), 05/22/23 122 degrees (F), 05/23/23 120 degrees (F), 05/24/23 116 degrees (F), 05/26/23 130 degrees (F), 05/29/23 130 degrees (F), 05/30/23 120 degrees (F), 05/31/23 124 degrees (F)


June 2023

06/01/23 120 degrees (F), 06/02/23 112 degrees (F), 06/05/23 120 degrees (F), 06/06/23 116 degrees (F), 06/07/23 120 degrees (F), 06/08/23 130 degrees (F), 06/09/23 130 degrees (F), 06/12/23 118 degrees (F), 06/13/23 126 degrees (F), 06/14/23 122 degrees (F), 06/15/23 124 degrees (F), 06/16/23 118 degrees (F), 06/19/23 121 degrees (F), 06/20/23 114 degrees (F), 06/21/23 120 degrees (F), 06/22/23 122 degrees (F), 06/23/24 116 degrees (F), 06/26/23 131 degrees (F), 06/27/23 122 degrees (F), 06/28/23 124 degrees (F), 06/29/23 120 degrees (F), 06/30/23 124 degrees (F)

July 2023

07/05/23 121 degrees (F), 07/06/23 120 degrees (F), 07/07/23 120 degrees (F), 07/10/23 121 degrees (F), 07/11/23 116 degrees (F), 07/14/23 120 degrees (F), 07/17/23 122 degrees (F), 07/18/23 132 degrees (F), 07/19/23 124 degrees (F), 07/20/23 114 degrees (F), 07/21/23 128 degrees (F),07/26/23 120 degrees (F), 07/27/23 118 degrees (F), 07/28/23 122 degrees (F), 07/31/23 120 degrees (F)

August 2023

08/01/23 120 degrees (F), 08/02/23 118 degrees (F), 08/03/23 120 degrees (F), 08/04/23 124 degrees (F), 08/07/23 120 degrees (F), 08/08/23 121 degrees (F), 08/09/23 118 degrees (F), 08/10/23 122 degrees (F), 08/11/23 130 degrees (F), 08/14/23 121 degrees (F), 08/15/23 129 degrees (F), 08/16/23 118 degrees (F), 08/18/23 136 degrees (F), 08/21/23 120 degrees (F), 08/22/23 124 degrees (F), 08/23/23 133 degrees (F), 08/24/23 114 degrees (F), 08/25/23 126 degrees (F), 08/28/23 130 degrees (F), 08/29/23 140 degrees (F), 08/30/23 128 degrees (F),

September 2023

09/01/23 125 degrees (F), 09/05/23 128 degrees (F), 09/06/23 130 degrees (F), 09/07/23 126 degrees (F), 09/08/23 130 degrees (F), 09/11/23 126 degrees (F), 09/12/23 124 degrees (F), 09/13/23 121 degrees (F) , 09/18/23 130 degrees (F), 09/19/23 126 degrees (F), 09/20/23 124 degrees (F), 09/21/23 120 degrees (F), 09/29/23 130 degrees (F)

October 2023

10/02/23 125 degrees (F), 10/03/23 130 degrees (F), 10/04/23 132 degrees (F), 10/05/23 130 degrees (F) 10/09/23 140 degrees (F), 10/10/23 138 degrees (F), 10/11/23 10/13/23 130 degrees (F), 10/16/23 120 degrees (F), 10/17/23 130 degrees (F), 10/18/23 124 degrees (F), 10/19/23 124 degrees (F),10/20/23 128 degrees (F), 10/24/23 132 degrees (F), 10/25/23 128 degrees (F), 10/26/23 130 degrees (F), 10/27/23 142 degrees (F), 10/30/23 140 degrees (F), 10/31/23 132 degrees (F)

November 2023

11/01/23 128 degrees (F), 11/02/23 132 degrees (F), 11/03/23 141 degrees (F), 11/06/23 140 degrees (F), 11/07/23 128 degrees (F), 11/08/23 130 degrees (F), 11/09/23 134 degrees (F), 11/13/23 130 degrees (F), 11/14/23 126 degrees (F),

December 2023

12/01/23 130 degrees (F), 12/04/23 130 degrees (F), 12/05/23 132 degrees (F), 12/06/23 140 degrees (F), 12/07/23 128 degrees (F), 12/08/23 132 degrees (F), 12/11/23 130 degrees (F), 12/12/23 126 degrees (F), 12/13/23 140 degrees (F), 12/14/23 140 degrees (F), 12/15/23 138 degrees (F), 12/20/23 130 degrees (F), 12/21/23 126 degrees (F), 12/22/23 140 degrees (F), 12/26/23 128 degrees (F), 12/28/23 132 degrees (F), 12/29/23 130 degrees (F)

January 2023

There were no temperatures avaialble prior to 01/04/24 when a temperature of 140 degrees (F) was recorded after the incident.

Record review revealed water temperatures continued to be above 110 degrees (F) on 01/05/24, 01/06/24, and on 01/07/24. These temperatures logs revealed temperateurs were taken at four (4) sinks, and in the shower room.

There were no temperatures recorded on weekends and holidays.

Record review on 01/09/24 at 2:18 PM, revealed no evidence was provided during the survey to show the corrective action or adjustments to the resident hot water system when water temperatures were routinely recorded above 110 degrees Fahrenheit (F) monthly from January 2023 through December 2023. Approximately 121 days had temperatures logged above 110 degrees Fahrenheit. These temperatures were logged by the Maintenance Department Staff for resident corridors A1, B1, and resident areas (Gore) and Dining Room (Gore). An interview on 01/09/24 at 2:20 PM. with the Assistant Administrator verified this finding.

Nurse Educator (NE) #78

An email from the nurse educator to administrative staff dated 01/07/24 at 9:54 AM revealed NE #78 was still concerned about the hot water in the sinks. In the email the nurse educator explained that the staff had been told not to use the hot water because it had been registering over 110 degrees (F). The nurse educator stated she was concerned that residents would use the sink and nursing could not monitor the situaiton. In her email the Nurse Educator said that Licensed Practical Nurse (LPN) #46 had asked about shutting the hot water off and was told it could not be done.

On 01/11/24 the administrator gave a statement to the surveyor indicating he ordered access to all hot water be shut down in the resident care areas on 01/07/24 at 6:54 PM.

g) The Quality Assurance and Performance Improvement Committee (QAPI) met on 01/09/24 at approximately 10:00 a.m. to discuss the current situation of water temps for resident care.

Documentation revealed that water temps were being checked every hour since 01/05/24 at the four (4) main sinks on Resident corridors of A1 and B1 and the resident showers on the corridors of A1 and Gore 1, with this documentation forwarded to Administration for review.

The showers had not been used since 01/04/24. Repairs were initiated on the hot water system on 01/08/24 to isolate the hot water distributed to the resident care areas and residents currently have no access to hot water until the final repairs are made.

Prior to the time of survey, potential mechanical issues with an isolation valve, hot water tank thermostat, and a water system distribution mixing valve and gauge were discovered. The isolation valve, thermostat, and mixing valve gauge had been replaced prior to survey. The water system distribution mixing valve was being investigated further with parts being ordered for repair during survey. Nursing staff were notified that they would be using wipes and no rinse shampoo and body wash until further notice.

Per the QAPI meeting minutes, reeducation was provided to staff reiterating appropriate hot water temperatures and completing maintenance work orders if issues are suspected with the temperature of the water system.

Phone interview on 01/09/24 at approximately 11:36 AM., with the Director of Facilities and Plant Operations #97 revealed the perceived issue with the hot water system was a faulty thermostat on the hot water tank serving resident corridors A1 and B1 of the Nursing Building. The issue with the thermostat was believed to have failed in the close position and was discovered mid-morning on Friday, January 5th. The hot water system was drained and refilled with 55-degree city water. An isolation valve was added on Monday, January 8th. Interview also noted that hot water temperatures were not supposed to be above 110 degrees (F).

Observation on 01/09/24 at approximately 12:14 PM. revealed the only hot water being provided was to the Dining Areas. The temperature of hot water at a hand sink in the Dining area was noted as 109.1 degrees (F). Hot water to the other resident areas such as Corridor A1, B1, and corridor Gore 1 was isolated off in the basement and handles removed form faucets and fixtures to prevent residents from accidentally turning on the hot water while repairs and adjustments were made to the system.

Interview on 01/09/24 at approximately 1:03 PM., with Building Maintenance Mechanic #95 revealed that an issue with a thermostat on a hot water tank in the basement (Potato Room) was discovered and replaced. A ball valve was also replaced as a suspected back-feed elimination. A gauge for the mixing valve for the water leaving this area to the resident areas was also replaced. Interview noted that a daily log of the water temperatures was maintained in each mechanical room. Interview noted that he was not aware that temperatures above 110 degrees (F) needed to be reported and only recorded what the gauges read and was not previously aware of what the water temperatures were supposed to be maintained at.

Phone interview on 01/10/24 at approximately 9:43 AM, with the Maintenance Supervisor #76 noted that he had been the Maintenance Supervisor for approximately 5 years. The interview revealed he recorded the temperatures of the hot water system as noted on the gauges and was aware that the temperatures were supposed to be maintained at 110 degrees (F). He also noted he tried to keep temperatures warm enough on the floors. He said nursing would let him know if the temperatures seemed too cold. Interview noted that he did not report the daily/monthly temperature logs to any committee or had not been asked for them.

The Office of Health Facilities Policy (Policy OHF.LS.0002) for Preventive Maintenance and Casualty Prevention Plan was updated to include an effective date based upon the date of approval on the signature page.

This policy outlined the testing and preventative maintenance procedures and documentation requirements for the Plant Operations, Maintenance, and Engineering Staff. Documentation from the Preventative Maintenance and Casualty Prevention Plan is monitored through safety surveillance, which is conducted hospital wide monthly by members of the Safety Committee. These inspection reports are to be given to the Safety Officer, who will then assign corrective action from the appropriate department. This policy outlines that all boiler room equipment gauges are to be visually monitored daily and that patient hot water is not to exceed 110 degrees Fahrenheit with any deviations reported the Maintenance Department immediately.

In a conversation between the local plumber and NHA, on 01/11/24 at 3:45 PM, the plumber stated the mixing value was defective and would have to be replaced as well as relocating the mixing valve. There were no mixing valves available locally and would have to be ordered. The plumber also suggested that filters be built into the water system to collect dirt. The NHA comment was "Whatever it takes."

1. Resident #19 was transferred out of facility 1/4/2024 to Preston Memorial Hospital for emergency care, and no longer resides at Hopemont Hospital.

2. All residents had the potential to be affected by the alleged deficient practice. All residents received skin assessments on 1/5/2024 by the MDS Coordinator/designee, resulting in no other residents with evidence of burns.

3. On 1/4/2024, the Administrator directed the maintenance supervisor to disconnect the water and electric to the whirlpool tub disabling the tub from further use. On 1/4/2024, the Administrator and Assistant Director of Nursing (ADON)/designee instructed the Licensed Nurses and Certified Nursing Assistants (CNA's) who were on duty at that time to no longer use the whirlpool tub. On 1/5/2024, the Quality Assurance Performance Improvement (QAPI) Nurse/designee informed the Licensed Nurses and CNA's who were on duty at that time not to use the showers for any resident care until further notice. On 1/5/2024, all Licensed Nurses and CNA's were informed by the Director of Nursing (DON)/designee to complete all resident baths via bed baths until further notice. On 1/7/2024, the facility hot water system was turned off as directed by the Administrator.

On 1/4/2024, the Administrator and ADON immediately reported Nursing Assistant (NA) # 99 to all required State agencies and law enforcement for allegations of abuse and neglect, and NA # 99 was immediately suspended from work. On 1/4/2024, the Administrator and ADON immediately reported Registered Nurse (RN) to all required State agencies and law enforcement for allegations of abuse and neglect and RN #100 was immediately suspended from work. On 1/5/2024, RN #100 was reported to the West Virginia Board of Registered Nurses (WVBRN). On 1/9/2024, the ADON followed up with the WVBRN and completed online reporting on RN # 100. An additional allegation of abuse/neglect was formulated on 1/5/24 regarding Maintenance Supervisor (MS) #76, resulting in immediate reporting of MS #76 by the Assistant Administrator to all required State agencies and law enforcement, and MS #76 was immediately suspended from work. During the course of the investigation, an allegation of abuse/neglect was formulated on 1/8/2024 regarding NA #41, this resulted in the immediate reporting of NA #41 by the ADON to all required State agencies and law enforcement, and NA #41 was immediately suspended from work. Hopemont Hospital completed all investigations and reported the results to all State agencies within the required 5 day time frame. NA #99, NA #41, RN #100, and MS #76 are no longer employed at Hopemont Hospital.

On 1/11/2024, Hopemont Hospital adopted a bathing policy which includes taking water temperatures prior to individual resident bathing to ensure a temperature of no higher than 110 degrees Fahrenheit, and supervision of residents during bathing to prevent harm. By 1/22/2024, the DON/ADON/designee educated all Licensed Nurses and Certified Nursing Assistants on the bathing policy, with return demonstration competencies that ensured understanding of resident bathing policy requirements. Staff Development Coordinator/designee will review and document competency skills with all Licensed Nurses and Certified Nursing Assistants (CNA's) upon hire and annually on this bathing policy.

On 1/17/2024, the DON/designee educated maintenance staff on this bathing policy for monitoring, recording, maintaining, and reporting water temperatures to ensure hot water does not exceed 110 degrees Fahrenheit. Maintenance staff/designee have been following this bathing policy with monitoring temperatures daily or more frequently as needed. On 2/12/2024, the QAPI committee held a meeting and updated this bathing policy to adjust the schedule of monitoring hot water temperatures to twice weekly or more frequently.

Staff Development Coordinator/designee will review and document competency skills with all Maintenance Staff upon hire and
annually on this bathing policy.

Upon inspection of the facility hot water system on 1/5/2024, the Maintenance Supervisor (MS) identified a faulty hot water tank
thermostat affecting residential hot water temperatures and the thermostat was replaced immediately on 1/5/2024 by the MS/designee. A new hot water mixing valve was installed on 1/16/2024 by the Maintenance Workers under the supervision of the Office of Health Facilities Buildings and Grounds Manager (OHFBGM). The maintenance staff will receive training and associated competency for the preventative and routine maintenance of the facility hot water system from the OHFBGM/designee by 3/22/2024.
Additionally, all newly hired maintenance staff will receive training with the associated competency on this bathing policy and preventative and routine maintenance of the facility hot water system during orientation. The safety compliance officer/designee is responsible for reporting water temperatures to the Administrator/designee immediately if any identified water temperatures are greater than 110 degrees Fahrenheit.

4.. Hot water temperatures measured above 110 degrees Fahrenheit during temperature monitoring, will be immediately reported by
nursing/maintenance staff/designee to the administrator/designee. Hot water will not be used if it is measured to be higher than 110
degrees Fahrenheit. Hot water temperature monitoring and any actions taken will be recorded on logs. Additionally, the QAPI
nurse/designee will audit the logs of bathing and hot water temperatures and actions taken weekly for a period of six months, twice a month for six months and then monthly. The QAPI nurse/designee will immediately inform the administrator/designee when concerns are discovered with the review of the temperature logs. A report of findings will be presented by the QAPI nurse/designee to the QAPI committee at least quarterly for analysis and any further actions.

§483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Based on a review of the orientation records, and staff interviews, the facility failed to ensure licensed staff and nurse aides were able to demonstrate competency skills and techniques necessary to care for resident needs. Registered Nurse #100 (RN) failed to render aid timely to Resident #19 who sustained third degree burns. A nurse aide (NA) failed to ensure one (1) of six (6) resident's safety during a bath. The nurse aide exposed the resident to water at 134 degrees Fahrenheit (F). This caused third degree burns to the resident. Resident identifier: #19. Staff identifiers: Registered Nurse (RN) #100, Nurse Aide #99. This failed practice created an immediate jeopardy situation that began on 01/04/24 when the resident was place in the bath and ended on 01/22/24 when all staff completed competencies on safe bathing. Water temperatures more than 110 degrees (F) were recorded from January 3, 2024, until the hot water access to resident care areas was shut down on 01/07/24 at 6:54 PM. This had the potential to affect all residents residing in the facility. Facility census: 44.

Findings included:

a) Facility Reportable Incident (FRI)

A facility reported incident was received at the state agency on 01/05/24. The report stated Nurse Aide #99 put Resident #19 into a whirlpool tub. She filled the tub to the knee level. The nurse aide realized the water was too warm. She had another aide try to adjust the water. The nurse aide admitted to not looking at the water temperature and this resulted in Resident #19 receiving severe burns to lower legs, feet, thighs, and left hand. The facility reported the immediate action taken was to suspend the nurse aide, take all tubs out of service and check for malfunction. Adult protective services were notified, the ombudsman, the local sheriff's department, and the nurse aide registry.

A second facility reported incident dated 01/04/24 related to Resident #19 was also received by the state agency. This incident stated the registered nurse did not assess or treat a resident with severe burns timely. The immediate action taken was a suspension of the registered nurse in addition to the nurse aide and a shutdown of the bathtubs.

A third facility reported incident dated 01/05/24 was sent to the state agency. This incident stated MS #76 had been monitoring water temperatures for over six (6) months that did not meet regulatory guidelines. MS #76 failed to report the temperatures or attempt to make any changes to meet regulatory compliance. The report revealed MS #76 said he was aware of the guidelines for water temperature and chose to keep it warmer per staff request.

The five (5) day follow up report obtained on 01/09/24 revealed the following:

"After reviewing camera and interviewing staff (Registered Nurse #100) was asked by CNA (ceritfied nurse assistant) that was giving (Resident #19) his bath to assess him. Another CNA asked nurse to assess him. Finally at 7:36 she went to shower room and left at 7:37. At 8:44 she got order to send to ER (emergency room). No 1st aide administered by unit nurse until 9:05. Nurse (Registered Nurse #100) sent home until investigation over. (Registered Nurse #100) failed to assess (Resident #19) when asked 3 times by CNAs. Did not administer treatment in a timely manner. I find this report to be substantiated for neglect of resident. (Registered Nurse #100) will be removed from schedule and her agency will be notified of decision. Excessive delay in treatment."

This report was completed by the social service supervisor.

A five day follow up to the immediate report for Certified Nurse Aide (NA) #41 revealed:
"After reviewing camera and interviewing NA #41 who was called to shower room and found the water too hot and adjusted water temperature. She was seen on camera leaving the shower room and going to nurses station but camera has no sound. I find this to be substantiated. NA #41 did adjust water but failed to assist in maintaining safety of resident. NA #41 sent home until investigation is done. I find this report to be substantiated for neglect of resident. NA #41 will be removed from schedule and her agency will be notified of decision." This report was completed by the social service supervisor.

Resident #19 was admitted to the facility 10/12/2017. Medical diagnoses included dementia with behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, peripheral vascular disease (PVD), alcohol dependence in remission, Fabry's disease, and high blood pressure. No Brief Interview for Mental Status (BIMS) was able to be obtained as the only verbal response was grunting.

A review of nursing progress note revealed the resident was transferred on 01/04/24 at 9:00 PM. Resident #19 was documented to have blistering and peeling skin to bilateral feet and calves.

Medical Record Review revealed the resident's general condition was marked as confused, required total care, and required total assistance for feeding. The resident moved all extremities. He had blistering to both lower extremities. He was incontinent of bowel and bladder with impairments of speech. RN #100 electronically signed her note on 01/04/24 at 8:40 PM.

A nursing note dated 01/05/24 at 1:02 AM stated that Resident (#19) sent to (initials of local hospital) by MD order for eval and treat for burns to BLE (both lower extremities). The resident was in bath and when water was let out it was reported that he had red skin and blisters BLE. The note stated "Contacted on call at 7:59 pm. MD notified and order for send out obtained and put in 9:10pm. Morphine 10 mg given P.O. before EMT arriving at 9:05pm. EMT left with resident at 9:15PM by ambulance on a stretcher." RN #100 electronically signed this note on 01/05/24 at 1:07 AM.

b) A video review with statements was provided to the surveyor by the facility

The following was a review of the video tape of the hallway activity conducted by the Social Worker (SW) and the Minimum Data Set (MDS) Coordinator. This video was on 01/04/24 and reviewed on 01/05/24.

7:12 PM Resident #19 was taken to the tub room by Nurse Aide (NA) #99.
7:16 PM NA #99 out in the hall times two (2) and back to tub room.
7:17 PM NA #99 out of tub room-went to Resident #19's room and returned to tub room.
7:20 PM NA #99 to Nurses Station (NS) then part way up hall got CNA #41 and together they went to tub room.
7:21 PM NA #41 leaves the tub room and goes to the NS back to tub room and back to NS.
7:23 PM NA #41 in NS and leaves the NS at 7:24 PM.
7:26 PM NA #41 in tub room then to NS at 7:27 PM.
7:29 PM NA #99 out in hall to linen cart and returns to tub room.
7:33 PM NA #99 to NS and appears to be returning to the tub room. CNA #99 gets CNA #59 who is coming down the hall and they both go to the tub room together at 7:34.
7:35 PM NA #59 to NS.
7:36 PM NA #59 and RN #100 to tub room
7:36 PM NA #41 at NS
7:37 PM RN #100 returns to NS
7:52 PM NA #99 to NS and back to tub room
7:54 PM NA #99 to NS and back to tub room
8:00 PM RN #100 to tub room
8:02 PM RN #100 to NS
8:04 PM NA #63 arrives from Unit A1 to assist.
8:08 PM NA #41 leaves NS and goes to tub room.
8:12 PM Resident #19 is taken back to his room.
8:15 PM NA #59 to NS and back to Resident #19's room
8:22 PM NA #41 to NS and then back to Resident #19's room
8:25 PM NA #63 leaves Resident #19's room, goes to linen cart and returns to Resident #19's room.
8:28 PM NA #63 leaves Resident #19's room and returns with more linens.
8:33 PM NA #63 leaves Resident #19's room and returns with more linens.
8:38 PM NA #63 to NS and then to tub room
8:40 PM NA #59 to tub room and then NS
8:41 PM NA #63 and #59 return to Resident #19's room.
8:42 PM NA #59 goes down B1 hall then returns to Resident #19's room.
8:43 PM NHA (nursing home administrator) on unit and immediately goes to tub room then NS and then to Resident #19's room.

8:44 PM ADON (assistant director of nursing) was on the unit and immediately went to Resident #19's room.
8:45 PM ADON running from unit to get supplies.
8:45 PM Building and Grounds Manager (BGM) #76 on unit and goes to tub room.
8:47 PM NHA and BGM #76 in tub room
8:49 PM BGM #76 checking water in hall
8:50 PM CNA #63 to NS and returns to Resident #19's room.
8:56 PM NHA goes to the Nursing Station.
8:57 PM Social Service Supervisor (SSS) #70-Advocate arrives on the unit.
8:57 PM CNA #63 running down hall for more supplies.
9:00 PM CNA #63 returning with supplies.
9:03 PM SSS #70 leaves unit
9:04 PM NHA goes to tub room.
9:05 PM CNA #63 rushing off unit.
9:05 PM RN (registered nurse) #100 leaves NS and goes to Resident #19's room.
9:06 PM RN #100 returns to NS
9:17 PM EMS leaves unit with Resident #19
9:18 PM NHA and ADON on unit at NS
9:19 PM NHA and ADON along with NA #99 walking off unit
9:21 PM RN #100 pushes med cart into hall
1:20 AM RN #100 clocked out and was escorted out of building by ADON.

c) Assistant Director of Nursing (ADON)

In a statement by the Assistant Director of Nursing (ADON) stated "(first name of RN #100) was called to the bathroom for reported blisters of Resident #19 more than once. Eventually RN #100 went to observe, then left the room after 1.5 minutes at 7:36 pm. RN #100 did not render first aid or pain management. RN #100 went back to desk at 7:36 pm and did not call appropriate help (Doctor, On call nurse, 911, EMS, other unit nurse) until 8:25 pm when she contacted the RN on call. Between 8pm and 8:25 pm she did get the doctor's order to send out. 8:26 pm doctors order to send out written. EMS records show she did not call them until 8:54 pm.

d) The Nursing Home Administrator's (NHA) statement dated 01/09/24 at 10:04 AM

The NHA said he arrived at the facility once he was made aware of this issue of the burn. NHA said he went to the resident floor. RN #100 was at the nurse's station. She said to me (Resident first name) #19 was in his room. NHA said he went to Resident #19's room and nurse aide staff advised they repeatedly told RN #100 that Resident #19 was burned and she needed to look at him. They said she only momentarily observed him while in the tub and left the bathroom. They got him out of the tub and took him to his room. NHA said he observed Resident #19 and stated he was in obvious discomfort and pain that needed addressed. The nurse aides stated the nurse never came to his room. The NHA said his involvement and goal was to see that appropriate steps regarding addressing this issue were implemented to identify, correct, process, and investigate the matter fully and thoroughly. NHA said he went to the nurses' station after watching the resident writhing in pain. He advised RN #100 that he needed pain management now. He asked if she had been to his room. She said no and asked if she should call the doctor. NHA said he told her something needed done now. Further he said he learned the doctor ordered the resident sent out and that after receiving the order 30 minutes passed before RN #100 called 911. NHA said in no way did RN #100 assess the resident and his care needs."

The NHA said RN #100 excused her action on training and orientation. NHA said he explained as a long-term RN and having worked here before she was well aware of the process, care responsibility, appropriate reaction to resident need and that emergency care was immediate and paperwork was second.

NHA said he told RN #100 in his opinion her actions clearly were a delay in treatment and neglect. NHA said he told RN #100 until the investigation was completed; she was removed from the schedule.

On 01/10/24 at 10:24 AM a review of employee records for skills competencies was conducted for Registered Nurse (RN) #100. No evidence was found of a skills competency being completed during orientation dated 11/14/23.

RN #100 scored on a scenario-based testing 86% on pain evaluation and management, and 67% on resident evaluation. No evidence was provided regarding skills demonstration or evaluation of returned demonstrations.


e) Nurse Aide #99

On 01/10/24 at 10:24 AM a review of employee records for skills competencies was conducted for HSW #99. No evidence was found of a skills competency being completed during orientation dated 11/13/23. The "New Staff Orientation Competency" with a start date of 11/13/23 and a completion date of 11/14/23 found in the area titled "Legend (How Met) " under Section F. Other (Specify: Return Demonstration) handwritten Discussion, Verbalized Understanding.

The areas found on the "New Staff Orientation Competency" included major topics of Initial Employee Orientation, Tour of Department and Facility, HIPPA Officer, Safety, Social Services, Ethics and Compliance, Quality Assurance, Infection Control, and Departmental Expectations/Tasks and Responsibilities.

The Safety section included the following:
Emergency Codes
Emergency Preparedness
Shelter in Place
Water Management Plan
Active Shooter Training
Interim Life Safety
Infection Control
Fire Watch Plan
Resident Safety
Fire Safety
Fire Drills
Fire Watch
Fire Extinguisher
Pull Stations
Emergency Exits
Workplace Security
Preventative Maintenance Requirements
Maintenance Work Orders
Resident Environment
Resident Equipment
General Environment
Location of MSDS Manuals
Labeling and Storing of Chemicals and other hazardous materials.
Elopement Procedure

f) On 01/11/24 at 10:40 AM in the presence of the Director of Nursing (DON), CNA #66 was interviewed.

NA #66 stated that she showed new employees how to operate the tub and then has the new employee complete a return demonstration. When asked how this was documented, CNA #66 stated "We used to have one (skills competency check off sheet) but I don't have one now."

During the night of 01/04/24 into 01/05/24 the ADON educated the night shift staff that temperatures that exceed 110 degrees were not within regulation and should not be used on any resident. The staff included RN #100, HSW's (health service worker) #99, # 41, #59, #63, #60 and #85.

g) Nurse Educator (NE) #78

An email from the nurse educator to administrative staff dated 01/07/24 at 9:54 AM revealed NE #78 was still concerned about the hot water in the sinks. In the email the nurse educator explains that the staff had been told not to use the hot water because it had been registering over 110 degrees (F). The nurse educator stated she was concerned that residents would use the sink and nursing could not monitor the situaiton. In her email the Nurse Educator said that Licensed Practical Nurse (LPN) #46 had asked about shutting the hot water off and was told it could not be done.

NE #78 had a written statement dated 1/11/24.

NE #78 statement reflected she worked on 01/05/24 on B -1 from 6:30 PM - 10:30 PM. She worked with Nurse Aide #63, #59, #87 on safe bathing, burns and maintenance orders. She also spoke with RN #62, and #22 on the subject as well. An in-service was held on bathing, burns and safe temperatures. This in-service had a post test. On 01/07/24 10 staff members attended; on 01/08/24 13 attended on 01/09/24 one (1) attended and on 01/10/24 one (1) attended.

Other discussions were held by the Staff Development Educator which included Bathing and burns with handouts that included a copy of the chain of command, flow chart for reporting process, assisting with a tub bath or shower, various bathing techniques, CMS chart "Time and Temperature Relationship to Serious Burns, and a copy of the Maintenance Work Order. 11 staff attended on 01/07/24, 10 staff attended on 01/08/24, 1 attended on 01/09/24 and 01/10/24 respectively and 8 attended on 01/11/24.

h) Maintenance Director and Maintenance Staff

On 01/06/24 at 12:20 PM the Maintenance Director and maintenance staff was in -serviced. The in-services included the following information:

"Anytime the water Temp is Above 110 you must notify the charge nurse that the hot water is not to be used in that specific area and make corrections. You must document when notification was made and to whom." Typed as written."

1. Resident #19 was transferred out of the facility on 1/4/2024 to Preston Memorial Hospital for emergency care, and no longer resides at Hopemont Hospital. On 1/4/2024, NA #99 and RN #100 are no longer employed at Hopemont Hospital making correction of the identified deficiency specific to NA #99 and RN #100 impossible to achieve.

2. All residents had the potential to be affected by the alleged deficient practice. By 3/15/2024, the Human Resource Director (HRD)/designee will complete an audit of all Licensed Nurses and CNA's records to ensure they have documented training and skill based competencies related to facility policy(s) for bathing and first aid treatment.

3. The Staff Development Coordinator/designee will ensure that all Licensed Nurses and CNA's will have documented training and skill based competencies for bathing and first aid treatment, according to facility policy(s) by 3/22/2024.

On 1/11/2024, Hopemont Hospital adopted a bathing policy which includes taking water temperature prior to each bathing to ensure a temperature of no higher than 110 degrees Fahrenheit, and supervision of residents during bathing to prevent harm. By 1/22/2024, the DON/ADON/designee educated all Licensed Nurses and CNA's on the bathing policy, with return demonstration competencies that ensured understanding of resident bathing policy requirements.

Additionally, all newly hired Licensed F 726 Nurses and CNA's will receive training with the associated competency on this bathing policy during orientation.

On 1/17/2024, the DON/designee performed education and competency with maintenance staff on the bathing policy, maintenance responsibilities in monitoring, recording, maintaining, and reporting water temperatures to ensure hot water does not exceed 110 degrees Fahrenheit. The maintenance staff will receive training and associated competency for the preventative and routine maintenance of the facility hot water system from the OHFBGM/designee by 3/22/2024. Additionally, all newly hired maintenance staff will receive training with the associated competency on this bathing policy and preventative and routine maintenance of the facility hot water system during orientation.

4. QAPI nurse/designee will audit documentation that education was completed on the bathing, first aid, and preventative routine maintenance policies on a monthly basis. Additionally, the QAPI nurse/designee will audit documentation that competencies were completed on the bathing, and preventative routine maintenance policies on a monthly basis. The findings will be presented by the QAPI nurse/designee to the QAPI committee at least quarterly for analysis and any further actions.

§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Based on observation, record review, and staff interview the licensee failed to maintain hot water mechanical equipment in safe operating condition. According to CMS guidelines exposure at water temperature of 133 degrees Fahrenheit can lead to third degree burns in 15 seconds. Resident #19 was bathed in 134 degrees Fahrenheit water. Resident #19 sustained second degree burns to his feet, legs, thigh, and hand. The staff responsible for monitoring water temperatures and maintaining equipment knew the hot water had measured more than 110 degrees Fahrenheit (F) since January 2023. This caused an immediate jeopardy situation that began on 01/03/23 and ended on 01/07/24. This practice had the potential to affect all facility residents. Resident identifier: #19. Facility census 44.

Findings included:

a) Facility Reported Incident

A facility reported incident was received at the state agency on 01/05/24. The report stated Nurse Aide #99 put Resident #19 into a whirlpool tub. She filled the tub to the knee level. The nurse aide realized the water was too warm. She had another aide try to adjust the water. The nurse aide admitted to not looking at the water temperature and this resulted in Resident #19 receiving severe burns to lower legs, feet, thighs, and left hand. The facility reported the immediate action taken was to suspend the nurse aide, take all tubs out of service and check for malfunction. Adult protective services were notified, the ombudsman, the local sheriff's department, and the nurse aide registry.

A second facility reported incident dated 01/04/24 related to Resident #19 was also received by the state agency. This incident stated the registered nurse did not assess or treat a resident with severe burns timely. The immediate action taken was a suspension of the registered nurse in addition to the nurse aide and a shutdown of the bathtubs.

A third facility reported incident dated 01/05/24 was sent to the state agency. This incident stated Maintenance Supervisor (MS) #76 had been monitoring water temperatures for over six (6) months that did not meet regulatory guidelines. MS #76 failed to report the temperatures or attempt to make any changes to meet regulatory compliance. The report revealed MS #76 said he was aware of the guidelines for water temperature and chose to keep it warmer per staff request.

The five (5) day follow up report obtained on 01/09/24 revealed the following:

"After reviewing camera and interviewing staff (Registered Nurse #100) was asked by CNA (ceritfied nurse assistant) that was giving (Resident #19) his bath to assess him. Another CNA asked nurse to assess him. Finally at 7:36 she went to shower room and left at 7:37. At 8:44 she got order to send to ER (emergency room). No 1st aide administered by unit nurse until 9:05. Nurse (Registered Nurse #100) sent home until investigation over. (Registered Nurse #100) failed to assess (Resident #19) when asked 3 times by CNAs. Did not administer treatment in a timely manner. I find this report to be substantiated for neglect of resident. (Registered Nurse #100) will be removed from schedule and her agency will be notified of decision. Excessive delay in treatment."

This report was completed by the social service supervisor.

A five day follow up to the immediate report for Certified Nurse Aide (NA) #41 revealed:
"After reviewing camera and interviewing NA #41 who was called to shower room and found the water too hot and adjusted water temperature. She was seen on camera leaving the shower room and going to nurses station but camera has no sound. I find this to be substantiated. NA #41 did adjust water but failed to assist in maintaining safety of resident. NA #41 sent home until investigation is done. I find this report to be substantiated for neglect of resident. NA #41 will be removed from schedule and her agency will be notified of decision." This report was completed by the social service supervisor.
b) Facility Entrance

During the entrance conference with the Assistant Nursing Home Administrator (ANHA) and the DON, on 01/09/24 at 12:25 PM, the DON stated Resident (#19) had received third degree burns to both lower extremities during a tub bath on the evening of 01/04/24. They said had been transferred to a local hospital and then transferred to an out of state burn unit.

b) Record Review

Record review on 01/09/24 2:18 PM, revealed no documentation was provided during the survey to show the corrective action or adjustments to the resident hot water system when water temperatures were routinely recorded above 110 degrees (F) monthly from August 2023 through December 2023 by the Maintenance Department Staff for resident corridors A1, B1, and resident areas Shower Room (Gore) and Dining Room (Gore). Interview on 01/09/24 at approximately 2:20 p.m. with the Assistant Administrator verified this finding.

c) Maintenance Supervisor (MS) #76

A phone interview on 01/10/24 at approximately 9:43 a.m., with MS #76 noted he had been the Maintenance Supervisor for approximately 5 years. Interview revealed he recorded the temperatures of the hot water system as noted on the gauges and seemed to be aware that the temperatures were supposed to be maintained at 110 degrees Fahrenheit. He also noted that he tried to keep temperatures warm enough on the floors as Nursing would let him know if the temperatures seemed too cold. Interview noted that he did not report the daily/monthly temperature logs to any committee or had not been asked for them by any of the reporting committees, such as the Safety Committee or the Quality and Performance Improvement (QAPI) Committee.

d) Preventative Maintenance and Casualty Prevention Plan Notes

Record review on 01/10/24 at 12:37 p.m., revealed Preventative Maintenance and Casualty Prevention Plan notes state that Safety Surveillance is conducted hospital wide monthly by members of the Safety Committee. Reports of inspection are given to the Safety Officer who will then assign the deficiency correction to the proper department for action. Per the Preventative Maintenance and Casualty Prevention Plan these reports and corrective action documents are then also attached to the master copy of the Quality Committee minutes. Record review revealed no documentation provided during the survey to show that Safety Surveillance was reported to the Quality and Performance Improvement (QAPI) Committee from July 2023 through December 2023, as outlined in the Preventative Maintenance and Casualty Prevention Plan.

e) Administrator and Assistant Administrator Interview

On 01/10/24 at 1:10 PM during an interview the assistant administrator and the administrator agreed they had not looked at the hot water temperatures being recorded by the maintenance employee, nor had they checked to see if any preventative maintenance was being done to the hot water equipment.

f) Resident #19

Record review revealed Resident #19 was admitted to the facility 10/12/17. Medical diagnoses included dementia with behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, peripheral vascular disease (PVD), alcohol dependence in remission, Fabry's disease, and high blood pressure. No Brief Interview for Mental Status (BIMS) was able to be obtained as the only verbal response was grunting.

g) Water Temperature Log Review of temperatures taken at the mixing valve are as follows:

January 2023

01/03/23 122 degrees (F), 01/04/23 120 degrees (F), 01/05/23 118 degrees (F), 01/06/23 124 degrees (F), 01/09/23 120 degrees (F), 01/10/23 126 degrees (F), 01/11/23 122 degrees (F), 01/12/23 120 degrees (F), 01/15/23 120 degrees 126 degrees (F), 01/18/23 124 degrees (F), 01/19/23 122 degrees (F), 01/20/23 120 degrees (F), , 01/24/23 126 degrees (F), 01/25/23 122 degrees (F), 01/26/23 126 degrees (F), 01/27/23 124 degrees (F), 01/30/23 126 degrees (F), 01/31/23 126 degrees (F),

February 2023

02/02/23 124 degrees (F), 02/03/23 124 degrees (F), 02/06/23 126 degrees (F), 02/07/23 124 degrees (F), 02/08/23 130 degrees (F),02/13/23 126 degrees (F), 02/14/23 124 degrees (F), 02/15/23 128 degrees (F), 02/16/23 126 degrees (F), 02/17/23 128 degrees (F), 02/21/23 124 degrees (F), 02/22/23 128 degrees (F), 02/23/23 126 degrees (F), 02/24/23 128 degrees (F), 02/27/23 120 degrees (F)

March 2023

03/01/23 126 degrees (F), 03/02/23 120 degrees (F), 03/03/23 124 degrees (F), 03/06/23 130 degrees (F), 03/07/23 124 degrees (F), 03/08/23 126 degrees (F), 03/09/23 126 degrees (F), 03/10/23 130 degrees (F), 03/16/23 120 degrees (F), 03/20/23 130 degrees (F), 03/21/23 130 degrees (F), 03/22/23 119 degrees (F), 03/23/23 124 degrees (F) 03/27/23 124 degrees (F), 03/28/23 128 degrees (F)
April 2023

04/03/23 120 degrees (F), 04/04/23 126 degrees (F), 04/05/23 124 degrees (F), 04/06/23 119 degrees (F), 04/07/23 121 degrees (F), 04/10/23 120 degrees (F), 04/11/23 124 degrees (F), 04/12/23 123 degrees (F), 04/13/23 121 degrees (F), 04/14/23 115 degrees (F), 04/17/23 125 degrees (F), 04/18/23 120 degrees (F), 04/19/23 119 degrees (F), 04/20/23 121 degrees (F), 04/21/21 122 degrees (F),
04/24/23 130 degrees (F), 04/25/23 128 degrees (F), 04/26/23 115 degrees (F), 04/28/23 120 degrees (F)

May 2023

05/01/23 120 degrees (F), 05/02/23 124 degrees (F), 05/03/23 122 degrees (F), 05/04/23 122 degrees (F), 05/05/23 118 degrees (F), 05/10/23 116 degrees (F), 05/11/23 124 degrees (F), 05/15/23 120 degrees (F), 05/16/23 126 degrees (F), 05/17/23 130 degrees (F), 05/18/23 120 degrees (F), 05/19/23 118 degrees (F), 05/22/23 122 degrees (F), 05/23/23 120 degrees (F), 05/24/23 116 degrees (F)< 05/26/23 130 degrees (F), 05/29/23 130 degrees (F), 05/30/23 120 degrees (F), 05/31/23 124 degrees (F)


June 2023

06/01/23 120 degrees (F), 06/02/23 112 degrees (F), 06/05/23 120 degrees (F), 06/06/23 116 degrees (F), 06/07/23 120 degrees (F), 06/08/23 130 degrees (F), 06/09/23 130 degrees (F), 06/12/23 118 degrees (F), 06/13/23 126 degrees (F), 06/14/23 122 degrees (F), 06/15/23 124 degrees (F), 06/16/23 118 degrees (F), 06/19/23 121 degrees (F), 06/20/23 114 degrees (F), 06/21/23 120 degrees (F), 06/22/23 122 degrees (F), 06/23/24 116 degrees (F), 06/26/23 131 degrees (F), 06/27/23 122 degrees (F), 06/28/23 124 degrees (F), 06/29/23 120 degrees (F), 06/30/23 124 degrees (F)

July 2023

07/05/23 121 degrees (F), 07/06/23 120 degrees (F), 07/07/23 120 degrees (F), 07/10/23 121 degrees (F), 07/11/23 116 degrees (F), 07/14/23 120 degrees (F), 07/17/23 122 degrees (F), 07/18/23 132 degrees (F), 07/19/23 124 degrees (F), 07/20/23 114 degrees (F), 07/21/23 128 degrees (F),07/26/23 120 degrees (F), 07/27/23 118 degrees (F), 07/28/23 122 degrees (F), 07/31/23 120 degrees (F)

August 2023

08/01/23 120 degrees (F), 08/02/23 118 degrees (F), 08/03/23 120 degrees (F), 08/04/23 124 degrees (F), 08/07/23 120 degrees (F), 08/08/23 121 degrees (F), 08/09/23 118 degrees (F), 08/10/23 122 degrees (F), 08/11/23 130 degrees (F), 08/14/23 121 degrees (F), 08/15/23 129 degrees (F), 08/16/23 118 degrees (F), 08/18/23 136 degrees (F), 08/21/23 120 degrees (F), 08/22/23 124 degrees (F), 08/23/23 133 degrees (F), 08/24/23 114 degrees (F), 08/25/23 126 degrees (F), 08/28/23 130 degrees (F), 08/29/23 140 degrees (F), 08/30/23 128 degrees (F),

September 2023

09/01/23 125 degrees (F), 09/05/23 128 degrees (F), 09/06/23 130 degrees (F), 09/07/23 126 degrees (F), 09/08/23 130 degrees (F), 09/11/23 126 degrees (F), 09/12/23 124 degrees (F), 09/13/23 121 degrees (F) , 09/18/23 130 degrees (F), 09/19/23 126 degrees (F), 09/20/23 124 degrees (F), 09/21/23 120 degrees (F), 09/29/23 130 degrees (F)

October 2023

10/02/23 125 degrees (F), 10/03/23 130 degrees (F), 10/04/23 132 degrees (F), 10/05/23 130 degrees (F) 10/09/23 140 degrees (F), 10/10/23 138 degrees (F), 10/11/23 10/13/23 130 degrees (F), 10/16/23 120 degrees (F), 10/17/23 130 degrees (F), 10/18/23 124 degrees (F), 10/19/23 124 degrees (F),10/20/23 128 degrees (F), 10/24/23 132 degrees (F), 10/25/23 128 degrees (F), 10/26/23 130 degrees (F), 10/27/23 142 degrees (F), 10/30/23 140 degrees (F), 10/31/23 132 degrees (F)
November 2023

11/01/23 128 degrees (F), 11/02/23 132 degrees (F), 11/03/23 141 degrees (F), 11/06/23 140 degrees (F), 11/07/23 128 degrees (F), 11/08/23 130 degrees (F), 11/09/23 134 degrees (F), 11/13/23 130 degrees (F), 11/14/23 126 degrees (F),

December 2023

12/01/23 130 degrees (F), 12/04/23 130 degrees (F), 12/05/23 132 degrees (F), 12/06/23 140 degrees (F), 12/07/23 128 degrees (F), 12/08/23 132 degrees (F), 12/11/23 130 degrees (F), 12/12/23 126 degrees (F), 12/13/23 140 degrees (F), 12/14/23 140 degrees (F), 12/15/23 138 degrees (F), 12/20/23 130 degrees (F), 12/21/23 126 degrees (F), 12/22/23 140 degrees (F), 12/26/23 128 degrees (F), 12/28/23 132 degrees (F), 12/29/23 130 degrees (F)

January 2024

Record review revealed water temperatures continued to be above 110 degrees (F) on 01/05/24, 01/06/24, and on 01/07/24. These temperatures logs revealed temperateurs were taken at four (4) sinks, and in the shower room.


h) Education of staff

During the night of 01/04/24 into 01/05/24 the ADON educated the night shift staff that temperatures that exceed 110 degrees were not within regulation and should not be used on any resident. The staff included RN #100, Nurse Aid #99, # 41, #59, #63, #60 and #85.


i) Maintenance Director Inservice

On 01/06/24 at 12:20 PM the Maintenance Director and maintenance staff was in -serviced the Maintenance staff as follows:

"Anytime the water Temp is Above 110 you must notify the charge nurse that the hot water is not to be used in that specific area and make corrections. You must document when notification was made and to whom." Typed as written."

j) Nurse Educator (NE) #78

An email from the nurse educator to administrative staff dated 01/07/24 at 9:54 AM revealed NE #78 was still concerned about the hot water in the sinks. In the email the nurse educator explains that the staff had been told not to use the hot water because it had been registering over 110 degrees (F). The nurse educator stated she was concerned that residents would use the sink and nursing could not monitor the situaiton. In her email the Nurse Educator said that Licensed Practical Nurse (LPN) #46 had asked about shutting the hot water off and was told it could not be done. Record review revealed the nursing home administartor gave an order and the hot water was shut off at 6:54 PM on 01/07/24.

k) Quality Assurance and Performance Improvement (QAPI)

Evidence provided by the QA-QAPI RN on 01/09/24 stated that this was the first rough draft of events involving hot water that resulted in third degree burns to Resident #19.

Resident #19 was transferred to the emergency room and is currently not residing in (name of facility).

All residents have the potential to be affected. On 01/05/24, DON conducted a skin assessment of all residents which revealed no other residents to have evidence of burns.

On 01/04/24 the maintenance director placed the identified whirlpool (tub) out of service and investigated what may have caused the increased hot water temperature in the tub during the incident. The investigation revealed a malfunctioning hot water tank thermostat, which was immediately replaced by the maintenance director/maintenance staff on 01/04/24.

On 01/05/24, the QAPI team instituted a more frequent monitoring of hot water temperatures, every hour and to prevent resident use of hot water above 110 degrees. Additionally, on 01/05/24, the QAPI stopped all showers and tub baths until hot water could be restored to no higher than 110 degrees. The administrator on 01/07/24 directed maintenance staff to physically shut off all hot water access by residents as an added precaution pending further maintenance evaluation/repairs to the hot water system.

On 01/05/24, the QAPI team instituted temperature checks of hot water outlets on the resident units, to be completed each hour. Temperatures found to be greater than 110 degrees, were to be reported immediately to the administrator, residents were to be prevented from using the identified outlet(S), and mechanical adjustments made to the hot water system in order to bring temperatures below 110 Fahrenheit. On 01/08/24, due to residents no longer having access/exposure to hot water outlets, the QAPI team modified the monitoring of hot water temperatures to an as needed basis due to repairs actively being made to the hot water system, until further.

The Quality Assurance and Performance Improvement Committee (QAPI) met on 01/09/24 at 10:00 AM to discuss the current situation of water temps for resident care. Documentation revealed that water temps were being checked every hour since 01/05/24 at the four (4) main sinks on Resident corridors of A1 and B1 and the resident showers on the corridors of A1 and Gore 1, with this documentation forwarded to Administration for review. The showers have not been used since 01/04/24. Repairs were initiated on the hot water system on 01/08/24 to isolate the hot water distributed to the resident care areas and residents currently have no access to hot water until the final repairs are made. Prior to the time of survey, potential mechanical issues with an isolation valve, hot water tank thermostat, and a water system distribution mixing valve and gauge were discovered. The isolation valve, thermostat, and mixing valve gauge had been replaced prior to the survey. The water system distribution mixing valve was being investigated further with parts being ordered for repair during the survey. Nursing staff were notified that they would be using wipes and no rinse shampoo and body wash until further notice.

Per the QAPI meeting minutes, reeducation was provided to staff reiterating appropriate hot water temperatures and completing maintenance work orders if issues are suspected with the temperature of the water system.

l) Phone interview on 01/09/24 at 11:36 AM., with the Director of Facilities and Plant Operations #97 revealed that the perceived issue with the hot water system was a faulty thermostat on the hot water tank serving resident corridors A1 and B1 of the Nursing Building. The issue with the thermostat was believed to have failed in the close position and was discovered mid-morning on Friday, January 5th. The hot water system was drained and refilled with 55-degree city water. An isolation valve was added on Monday, January 8th. Employee #97 also noted that hot water temperatures were not supposed to be above 110 degrees.

m) An observation on 01/09/24 at 12:14 PM, revealed that the only hot water being provided to the resident areas was to the Dining Area. The temperature of the hot water as recorded at a hand sink in the Dining area was noted as 109.1. Hot water to the other resident areas such as Corridor A1, B1, and Gore 1 was isolated off in the basement and handles removed from faucets and fixtures to prevent residents from accidentally turning on the hot water while repairs and adjustments were made to the system.

n) Building Maintenance Mechanic (BMM)#95

An interview on 01/09/24 at 1:03 PM, with BMM #95 revealed that an issue with a thermostat on a hot water tank in the basement (Potato Room) was discovered and replaced. A ball valve was also replaced as a suspected back-feed elimination. A gauge for the mixing valve for the water leaving this area to the resident areas was also replaced. Employee #95 noted that a daily log of the water temperatures was maintained in each mechanical room. In addition, Employee #95 stated that he was not aware that temperatures above 110 degrees needed to be reported and only recorded what the gauges read and was not previously aware of what the water temperatures were supposed to be maintained at.

o) Building Maintenance Mechanic (BMM) #14An interview on 01/09/24 at 1:15 PM, with Building Maintenance Mechanic #14 revealed that he was off work during the time of noted issues with the water system and had just returned to work on the morning of Monday, January 8th. Employee #14 noted that he was not aware that any issues with the noted water temperatures needed to be reported to anyone.

p) Maintenance Supervisor (MS) #76

During a phone interview on 01/10/24 at 9:43 AM, the Maintenance Supervisor (MA) #76 noted that he had been the Maintenance Supervisor for approximately five (5) years.MS #76 noted that he recorded the temperatures of the hot water system as noted on the gauges and seemed to be aware that the temperatures were supposed to be maintained at 110 degrees. He also noted that he tried to keep temperatures warm enough on the floors as Nursing would let him know if the temperatures s#76 noted that he did not report the daily/monthly temperature logs to any committee or had not been asked for them.

q) Preventive Maintenance and Caualty Prevention Plan

The Office of Health Facilities Policy (Policy OHF.LS.0002) for Preventive Maintenance and Casualty Prevention Plan has been updated to include an effective date based upon the date of approval on the signature page. This policy outlines the testing and preventative maintenance procedures and documentation requirements for the Plant Operations, Maintenance, and Engineering Staff. Documentation from the Preventative Maintenance and Casualty Prevention Plan is monitored through safety surveillance, which is conducted hospital wide monthly by members of the Safety Committee. These inspection reports are to be given to the Safety Officer, who will then assign corrective action from the appropriate department. This policy outlines that all boiler room equipment gauges are to be visually monitored daily and that patient hot water is not to exceed 110 degrees (F) with any deviations reported to the Maintenance Department immediately.

§483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Based on observation, record review, and staff interview the licensee failed to maintain hot water mechanical equipment in safe operating condition. According to CMS guidelines exposure at water temperature of 133 degrees Fahrenheit (F) can lead to third degree burns in 15 seconds. Resident #19 was bathed in 134 degrees (F) water. Resident #19 sustained second degree burns to the left hand, bilateral lower extremeties, bilateral buttocks, and scrotum. The staff responsible for monitoring water temperatures and maintaining equipment knew the hot water had measured more than 110 degrees (F) since January 2023. This caused an immediate jeopardy situation that began on 01/03/23 and ended on 01/07/24. This practice had the potential to affect all facility residents. Resident identifier: #19. Facility census 44.

Findings included:

a) Facility Reported Incident

A facility reported incident was received at the state agency on 01/05/24. The report stated Nurse Aide #99 put Resident #19 into a whirlpool tub. She filled the tub to the knee level. The nurse aide realized the water was too warm. She had another aide try to adjust the water. The nurse aide admitted to not looking at the water temperature and this resulted in Resident #19 receiving severe burns to lower legs, feet, thigh, and left hand. The facility reported the immediate action taken was to suspend the nurse aide, take all tubs out of service and check for malfunction. Adult protective services were notified, the ombudsman, the local sheriff's department, and the nurse aide registry.

A second facility reported incident dated 01/04/24 related to Resident #19 was also received by the state agency. This incident stated the registered nurse (RN #100) did not assess or treat a resident with severe burns timely. The immediate action taken was a suspension of the registered nurse in addition to the nurse aide and a shutdown of the bathtubs.

A third facility reported incident dated 01/05/24 was sent to the state agency. This incident stated Maintenance Supervisor (MS) #76 had been monitoring water temperatures for over six (6) months that did not meet regulatory guidelines. MS #76 failed to report the temperatures or attempt to make any changes to meet regulatory compliance. The report revealed MS #76 said he was aware of the guidelines for water temperature and chose to keep it warmer per staff request.

The five (5) day follow up report obtained on 01/09/24 revealed the following:

"After reviewing camera and interviewing staff (Registered Nurse #100) was asked by CNA (ceritfied nurse assistant) that was giving (Resident #19) his bath to assess him. Another CNA asked nurse to assess him. Finally at 7:36 she went to shower room and left at 7:37. At 8:44 she got order to send to ER (emergency room). No 1st aide administered by unit nurse until 9:05. Nurse (Registered Nurse #100) sent home until investigation over. (Registered Nurse #100) failed to assess (Resident #19) when asked 3 times by CNAs. Did not administer treatment in a timely manner. I find this report to be substantiated for neglect of resident. (Registered Nurse #100) will be removed from schedule and her agency will be notified of decision. Excessive delay in treatment."

This report was completed by the social service supervisor.

A five day follow up to the immediate report for Certified Nurse Aide (NA) #41 revealed:
"After reviewing camera and interviewing NA #41 who was called to shower room and found the water too hot and adjusted water temperature. She was seen on camera leaving the shower room and going to nurses station but camera has no sound. I find this to be substantiated. NA #41 did adjust water but failed to assist in maintaining safety of resident. NA #41 sent home until investigation is done. I find this report to be substantiated for neglect of resident. NA #41 will be removed from schedule and her agency will be notified of decision." This report was completed by the social service supervisor.

b) Entrance by State Agency

During the entrance conference with the Assistant Nursing Home Administrator (ANHA) and the DON, on 01/09/24 at 12:25 PM, the DON stated Resident (#19) had received third degree burns to both lower extremities during a tub bath on the evening of 01/04/24. They said the resident had been transferred to a local hospital and then transferred to an out of state burn unit. Hospital records revealed the resident had second degree burns to bilateral lower extremities, the left hand, bilateral buttocks, and scrotum. The hospital report reflected the resident was burned an estimated 35% of his body.

c) Facility provided hot water temperature logs from the mixing valve


January 2023

01/03/23 122 degrees (F), 01/04/23 120 degrees (F), 01/05/23 118 degrees (F), 01/06/23 124 degrees (F), 01/09/23 120 degrees (F), 01/10/23 126 degrees (F), 01/11/23 122 degrees (F), 01/12/23 120 degrees (F), 01/15/23 120 degrees 126 degrees (F), 01/18/23 124 degrees (F), 01/19/23 122 degrees (F), 01/20/23 120 degrees (F), , 01/24/23 126 degrees (F), 01/25/23 122 degrees (F), 01/26/23 126 degrees (F), 01/27/23 124 degrees (F), 01/30/23 126 degrees (F), 01/31/23 126 degrees (F),

February 2023

02/02/23 124 degrees (F), 02/03/23 124 degrees (F), 02/06/23 126 degrees (F), 02/07/23 124 degrees (F), 02/08/23 130 degrees (F),02/13/23 126 degrees (F), 02/14/23 124 degrees (F), 02/15/23 128 degrees (F), 02/16/23 126 degrees (F), 02/17/23 128 degrees (F), 02/21/23 124 degrees (F), 02/22/23 128 degrees (F), 02/23/23 126 degrees (F), 02/24/23 128 degrees (F), 02/27/23 120 degrees (F)

March 2023

03/01/23 126 degrees (F), 03/02/23 120 degrees (F), 03/03/23 124 degrees (F), 03/06/23 130 degrees (F), 03/07/23 124 degrees (F), 03/08/23 126 degrees (F), 03/09/23 126 degrees (F), 03/10/23 130 degrees (F), 03/16/23 120 degrees (F), 03/20/23 130 degrees (F), 03/21/23 130 degrees (F), 03/22/23 119 degrees (F), 03/23/23 124 degrees (F) 03/27/23 124 degrees (F), 03/28/23 128 degrees (F)
April 2023

04/03/23 120 degrees (F), 04/04/23 126 degrees (F), 04/05/23 124 degrees (F), 04/06/23 119 degrees (F), 04/07/23 121 degrees (F), 04/10/23 120 degrees (F), 04/11/23 124 degrees (F), 04/12/23 123 degrees (F), 04/13/23 121 degrees (F), 04/14/23 115 degrees (F), 04/17/23 125 degrees (F), 04/18/23 120 degrees (F), 04/19/23 119 degrees (F), 04/20/23 121 degrees (F), 04/21/21 122 degrees (F),
04/24/23 130 degrees (F), 04/25/23 128 degrees (F), 04/26/23 115 degrees (F), 04/28/23 120 degrees (F)

May 2023

05/01/23 120 degrees (F), 05/02/23 124 degrees (F), 05/03/23 122 degrees (F), 05/04/23 122 degrees (F), 05/05/23 118 degrees (F), 05/10/23 116 degrees (F), 05/11/23 124 degrees (F), 05/15/23 120 degrees (F), 05/16/23 126 degrees (F), 05/17/23 130 degrees (F), 05/18/23 120 degrees (F), 05/19/23 118 degrees (F), 05/22/23 122 degrees (F), 05/23/23 120 degrees (F), 05/24/23 116 degrees (F), 05/26/23 130 degrees (F), 05/29/23 130 degrees (F), 05/30/23 120 degrees (F), 05/31/23 124 degrees (F)


June 2023

06/01/23 120 degrees (F), 06/02/23 112 degrees (F), 06/05/23 120 degrees (F), 06/06/23 116 degrees (F), 06/07/23 120 degrees (F), 06/08/23 130 degrees (F), 06/09/23 130 degrees (F), 06/12/23 118 degrees (F), 06/13/23 126 degrees (F), 06/14/23 122 degrees (F), 06/15/23 124 degrees (F), 06/16/23 118 degrees (F), 06/19/23 121 degrees (F), 06/20/23 114 degrees (F), 06/21/23 120 degrees (F), 06/22/23 122 degrees (F), 06/23/24 116 degrees (F), 06/26/23 131 degrees (F), 06/27/23 122 degrees (F), 06/28/23 124 degrees (F), 06/29/23 120 degrees (F), 06/30/23 124 degrees (F)

July 2023

07/05/23 121 degrees (F), 07/06/23 120 degrees (F), 07/07/23 120 degrees (F), 07/10/23 121 degrees (F), 07/11/23 116 degrees (F), 07/14/23 120 degrees (F), 07/17/23 122 degrees (F), 07/18/23 132 degrees (F), 07/19/23 124 degrees (F), 07/20/23 114 degrees (F), 07/21/23 128 degrees (F),07/26/23 120 degrees (F), 07/27/23 118 degrees (F), 07/28/23 122 degrees (F), 07/31/23 120 degrees (F)

August 2023

08/01/23 120 degrees (F), 08/02/23 118 degrees (F), 08/03/23 120 degrees (F), 08/04/23 124 degrees (F), 08/07/23 120 degrees (F), 08/08/23 121 degrees (F), 08/09/23 118 degrees (F), 08/10/23 122 degrees (F), 08/11/23 130 degrees (F), 08/14/23 121 degrees (F), 08/15/23 129 degrees (F), 08/16/23 118 degrees (F), 08/18/23 136 degrees (F), 08/21/23 120 degrees (F), 08/22/23 124 degrees (F), 08/23/23 133 degrees (F), 08/24/23 114 degrees (F), 08/25/23 126 degrees (F), 08/28/23 130 degrees (F), 08/29/23 140 degrees (F), 08/30/23 128 degrees (F),

September 2023

09/01/23 125 degrees (F), 09/05/23 128 degrees (F), 09/06/23 130 degrees (F), 09/07/23 126 degrees (F), 09/08/23 130 degrees (F), 09/11/23 126 degrees (F), 09/12/23 124 degrees (F), 09/13/23 121 degrees (F) , 09/18/23 130 degrees (F), 09/19/23 126 degrees (F), 09/20/23 124 degrees (F), 09/21/23 120 degrees (F), 09/29/23 130 degrees (F)

October 2023

10/02/23 125 degrees (F), 10/03/23 130 degrees (F), 10/04/23 132 degrees (F), 10/05/23 130 degrees (F) 10/09/23 140 degrees (F), 10/10/23 138 degrees (F), 10/11/23 10/13/23 130 degrees (F), 10/16/23 120 degrees (F), 10/17/23 130 degrees (F), 10/18/23 124 degrees (F), 10/19/23 124 degrees (F),10/20/23 128 degrees (F), 10/24/23 132 degrees (F), 10/25/23 128 degrees (F), 10/26/23 130
(F) degrees (F), 10/27/23 142 degrees (F), 10/30/23 140 degrees (F), 10/31/23 132 degrees (F)

November 2023

11/01/23 128 degrees (F), 11/02/23 132 degrees (F), 11/03/23 141 degrees (F), 11/06/23 140 degrees (F), 11/07/23 128 degrees (F), 11/08/23 130 degrees (F), 11/09/23 134 degrees (F), 11/13/23 130 degrees (F), 11/14/23 126 degrees (F),

December 2023

12/01/23 130 degrees (F), 12/04/23 130 degrees (F), 12/05/23 132 degrees (F), 12/06/23 140 degrees (F), 12/07/23 128 degrees (F), 12/08/23 132 degrees (F), 12/11/23 130 degrees (F), 12/12/23 126 degrees (F), 12/13/23 140 degrees (F), 12/14/23 140 degrees (F), 12/15/23 138 degrees (F), 12/20/23 130 degrees (F), 12/21/23 126 degrees (F), 12/22/23 140 degrees (F), 12/26/23 128 degrees (F), 12/28/23 132 degrees (F), 12/29/23 130 degrees (F)

January 2024

Record review revealed water temperatures continued to be above 110 degrees (F) on 01/05/24, 01/06/24, and on 01/07/24. These temperatures logs revealed temperatures were taken at four (4) sinks, and in the shower room.

Record review on 01/09/24 at approximately 2:18 PM, revealed no documentation to show the corrective action or adjustments to the resident hot water system when water temperatures were routinely recorded above 110 degrees Fahrenheit from January 2023 through December 2023 by the Maintenance Department Staff. The water supplied resident corridors A1, B1, and Shower Room (Gore) and Dining Room (Gore). An interview on 01/09/24 at approximately 2:20 p.m. with the Assistant Administrator verified this finding.

d) Maintenance Supervisor (MS) #76

Phone interview on 01/10/24 at approximately 9:43 AM, with MS #76 noted he had been the MS for approximately five (5) years. Interview revealed he recorded the temperatures of the hot water system as noted on the gauges and seemed aware the temperatures were supposed to be maintained at 110 degrees (F). He also said he tried to keep temperatures warm enough on the floors. He said nursing would let him know if the temperatures seemed too cold. The interview with MS #76 noted that he did not report the daily/monthly temperature logs to any committee. Furthermore, he said he had not been asked for these records by any of the reporting committees, such as the Safety Committee or the Quality and Performance Improvement (QAPI) Committee.

Record review, on 01/10/24 at 12:37 PM, of Preventative Maintenance and Casualty Prevention Plan revealed that Safety Surveillance was conducted hospital wide monthly by members of the Safety Committee. Reports of inspection are given to the Safety Officer who will then assign the deficiency correction to the proper department for action. Per the Preventative Maintenance and Casualty Prevention Plan these reports and corrective action documents are also attached to the master copy of the Quality Committee minutes. Record review revealed no documentation provided during the survey to show that Safety Surveillance was reported to the Quality and Performance Improvement (QAPI) Committee from July 2023 through December 2023, as outlined in the Preventative Maintenance and Casualty Prevention Plan.

On 01/10/24 at 1:10 PM during an interview the assistant administrator and the administrator confirmed they had not looked at the hot water temperatures being recorded by the maintenance employee, nor had they checked to see if any preventative maintenance was being done to the hot water equipment.

e) Resident #19

Record review revealed Resident #19 was admitted to the facility 10/12/17. Medical diagnoses included dementia with behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, peripheral vascular disease (PVD), alcohol dependence in remission, Fabry's disease, and high blood pressure. No Brief Interview for Mental Status (BIMS) was able to be obtained as the only verbal response was grunting.

f) Nurse Educator (NE) #78

An email from the nurse educator to administrative staff dated 01/07/24 at 9:54 AM revealed NE #78 was still concerned about the hot water in the sinks. In the email the nurse educator explains that the staff had been told not to use the hot water because it had been registering over 110 degrees (F). The nurse educator stated she was concerned that residents would use the sink and nursing could not monitor the situation. In her email the Nurse Educator said that Licensed Practical Nurse (LPN) #46 had asked about shutting the hot water off and was told it could not be done. Rercord review revealed the Nursing Home Administrator gave an order for the hot water to be shut off at 6:54 PM on 01/07/24.

g) Maintenance Director In service

On 01/06/24 at 12:20 PM the Maintenance Director and maintenance staff was in -serviced. The in-service included:

"Anytime the water Temp is Above 110 you must notify the charge nurse that the hot water is not to be used in that specific area and make corrections. You must document when notification was made and to whom." Typed as written."

On 01/11/24 at 10:40 AM, in the presence of the Director of Nursing (DON), NA #66 was interviewed. NA #66 stated she showed new employees how to operate the tub and then had the new employee complete a return demonstration. When asked how this was documented, CNA #66 stated, "We used to have one (skills competency check off sheet) but I don't have one now."


h) Quality Assurance and Performance Improvement (QAPI)

Evidence provided by the QA-QAPI RN on 01/09/24 stated that this was the first rough draft of events involving hot water that resulted in third degree burns to Resident #19.

Resident #19 was transferred to the emergency room and is currently not residing in (name of facility).

All residents have the potential to be affected. On 01/05/24, DON conducted a skin assessment of all residents which revealed no other residents to have evidence of burns.

On 01/04/24 the maintenance director placed the identified whirlpool (tub) out of service and investigated what may have caused the increased hot water temperature in the tub during the incident. The investigation revealed a malfunctioning hot water tank thermostat, which was immediately replaced by the maintenance director/maintenance staff on 01/04/24.

On 01/05/24, the QAPI team instituted a more frequent monitoring of hot water temperatures, every hour and to prevent resident use of hot water above 110 degrees. Additionally, on 01/05/24, the QAPI stopped all showers and tub baths until hot water could be restored to no higher than 110 degrees. The administrator on 01/07/24 directed maintenance staff to physically shut off all hot water access by residents as an added precaution pending further maintenance evaluation/repairs to the hot water system. The plan of correction supported this.

On 01/05/24, the QAPI team instituted temperature checks of hot water outlets on the resident units, to be completed each hour. Temperatures found to be greater than 110 degrees, were to be reported immediately to the administrator, residents were to be prevented from using the water.

The facility's hot water temperatures were recorded above 110 degrees Fahrenheit monthly from January 2023 through December 2023. However, the facility had established procedures and monitoring processes to address the self-reported issues with the hot water system.

i) The Quality Assurance and Performance Improvement Committee (QAPI) met on 01/09/24 at 10:00 AM to discuss the current situation of water temps for resident care. Documentation revealed that water temps were being checked every hour since 01/05/24 at the four (4) main sinks on Resident corridors of A1 and B1 and the resident showers on the corridors of A1 and Gore 1, with this documentation forwarded to Administration for review. The showers have not been used since 01/04/24. Repairs were initiated on the hot water system on 01/08/24 to isolate the hot water distributed to the resident care areas and residents currently have no access to hot water until the final repairs are made. Prior to the time of survey, potential mechanical issues with an isolation valve, hot water tank thermostat, and a water system distribution mixing valve and gauge were discovered. The isolation valve, thermostat, and mixing valve gauge had been replaced prior to the survey. The water system distribution mixing valve was being investigated further with parts being ordered for repair during the survey. Nursing staff were notified that they would be using wipes and no rinse shampoo and body wash until further notice.

Per the QAPI meeting minutes, reeducation was provided to staff reiterating appropriate hot water temperatures and completing maintenance work orders if issues are suspected with the temperature of the water system.

Phone interview on 01/09/24 at 11:36 AM., with the Director of Facilities and Plant Operations (Employee #97) revealed that the perceived issue with the hot water system was a faulty thermostat on the hot water tank serving resident corridors A1 and B1 of the Nursing Building. The issue with the thermostat was believed to have failed in the close position and was discovered mid-morning on Friday, January 5th. The hot water system was drained and refilled with 55-degree city water. An isolation valve was added on Monday, January 8th. Employee #97 also noted that hot water temperatures were not supposed to be above 110 degrees.

An observation on 01/09/24 at 12:14 PM revealed that the only hot water being provided to the resident areas was to the Dining Area. The temperature of the hot water recorded at a hand sink in the Dining area was noted as 109.1. Hot water to the other resident areas such as Corridor A1, B1, and Gore 1 was isolated in the basement and handles removed from faucets and fixtures to prevent residents from accidentally turning on the hot water while repairs and adjustments were made to the system.

An interview on 01/09/24 at 1:03 PM, with the Building Maintenance Mechanic (BMM) #95 revealed that an issue with a thermostat on a hot water tank in the basement (Potato Room) was discovered and replaced. A ball valve was also replaced as a suspected back-feed elimination. A gauge for the mixing valve for the water leaving this area to the resident areas was also replaced. BMM #95 noted that a daily log of the water temperatures was maintained in each mechanical room. In addition, BMM #95 stated he was not aware that temperatures above 110 degrees needed to be reported and only recorded what the gauges read and was not previously aware of what the water temperatures were supposed to be maintained at.

An interview on 01/09/24 at 1:15 PM, with Building Maintenance Mechanic (BMM) #14 revealed that he was off from work during the time of noted issues with the water system and had just returned to work on the morning of Monday, January 8th. BMM#14 noted that he was not aware that any issues with the noted water temperatures needed to be reported to anyone.

During a phone interview on 01/10/24 at 9:43 AM, the Maintenance Supervisor (MS) #76 said he had been the MS for approximately five (5) years. MS #76 noted that he recorded the temperatures of the hot water system as noted on the gauges and seemed to be aware that the temperatures were supposed to be maintained at 110 degrees. He also noted that he tried to keep temperatures warm enough on the floors as Nursing would let him know if the temperatures seemed too cold. Employee #76 noted that he did not report the daily/monthly temperature logs to any committee or had not been asked for them.

An unannounced revisit was conducted at Hopemont Hospital on March 26, 2024 for the complaint survey concluding on February 9, 2024. The facility was found to have corrected the previously cited deficient practices and these are reflected on the CMS-2567B. The facility's census on the first day of the revisit survey was 48 residents

§483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

§483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

§483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

An unannounced complaint investigation survey was conducted at Hopemont Hospital from 01/03/24 to 01/04/24. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and/or 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. The facility's census on the first day of the survey was 43 residents.

Complaint #29393 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced complaint investigation survey was conducted at Hopemont Hospital from 09/05/23 to 09/06/23. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and/or 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. The facility's census on the first day of the survey was 46 residents.

Complaint #28226 and #27674 was unsubstantiated with no related or unrelated deficiencies cited. Complaint # 27825 was substantiated with no deficiencies.

An unannounced complaint investigation survey was conducted at Hopemont Hospital from 06/12/23 to 06/13/23. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and/or 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. The facility's census on the first day of the survey was 48 residents.

Complaint #28581 was unsubstantiated with no related or unrelated deficiencies cited.

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An unannounced annual recertification, annual relicensure, and complaint investigation survey was conducted at Hopemont Hospital from August 22-24, 2022. The deficiencies contained in this report are based on observations, review of residents' clinical records, resident interviews, family interviews, and staff interviews, and review of other facility documentation as indicated. The facility's census on the first day of the survey was 44 residents.

--Complaint #26702 was unsubstantiated with no related or unrelated deficiciencies cited.
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§483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

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Based on medical record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment in the area of psychiatric/mood disorders for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #23. Facility census: 44.

Findings included:

a) Resident #23

Review of Resident #23's medical records showed a diagnosis of schizoaffective disorder. The resident was taking the medication iloperidone for schizoaffective disorder.

Review of Resident #23's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 06/23/22 showed the resident was not coded as having schizophrenia, which included schizoaffective disorder.

During an interview on 08/24/22 at 11:01 AM, the Minimum Data Set Coordinator confirmed Resident #23 had a diagnosis of schizoaffective disorder and the MDS with ARD 06/23/22 was incorrect.

No further information was provided through the completion of the survey.
.

1. Therewere noresidents identified in the surveyor findings as being affected by the alleged deficient practice. On 9/4/2022, the MDS Nurse corrected the MDS section 16000 for resident #23 (See Exhibit Al, A2, A3).

2. All residents have the potential to be affected by this alleged deficient practice. The MDS Nurse will review all current resident's last MDS assessments Section 16000 by 10/19/2022 for compliance (See Exhibit B).

3. The Director ofNursing reeducated the MDS Nurseon 9/15/2022, on completing the MDS assessments accurately (See Exhibit C).

4. The Quality Assurance Nurse/Designee will monitor MDS Section 16000 (See Exhibit D), twice weekly for one month and then once monthly for6 months. Thereafter, monitoring will occur on a quarterly basis. All data will be presented by the QAPI Nurse to the QAPI committee at least quarterly for analysis and any further action.

§483.24(c)(2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who- (i) Is licensed or registered, if applicable, by the State in which practicing; and (ii) Is: (A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or (B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or (C) Is a qualified occupational therapist or occupational therapy assistant; or (D) Has completed a training course approved by the State.

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Based 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 more than a limited number of residents residing in the facility. Facility census: 44.

Findings Included:

a) Qualified Activity Professional

During an observation on 08/22/22 at 12:05 PM the Activity Department was void of a certificate for a qualified activity professional.

During an interview on 08/23/22 at 9:10 AM, the Social Worker #82 stated, "We don't have an activity director we have not had one in months, I have told them we needed one, I am doing the best I can but I am not certified and really don't know what I am doing."

During an interview on 08/23/22 at 10:39 AM, the Administrator stated, "The Activity Director has been gone since August 2021. The Division of Personnel will not let us hire due to not knowing if its a Supervisor 2 or 1 position. I have been telling them we were going to get a tag for not having an Activity Director."
.

1. Therewere no residents identified in the surveyor findings as being affected by the alleged deficient practice.

2. All residents have the potential to be affected by this alleged deficient practice.

3. On 9/15/2022 the Director of Human Resources contacted the division of personnel as they are still working on an approved posting. The Division of WV Personnel is clarifying the position posting requirements/qualifications so as to post and fill the position. The facility will post and hire upon WV Personnel decision of an approved posting. The Administrator/Designee will make weekly contacts to the Human Resources Director until the position is posted/filled.

4. The Administrator/Designee will provide monthly updates of progress to the Quality Assurance Nurse. All data will be presented by the QAPI Nurse to the QAPI committee at least quarterly for analysis and any further section.

§483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

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Based on record review staff interview, the facility failed to ensure pressure ulcer care was provided in accordance with professional standards of practice. Resident #4's pressure ulcer treatment to the coccyx was not on the treatment administration record. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the care area of pressure ulcers. Resident identifier: #4. Facility census: 44.

Findings included:

a) Resident #4

Review of Resident #4's physician's orders showed the following orders written on 06/01/22 for pressure ulcer care:

--Cleanse left hip with mild soap and water, pat dry. Apply daikon's to the fluffed tip of 2x2 gauze and gently insert into the tunneled area on side of the wound going approximately 1 cm, pack gently and loosely, do not force 2x2 gauze into area, cover with 2x2 gauze into area, cover with 2x2 gauze and paper tape. Change daily and PRN (as needed).

--Cleanse coccyx with mild soap and water, pat dry. Apply fluffed dry 2x2 gauze in the coccyx area, tape not needed. Change every day and PRN.

On 08/24/22 at 9:13 AM, Licensed Practical Nurse (LPN) #49 was observed performing Resident #4's pressure ulcer dressing changes. Prior to the dressing changes, LPN #49 reviewed Resident #4's Treatment Administration Record (TAR) to determine the current treatment of the resident's pressure ulcers. The left hip pressure ulcer care treatment was on the TAR. The coccyx pressure ulcer care treatment was not on the TAR. LPN #49 obtained a copy of Resident #4's current physician's order for the coccyx pressure ulcer before preceding to the dressing change.

During an interview on 08/24/22 at 10:26 AM, the Director of Nursing (DON) verified Resident #4's coccyx pressure treatment was not on the resident's current TAR. The treatment was on the June 2002 and July 2022 TARs but had not been carried over to the August TAR.

There were nursing notes referring to the coccyx pressure ulcer assessment and dressing change. However, it could not be shown that the coccyx pressure ulcer dressing change was performed every day as ordered.

No further treatment was provided through the completion of the survey.
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1a. There were noresidents identified in the surveyor findings as being affected by the alleged deficient practice. On 8/24/2022 the LPN placed pressure treatment order for resident #4 on the treatment administration record and signed off as completed (See Exhibit E, Ea, Eb, and Ec).

2a. All residents identified with pressure ulcers have the potential to be affected by this alleged deficient practice. On 8/24/2022 the Quality Assurance Nurse checked all residents with orders for pressure ulcer treatment administration records for compliance. No other residents were identified as being out of compliance.

3a. By 10/19/2022, the Staff Development/Designee will reeducate all nursing staff on making sure all pressure ulcers have treatment administration records in place for all residents with a pressure ulcer (See Exhibit F).

4a. The Quality Assurance Nurse/Designee will monitor residents with pressure ulcer treatments to ensure compliance of treatment administration record (See Exhibit G), twice weekly for one month and then once monthly for 6 months. Thereafter, monitoring will occur on a quarterly basis. All data will be presented by the QAPI Nurse to the QAPI committee at least quarterly for analysis and any further action.

§483.35(d)(7) Regular in-service education. The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

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Based on employee record reviews and staff interview, the facility failed to complete the annual performance evaluations for nurse aides. This was true for five (5) of five (5) agency nurse aides reviewed during the sufficient and competent nurse staffing. Employee #23, #32, #46, #57, and #61 had not received their annual nurse aide performance reviews. Facility census: 44

Findings included:

a) Performance reviews for agency nurse aides

During a review of employee records on 08/24/22, it was discovered Employee #23, #32, #46, #57, and #61 agency nurse aides (NA) had not had their annual performance reviews completed on or before their annual date of hire.

In an interview with the interim Director of Nursing (DON) on 08/23/22 at 1:00 PM, reported he had never completed annual performance reviews for any agency NA staff.
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1. There were no residents identified in the surveyor findings as being affected by the alleged deficient practice.

2. All residents have the potential to be affected by this alleged deficient practice. A list of nursing assistants that were out of compliance for a performance review was provided to the Assistant Director of Nursing on 8/26/2022.

3. On 9/6/2022 all performance reviews had been completed and given to the nursing assistants that were out of compliance. This was completed by the Assistant Director of Nursing (See Exhibit H).

4. The Quality Assurance Nurse/Designee will monitor staff performance records to ensure compliance of timely performance reviews (See Exhibit I, twice weekly for one month and then once monthly for 6 months. Thereafter, monitoring will occur on a quarterly basis. All data will be presented by the QAPI Nurse to the QAPI committee at least quarterly for analysis and any further action.

§483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

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Based on observation, record review and staff interview, the facility failed to ensure temperature checks were completed daily for one (1) of the two (2) refrigerators used for medication storage. This failed practice had the potential to affect a limited number of residents. Facility census:44.

Findings included:

a) Medication Temperatures

During an observation of the A1 medication storage room (located on A Hall) on 08/23/22 at 9:15 AM, the temperature log for the medication refrigerator was found to incomplete for August 2022. The following dates were blank on the temperature log: 08/04/22, 08/09/22, 08/13/22, 08/17/22, and 08/18/22.

Licensed Practical Nurse (LPN) #80 verified the temperature log was incomplete and stated that night shift usually completes the temperature log and stated, "We've hired so many new people on nights they probably forgot." LPN #80 further stated that the medications routinely kept in the refrigerator were vaccines, insulin, suppositories, eye drops in addition to a vial Ativan for intramuscular injections at that moment.

Record review of the facility's policy titled, "Medication Administration," effective date 02/24/21, showed that it is the responsibility of the Medication Nurse to keep the refrigerator at the recommended temperature. The medication refrigerator temperature is to be checked daily and logged to maintain temperature range of 36\'b0 Fahrenheit - 46\'b0 Fahrenheit.
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1. There were no residents identified in the surveyor findings as being affected by the alleged deficient practice.

2. All residents have the potential to be affected by the alleged deficient practice.

3. By 10/19/2022 the Staff Development/Designee will reeducate all licensed nurses on making sure the medication refrigerator temperatures are checked and documented for compliance (See Exhibit J).

4. The Quality Assurance Nurse/Designee will monitor medication refrigerators (See Exhibit K), twice weekly for one month and then once monthly for 6 months to ensure refrigerated with medications have temperature checked in a timely manner. Thereafter, monitoring will occur on a quarterly basis. All data will be presented by the QAPI Nurse to the QAPI committee at least quarterly for analysis and any further action.

§483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

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Based on observation and staff interviews, the facility failed to store food in sanitary conditions by not labeling foods appropriately and not discarding when foods expired in the kitchen. The facility also failed to correctly document temperatures for all the dietary equipment requiring temperature logs. This deficient practice had the potential to affect more than a limited number of residents that receive nutrients from the kitchen. Facility Census:44

Findings Included:

A facility policy titled Food Storage Labeling with a revision date of 04/2018 stated (Typed as written)
...Procedures
4. An accurate thermometer will be kept in each refrigerator and freezer. A written record or daily temperatures will be recorded.
5. All foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination.

a) Reach In Freezer

An initial tour of the kitchen with the Food Service Worker (FSW)#209 beginning on 08/22/22 at 11:17 AM, the reach in freezer found the following items
:
-An opened box of Hamburger Patties: no opened date
-An opened bag of cheese omelet: no opened date
-An opened box of pizza dough: no opened date
-An opened box of fish filets: no opened date
-An opened box of biscuit dough: no opened date
-An opened box of chocolate chip cookie dough: no opened date
-An opened box of Beef steak sandwich: no opened date
-An opened box of dinner roll dough: no opened date
-Four (4) opened bags of chicken: no opened date
-An opened box of frozen strawberries: no opened date
-Two (2) opened boxes of sugar cookie dough: no opened date
-An opened box of peanut butter cookie dough: no opened date

b) Meat Cooler

An initial tour of the kitchen with the Food Service Worker (FSW)#209 beginning on 08/22/22 at 11:17 AM, found the following in the meat cooler:

-A container of corned beef: 08/16 use by date 08/21
-A container of corned beef hash: not dated
-A container of scrambled eggs: not dated
-A container of pureed chicken patty: 07/24 use by date 08/01
-A container of salad: not dated
-A container of diced tomatoes: 08/06 use by date 08/13
-A container of BBQ chicken: 07/26 use by date 08/02
-A container of ground BBQ chicken: 07/26 use by date 08/02
-A container of opened Sour Cream: no opened date
-A container of diced chicken: not dated
-Deli Turkey sliced: dated 08/09 use by date 08/18/22
-A container of Mustard: 11/04/21 use by date 02/04/22
-A carton of parmesan cheese: not dated
-A container of V-8 Juice: not dated
-A opened package of hot dogs: not dated
-A container of BBQ sauce: not dated
-A container of pureed eggs: 07/27 use by date 08/04
-A container of diced tomatoes: 07/16 use by date 07/23
-3 opened packages of sliced cheese not dated

c) Cooks Cooler

An initial tour of the kitchen with the Food Service Worker (FSW) #209 beginning on 08/22/22 at 11:17 AM, the Cooks Cooler the following items were found:

-A container of cream of mushroom soup: 08/14 use by date 08/21
-A container of marinated bean salad: 08/13 use by date 08/20
-A container of cream corn: 08/14 use by date 08/21
-A container of cream of potato soup: not dated
-A container of corn: 08/14 use by date 08/21
-A unopened bag of boiled egg: not dated
-A container of rice: not dated

FSW #209, indicated the food need to be discarded because it was either out of date or not date when opened.

d) Dish Machine temperature Log

Dish Machine temperature log the month of July was posted was void of all temperatures

e) Three compartment sink temperature log

Three compartment sink temperature log the month of July was posted with 07/04/22 and 07/05/22 temperatures filled in.

f) Three door freezer temperature log

Freezer three door temperature log were void of the following PM temperatures on the following dates:
-08/08/22
-08/09/22
-08/11/22
-08/14/22
-08/21/22

g) Walk-in Refrigerator temperature log

-The Walk-In Refrigerator temperature log was void of temperatures on the following dates:
-08/04/22 AM
-08/05/22 AM
-08/06/22 AM & PM
-08/07/22 AM & PM
-08/08/22 AM & PM
-08/09/22 AM & PM
-08/10/22 AM & PM
-08/11/22 PM
-08/12/22 AM
-08/15/22 AM & PM
-08/16/22 AM & PM
-08/17/22 AM
-08/18/22 AM
-08/19/22 AM
-08/20/22 AM & PM
-08/21/22 AM & PM

h) Meat Cooler temperature log

The Meat Cooler temperature log were void of temperatures on the following dates:
-08/20/22 AM
-08/21/22 PM

i) Cooks Cooler #1 temperature log

The Cooks Cooler #1 temperature log were void of temperatures on the following dates:
-08/05/22 PM
-08/06/22 PM
-08/07/22 AM & PM
-08/08/22 AM & PM
-08/09/22 AM & PM
-08/10/22 AM
-08/11/22 AM & PM
-08/12/22 AM
-08/14/22 PM
-08/20/22 AM
--08/21/22 AM

j) Cooks Cooler #2 temperature log

The Cooks Cooler #2 temperature log was void of temperatures on the following dates:
-08/05/22 PM
-08/06/22 PM
-08/07/22 AM & PM
-08/08/22 AM & PM
-08/09/22 AM & PM
-08/10/22 AM
-08/11/22 AM & PM
-08/12/22 AM
-08/20/22 AM
-08/21/22 AM

k) Tray line temperature log

The Tray line refrigerator temperature log was void temperatures on the following dates:
--08/04/22 AM
-08/05/22 AM & PM
-08/06/22 AM & PM
-08/07/22 AM & PM
-08/08/22 AM & PM
-08/09/22 AM & PM
-08/10/22 AM
-08/11/22 AM & PM
-08/12/22 AM
-08/15/22 AM
-08/16/22 AM
-08/17/22 AM
-08/18/22 AM
-08/19/22 AM
-08/20/22 AM
-08/21/22 AM & PM

l) Serving line temperature log

During the tour of the kitchen with the Food Service Worker (FSW)#209 on 08/22/22 at 12:00 PM, this surveyor asked the FSW #209 to test the temperatures on the steam table. The kitchen staff were unable to find the temperature log for the serving line steam table. The FSW stated its not were they normal keep it and no one can find it. The following kitchen staff were present at the time and unable to locate the temperature log FSW #210 and Cook # 212 and #203. All staff present can not remember the last time they wrote down the temperatures.

The FSW #209 acknowledged the temperature logs were incomplete for all kitchen equipment.

During an interview on 08/22/22 at 1:39 PM, the District Manager #201 was informed of all dietary concerns. She stated that I did an in-service on Friday about temperature log on the serving line, I can't believe they can't find it.
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1a. There were no residents identified in the surveyor findings as being affected by the alleged deficient practice. All food items
identified were discarded immediately.

2a. All residents have the potential to be affected by this alleged deficient practice. On 8/22/2022, dietary staff inspected all
refrigerated food dates and labels. Any items lacking dates were discarded.

3a. District Manager for HealthCare Services Group provided I documentation that HCSG's staff received required education for food safety on 9/14/2022 (See Exhibit L).

4. The Quality Assurance Nurse/Designee will monitor refrigerator foods (See Exhibit M), twice weekly for one month and then once monthly for 6 months to ensure refrigerated foods contain an expiration date. Thereafter, monitoring will occur on a quarterly basis. All data will be presented by the QAPI Nurse to the QAPI committee at least quarterly for analysis and any further action.

lb. There were no residents identified in the surveyor findings as being affected by the alleged deficient practice.

2b. All residents have the potential to be affected by this alleged deficient practice. On 8/22/2022, all temperatures of hot/cold food/storage appliances were completed, and no noncompliance issues were identified.

3b. District Manager for HealthCare ServicesGroup provided documentation that HCSG's staff received required education for food safety (See Exhibit L).

4b. The Quality Assurance Nurse/Designee will monitor hot-cold food temperatures/appliance temperatures (See Exhibit M), twice weekly for one month and then once monthly for 6 months to ensure hot/cold temperatures are in compliance as required. Thereafter, monitoring will occur on a quarterly basis. All data will be presented by the QAPI Nurse to the QAPI committee at least quarterly for analysis and any further action.

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Hopemont Hospital is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. A review of the plans of correction and credible evidence was accepted in lieu of an onsite revisit for the annual recertification and annual relicensure survey concluding on 08/24/2022. The facility is in substantial compliance with the previously cited deficient practices.
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§483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

§483.24(c)(2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who- (i) Is licensed or registered, if applicable, by the State in which practicing; and (ii) Is: (A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or (B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or (C) Is a qualified occupational therapist or occupational therapy assistant; or (D) Has completed a training course approved by the State.

§483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

§483.35(d)(7) Regular in-service education. The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

§483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

§483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

One hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

If there is an automatic sprinkler system, it is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. The system is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. It is fully supervised. There is a reliable, adequate water supply for the system. Required sprinkler systems are equipped with water flow and tamper switches, which are electrically connected to the building fire alarm system. 19.3.5

Clear Width of Exit and Exit Access Doors 2012 EXISTING Exit access doors and exit doors are of the swinging type and are at least 32 inches in clear width. Exceptions are provided for existing 34-inch doors and for existing 28-inch doors where the fire plan does not require evacuation by bed, gurney, or wheelchair. 19.2.3.6, 19.2.3.7

Hazardous Areas - Enclosure 2012 EXISTING Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)

Interior Wall and Ceiling Finish 2012 EXISTING Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2 Indicate flame spread rating(s). _____________________

Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter's Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter's Service Requirements of ASME/ANSI A17.3. (Includes firefighter's service Phase I key recall and smoke detector automatic recall, firefighter's service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3

Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7

Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

The [facility, except for Transplant Center] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach.

Based on the facility document review and staff interview, the facility failed to establish and maintain a comprehensive emergency preparedness program that complies with all applicable Federal, State and local emergency preparedness requirements. Facility census 50.

Findings include:

a) During the facility emergency preparedness document review conducted on 05/29/24 between the hours of 12:00 p.m. and 2:00 p.m., the facility failed to complete the following emergency preparedness elements:

1) Failed to Develop and Maintain EP Program.

2) Failed to Maintain and Annual EP Updates.

3) EP Program Patient Population.

4) Failed to Process for EP Collaboration

5) A documented facility based and community- based risk assessment was not available for review.

6) Policies and procedures addressing the subsistence needs of staff and patients were not available for review.

7) Policies and procedures for tracking of staff and patients were not available for review.

8) Policies and procedures Including Evacuation

9) Policies and procedures for Sheltering were not available for review.

10) Policies and procedures for Medical Docs was not available for review.

11) Policies and procedures for volunteers was not available for review.

12) Policies and procedures for roles under a Waiver declared by Secretary not available for review.

13) Policies and procedures for a Communication Plan were not available for review.

14) Policies and procedures for names and contact information for staff, entities providing services under agreement, patients, physicians, other hospitals and volunteers were not available for review.

15) Primary and alternate means for communication plans were not available for review.

16) Policies and procedures for sharing information on occupancy needs were not available for review.

17) Policies and procedures for emergency prep and a training program were not available for review.

18) An emergency training program was not available for review.

19) No Emergency Officials Contact Information.

20) No Emergency Prep Training and Testing.

21) No Emergency Prep Testing Requirements.

22) No Integrated Health Systems.


b) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.

E 001

1. The emergency preparedness manual was located after the life safety inspector had exited on 05/30/2024. A review of the manual was conducted by the Administrator on 06/17/2024 that verified elements: 1-22 and that they will require updates to be completed by 07/18/2024.

2. The deficient practice has the potential to affect all residents.

3. Copies of the Emergency Preparedness Manual will be made and placed at the Main Entrance and the Nursing stations by the administrator or designee by 07/18/2024.

4. The Emergency Preparedness Manual will be monitored by the Administrator/Designee quarterly and any findings/changes will be presented at the safety meeting for review on a quarterly basis.

5. Completion of review of policy and procedures and placement of copies of manuals is to be completed by 07/18/2024.

Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Based on observation and staff interview, the facility failed to ensure that delayed-egress locking systems were installed in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m. it was revealed that the door in the solarium going in to A hallway had a mag lock and a turn knob handle on the door. This created two locking devices on the door for exit.

b) The aforementioned deficiency was discussed with the director of maintenance at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.

K 211

1. The mag lock for the door entering A Hall was removed, preventing two locking devices on the door on 06/10/2024.

2. The deficient practice has the potential to affect all residents

3. Maintenance staff will be re-educated by 07/18/2024 by the Maintenance Director or designee to check the doors throughout the facility monthly to ensure doors meet regulations. The Maintenance Director/designee will order a replacement door by 07/18/2024 that will allow placement of 15 second push release for emergencies.

4. The Maintenance director/Designee will inspect and monitor corridor/barrier doors monthly to ensure a double lock arrangement is not in place. Findings of the audit will be presented to the quality assurance performance improvement committee on a quarterly basis.

5. Education of regulations to maintenance personnel and check of doors within care areas will be completed by 07/18/2024.

Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1

Based on record review and staff interview, the facility failed to ensure that required emergency lighting was tested and maintained in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., revealed no documentation that battery powered emergency lights throughout the facility had received annual functional testing for a minimum of 90 minutes.

b) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.

K 291

1. The Maintenance Director/designee will ensure that battery powered emergency lights throughout the facility will receive the annual functional testing of 90 minutes on 06/14/2024.

2. The deficient practice has the potential to affect all residents.

3. The annual emergency battery powered light testing will be added to the testing sheet, and maintenance staff will be re-educated on this check by the Maintenance Director/designee by July 18, 2024.

4. The maintenance supervisor/designee will monitor quarterly that the annual testing of the emergency lighting testing has been completed, and report the findings to the facility safety committee on a quarterly basis.

5. Completion of testing of the emergency lighting and changing of the testing sheet will be completed by 07/18/2024.

Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Based on observation and staff interview, the facility failed to ensure that automatic sprinkler and standpipe systems were maintained in accordance with NFPA (National Fire Protection Association) 25. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., the facility failed to provide evidence of the dry pipe sprinkler system of all heads replaced, or sample of heads tested every 10 years. In accordance with NFPA (National Fire Protection Association) 25.

b) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., the facility failed to provide evidence of a five year internal inspection of the sprinkler system piping and water storage interior tank inspection. In accordance with NFPA (National Fire Protection Association) 25.

c) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., the facility failed to provide evidence of a sprinkler inspection for the second Quarter sprinkler system testing in accordance with NFPA ( National Fire Protection Association) 72.

d) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., the facility failed to provide evidence of a sprinkler inspection for the forth Quarter sprinkler system testing in accordance with NFPA ( National Fire Protection Association) 72.

e) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.

K 353

1. a. A fire sprinkler contractor was contacted on 06/10/2024 by the Chief Operating Officer to schedule the completion of the 10 year dry pipe inspection. A work order number of #97352 was given by the fire sprinkler contractor with the assignment of completion of the 5 year and 10 year inspection to be completed upon their arrival.

B. A fire sprinkler contractor was contacted on 06/10/2024 by the Chief Operating Officer to schedule the completion of the five year internal inspection of the sprinkler piping and water storage interior tank inspection. A work order number of #97352 was given by the Fire sprinkler contractor with the assignment of completion of the 5 year and 10 year inspection to be completed upon their arrival.

C. An inspection of the sprinkler system was completed on July 5, 2023 by Brewer & Company of WV.

D. An inspection of the sprinkler system was completed on January 2 2024 by Brewer & Company of WV.

2. All residents have the potential to be affected by the deficient practice.

3. Sprinkler Inspection will be added to the Safety Committee Agenda and will be reviewed on a monthly basis. The Safety meeting Coordinator will report any deficient practices to the Administrator immediately for review and correction.

4. Sprinkler reports will be monitored by the Maintenance Director and/or designee and reported to the Safety Committee on a minimum of quarterly basis to ensure compliance of all requirements this is to include:

A: 10 year inspection
B: 5 year inspection
C/D: Quarterly inspections

5. Inspection of Sprinklers is to be Completed by 07/18/2024. (this may need to be adjusted based on the availability of Brewer or change wording to appointment made.)

Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10

Based on observation and staff interview, the facility failed to ensure that portable fire extinguishers were installed and maintained in accordance with NFPA (National Fire Protection Association) 10. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed a fire extinguisher located in the recreation room ( PT ), which had the top of the fire extinguisher installed greater than five (5) feet above the floor.

b) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed a fire extinguisher located in the CSR room, which had the top of the fire extinguisher installed greater than five (5) feet above the floor.

c) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.

K 355

1. The fire extinguisher located in the Recreation room and the CSR room were lowered to have the top of the extinguisher to be lower than five (5) feet above the floor on 06/01/2024, by the maintenance personnel.

2. This deficient practice has the potential to affect fire safety for all persons utilizing the Recreation and CSR rooms. A facility wide check of all fire extinguishers will be conducted by the maintenance personnel/designee to ensure compliance will be completed by 07/18/2024.

3. The maintenance director/designee will conduct quarterly audits to ensure compliance that no fire extinguisher be installed greater than five feet. Findings of the audit will be presented to the quality assurance performance improvement committee on a quarterly basis.

4. Education of maintenance personnel will be provided by the Maintenance Director/designee) by 07/18/2024 to ensure that wall mounted fire extinguishers are no higher than five feet from floor level.

5. Inspection of all fire extinguishers and education to maintenance staff is to be completed by 07/18/2024

Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Based on observation and staff interview, the facility failed to maintain smoke barrier doors in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed the Smoke Barrier doors by the dining room exceeded the 1/8 inch gap at the meeting edges of the doors.

b) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.

K 374

1. On 06/01/2024, Maintenance personnel adjusted the swing of the door identified in the surveyor findings, which closed the gap of the door of less than 1/8" at meeting edges of the doors.

2. All residents had the potential to be affected by the deficient practice.

3. Maintenance personnel will be re-educated by the Maintenance Director/designee, by July 18,2024 to inspect and ensure door closure gap of less than 1/8" at meeting edges on a monthly basis, documenting the inspection and results.

4. The maintenance director and/or designee will monitor and report any deficiencies and corrective actions to the Safety Committee on a minimum of a quarterly basis.

5. Compliance with this regulation will be by 07/18/2024.

Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7

Based on document review and staff interview, it was determined the facility failed to conduct fire drills at unexpected times under varying conditions in accordance with NFPA (National Fire Protection Association) This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., revealed on the first Quarter no day shift fire drill was conducted.

b) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., revealed on the first Quarter no afternoon shift fire drill was conducted.

c) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Assistance Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.

K 712

1. A fire drill for afternoon shift was conducted on 06/12/2024 by maintenance personnel for day shift and a fire drill was conducted by the maintenance personnel for afternoon shift on 06/13/2024 with a fire drill to be conducted by maintenance personnel for night shift on 06/30/2024 to ensure compliance for the second quarter.

2. All residents have the potential to be affected by the deficient practice.

3. The Safety Committee will review fire drills with the Maintenance Director/Designee and schedule fire drill dates to ensure compliance, this will occur on a minimum of a quarterly basis.

4. The Maintenance Director/Designee will monitor fire drill reports on a monthly basis to ensure drills are being conducted within required frequency. Results of this monitoring will be reported by the Maintenance Director/ Designee to the facility Safety Committee on a monthly basis. The Safety Meeting Coordinator will report any deficient practices to the Administrator immediately for review and correction.

5. Completion of fire drills for 2nd quarter is to be completed by 07/18/2024. Safety Committee reporting will be ongoing.

Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Based on record review and staff interview, the facility failed to maintain the testing and maintenance requirements for fixed and portable patient-care equipment in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed on A hallway soiled linen room no annual sticker or documentation of electrical resistance, current leakage, or touch current testing for (3) Oxygen concentrator ( rental equipment) used within the facility during survey.

b) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed on B hallway Oxygen room no annual sticker or documentation of electrical resistance, current leakage, or touch current testing for (4) Oxygen concentrator (rental equipment) used within the facility during survey.

c) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed on B hallway Soiled Linen room no annual sticker or documentation of electrical resistance, current leakage, or touch current testing for (1) Oxygen concentrator ( rental equipment) used within the facility during survey.

d) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed on B hallway Oxygen room no annual sticker or documentation of electrical resistance, current leakage, or touch current testing for (9) New Nebulizers ( rental equipment) used within the facility during survey.

e) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.

K 921

1. The oxygen concentrators throughout the facility were serviced and checked by the contracted agency on 05/31/2024 with a sticker placed on them to ensure compliance. This also included servicing of the new nebulizers that are in current storage.

2. All residents that have an order for oxygen have the potential to be affected by the deficient practice.

3. The Medical Records Director and/or Designee will make a monthly round to ensure that all electrical equipment is tested/serviced prior to being placed on the floor for use and ensure they are serviced annually.

4. The Medical Records Director and/or designee will monitor concentrators and nebulizers that have been inspected and labeled on a monthly basis and report findings to the Safety Committee on a minimum of a quarterly basis.

5. The first round of electric equipment check is to be completed by 6/30/2024. Safety Committee reporting will be ongoing.

The [facility, except for Transplant Center] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach.

Based on the facility document review and staff interview, the facility failed to establish and maintain a comprehensive emergency preparedness program that complies with all applicable Federal, State and local emergency preparedness requirements. Facility census 50.

Findings include:

a) During the facility emergency preparedness document review conducted on 05/29/24 between the hours of 12:00 p.m. and 2:00 p.m., the facility failed to complete the following emergency preparedness elements:

1) Failed to Develop and Maintain EP Program.

2) Failed to Maintain and Annual EP Updates.

3) EP Program Patient Population.

4) Failed to Process for EP Collaboration

5) A documented facility based and community- based risk assessment was not available for review.

6) Policies and procedures addressing the subsistence needs of staff and patients were not available for review.

7) Policies and procedures for tracking of staff and patients were not available for review.

8) Policies and procedures Including Evacuation

9) Policies and procedures for Sheltering were not available for review.

10) Policies and procedures for Medical Docs was not available for review.

11) Policies and procedures for volunteers was not available for review.

12) Policies and procedures for roles under a Waiver declared by Secretary not available for review.

13) Policies and procedures for a Communication Plan were not available for review.

14) Policies and procedures for names and contact information for staff, entities providing services under agreement, patients, physicians, other hospitals and volunteers were not available for review.

15) Primary and alternate means for communication plans were not available for review.

16) Policies and procedures for sharing information on occupancy needs were not available for review.

17) Policies and procedures for emergency prep and a training program were not available for review.

18) An emergency training program was not available for review.

19) No Emergency Officials Contact Information.

20) No Emergency Prep Training and Testing.

21) No Emergency Prep Testing Requirements.

22) No Integrated Health Systems.


b) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.

E 001
1st Emergency Preparedness Revisit: 07/23/24

Based on the facility document review and staff interview, the facility failed to establish and maintain a comprehensive emergency preparedness (EP) program that complies with all applicable Federal, State and local emergency preparedness requirements. Facility census 47.

Findings include:

a) During the facility emergency preparedness document review conducted on 07/23/24 between the hours of 9:30 a.m. and 12:15 p.m., the facility failed to complete the following emergency preparedness elements:

1) Failed to Develop and Maintain EP Program.

2) No documented community based risk assessment

3) Policies and procedures for tracking of staff and patients were not available for review.

4) Policies and procedures for Sheltering were not available for review.

5) Policies and procedures for volunteers was not available for review.

6) Policies and procedures for roles under a Waiver declared by Secretary not available for review.

7) Policies and procedures for names and contact information for staff, entities providing services under agreement, patients, physicians, other hospitals and volunteers were not available for review.

8) Policies and procedures for sharing information on occupancy needs were not available for review.

9) Policies and procedures for a method of sharing information from the emergency plan, that the facility has determined appropriate, with the residents and their families or representatives

E 001

1. A review of the manual was conducted by the Emergency Planning Committee on 07/29/2024 that verified emergency
preparedness elements: 1-9 and that they will require updates to be completed by 08/19/2024.

2. The deficient practice has the potential to affect all residents.

3. Copies of the updated Emergency Preparedness Manual will be made and placed at the Main Entrance and the Nursing stations by the Administrator or Designee by 08/19/2024.

4. The Emergency Preparedness Manual will be monitored by the Administrator/Designee quarterly and any findings/changes will be presented at the safety meeting for review on a quarterly basis.

5. Completion of review of policy and procedures and placement of copies of manuals is to be completed by 08/19/2024.

Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Based on observation and staff interview, the facility failed to ensure that delayed-egress locking systems were installed in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m. it was revealed that the door in the solarium going in to A hallway had a mag lock and a turn knob handle on the door. This created two locking devices on the door for exit.

b) The aforementioned deficiency was discussed with the director of maintenance at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.

Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1

Based on record review and staff interview, the facility failed to ensure that required emergency lighting was tested and maintained in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., revealed no documentation that battery powered emergency lights throughout the facility had received annual functional testing for a minimum of 90 minutes.

b) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.

Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Based on observation and staff interview, the facility failed to ensure that automatic sprinkler and standpipe systems were maintained in accordance with NFPA (National Fire Protection Association) 25. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., the facility failed to provide evidence of the dry pipe sprinkler system of all heads replaced, or sample of heads tested every 10 years. In accordance with NFPA (National Fire Protection Association) 25.

b) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., the facility failed to provide evidence of a five year internal inspection of the sprinkler system piping and water storage interior tank inspection. In accordance with NFPA (National Fire Protection Association) 25.

c) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., the facility failed to provide evidence of a sprinkler inspection for the second Quarter sprinkler system testing in accordance with NFPA ( National Fire Protection Association) 72.

d) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., the facility failed to provide evidence of a sprinkler inspection for the forth Quarter sprinkler system testing in accordance with NFPA ( National Fire Protection Association) 72.

e) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.


K 353
1st-Revisit Life Safety Code

Based on observation and staff interview, the facility failed to ensure that automatic sprinkler and standpipe systems were maintained in accordance with NFPA (National Fire Protection Association) 25. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 47.

Findings include:

a) During the facility document review conducted on 07/23/24 between the hours of 9:30 a.m. and 12:15 p.m., the facility failed to provide evidence of the dry pipe sprinkler system of all heads replaced, or sample of heads tested every 10 years. In accordance with NFPA (National Fire Protection Association) 25.

b) The aforementioned deficiency was discussed with the Assistant Administrator at the time of discovery and again with the Administrator on 07/23/24 at approximately 12:30 p.m. at the time of exit.

K 353

1. A fire sprinkler contractor was contacted on 06/10/2024 by the Chief Operating Officer to schedule the completion of the five year internal inspection of the sprinkler piping and water storage interior tank inspection. A work order number of #97352 was given by the Fire sprinkler contractor with the assignment of completion of the 5 year and 10 year inspection to be completed by 07/30/2024.

2. All residents have the potential to be affected by the deficient practice.

3. Sprinkler Inspection will be added to the Safety Committee Agenda and will be reviewed on a monthly basis. The Safety meeting Coordinator will report any deficient practices to the Administrator immediately for review and correction.

4. Sprinkler reports will be monitored by the Maintenance Director and/or Designee and reported to the Safety Committee on a minimum of quarterly basis to ensure compliance of all requirements this is to include:
a. 10 year inspection.

5. Inspection of Sprinklers is to be completed by 7/31/2024.

Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10

Based on observation and staff interview, the facility failed to ensure that portable fire extinguishers were installed and maintained in accordance with NFPA (National Fire Protection Association) 10. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed a fire extinguisher located in the recreation room ( PT ), which had the top of the fire extinguisher installed greater than five (5) feet above the floor.

b) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed a fire extinguisher located in the CSR room, which had the top of the fire extinguisher installed greater than five (5) feet above the floor.

c) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.

Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Based on observation and staff interview, the facility failed to maintain smoke barrier doors in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed the Smoke Barrier doors by the dining room exceeded the 1/8 inch gap at the meeting edges of the doors.

b) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.

K 374
1st Revisit Life Safety Code

Based on observation and staff interview, the facility failed to maintain smoke barrier doors in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 47..

Findings include:

a) Observation during the facility inspection tour on 07/23/24, between the hours of 9:30 a.m. and 12:15 p.m., revealed the Smoke Barrier doors by the dining room would not close completely when closing.

b) The aforementioned deficiency was discussed with the Assistant Administrator at the time of discovery and again with the Administrator on 07/23/24 at approximately 12:30 p.m. at the time of exit.

K 374

1. On 07/23/2024 Maintenance personnel adjusted the swing of the door identified in the surveyor findings, which closed the gap of the door of less than 1/8 inch meeting edges of the doors.

2. All residents had the potential to be affected by the deficient practice.

3. The Maintenance Director has placed an order to replace the two doors that continue to require adjustment. These doors will be replaced upon arrival and continued to be monitored daily until replacement is completed.

4. The Maintenance Director and/or Designee will monitor and report any deficiencies and corrective actions to the Safety Committee on a minimum of a quarterly basis.

5. Compliance with this regulation has been met and will continue to be monitored.

Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7

Based on document review and staff interview, it was determined the facility failed to conduct fire drills at unexpected times under varying conditions in accordance with NFPA (National Fire Protection Association) This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., revealed on the first Quarter no day shift fire drill was conducted.

b) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., revealed on the first Quarter no afternoon shift fire drill was conducted.

c) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Assistance Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.

Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Based on record review and staff interview, the facility failed to maintain the testing and maintenance requirements for fixed and portable patient-care equipment in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed on A hallway soiled linen room no annual sticker or documentation of electrical resistance, current leakage, or touch current testing for (3) Oxygen concentrator ( rental equipment) used within the facility during survey.

b) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed on B hallway Oxygen room no annual sticker or documentation of electrical resistance, current leakage, or touch current testing for (4) Oxygen concentrator (rental equipment) used within the facility during survey.

c) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed on B hallway Soiled Linen room no annual sticker or documentation of electrical resistance, current leakage, or touch current testing for (1) Oxygen concentrator ( rental equipment) used within the facility during survey.

d) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed on B hallway Oxygen room no annual sticker or documentation of electrical resistance, current leakage, or touch current testing for (9) New Nebulizers ( rental equipment) used within the facility during survey.

e) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.


K 921
1st Life Safety Code Revisit

Based on record review and staff interview, the facility failed to maintain the testing and maintenance requirements for fixed and portable patient-care equipment in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 47.

Findings include:

a) Observation during the facility inspection tour on 07/23/24, between the hours of 9:30 a.m. and 12:15 p.m., revealed no available documentation during the time of survey of any electrical resistance, current leakage, or touch current testing on any fixed or portable patient care equipment.

b) The aforementioned deficiency was discussed with the Assistant Administrator at the time of discovery and again with the Administrator on 07/23/24 at approximately 12:30 p.m. at the time of exit.

K 921

1. The elements of electrical resistance, current leakage or touch current testing were verified by the maintenance staff on 07/30/2024.

2. All residents that have an order for oxygen have the potential to be affected by the deficient practice.

3. The Maintenance Director and/or Designee will make monthly inspections to ensure that all electrical equipment is tested/ serviced prior to being placed on the floor for use.

4. The Maintenance Director and/or Designee will monitor concentrators and nebulizers that have been inspected and documented on a monthly basis and report findings to the Safety Committee on a minimum of a quarterly basis.

5. The first round of electric equipment with the updated documentation is to be completed by 07/30/2024. Safety Committee reporting will be ongoing.

The [facility, except for Transplant Center] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach.

Based on the facility document review and staff interview, the facility failed to establish and maintain a comprehensive emergency preparedness program that complies with all applicable Federal, State and local emergency preparedness requirements. Facility census 50.Findings include:a) During the facility emergency preparedness document review conducted on 05/29/24 between the hours of 12:00 p.m. and 2:00 p.m., the facility failed to complete the following emergency preparedness elements: 1) Failed to Develop and Maintain EP Program. 2) Failed to Maintain and Annual EP Updates. 3) EP Program Patient Population. 4) Failed to Process for EP Collaboration5) A documented facility based and community- based risk assessment was not available for review.6) Policies and procedures addressing the subsistence needs of staff and patients were not available for review.7) Policies and procedures for tracking of staff and patients were not available for review.8) Policies and procedures Including Evacuation9) Policies and procedures for Sheltering were not available for review.10) Policies and procedures for Medical Docs was not available for review.11) Policies and procedures for volunteers was not available for review.12) Policies and procedures for roles under a Waiver declared by Secretary not available for review.13) Policies and procedures for a Communication Plan were not available for review.14) Policies and procedures for names and contact information for staff, entities providing services under agreement, patients, physicians, other hospitals and volunteers were not available for review.15) Primary and alternate means for communication plans were not available for review.16) Policies and procedures for sharing information on occupancy needs were not available for review.17) Policies and procedures for emergency prep and a training program were not available for review.18) An emergency training program was not available for review. 19) No Emergency Officials Contact Information. 20) No Emergency Prep Training and Testing. 21) No Emergency Prep Testing Requirements. 22) No Integrated Health Systems.b) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit. E 0011st Emergency Preparedness Revisit: 07/23/24Based on the facility document review and staff interview, the facility failed to establish and maintain a comprehensive emergency preparedness (EP) program that complies with all applicable Federal, State and local emergency preparedness requirements. Facility census 47.Findings include:a) During the facility emergency preparedness document review conducted on 07/23/24 between the hours of 9:30 a.m. and 12:15 p.m., the facility failed to complete the following emergency preparedness elements:1) Failed to Develop and Maintain EP Program.2) No documented community based risk assessment3) Policies and procedures for tracking of staff and patients were not available for review.4) Policies and procedures for Sheltering were not available for review.5) Policies and procedures for volunteers was not available for review.6) Policies and procedures for roles under a Waiver declared by Secretary not available for review.7) Policies and procedures for names and contact information for staff, entities providing services under agreement, patients, physicians, other hospitals and volunteers were not available for review.8) Policies and procedures for sharing information on occupancy needs were not available for review.9) Policies and procedures for a method of sharing information from the emergency plan, that the facility has determined appropriate, with the residents and their families or representatives

Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Based on observation and staff interview, the facility failed to ensure that automatic sprinkler and standpipe systems were maintained in accordance with NFPA (National Fire Protection Association) 25. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., the facility failed to provide evidence of the dry pipe sprinkler system of all heads replaced, or sample of heads tested every 10 years. In accordance with NFPA (National Fire Protection Association) 25.

b) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., the facility failed to provide evidence of a five year internal inspection of the sprinkler system piping and water storage interior tank inspection. In accordance with NFPA (National Fire Protection Association) 25.

c) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., the facility failed to provide evidence of a sprinkler inspection for the second Quarter sprinkler system testing in accordance with NFPA ( National Fire Protection Association) 72.

d) During the facility document review conducted on 05/28/24 between the hours of 12:00 p.m. and 5:00 p.m., the facility failed to provide evidence of a sprinkler inspection for the forth Quarter sprinkler system testing in accordance with NFPA ( National Fire Protection Association) 72.

e) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.


K 353
1st-Revisit Life Safety Code

Based on observation and staff interview, the facility failed to ensure that automatic sprinkler and standpipe systems were maintained in accordance with NFPA (National Fire Protection Association) 25. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 47.

Findings include:

a) During the facility document review conducted on 07/23/24 between the hours of 9:30 a.m. and 12:15 p.m., the facility failed to provide evidence of the dry pipe sprinkler system of all heads replaced, or sample of heads tested every 10 years. In accordance with NFPA (National Fire Protection Association) 25.

b) The aforementioned deficiency was discussed with the Assistant Administrator at the time of discovery and again with the Administrator on 07/23/24 at approximately 12:30 p.m. at the time of exit.

Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Based on observation and staff interview, the facility failed to maintain smoke barrier doors in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed the Smoke Barrier doors by the dining room exceeded the 1/8 inch gap at the meeting edges of the doors.

b) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.

K 374
1st Revisit Life Safety Code

Based on observation and staff interview, the facility failed to maintain smoke barrier doors in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 47..

Findings include:

a) Observation during the facility inspection tour on 07/23/24, between the hours of 9:30 a.m. and 12:15 p.m., revealed the Smoke Barrier doors by the dining room would not close completely when closing.

b) The aforementioned deficiency was discussed with the Assistant Administrator at the time of discovery and again with the Administrator on 07/23/24 at approximately 12:30 p.m. at the time of exit.

Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Based on record review and staff interview, the facility failed to maintain the testing and maintenance requirements for fixed and portable patient-care equipment in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 50.

Findings include:

a) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed on A hallway soiled linen room no annual sticker or documentation of electrical resistance, current leakage, or touch current testing for (3) Oxygen concentrator ( rental equipment) used within the facility during survey.

b) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed on B hallway Oxygen room no annual sticker or documentation of electrical resistance, current leakage, or touch current testing for (4) Oxygen concentrator (rental equipment) used within the facility during survey.

c) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed on B hallway Soiled Linen room no annual sticker or documentation of electrical resistance, current leakage, or touch current testing for (1) Oxygen concentrator ( rental equipment) used within the facility during survey.

d) Observation during the facility inspection tour on 05/29/24, between the hours of 8:00 a.m. and 1:30 p.m., revealed on B hallway Oxygen room no annual sticker or documentation of electrical resistance, current leakage, or touch current testing for (9) New Nebulizers ( rental equipment) used within the facility during survey.

e) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/29/24 at approximately 2:00 p.m. at the time of exit.


K 921
1st Life Safety Code Revisit

Based on record review and staff interview, the facility failed to maintain the testing and maintenance requirements for fixed and portable patient-care equipment in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 47.

Findings include:

a) Observation during the facility inspection tour on 07/23/24, between the hours of 9:30 a.m. and 12:15 p.m., revealed no available documentation during the time of survey of any electrical resistance, current leakage, or touch current testing on any fixed or portable patient care equipment.

b) The aforementioned deficiency was discussed with the Assistant Administrator at the time of discovery and again with the Administrator on 07/23/24 at approximately 12:30 p.m. at the time of exit.

Based upon review of facility documentation, staff interview, observations, and performance testing, it was determined that the facility is without waivers and in compliance with the provisions, the long term care facility was found to comply with all Federal, and State requirements.

Based upon review of facility documentation, staff interview, observations, and performance testing, it was determined that the facility is without waivers and in compliance with the provisions, the long term care facility was found to comply with all Federal, and State requirements.