Tygart Valley Health & Rehabilitation

Inspectors wroteBased on observation and staff interview, the facility failed to allow Resident #46 to have a dignified dining experience. This finding was related to the facility failing to serve his meal with the other residents at his table before serving other tables. This failed practice was a random opportunity for discovery. Resident identifier: #46. Facility Census: 54. Findings Included:a) Resident #46 On 11/17/25 at 12:46 PM, during a dining room observation, It was observed that Resident #46 was not served his lunch tray with the rest of his tablemates before staff began serving other tables. In an interview with Certified Nurse Assistant(CNA) employee identifier # on 11/17/20250 at 1:14 PM, she acknowledged Resident #46 was not served correctly with the other resident at his table. [...]

Inspectors wroteBased on observation, and staff interview, the facility failed to properly store food in accordance with professional standards. This is true for the kitchen walk in cooler and utensil storage. This had the potential to affect all residents in the facility. Facility census: 54.

Inspectors wroteBased on observation, staff interviews and record review the facility failed to ensure it had a complete and accurate medical record related to dental status. This failed practice was found true for (1) one of (3) three residents reviewed for dental during the Long-Term Care Survey Process. Resident identifier #54. Facility census: 54. Findings Include: a) Resident #54 An observation on 11/17/25 at 3:15 PM revealed Resident #54 sitting in the hallway in her wheelchair. She had several teeth missing and some were decayed and broken off at the gums. A record review on 11/18/25 at 12:30 PM, revealed that Resident #54 had seen an in-house dentistry on 02/06/25. The dental consult showed the following:Teeth numbers 11, 21, 22, and 6 are decayed. Teeth numbers 1-3, 13-20, 31 and 32 are missing. Teeth numbers 7-10 and 25-30 are retained root. The summary of the dental consult read as follows: [...]

Inspectors wroteBased on observations, review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases, to help prevent cross-contamination and infections including Covid-19 in regard to, follow CDC (Centers for Disease Control) guidelines for use of PPE (Personal Protective Equipment) and ensure staff donned appropriate personal protective equipment (PPE) prior to wound care for a resident on (Enhanced Barrier Precautions). The facility also failed to ensure a barrier was maintained in the laundry area and failed to repair unhygienic wheelchair surfaces. These failed practices had the potential to affect every resident currently residing in the facility. Resident identifiers: #4, #24, #8, #46, and #50. Facility census: [...]

Inspectors wroteBased upon Record Review and Interviews, the facility failed to promote Resident #7's self determination through choices for her shower preference and time. This was true for one (1) out of four (4) residents reviewed. Resident identifier: #7. Census: 54.

Inspectors wroteBased on record review and staff interview the facility failed to coordinate with the appropriate State-designated authority,to ensure that individuals with a mental disorder, intellectual disability or a related condition received care and services in the most integrated setting appropriate to their needs when completing/revising a Pre-admission Screening and Resident Review (PASSR). Resident identifier #34. Facility Census: 54Findings Included:a) Resident # 34Review of the PASSR dated 11/18/24 found the following medical diagnosis was not identified on the Pre admission Screening and Resident Review. Major Depressive Disorder onset 04/29/25,Schizophrenic Disorder onset 12/03/24The above information was confirmed with the Director Of Nursing (DON) on 11/18/25 at 2:20 PM. The DON agreed that the additional medical diagnosis should be on the PASSR.

Inspectors wroteBased on record review, resident interview and staff interview the facility failed to provide Activities of Daily Living (ADL) care to dependent residents. This failed practice was found true for (1) one of (4) four residents reviewed for ADL care during the Long-Term Care Survey Process. Resident identifier: #54. Facility census: 54. Findings Include:a) Resident #54 An observation on 11/17/25 at 3:15 PM, revealed Resident #54 sitting in the hallway, she had several hair stubbles on her chin and her mustache area. During an interview on 11/17/25 at 3:15 PM, Resident #54 stated, I would like for them to shave them off every time, but they don't. During an interview on 11/17/25 at 3:20 PM, The Director of Nursing (DON) stated, Her shower day is today. The system shows she had her shower today already. I will get it taken care of. [...]

Inspectors wroteBased upon Record review and interviews, the facility failed to provide one on one activities fo one (1) of four 4) residents that were unable to participate in group activities. Residents identifier: #7. Census: 54.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide care and services in accordance with professional standards of practice by not following physician orders related to insulin and weights. This failed practice was found true for (2) two of 25 residents reviewed for physician order accuracy during the long term care survey process. Resident identifiers: #11 and #4. Facility census: 54.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to ensure emergency dental services were provided to Medicaid funded residents in a timely manner. This failed practice was found true for (2) two of (3) three residents reviewed for dental services during the Long-Term Care Survey Process. Resident identifiers: #54 and #20. Facility census: 54. a) Resident #20 On 11/17/2025 at 2:55 PM, during interview and observation with Resident #20, it was observed that the resident had some missing, and decayed teeth. Resident #20 stated, I have asked to have some pulled and a plate put in a while back and nothing has been done. She pointed to one tooth that had been cracked and stated that had happened about a week ago. Record review on 11/18/25 at 12:30 PM, revealed that Resident #20 had seen an in-house dentist on 08/15/25. The dental consult showed the following: [...]

Inspectors wroteBased on observation and staff interview the facility failed to support the residents' rights, by not placing the name and contact information for the State Ombudsman in a location that was easily accessible for all residents to read. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 47.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to three (3) of three (3) residents reviewed for the facility's beneficiary protection notification practice. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #38, #40, and #5. Facility census: 47 Findings Included: a. Failure to Issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) Form Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (2018) indicates Medicare requires Skilled Nursing Facilities to issue the SNF ABN to Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is: [...]

Inspectors wroteBased on observation, resident interview and staff interview the facility failed to ensure the temperatures were within the required parameters, which is 71 degrees Fahrenheit (F) to 81 Degrees F. in the shower room. In addition, the facility failed to ensure Resident #1's room was clean. This failed practice has the potential to affect more than a limited number of residents. Resident Identifiers #1. Facility census 47. Findings Included: a) Resident #1 During an observation on 01/08/24 at 12:00 PM, in Resident #1's room, under the bed there is a very sticky substance with black dirt and dust buildup on it. There were also 6 caps of what appears to be tops to the tube feeding bolus under the bed. During an observation on 01/09/24 at 10:00 AM, of Resident #1's room under the bed there is a very sticky substance with black dirt and dust buildup on it. [...]

Inspectors wroteBased on record review, staff interview observation the facility failed to develop and or implement the comprehensive person-centered care plan as required. This was true for four (4) of twenty-three (23) care plans reviewed during the long-term care survey. Resident identifiers: #195, #21, #15, #27 Facility Census: 47.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure it was free from accident hazards in which it had control. One (1) medication cart was left unlocked and unattended. Additionally, the facility failed to complete a safety assessment on Resident #195 related to his use of smokeless tobacco in his room. These were random opportunities for discovery and had the potential to effect more than a limited number of residents. Resident identifier: #195. Facility census: 47.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the staff posting was accurate and correct. This had the potential to affect more than a limited number of residents residing at the facility. Facility census: 47.

Inspectors wroteBased on staff interview, resident interview, and record review the facility failed to ensure food was served at a safe and appetizing temperature. This failed practice had the potential to affect more than a limited number of residents. Facility census 47.

Inspectors wroteBased on observation and staff interview the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. It was discovered the ice machine was not draining properly, there was expired food found in walk-in cooler and food stored on the floor in the storage area. This had the potential to affect all residents receiving nutrition from the kitchen. Facility census: 47.

Inspectors wroteBased on observation and staff interview the facility failed to 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. This had the potential to affect more than an isolated number of residents. Resident Identifiers: #194 and #11. Facility Census: 47. Findings Included: a) 300 [NAME] hallway On 01/08/24 at 12:50 PM during observation of the lunch meal trays being passed on the 300 [NAME] hallway, no hand hygiene was provided to the residents prior to their meal. When Nurse Aide (NA) #69 and #27 were asked how they provide hand hygiene, they looked at each other and laughed. NA #27 stated, 'they use to put hand wipes on the trays, but they don't anymore. [...]

Inspectors wroteBased on observation and staff interview the facility failed to promote a dignified dining experience by not providing meals to all residents seated at the same table at the same time. This failed practice was a random opportunity for discovery. Resident identifiers: #5 and #30. Facility census 47.

Inspectors wroteBased on record review and staff interview the facility failed to ensure [NAME] Virginia Physician Orders for Scope of Treatment (POST) forms were completed correctly for two (2) of twenty-three (23) residents in the long-term care survey sample. Resident identifiers: #18 and #15. Facility Census: 47.

Inspectors wroteBased on record review and staff interview, the facility failed to report the results of a thorough investigation of a fall with serious bodily injury to Adult Protective Services and the State Survey Agency, within five (5) working days of the incident in accordance with State law. This was true for two (2) of two (2) residents reviewed under falls in the Long-Term Care Survey Process. Resident identifiers: #3 and #144. Facility census: 47.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence a copy of the notice of transfer/discharge was sent to the Ombudsman. This was true for one (1) of four (4) residents reviewed under the Hospitalization pathway in the Long-Term Care Survey Process. Resident identifier: #144. Facility census: 47.

Inspectors wroteBased on record review, observation, staff interview and resident interview, the facility failed to ensure two (2) of 23 residents had an accurate Minimum Data Sets (MDS) which reflected the resident's status at the time of the assessment. Resident identifiers: #12 and #21. Facility census: 47.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #35 had a baseline care plan developed within 48 hours of admission which addressed a Urinary Tract Infection (UTI) treated with an antibiotic. This was true for one (1) of three (3) residents recently admitted to the facility. Resident identifier: #35. Facility census: 47.

Inspectors wroteBased on record review and staff interview the facility failed to involve the resident and/or resident representative when developing a comprehensive person-centered care plan for discharge planning for Resident #42. This was true for one (1) of one (1) resident reviewed for discharge planning during the Long-Term Care Survey Process. Resident identifier: #42. Facility census: 47.

Inspectors wroteBased on record review and staff interview the facility failed to complete the discharge/physician's recapitulation of residents stay. This was true for two (2) of two (2) residents reviewed for the area of discharges during the Long-Term Care Survey Process. Resident #42 had no recapitulation for a community discharge and Resident #43 expired at the facility and also had no physician's recapitulation. Resident identifiers: #42 and #43. Facility census: 47.

Inspectors wroteBased on record review, staff interview, and observation, the facility failed to provide the communication book and dry erase board used as assistive device to communicate with staff. This was true for one (1) of one (1) residents reviewed for communication during the Long-Term Care Survey Process. Resident identifier: #27. Facility census: 47.

Inspectors wroteBased on observation, and staff interview the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being for one (1) of three (3) residents. Resident identifier: # 32. Facility census 47.

Inspectors wroteBased on resident interview, observation, record review, and staff interview, the facility failed to provide care and services in accordance with professional standards of practice for three (3) of 23 residents reviewed during the long term care survey. Resident #36 did not have an Unna boot as ordered by the physician. For Resident #12 the facility did not follow the physician ordered parameters for medication administration. For Resident #28 the facility failed to notify the physician when the resident refused medication. Resident identifiers: #36, #12, and #28. Facility census: 47.

Inspectors wroteBased on observation and staff interview the facility failed to ensure pressure ulcer treatments and care were performed within professional standards of care. This was true for two (2) of two (2) wound dressings observed during the long term survey process. Resident Identifiers: #194 and #11 Facility Census: 47. Findings Included: a) #194 On 01/08/24 at 2:38 PM record review shows Resident #194 has a stage 2 pressure ulcer to the right buttock. There is a dressing change order as follows: Cleanse stage 2 with soap and water. Pat dry. Cover with border dressing daily and porn if loose or soiled until clear one time a day for Stage 2 pressure Ulcer related to PRESSURE ULCER OF RIGHT BUTTOCK, STAGE 2 until clear and as needed for of loose or soiled related to PRESSURE ULCER OF RIGHT BUTTOCK, STAGE 2 until clear. [...]

Inspectors wroteBased on record review and staff interview the facility failed to address a resident receiving nutrition via peg tube when weight loss occurred. This failed practice was true for 1 of 2 residents reviewed for tube feeding during the long term care survey process. Resident Identifier: #1. Facility census 47.

Inspectors wroteBased on observation, resident interview, record review, and staff interview, the facility failed to ensure the oxygen humidifier bubbler on the oxygen concentrator was working. This was true for one (1) of one (1) resident reviewed for respiratory care during the long term care survey process. Resident identifier: #12. Facility census: 47.

Inspectors wroteBased on record review, resident interview, observation and staff interview, the facility failed to ensure follow up dental services were provided to one (1) of two (2) Resident's reviewed for the care area of dental services during the long-term care survey. Resident identifier: #12. Facility census: 47.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure Resident #35 had physician ordered assistive devices available to improve her ability to drink. This was a random opportunity for discovery. Resident identifier: #35. Facility census: 47.

Inspectors wroteBased on record review, policy review and staff interview the facility failed to ensure staff maintained current Cardiopulmonary Resuscitation (CPR) certification for healthcare providers through a CPR provider whose training includes hands-on practice and in-person skills assessment. This was true for four (4) licensed nursing staff. This was a random opportunity of discovery. Employee Identifiers: Registered Nurse (RN) #35, Licensed Practical Nurse (LPN) #12, #40, and #27. Facility Census: 48 Findings Included: a) On [DATE] at 12:29 PM during a review of records of active CPR certified nursing employees, it was found that four (4) nursing employees were not certified in CPR. Registered Nurse (RN) #35 was not certified through the American Red Cross or The American Heart Association. Her certification was from the national CPR foundation making it invalid. [...]

Inspectors wroteBased on record review and staff interview the facility failed to meet professional standards of practice in providing the medical needs of the resident. Resident #11's physician was not notified of a weight gain as directed by the physicians orders. For Resident #4 and Resident #41 neurological checks were not performed as required following falls. This was true for three (3) of 26 sampled residents. Resident Identifiers: # 11, #4, #41. Facility Census: 48 Findings Included: a) Resident #11 Resident #11 has a history of Congestive Heart Failure. There is a Physicians order to weigh the resident daily and call the Physician if the weight gain is greater than three (3) pounds in 24 hours. There were four (4) instances that the Residents' weight reflected a gain of three (3) or more pounds in 24 hours and the Physician was not notified. [...]

Inspectors wroteBased on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. The facility also failed to maintain an accurate dishwasher and resident refrigerator temperature log. The facility also stores other food in the resident's refrigerator. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen and the Resident's refrigerator. Facility Census: 48 Findings Included: a) Walk-in Freezer A review of a facility policy titled date marking-food and nutrition with a revision date of 05/03/22 found the following. Procedure: [...]

Inspectors wroteBased on observation, resident interview, staff interview and resident council meeting, the facility failed to provide care and treatment in a dignified manner for Resident #28 and Resident #43. This was a random opportunity for discovery. Resident Identifiers: Resident #28 and Resident #43. Facility Census: 48. Findings Included: a) Resident #28 During an interview on 09/19/22 at 1:17 PM, Resident #28 stated I need help, nobody will help you here, I will not come back to this place again. When you don't feel good, and you just want to lay down. The resident then started crying and stated, The girl brought me back from the dining room and just left me and I just wanted to go to bed. Resident #28 pulled her call light at 1:20 PM. A nurses Aide came into the room and turned off the call light at 1:22 PM. [...]

Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to ensure when a resident self administered medications, the interdisciplinary team had determined this practice was clinically appropriate. This deficient practice was identified during a random opportunity for discovery when Resident #36 was observed in the dining room to have a medication cup with medications present. The licensed nurse passing the medications was not present to supervise the administration and left the medications with the resident. Resident identifier: Resident #36. Census: 48.

Inspectors wroteBased on resident council minutes, policy review, resident interview and staff interview, the facility failed to consider the voiced concerns of residents in resident council as grievances. The facility failed to act promptly to investigate resident grievances concerning issues of Television and meal delivery. This had the potential to affect a limited number of residents living in the facility. Facility census: 48. Findings Included: a) Policy Review A review of the facility policy titled Grievances, Suggestions or Concerns-Rehab/Skilled with a revision date of 09/16/21 found the following. .4. The grievance will be documented on the Suggestion or Concern (GSS #213) and submitted to the grievance official. 5. The grievance official will route the GSS #213 to the appropriate department manager as soon as is reasonably possible. 6. [...]

Inspectors wroteBased on medical record review, policy review and staff interview the facility failed to notify the physician or resident representative in a timely manner when the resident suffered a change in condition. Resident #4 suffered side effects from the medication Seroquel and the physcian was not notified of the side effects. The facility also failed to notify Resident #8's representative when they had an incident involving a medicated cream. This was a random opportunity for discovery. Resident Identifiers: Resident #4 and Resident #8. Facility census: 48. Findings Included: a) Resident #4 A review of the facility policy titled Medication Documentation-R/S, LTC with a revision date of 09/22/22 found the following. .7. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to promote privacy during medical treatments for two (2) of six (6) treatments observed during the Long Term Care Survey Process (LTSP). This deficient practice was identified for Resident #43 during two (2) separate wound treatments. Resident identifier: Resident #43. Census: 48.

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to ensure that all alleged violations of abuse and neglect, including serious bodily injury, were reported immediately, and failed to ensure the results of the investigations were reported to other officials (including to the State Survey Agency and Adult Protective Services (APS) where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Resident #4 sustained serious bodily injury in the facility and the injury was not reported within two (2) hours of staff's knowledge of the severity of the resident's injuries sustained from a fall. This deficient practice was identified through a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: Resident #4. Census: 48.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence that a copy of the Notice of Transfer was sent to to the Office of the State Long-Term Care Ombudsman. This was true for one (1) of two (2) reviewed for the care area of hospitalization during the Long-term care process. Resident Identifiers: Resident # 249. Facility Census: 48 Findings Included: a) Resident # 249 During an interview on 09/19/22 at 1:37 PM Resident # 249's Husband stated She has been in the hospital a few times. A medical record review on 09/19/22 revealed Resident #249 was transferred to the hospital on [DATE]. The records did not reveal a notification of Transfer was sent to the Ombudsman. [...]

Inspectors wroteBased on record review, staff interview and resident interview the facility failed to implement the care plan for Residents #36 and #38. This was true for two (2) of 26 sampled residents. Resident identifiers: #36 and #38. Facility Census: 48 Findings Included: a) Resident #36 An interview with Resident #36 on 09/19/22 at 1:30 PM, revealed the resident stating he/she had not been receiving rehabilitation services that had been ordered to help with physical limitations identified. A review of the comprehensive person centered care plan for Resident #36 showed the resident had a problem / focus area identified for the need for restorative intervention due to Activities of Daily Living (ADL) self-care performance deficit / limited physical mobility related to hemiplegia as evidenced by limited mobility. [...]

Inspectors wroteBased on observation, medical record review, family interview and staff interview the facility failed to provide care required to maintain proper nail care to a resident who is dependent for Activities Of Daily Living (ADL) care. This was true for one (1) of one (1) reviewed for ADL's during the long term care survey process. Resident Identifiers: Resident #249 Facility Census: 48 Findings Included: a) Resident #249 During a resident representative interview on 09/19/22 at 1:37 PM Resident #249's Husband stated my only concerns are her jagged toenails and fingernails. They look awful, just look at them. An observation on 09/19/22 at 1:39 PM Resident #249's toenails were long and jagged and fingernails were broken and jagged and fingernail polish was faded. A medical record review on 09/20/22 revealed on 05/05/22 a physician order which stated: Foot Assessment: [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide care to residents with pressure ulcers consistent with professional standards of practice to promote healing, prevent infection and prevent new pressure ulcers from developing for one (1) of six (6) residents reviewed for pressure ulcers during the LTCSP. Resident identifier:

Inspectors wroteensure the environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery. Resident Identifiers: Resident # 8. Facility Census: 48. Findings Included: a) Resident #8 A review of facility policy titled Incident Report-Rehab/Skilled with a revision date of 04/05/22 found the following. .Procedure .4 The investigation will be initiated by a supervisor or a member of the investigation team as soon as possible after the incident occurred. 5. The investigation team consisting of the administrator, the director of nursing services and social services will review each incident no later than the next business day. Ensure that someone is assigned to complete the investigation and that the care plan has been update with new interventions put into place. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure a resident with a urinary catheter received care and treatment to prevent infections. This was true for one (1) of two (2) residents reviewed with urinary catheters. Resident #43 was observed to have the catheter bag laying on the floor. Resident identifier: Resident #43. Census:

Inspectors wroteBased on observation, policy review and staff interview the facility failed to provide necessary respiratory care and services that were in accordance with professional standard practice. A Nebulizer treatment T-piece was hanging from the residents' bed railing. This observation was a random opportunity for discovery. Resident identifier: Resident #27. Facility census: 48. Findings Included: a) Resident #27 A review of the facility policy titled Oxygen Administration, Safety, Mask Types- R/S, LTC, Therapy & Rehab with a revision date of 06/29/22 found the following. .11. When not in use, store in zip lock/plastic bag . During initial tour of the facility on 09/19/22 at 12:08 PM Resident # 27's Nebulizer treatment T-piece was hanging from the resident's bed railing. [...]

Inspectors wroteBased on medical record review and staff interview the pharmacist failed to identify and report the irregularity of Resident #4 Seroquel, as evidenced by documentation of side effects by nursing. This was true for one (1) of five (5) reviewed for unnecessary medications during the long term care survey process. Resident identifier: Resident #4. Facility Census: 48 Findings Included: a) Resident # 4 A review of Resident #4's medical record on 09/27/22 of revealed a physician order dated 04/06/22 Quetiapine Fumarate Tablet (Seroquel) 100 MG Give 1 tablet by mouth one time a day. A review of Resident #4's Medication Administration Record (MAR) for 09/2022 revealed from 09/01/22 to 09/12/22 had documented yes for side effects daily. A review of the Resident #4's MAR for 08/2022 revealed on 08/31/22 Resident #4 had side effects from the medication. [...]

Inspectors wroteBased on observation, policy and procedure and staff interview the facility failed to ensure the medication room controlled substance box was double locked. This failed practice had the potential to affect a limited number of residents. Facility Census: 48 Findings Included: a) On 9/20/22 at 9:10 AM while observing the medication storage room, the controlled medication double lock box in the refrigerator was not locked. This was confirmed on 9/20/22 at 9:10 AM with Registered Nurse #9. According to their Policy for Medications: Acquisition Receiving Dispensing and Storage dated 2/08/22 If the medication requires a refrigerator, these need to be locked in a separate container which they failed to do. .

Inspectors wroteBased on observation, record review and staff interview the facility failed to provide nutritional adequacy by providing inconsistent portions of the food to maintain perimeters of health. This failed practice had the potential to a limited number of residents currently receiving nourishment from the facility's kitchen. Facility Census: 48. Findings Included: a) Resident #41 During a dining observation of the main dining room on 09/26/22 at 12:09 PM, Resident # 41 received a very small amount of ground meat with gravy, a small portion of mashed potatoes. Resident #41's meal tray ticket diet order level 2 no restrictions did not have an order for smaller portions of meat/protein. An observation on 09/26/22 of several other residents' lunch tray no portions on the lunch trays were consistent. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure Resident #249, and #46 medical record was complete and accurate. The Physician Orders for Scope of Treatment (POST) forms were not completed per directions specified by the [NAME] Virginia Center for End of Life Care. This is true for three (3) of 18 reviewed for the Long-Term Care Survey Process . Resident Identifiers: Resident #249 and Resident #46. Facility Census: 48. Findings Included: a) Resident #249 A medical record review on 09/19/22 revealed a POST form on Resident # 249's chart signed and dated by the physician on 09/12/22 which was void of the following: Section F entitled Signature Health Care Provider Printed Full Name: required; [...]