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Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #65's Physician Orders for Scope of Treatment (POST) form was honored by directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). This has to potential to affect all residents that reside in the facility. Resident identifiers: 65. The facility was notified of the Immediate Jeopardy (IJ) at 4:35 PM on [DATE]. The facility submitted their first abatement plan of correction (POC) at[DATE] at 5:29 PM. The state agency requested changes and the second abatement POC was submitted [DATE] at 6:01PM. The abatement POC was accepted by the state agency at 6:05 PM on [DATE]. After observation of the implementation of the abatement POC, the IJ was abated on [DATE] at 10:20 AM. The IJ started on [DATE] and ended on [DATE]. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for resident rooms/bathrooms on the 100 hall. This was a random opportunity for discovery. Rooms: 101, 102, 103, and 104. Facility census: 52.

Inspectors wroteBased on observation, interview and policy review, the facility failed to properly store food in accordance with professional standards of practice. This failed practice had the potential to affect more than a limited number of residents who are served food from the kitchen. Facility census:

Inspectors wroteBased on observation and interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible in regards to bed safety. This was a random opportunity for discovery. Resident identifier: #28. Facility census: 52.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the daily nursing staff form posted was accurate and complete. The daily census was not included on the posting for three (3) of four (4) days observed. Facility census: 52.

Inspectors wroteBased on observation and staff interview, the facility failed to 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 with regards to unsanitary practices. This failed practice was a random opportunity of discovery. Resident identifier: #10 Facility census: 52. [...]

Inspectors wroteBased on resident interview, record review, staff interview and observation, the facility failed to ensure a resident did not develop avoidable pressure ulcers. Resident #8 returned from the emergency room with bilateral leg immobilizes. The facility failed to implement a plan to prevent Resident #8 from developing pressure ulcers because of the leg immobilizers. Resident #8 developed bilateral unstageable pressure ulcers to both calves. The wounds have worsened and required the resident to be hospitalized and undergo debridement procedures on each of the wounds. The resident has voiced concerns and fears that his right leg will need an amputation because of the wound. The state agency (SA) determined the failures related to Resident #8 placed him and any other residents with medical devices such as leg braces in an immediate jeopardy (IJ) situation. [...]

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #8 requested the facility transport him to the bank in the facility van. The facility had decided prior to Resident #8's request to go to the bank that power wheelchairs could not be used on the facility van any longer. As a result of this decision the resident requested his manual wheelchair and chose to use the manual wheelchair in the van to go to the bank. The resident had not been in his manual wheelchair for at least a year prior to this. Since then, he had lost use of his legs and was paralyzed in both lower extremities. The resident slid from the wheelchair while on the van. [...]

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to develop and/or implement a comprehensive care plan regarding food dislikes for Resident #23, a skin condition for Resident #14, behaviors and emotional status for Resident #8 and prevention of pressure ulcers for Resident #4. This was true for four (4) of 21 residents reviewed during the survey process. Resident Identifiers: #23, #14, #8 and #4. Facility Census: 54. Findings Included: a) Resident #23 On 11/18/24 at 11:45 AM, an interview was held with Resident #23. The resident stated, They sent my salad with chicken on it .I detest chicken and turkey .it's on my ticket. On 11/18/24 at 12:30 PM, a record review was completed for Resident #23. The review found the care plan did not list the food dislikes under any focus area on the care plan. [...]

Inspectors wroteBased on record review and interview the Pharmacist failed to accurately review and complete monthly Medication Regimen Review (MRR). This failed practices was found to be true for 3 of 5 residents reviewed for the unnecessary medication care area during the Long Term Care Survey process. Resident identifiers: #47, #8, #33. Facility census: 54.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure all residents were free from significant medication errors. This was a random opportunity for discovery found during the investigation of a facility complaint. Resident Identifiers: Resident # #160, #11, #15, #14, #13, #161, #3, #59, #23, #164, #24, #35, #165, #166. Facility Census: 54.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure menus were followed for the noon time meal on 11/18/24. This was true for 10 residents who were eating their noontime meal in the dining room on 11/18/24. Facility Census: 54 Findings Included: a) Noon time Meal Observation An observation of the noon meal service on11/18/24 found the Certified Dietary Manager (CDM) was serving the meal from a steam table located in the dining room. Near the end of the service, it was noted the residents were no longer being served broccoli with their meal. The residents were only served pinto beans, pan fried potatoes, and corn bread. An interview with the CDM immediately following the meal service confirmed she ran out of broccoli. When asked why there was not enough broccoli for all the residents she stated, I must of over scooped (gave too much) you made me nervous. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the medical record was complete and accurate for 18 residents reviewed during the long-term care survey process. Resident identifiers: #4, #209, #47, #23, #8, #160, #11, #15, #14, #13, #161, #3, #59, #164, #24, #35, #165, and #166. Facility Census: 54. Findings Included: a) Resident #4 An interview with Resident #4 on 11/20/24 at approximately 4:45 PM, Resident #4 stated, I have to wear this brace all the time. I changed braces recently because the bar on the other rubbed a blister on my lower leg, but it is healed now. When asked if the facility staff remove the brace daily to look at his skin he stated, Yes they take it off every day and look at my skin underneath it and then put it back on. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to treat each resident with dignity by placing undignified pictures in their medical record. This was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifiers #40 and #43. Facility Census 54. Findings Included: a) Resident #40 A record review on 11/20/24 at 4:56 PM, revealed that Resident # 40 had a Stage II pressure ulcer on her sacrum upon admission. Further record review found (2) two pictures of Resident #40's Stage II pressure ulcer to her sacrum. The picture dated 10/07/24, revealed a brown lumpy substance in Resident #40's brief. The picture dated 10/28/24, revealed a brown substance smeared up Resident # 40's intergluteal cleft. [...]

Inspectors wroteBased on observation, record review, staff interview and resident interview, the facility failed to ensure one (1) resident's call lights were within reach. This was a random opportunity for discovery. Resident identifiers #15. Facility Census was 54.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the attending physician for Resident #4 was notified when the resident developed a blister to his lower leg. This was true for one (1) of three (3) residents reviewed for the care area of pressure ulcers during the long-term care process. Resident Identifier: #4. Facility Census: 54. Findings Included: a) Resident #4 A review of Resident #4's medical record on 11/20/24 found an order for Cleanse burst blister to the left lower leg with wound cleanser, pat dry and cover with bordered dressing. Change weekly and PRN for loose or soiled dressing. This order was dated 10/31/24. Further review of the medical record found no indication the physician was notified of the residents change in condition. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the receiving facility received adequate information to ensure a safe and effective transition of care for Resident #8 when he was transferred to the hospital. This was true for one (1) of three (3) residents reviewed for the care area of hospitalizations during the long-term care survey process. Resident Identifier: #8. Facility Census: 54.

Inspectors wroteBased on record review and staff interview, the facility failed to provide a bed hold policy to Resident #23 for two (2) transfers to an acute care facility. This was true for one (1) of four (4) residents reviewed under the care area of hospitalizations. Resident identifier: #23. Facility Census: 54. Findings Included: a1) Resident #23 On 11/18/24 at 1:02 PM, a record review was completed for Resident #23. The review found the resident had been sent to an acute care facility on 03/02/24 for altered mental status. An interview was held with Business Office Manager (BOM) #36. BOM 36 stated, we don't have a bed hold policy for the transfer on 03/02/24. On 11/21/24 at 9:45 AM, the Director of Nursing (DON) was notified and confirmed the bed hold policy should have been completed. b1) Resident #23 On 11/18/24 at 1:02 PM, a record review was completed for Resident #23. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS)for Resident #8 accurately reflected whether his pressure ulcer was in house acquired or present on admission. This was true for one (1) of three (3) residents reviewed for the care area of pressure ulcers during the long-term care survey process. Resident Identifier: #8. Facility Census: #54.

Inspectors wroteBased on record review and staff interview, the facility failed to identify diagnosis of Traumatic Brain Injury (TBI), mood disorder, personality disorder, and Post Traumatic Stress Syndrome (PTSD) on the Pre-admission Screening and Resident Review (PASARR). This failed practice was found true for (2) two of (4) four residents reviewed for PASARR during the Long-Term Care Survey Process. Resident identifiers: #33 and #8. Facility Census: 54.

Inspectors wroteBased on record review and staff interview, the facility failed to revise a care plan related to code status. This failed practice was found true for (1) one of 21 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifier: #45. Facility Census: 54. Findings Included: a) Resident #45 A record review on 11/18/24 at 4:25 PM, revealed a POST form dated 10/31/24 that indicated Resident #45 is marked Do Not Attempt Resuscitation (DNR) Further record review revealed a care plan for Resident #45 that had a focus that reads as follows: (Resident #45's name ) has an established advanced directive of FULL CODE on file. During an interview, on 11/19/24 at 1:01 PM, the Licensed Social Worker (LSW) confirmed that the care plan had not been updated related to Resident #45's code status.

Inspectors wroteBased on resident interview, record review and staff interview, the facility failed to ensure Resident #8 who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice which accounted for his experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. This was true for one (1) of two (2) residents reviewed for the care area of mood and behavior during the long-term care survey process. Resident Identifier: #8. Facility Census: 54. Findings Included: a) Resident #8 During the initial screening process of the long-term care survey, it was discovered Resident #8 had an Minimum Data Set (MDS) trigger for Post Traumatic Stress Disorder (PTSD). [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to have an effective infection control program by leaving an oxygen tube laying on the floor. This was a random opportunity for discovery during the long-Term Care Survey process. Resident identifier: #47. Facility Census: 54.

Inspectors wroteBased on record review, and staff interview, the facility failed to accurately complete section C (Cognitive Patterns) status of the Minimum Data Set (MDS). This is true for eight (8) of eight (8) reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #26, #12, #48, #25, #49, #6, #201 and #41. Facility census:55.

Inspectors wroteBased on observation and staff interview, the facility failed to keep residents medical information confidential. The facility failed to safeguard private information that was posted on the wall at the nurses station. This was a random opportunity for discovery. The failed practice was true for 11 residents who had medical appointments throughout the week. This was a random opportunity for discovery. Resident identifiers: #38, #20, #40, #21, #44, #14, #156, #206, #107, #22, and #4. Facility census:

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer/Discharge for an acute hospital transfer. This was true for three (3) of three (3) residents reviewed for hospitalizations during the long-term care survey process. Resident identifiers: #6, #38, and #206. Facility census: 55.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Bed Hold Notice for a hospital transfer. This was true for three (3) of three (3) residents reviewed for hospitalizations during the long-term care survey process. Resident identifiers: #6 and #38, and #206. Facility census: 55.

Inspectors wroteBased on medical record review and interview, the facility failed to revise and complete a person-centered comprehensive care plan in a timely manner. This practice affected four (4) of (19) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was reviewed and revised for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident identifier: #44, #20, #24, and #41. Facility census: 55.

Inspectors wroteBased on facility documentation and staff interview, the facility failed to inform residents, their representatives, and families of those residing in facilities by 5 PM the next calendar day following the occurrence of a confirmed infection of COVID-19. This failed practice had the potential to affect more than a limited number of residents in the facility. Facility census: 55.

Inspectors wroteBased on record review and staff interview, the facility failed to develop a baseline care plan that included minimum healthcare information to provide effective person-centered care for one (1) of 19 residents reviewed in the long-term care survey process. Resident identifier: #208. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement comprehensive person-centered care plans with measurable objectives for each resident. This is true for two (2) of 19 residents whose care plans were reviewed. Resident identifiers: #6 and #41. Facility census: 55.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure each resident was assessed to determine the amount of supervision required to prevent accidents during staff assistance with toileting and bathing. This was true for one (1) of 19 residents reviewed in the long-term care process. Resident identifier: #6. Facility census: 55.

Inspectors wroteBased on observation and staff interview, the facility failed to monitor temperatures on personal refrigerators. This was a random opportunity for discovery. Resident identifiers: #10 and #106. Facility census: 55.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure two (2) of 19 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). The POST forms were unsigned by the Resident or Medical Power of Attorney (MPOA). Resident identifiers: Resident #20 and #6. Facility census: 55.