Ashland Nursing and Rehabilitation

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to notify the physician per the physician orders for one of four residents in the survey sample, Resident #202.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to prevent an alleged allegation sexual abuse for one of four residents in the survey sample, Resident #202.

Inspectors wroteFor Resident #202 (R202), the facility staff failed to clarify two orders for insulin. R202 was admitted to the facility on [DATE] with recent readmission on [DATE], with diagnoses that included but were not limited to: insulin dependent diabetes, stroke, underweight, depression, anorexia, dementia and high blood pressure. The most recent MDS (Minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/16/2026, coded the resident as scoring a 99, indicating the resident was unable to complete the interview. In Section C0700, the resident was coded as having but short- and long-term memory difficulties. In Section N - Medication, the resident was coded as receiving three insulin injections over the past seven days. The physician order dated, 7/20/2026, documented, Insulin Lispro Injection Solution 100 UNIT/ML (milliliter); [...]

Inspectors wroteBased on observations, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to protect one of eight residents in the survey sample, Resident #1, from sexual abuse when the resident was unable to consent to sexual acts and failed to prevent neglect due to lack of adequate supervision for Resident #1 with a history of elopement. This resulted in Immediate Jeopardy and substandard quality of care. After the Immediate Jeopardy was removed the scope and severity level was lowered to a level two (2) pattern.

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide an accident and hazard free environment which lacked supervision involving two of eight residents in the survey sample, Residents #1, and #2. This resulted in Immediate Jeopardy and substandard of care. After the Immediate Jeopardy was removed the scope and severity was lowered to a level two (2) pattern.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to review and revise the Facility Assessment with changes in the administrative team members.

Inspectors wroteBased on observation, resident and staff interviews, the facility staff failed to maintain a clean, comfortable, and homelike environment and appropriate grooming for residents on 2 of 3 nursing units within the facility. (Units W1 and W2).

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure it was clinically appropriate for the self-administration of medications for one resident (Resident #7) in survey sample of eight residents.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to notify the physician per the physician orders for one of four residents in the survey sample, Resident #202.

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to implement their abuse policies involving a sexual encounter between two of eight residents in the survey sample, Residents #1 and #2.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to clarify two separate orders for insulin administration for one of four residents in the survey sample, Resident #202.

Inspectors wroteBased on staff interview, facility document review and employee record review, the facility staff failed to provide required training in communication for three of ten employee records reviewed, CNA (certified nursing assistant) #1, CNA #2, and CNA #3The

Inspectors wroteBased on staff interview, facility document review and employee record review, the facility staff failed to provide required training in resident rights for one of ten employee records reviewed, CNA (certified nursing assistant) #3.

Inspectors wroteBased on staff interview, facility document review and employee record review, the facility staff failed to provide required training in QAPI (quality assurance performance improvement) for one of ten employee records reviewed, CNA (certified nursing assistant) #3. On 5/13/2026 at 6:00 p.m. a request was made for the employee training records for CNA #3. The review of the employee training records revealed that CNA #3 did not have the required training in QAPI. On 5/14/2026 at approximately 3:45 p.m. the Director of Nursing verified that the CNA #3 did not have the required training in QAPI.A request for the policy for the required training elements was requested but not provided prior to exit. The Executive Director, Director of Nursing and the Regional Director of Operations were made aware of the above finding on 5/14/206 at 4:10 p.m. No further information was provided prior to exit.

Inspectors wroteBased on staff interview, facility document review and employee record review, the facility staff failed to provide required training in Behavioral Health for four of ten employee records reviewed, CNA (certified nursing assistant) #2, CNA #3, other staff member (OSM) #2, dietary, and OSM #3, housekeeping.

Inspectors wroteBased on observation and staff interview, the facility staff failed to post the staff posting at the beginning of the shift on one of three days observed.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to facilitate resident council meetings for three of nine months, potentially affecting all residents, and failed to resolve grievances identified in the resident council meetings for two months reviewed.1. The facility staff failed to facilitate resident council meetings from 5/1/2025 through the present potentially affecting all residents in the facility. A review of the facility resident council meeting minutes from 10/1/2024 to the present failed to evidence any meeting minutes after 4/17/2025. On 8/20/2025 at 2:00 p.m., an interview was conducted with Resident #18 (R18) who stated that there were no activities in the building from February through June. [...]

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure the activities program was directed by a qualified professional between 1/29/2025 and 6/27/2025 potentially affecting all residents in the facility.

Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to review and revise the facility assessment after a change of ownership effective 6/1/2025.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide evidence of updated contracts with outside providers for three of three contracts reviewed, potentially affecting all residents.

Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to ensure attendance of the infection preventionist at one of five QAPI (quality assurance performance improvement) meetings reviewed, Q4 (quarter four) 2024 potentially affecting all residents in the facility.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to implement a complete infection control program for two of two months reviewed, November and December 2024.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to protect residents from abuse for four of 27 residents in the survey sample, Residents #20, #21, #22, and #23.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to implement their policies for the investigation of an allegation of abuse for two of 27 residents in the survey sample, Residents #7 and #2.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to thoroughly investigate an allegation of abuse for two of 27 residents in the survey sample, Residents #7 and #2.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for six of 27 residents in the survey sample, Resident #6, #13, #8, #10, #25, and #1.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and/or revise the comprehensive care plan for four of 27 residents in the survey sample, Residents #14, #8, #20 and #25.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for four of 27 residents in the survey sample, Resident #8, Resident #14, Resident #6, and Resident #1.

Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide activities for five of 27 residents in the survey sample, Residents #17, #13, #14, #2, and #8.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide adequate supervision for one of 27 residents in the survey sample, Resident #25.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to provide sufficient staff in one of one facility kitchens.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to serve palatable food on one of three facility units, Unit One.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to serve lunch in a timely manner on one of three facility units, Unit One.

Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to invite residents and/or residents' representatives to attend and participate in care plan meetings for two of 27 residents in the survey sample, Residents #16, and #8.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to promote dignity for one of 27 residents in the survey sample, Resident #14, and on one of three nursing units, the [NAME] unit.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to notify a resident's responsible party of a change in condition for one of 27 residents in the survey sample, Resident #12The

Inspectors wroteBased on observations, resident interview and staff interview, it was determined that facility staff failed to maintain a clean, homelike environment for one of 13 current residents in the survey sample, Residents #2 (R2) and one of three units ([NAME] Unit).

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to report an allegation of abuse in a timely manner for one of 27 residents in the survey sample, Resident #7.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide a written notice of transfer, and a written notice of the bed hold policy to the resident and/or resident representative upon hospital transfer for two of 27 residents in the survey sample, Residents #12, and #8.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide foot care for one of 27 residents in the survey sample, Resident #14.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide sufficient nursing staff for one of 27 residents in the survey sample, Resident #25.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to complete an annual performance evaluation for one of five CNA (certified nursing assistant) records reviewed, CNA #5.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide medically related social services for one of 27 residents in the survey sample, Resident #20.

Inspectors wroteBased on staff interview and clinical record review it was determined that the facility staff failed to maintain a completed and accurate clinical record for two of 27 residents in the survey sample, Resident #2 (R2) and R23.

Inspectors wroteBased on staff interview, facility documentation, and clinical record review, it was determined the facility staff failed to evidence communication between the hospice company and the facility for one of 27 residents in the survey sample, Resident #19 (R19).

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide communications training for one of ten staff records reviewed, CNA (certified nursing assistant) #5.

Inspectors wroteFor RN #2 and OSM #15, the facility staff failed to provide required resident rights training. On 8/20/25 at 5:13 p.m., RN #2's and OSM #15's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records. On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed. She stated she is very new to this role and will be taking over staff training. She stated she could not speak to why the required trainings were not done in the past, but in the future, she will be taking care of these. [...]

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide training in prevention of resident abuse, neglect, and exploitation for one of ten staff records reviewed, RN (registered nurse) #2.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide QAPI (quality assurance and performance improvement) training for two of ten staff records reviewed, RN (registered nurse) #2 and OSM (other staff member) #15, a member of the dietary staff.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide infection control training for one of ten staff records reviewed, RN (registered nurse) #2.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide compliance and ethics training for one of ten staff records reviewed, RN (registered nurse) #2.

Inspectors wroteFor CNA #5 and CNA #8, the facility staff failed to provide at least 12 hours of education annually for the past 12 months. On 8/20/25 at 5:13 p.m., CNA #5's and CNA #8's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records. On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed. She stated she is very new to this role and will be taking over staff training from this point forward. She stated she could not speak to why the required hours were not done in the past, but in the future, she will be taking care of these. [...]

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide behavioral health training for two of ten staff records reviewed, RN (registered nurse) #2 and OSM (other staff member) #15, a member of the dietary staff.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to promote the highest level of well-being for one of 49 residents in the survey sample, Resident #102.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for an indwelling catheter for one of 49 residents in the survey sample, Resident #102.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to store and prepare food in a sanitary manner in one of one kitchen.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the care plans for one of 49 residents in the survey sample, Resident #128.

Inspectors wroteBased on observation, resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice for one of 49 residents, Resident #112.

Inspectors wroteBased on observation, resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to assess a resident for the use of bed rails prior to installation for one of 49 residents, Resident #112.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to complete an annual performance review for two of five CNA (certified nursing assistant) record reviews.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to obtain physician ordered laboratory tests for one of 49 residents in the survey sample, Resident #102.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to ensure the activities program was directed by a qualified professional potentially affecting all residents in the facility.

Inspectors wrote4. For Resident #48 (R48), the facility staff failed serve a meal using the facility's standard everyday place settings. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 12/14/2023, R48 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R48 was cognitively intact for making daily decisions. On 02/04/24 at approximately 5:14 p.m., an interview was conducted with R48 regarding the facility's meals. R48 stated he did not get breakfast until after 9:00 a.m. this morning, and it was served on Styrofoam. R48 further stated it was not dignified. On 02/05/24 at approximately 3:13 p.m., an interview was conducted with OSM (other staff member) #1, dining services manager, regarding the use of Styrofoam place settings for breakfast on 02/04/2024. [...]

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician about a change in condition for four of 68 sampled residents, Resident #32, #46, #114 and #22.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to investigate an allegation of abuse and report the finding to the State Agency for two of 68 residents in the survey sample, Resident #115 and Resident #93.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence that all required documentation was provided for hospital transfers for three out of 68 residents in the survey sample; Residents #21, #61, and #160.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence that a written bed hold notice was provided to the resident representative upon hospital transfers for three out of 68 residents in the survey sample; Residents #21, #61, and #160.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide services for a baseline care plan for four of 68 residents in the survey sample, Residents #312, #160, #165, and #362.

Inspectors wroteBased on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for 20 of 68 residents in the survey sample, Residents #75, #111, #62, #148, #141, #145, #78, #21, #54, #6, #41, #42, #45, #55, #119, #47, #10, #3, #73 and #46.

Inspectors wroteBased on staff interview, resident interview, clinical record review, and facility document review, it was determined the facility staff failed to review/revise the care plan for eight of 68 residents in the survey sample, Residents #111, #129, #41, #25, #21, #54, #72 and #162.

Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of quality for five of 68 residents in the survey sample, Residents #46, #114, #148, #362, #3, and #54.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for six of 68 residents in the survey sample, Residents #119, #39, #148, #75, #145, and #165.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide activities to meet residents' interests and needs for five of 68 residents in the survey sample, Residents #63, #93, #141, #145, and #167.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide care and services for pressure injuries for five of 68 residents in the survey sample, Residents #41, #54, #312, #145, and #47.

Inspectors wrote2. For Resident #54, the facility staff failed to investigate falls to evaluate root causes and prevention for falls on 11/16/23 and 12/13/23. A review of the clinical record revealed a nurse's note dated 11/16/23 that documented, Resident had a fall today on 11/16/23. Resident was walking to his walker that was place beside his bed and fell without hitting his head. Resident fell on the floor matt that is placed on the floor. Resident has no injuries or bruising from the fall. Resident's vital signs are within normal limits, blood pressure a little high after the fall. Will continue to monitor residents' status post fall. Interventions that were put into place was to place the resident's walker closer to the bedside so that the resident has less increase of a fall happening. [...]

Inspectors wrote4. For Resident #6, the facility staff failed to administer oxygen per the physician's order. On 2/4/24 at 2:53 PM, Resident #6 was observed in bed with the oxygen concentrator rate set at 3 liters per minute. When asked if he knew what his rate should be, he stated two to three liters. On 2/6/24 at 11:47 AM, Resident #6 was observed in bed with the oxygen concentrator rate at 3.5 liters per minute. Resident #6 stated that the staff changed it last night. A review of the clinical record revealed a physician's order dated 11/1/23 for Oxygen therapy 2LPM (liters per minute) via NC (nasal cannula) continuously every shift for COPD (chronic obstructive pulmonary disease). There were no orders to change the rate on or about 2/5/24, as the resident had indicated. On 2/7/24 at 1:08 PM an interview was conducted with LPN #7 (licensed practical nurse). [...]

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for one of 68 residents in the survey sample, Resident #3.

Inspectors wrote2. For Resident #119 (R119), the facility staff failed to provide sufficient nursing staffing to meet the resident's incontinence needs. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/27/23, R119 was coded as being cognitively intact for making daily decisions, and as being always incontinent of bowel and bladder. On 2/4/24 at 2:35 p.m., R119 was interviewed and stated the facility staff does not take care of the patients. He stated: There is not enough staff, people go 16 or 17 hours without being changed. He stated he had not had his incontinence brief changed since 10:30 p.m. the night before (2/3/24). R119 agreed to allow the surveyor to observe his brief change. CNA (certified nursing assistant) #14 stated she was assigned to R119 during that day shift. She stated: [...]

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to determine competencies for nurses for one of 68 residents in the survey sample, Resident #164.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to meet the RN (registered nurse) requirements for two of 30 days of RN coverage review.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to complete an annual performance review for five of five CNA (certified nursing assistant) record reviews.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions to prevent administration of unnecessary psychotropic medications for two of 68 residents in the survey sample, Resident #78 and #63.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to serve food at an appetizing temperature and form from one of one facility kitchens.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to provide meals at the scheduled time from one of one facility kitchens.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to store, prepare, and serve food in a sanitary manner in one of one facility kitchens and for three of 68 residents in the survey sample, Residents #46, #163 and #22.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to maintain a written transfer agreement with a hospital potentially affecting all residents in the facility.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to maintain an effective training program for six of ten employee record reviews and failed to develop and implement a training program based on the facility assessment.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to ensure required dementia management and abuse training was completed for four of five CNA (certified nursing assistant) reviews.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure CNAs (certified nursing assistants) completed required annual in-service training for four of five CNA reviews.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to inform a resident/resident representative of the risks and benefits of medication treatment in a timely manner for one of 68 residents in the survey sample, Resident #63.

Inspectors wroteBased on observation, resident/staff interview, facility document review, and clinical record review, it was determined the facility staff failed to accommodate needs for one of 68 residents, Resident #62.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide required notification of a room change for one of 68 residents in the survey sample, Resident #22.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide personal privacy for one of 68 residents in the survey sample, Resident #45.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, it was determined that the facility staff failed to provide a clean, comfortable, homelike environment for two of 68 residents (Residents #21 and #119) in the survey sample; and for one of three facility shower rooms (Unit 1).

Inspectors wroteBased on staff interview, resident interview, facility document review, and clinical record review, it was determined the facility staff failed to protect three of 68 residents from abuse and/or neglect, Residents #129, #148 and #119.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement policies and procedures for the investigation and reporting of abuse for two of 68 residents in the survey sample; Residents #115 and #93.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to report findings regarding an allegation of abuse for two of 68 residents in the survey sample; Residents #115 and #93.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined the facility staff failed to evidence written notification of transfer provided to the resident and/or responsible party at the time of transfer and/or ombudsman notification of transfer for three of 68 residents in the survey sample, Residents #25, #45 and #42.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to evidence completion of a Level 1 PASRR (preadmission screening and resident review) for one of 68 residents, Resident #55.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to implement communication techniques to maintain a resident's highest level of quality of life for one of 68 residents in the survey sample, Resident #145.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide assistance to maintain ADL (activities of daily living) abilities for two of 68 residents in the survey sample, Residents #45 and #55.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care to promote the highest level of well-being for two of 68 residents in the survey sample, Residents #22 and #312.

Inspectors wroteBased on observations, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide foot care for two of 68 residents in the sample Resident #166 and Resident #47.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions to prevent a decrease in ROM (range of motion) for a resident's contractures for one of 68 residents in the survey sample, Resident #47.

Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions to promote continence and/or provide indwelling catheter care for three of 68 residents in the survey sample, Residents #39, #93, and #61.

Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for one of one residents receiving dialysis care, Resident #119.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide trauma informed care for one of 68 residents in the sample Resident #111.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence bed rail requirements were completed prior to use for two of 68 residents in the survey sample, Residents #41 and #54.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to ensure required physician visits for two of 68 residents in the survey sample, Residents #14, and #124.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide mental and behavioral health services for two of 68 residents in the survey sample, Residents #63 and #95.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide medically related social services for three of 68 residents in the survey sample, Residents #63, #95, and #111.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to prevent significant medication errors for one of 68 sampled residents, Resident #32.

Inspectors wroteBased on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to obtain timely radiology services for one of 68 residents in the survey sample, Resident #42.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide dental services for one of 68 residents in the survey sample, Resident #41.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to follow the posted menu for two of 68 residents in the survey sample, Residents #48, and #362.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to serve food in the form ordered by the physician for one of 68 residents in the survey sample, Resident #47.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to provide an assistive device for a meal for one of 68 residents in the survey sample, Resident #145.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide a complete pneumonia immunization program for two of five residents reviewed for immunizations, Residents #46 and #61.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide a complete COVID-19 immunization program for one of five residents reviewed for immunizations, Resident #61.

Inspectors wroteBased on observations, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to evidence bed inspections for one of 68 residents in the survey sample, Residents #148.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to maintain an effective pest control program for one of three facility units, Unit 3.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure effective communication training was completed for one of five direct care staff employee reviews.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure resident rights training was completed for one of five employee reviews.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure QAPI (quality assurance and performance improvement) program training was completed for two of five employee reviews.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure annual compliance and ethics training was completed for two of five employee reviews.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure behavioral health training was completed for one of five employee reviews.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to notify the physician of a change in status for two of five residents in the survey sample, Residents #2 and #4.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure one of five residents in the survey sample, Resident #2, was free from unnecessary medication.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement infection control standards of practice for one of five residents in the survey sample, Resident #2.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide supervision for six of 17 residents in the survey sample, Resident #4, #5, #6, #7, #8, #12.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide sufficient staffing to meet resident needs for one of three resident hallways which affected 35 residents on 8/6/23.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide RN (registered nurse) coverage 8 hours a day, 7 days a week, with the potential to affect all residents that require RN services.

Inspectors wroteBased on observation, staff interview and facility document review it was determined facility staff failed to administer medications on one of three hallways of Wing 3, which affected 35 residents.

Inspectors wroteBased on resident interviews, responsible party interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to prepare and provide well-balanced meals that take into consideration the needs and choices of the residents, in one of one kitchen.

Inspectors wroteBased on resident interviews, responsible party interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide food that was palatable or served at an appetizing temperature.

Inspectors wroteBased on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to follow infection control practices for twelve of seventeen COVID-19 positive resident isolation rooms.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility failed to protect the resident's right to be free from physical abuse by another resident, for one of 17 residents in the survey sample, Residents #10.

Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to develop/implement the care plan for two of 17 residents in the survey sample, Resident #10 and Resident #12.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to monitor weights as directed for one of 17 residents in the survey sample, Resident #13.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to follow dietary menus for for one of five meals served during the survey dates, lunch service on 9/6/2023.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to review food preferences/dislikes with one of 17 residents in the survey sample, Resident #3.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to maintain a complete record for one of 17 residents, Resident #12.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to maintain a clean, comfortable, homelike environment for 7 of 44 residents in the survey sample, Residents #97, #45, #52, #31, #1, #54 and #114.

Inspectors wroteBased on observation, resident interview, and staff interview, it was determined that the facility staff failed to serve food in a palatable manner from one of one kitchen.

Inspectors wroteBased on observation, staff interview, and facility document review it was determined the facility staff failed to prepare food in the facility's kitchen in a sanitary manner in one of one facility kitchens.

Inspectors wroteBased on observation, staff interview and clinical record review, it was determined the facility staff failed to ensure a resident's call bell was within their reach while in bed for one of 44 residents in the survey sample, Resident #122 (R122).

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to complete a required PASRR (Preadmission Screening and Resident Review) (1) for one of 44 residents in the survey sample, Resident #90 (R90). The facility failed to complete a Level 2 PASRR as recommended on the resident's Level 1 PASRR dated 8/14/19.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for one of 44 residents in the survey sample, Resident #122 (R122). The facility staff failed to implement the comprehensive care plan for having R122's call bell within their reach for the prevention intervention for falls.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan after a fall, for one of 44 residents in the survey sample, Resident #122 (R122).

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services in accordance with professional standards and the comprehensive care plan for the treatment of wounds for one of 44 residents in the survey sample, Resident #180 (R180).

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services in accordance with professional standards and the comprehensive care plan for the treatment of pressure injuries for one of 44 residents in the survey sample, Resident #180 (R180).

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide medically related social services for one of one of 44 residents in the survey sample, Resident #90 (R90). The facility failed to complete a Level 2 PASRR (Preadmission Screening and Resident Review) (1) as recommended on the resident's Level 1 PASRR dated 8/14/19.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure a medication error rate less than five percent for two of four residents observed during the medication administration observation. During the medication administration observation, 2 errors out of 27 opportunities occurred, resulting in a 7.41 percent medication error rate.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to honor reasonable food preferences and choices for one of 44 residents in the survey sample, Resident #24.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to evidence a current dialysis contract between the facility and the outpatient dialysis center providing services for 1 of 44 residents in the survey sample, Resident #29 (R29).

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure four of sixty-three sampled residents, (Residents #62, #73, #101, and #36), were free from abuse and neglect. On 4/12/19, Resident #217 exposed his genitals to Resident #62. On 10/14/2019, Resident #10 hit Resident #73 in the stomach. On 11/27/19, Resident #101 was grabbed around the neck in the dining room by Resident #107. On 11/4/2019, when Resident #36 was found lying on the floor by staff, the staff picked the resident up and assisted her back to bed and neglected to implement the fall management protocol to assess for injury and a change in condition.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement the comprehensive plan of care for four of 63 residents in the survey sample, Residents #70, #98, #38 and #153. The facility staff failed to implement Resident #70's comprehensive care plan regarding insulin administration on multiple dates in December 2019, January 2020, and February 2020. The facility staff failed to implement Resident #98's comprehensive plan of care to complete a gradual dose reduction (GDR) for Mirtazapine in the required time frame. The facility staff failed implement the comprehensive care plan to attempt non-pharmacological interventions prior to the administration of as needed pain medications to Resident # 38 and #153.

Inspectors wroteBased on staff interview, clinical record review, facility document, and in the course of complaint investigation, it was determined that the facility staff failed to provide ADL (activities of daily living) care for one of 63 residents in the survey sample, Resident #416. The facility staff failed to provide a bed bath and/or shower to Resident #416, coded as dependent on staff for bathing on multiple occasions in June, July, August and September 2019.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide treatment and care in accordance with professional standards of practice, and the comprehensive person-centered plan of care for one of 63 residents in the survey sample, Resident #70. The facility staff failed to administer Resident #70's insulin as ordered by the physician on multiple dates in November 2019, December 2019, January 2020, and February 2020.

Inspectors wroteBased on resident interview, staff interviews, facility document review, and clinical record review, it was determined that the facility staff failed to ensure the medication regimen for three out of 63 residents in the survey sample, Residents #70, #153, and #38, was free from unnecessary medications. The facility staff administered Resident #70's insulin on multiple dates in November 2019, December 2019, January 2020, and February 2020, despite the resident's blood sugar reading being below the physician prescribed parameter for administering the medication. The facility administered as needed pain medication to Resident #153 and #38 without attempting non-pharmacological interventions.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to prevent significant medication errors for one of 63 residents in the survey sample, Resident #70. The facility staff administered insulin to Resident #70 when the resident's blood sugar level was below the physician prescribed parameter for administration of the medication.

Inspectors wroteBased on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain the kitchen in a sanitary manner. The facility staff failed to maintain ovens in a sanitary manner and failed to dispose of expired food during the facility task- kitchen observation on 2/4/20 at 10:58 AM.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to notify and consult the physician when prescribed medication was not administered as ordered for one of 63 residents in the survey sample, Resident #70. The facility staff failed to notify and consult the physician, when Resident #70's prescribed insulin was not administered as ordered by the physician on multiple dates in December 2019.

Inspectors wroteBased on observation, facility document review and staff interview, it was determined the facility staff failed to maintain a clean, comfortable, homelike environment for two of 98 resident rooms, resident rooms [ROOM NUMBERS]. The closet doors in resident 109 and 110 were observed in disrepair with edge molding coming off both closet doors; the door in 110 was observed separating coming apart from the core.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence physician documentation for a facility imitated transfer to the hospital transfer for one of 63 residents in the survey, Resident #147. The attending physician failed to document the rationale and reason for Resident #147's transfer and admission to the hospital on [DATE].

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide written notification of a facility-initiated transfer to the ombudsman, resident or resident representative for one of 63 residents in the survey sample, Resident # 118. On 12/20/2019, the facility transferred Resident # 118 to the hospital and staff failed to evidence written notification for the transfer to the ombudsman, resident or Resident # 118's representative.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for one of 63 residents in the survey sample, Resident #153. The facility staff to clarify physician orders for two as needed pain medications to determine when and which medication to administer.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide adequate supervision, to ensure an environment free from resident to resident inappropriate physical contact for two of 63 residents in the survey sample, Residents #73 and #19. The facility staff failed to supervise Residents #73 and #19, resulting in an incident of in appropriate physical contact on 11/5/19, when Resident #19 was found by facility staff naked from the waist down, sitting on Resident #73's face. The facility staff failed to ensure adequate supervision to prevent in appropriate resident to resident contact. On 11/21/2019, Resident # 73 was naked from the waist down, laying on Resident # 2's bed, Resident #2 was undressed in the room standing by the bed.

Inspectors wroteBased on observation, staff interview, and clinical record review, it was determined that facility staff failed to provide care and services for an indwelling catheter for one of 63 residents in the survey sample, Residents # 118.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to have a complete pain management program for two of 63 residents in the survey sample, Residents #153 and #38. The facility staff failed to assess Resident #153's pain levels prior to the administration of pain medication, document the location of the pain and failed to document the effectiveness of the medication administered. The staff failed to assess the effectiveness of pain medication administered to Resident #38 and failed to document the resident's pain levels, and the location of the pain prior to the administration of as needed pain medication.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure a gradual dose reduction was attempted for the psychotropic medication Mirtazapine for one of 63 residents in the survey sample, Resident #98. The facility staff failed to evidence an attempted a gradual dose reduction (GDR) or documentation the GDR was contradicted for Mirtazapine prescribed and administered to Resident #98, since 11/10/18.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to comply with the state licensing regulations for one of 63 residents, Resident #217. The facility failed to ensure, a sexual offender, registry background check for Resident #217 was completed prior to admission per the State of Virginia licensing regulations. G. The nursing facility shall register with the Department of State Police to receive notice of the registration or reregistration of any sex offender within the same or a contiguous zip code area in which the facility is located pursuant to § 9.1-914 of the Code of Virginia. H. Prior to admission, each nursing facility shall determine if a potential resident is a registered sex offender when the potential resident is anticipated to have a length of stay: 1. Greater than three days; or 2. [...]

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain and complete and accurate clinical record. There was no documentation in the clinical record evidencing staff found Resident #36 lying on the floor on 11/4/19.

Inspectors wroteBased on observation, staff interview, facility document review and in the course of complaint investigation, it was determined that the facility staff failed to maintain a fully functional resident call system for four of 98 resident rooms. The facility staff failed to ensure the call light located in the ceiling outside the room and indicating a resident had triggered the call system was functioning for resident rooms #104, #114, #127 and #132.