Based on staff interview, employee record review, and facility document review, the facility staff failed to follow their policy regarding screening of new hires for 2 of 15 employees. New hire #1 and #14. The findings include: The facility staff failed to follow their policy for screening of new employees. The facility staff failed to obtain criminal background checks through the Virginia State Police (VSP) criminal records exchange. The facility administrative staff provided the surveyor with a copy of their policy titled, Background Checks-Human Resources. This policy read in part, The Recruitment Team will initiate the background investigation after a conditional job offer has been made .screenings are done in addition to the required criminal history records obtained through the state of Virginia .candidates for positions to be employed in Virginia who are working in those areas required by the state of Virginia to have a criminal history background check obtained through the Central Criminal Records Exchange, Department of State Police will consent to a full criminal background check . On 08/14/24 at approximately 12:27 p.m., the surveyor completed a review of employee records for the staffing task with Human Resource (HR) personnel #1 and #2. Fifteen employee records were reviewed of these 15 records 2 employee files were identified as not having VSP background checks. New hire #1 was employed as an Occupational Therapist, their hire date was documented as 07/29/24. The employee record did not include a VSP background check through the central records exchange. HR personnel #1 stated this employee worked at a hospital for the same company prior to working at this facility and the hospital staff were not aware a VSP background check needed to be completed. New hire #14 was employed in the dietary department, their hire date was documented as 09/14/23. The employee record did not include a VSP background check through the central records exchange. HR personnel #1 confirmed this was a contract employee and the VSP background check had not been completed. On 08/14/24 at 4:00 p.m., during an end of the day meeting with the Administrator/Chief Executive Officer (CEO) and Director of Nursing (DON) the issue with the missing VSP background checks were reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and facility document review, the facility staff failed to ensure Registered Nurse (RN) coverage for 8 consecutive hours a day 7 days a week for quarter 3 of 2023. The findings include: The facility staff failed to ensure they had RN coverage for 8 consecutive hours a day 7 days a week for quarter 3 of 2023 (April, May, June). There was no facility employed RN on staff on 04/30/23, 05/14/23, 05/27/23, 05/28/23, 06/11/23, and 06/25/23. The facility census was as follows 04/30/23 (40), 05/14/23, 05/27/23, 05/28/23 (39), 06/11/23 (38), and for 06/25/23 (35). Three surveyors entered the facility on 08/12/24 at 6:10 p.m., staffing was as follows 1 RN, 2 Licensed Practical Nurses (LPN's), and 3 Certified Nursing Assistants (C.N.A.'s). The census was 25. This facility had triggered for one star staff rating and No Registered Nurse (RN) coverage for quarter 3 of 2023 (April, May, June). A review of the facility payroll-based journal (PBJ) reports revealed that the facility had no RN coverage on the above named dates. On 08/13/24 at 3:10 p.m., during a meeting with the Administrator/Chief Executive Officer (CEO) and Director of Nursing (DON) the issue regarding RN coverage was reviewed. These staff confirmed they did not have RN coverage on these days as they had a staff person out on medical leave. On 08/14/24 at 10:50 a.m., during an interview with LPN #2 this staff stated they did not recall any issues when they did not have an RN, and this would have been their weekends to work. LPN #2 stated if they had issues, they could have called the house supervisor at the hospital (same company), the DON, or RN #2 as they lived near the facility. LPN #2 stated they weren't accepting admissions at one point due to staffing issues. During interviews with C.N.A. #1, #2, #3, #4, and #5, no staff expressed any concerns regarding nursing coverage and issues with the residents of the facility. On 08/14/24 at 1:10 p.m., the Administrator/CEO and DON stated they did not recall any issues regarding not having an RN on site at the facility for the above dates. On 08/14/24 at 1:35 p.m., during an interview with the Social Worker this staff denied having any complaints from families and/or residents regarding RN coverage. No issues regarding staffing were observed while on site. No further information regarding this issue was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #23 the facility staff failed to accurately complete a Virginia Department of Health Durable Do Not Resuscitate (DDNR) form. Resident #23's clinical record was reviewed and contained a signed DDNR for dated 07/28/22. This form read in part, I, the undersigned, state that I have a [NAME] fide physician/patient relationship with the patient named above. I have certified in the patient's medical record that he/she or a person authorized to consent on the patient's behalf has directed that life-prolonging procedures be withheld or withdrawn in the event of cardiac or respiratory arrest. I further certify (must check 1 or 2): Neither box one nor two was checked. The form continued to read, If you checked 2 above, check A, B, or C below. No boxes were checked in this section. The concern of the incomplete DDNR form was discussed with the administrator and director of nursing on 08/13/24 at 3:30 pm. No further information was provided prior to exit. Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for 2 of 14 residents, Resident #19 and #23. The findings include: 1. For Resident #19, the facility staff failed to ensure the residents' order for Digoxin was accurate regarding administering the medication with food. Resident #19's diagnoses included atrial fibrillation and chronic heart failure. Section C (cognitive patterns) of Resident #19's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/08/24 included a brief interview for mental status (BIMS) summary score of 15. Per the MDS manual a score of 15=cognitively intact. The clinical record included an order dated 08/07/24 for Digoxin 62.5 mcg to be given daily at 8:00 a.m. the administration instructions included with this order read as follows, Digoxin should be given one hour before or two hours after eating. On 08/14/24 at 9:03 a.m., during an interview with the Director of Nursing (DON) the DON stated the original order for the Digoxin had a stop date, the physician rounded, and the resident requested it be reordered. Their software pre-populated the documentation regarding mealtimes, and it previously had to hold if the pulse less than 60. The DON stated the nurse putting the order in did not notice that the software had pre-populated the comment regarding meals. On 08/14/24 at 9:45 a.m., during an interview with Medical Director #1, this staff stated the residents Digoxin level was sub-therapeutic and they wanted them off it. Resident #19 has a cardiologist appointment coming up and insisted on the time that it's administered. The part of the order that speaks of it being given with or without food is part of EPIC (software).I did not remove it from the order . On 08/14/24 at 12:18 p.m., during an interview with Registered Nurse (RN) #1 this staff stated the original Digoxin order ended after the dosage on 08/03/24, Resident #19 wanted the medication back, they were seen by the physician, and it was reordered. RN #1 stated breakfast was served around 7 a.m. till 8:30 a.m. and they did not know the order regarding the food and holding the medication was attached to the order, before it was just the heart rate. RN #1 stated the dosage this morning was given by the night shift nurse this at 7:02 a.m. The surveyor was able to verify through the clinical record review that the pulses had been obtained daily. On 08/14/24 at 4:00 p.m., during a meeting with the Administrator/Chief Executive Officer and Director of Nursing (DON) the issue regarding the Digoxin was reviewed. The DON stated a ticket had been put in regarding the food and administration of Digoxin to get it removed from the software. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and facility document review, the facility staff failed to ensure information provided on the payroll-based journal (PBJ) was accurate. The findings include: The facility staff were including Hospice staff not employed by the facility on the PBJ report. This facility had triggered for one star staff rating and No Registered Nurse (RN) coverage for quarter 3 of 2023 (April, May, June). When reviewing these reports, the surveyor noted the facility staff had included Hospice staff on the report. On 08/14/24 at 9:15 a.m., the surveyor interviewed the staff the facility identified as being responsible for these reports RN #3. This staff stated Hospice personnel were contracted and they were patient care givers. RN #3 confirmed they were not paid by the company, and they would reach out to the email provided on the guidelines for completing the PBJ reports. On 08/14/24 at 10:12 a.m., RN #3 stated they had received a response from their email, and they should not have been including Hospice personnel on their PBJ reports. This staff provided the surveyor with copies of their email and part of a booklet titled, Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual Version 2.6 June 2022. Page 3 of this document read in part, .Reminder .visits to residents billed to Medicare or another payer, hours for service provided by hospice staff and private duty nurses shall not be reported . On 08/14/24 at 1:10 p.m., during a meeting with the Administrator/Chief Executive Officer and Director of Nursing (DON) the issue with Hospice personnel being included on the PBJ report was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

2. For Resident #49 the facility staff failed to ensure a complete Virginia Department of Health DDNR (durable do not resuscitate) form. Resident #49's face sheet listed diagnoses which included but not limited to respiratory failure, congestive heart failure, chronic obstructive pulmonary disease, anorexia, dysphagia, dementia, and atrial fibrillation. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 10/15/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15 in section C, cognitive patterns. This indicates the resident is severely cognitively impaired. Resident #49's clinical record was reviewed on 11/03/21 and contained a signed physician's order summary, which read in part Code Status: DNR (do not resuscitate). Resident #49's clinical record contained a Virginia Department of Health DDNR form dated 04/28/21, which read in part I further certify (must check 1 or 2). On this section of the form, 2 was checked. The form also read If you check 2 above, check A, B or C below. In this section, no areas were checked. The incomplete DDNR was discussed with the administrator on 11/03/21 at 5:15 pm. Administrator stated they would correct the DDNR. Administrator provided the surveyor with a copy of a corrected DDNR for on 11/04/21 at 8:50 am. No further information was provided prior to exit. Based on observations, staff interviews, and facility document review, it was determined the facility staff failed to accurately implement facility policies, procedures, and/or processes relating to DNR (do not resuscitate) status for two (2) of 21 facility residents (Resident #15 and Resident #49). The following information was found in a facility policy titled DO NOT RESUSCIATE ORDERS (DNR) AND DURABLE DO NOT RESUSCITATE (DDNR) ORDERS - VIRGINIA - (medical corporation name omitted) (with an effective date of 10/1/21): To issue a DDNR order, an Authorized Practitioner must: a. Explain to the patient or Legally Authorized Representative the DDNR Order and alternatives available for response in the event of Cardiac or Respiratory Arrest. b. If the option of a DDNR Order is agreed upon, an Authorized Practitioner will: . Complete the state approved DDNR form . The findings include: 1. The facility staff failed to ensure Resident #15's Virginia Department of Health DDNR (durable do not resuscitate) Order form was complete. The facility staff failed to ensure Resident #15's wristband had a 'purple star' on it; the purple start indicated the resident had a DNR (do not resuscitate) order. Resident #15 minimum data set (MDS) assessment, with an assessment reference date (ARD) of 8/27/21, was completed on 8/31/21. Resident #15 was assessed as able to make self understood and as usually able to understand others. Resident #15's BIMS (Brief Interview for Mental Status) summary score was a five (5) out of 15. Resident #15 was assessed as requiring assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #15's diagnoses included, but were not limited to: anemia, renal disease, diabetes, and dementia. Resident #15's active plan or care included the following 'focus' area: (Resident #15's name omitted) wishes to be a Do Not Resucitate [sic] in the event of cardiopulmonary arrest. Resident #15's clinical record contained a signed Virginia Department of Health DDNR Order form dated 10/15/21. This form included an area which read in part I further certify (must check 1 or 2); this documented whether or not the resident was 'capable' of making an informed decision. Neither 1 nor 2 was checked. A completed copy of this form, for Resident #15, was provided to the survey team prior to the conclusion of the survey. On 11/3/21 at 5:05 p.m., CNA (certified nurse aide) #21 stated one of the ways to know a resident's DNR status is to check the resident's armband for a purple star. CNA #21 reported a 'purple star' indicates the resident has a DNR order. Review of Resident #15's clinical record revealed a medical provider order for a DNR but Resident #15's armband did not have a 'purple star' on it. On 11/3/21 at 5:09 p.m., the facility's Nurse Manager confirmed that Resident #15's armband did not have a 'purple star' but that it should. The Nurse Manager corrected Resident #15's armband to include a 'purple star'. On 11/4/21 at 8:30 a.m., the facility's Administrator reported the facility's DNR policy did not address the use of a 'purple star' on residents' armband to identify presence of a DNR order for the resident. On 11/4/21 at 2:23 p.m., the facility's Administrator, Director of Nursing, Infection Preventionist, and Unit Manager participated in a survey team meeting. During this meeting the failure of the facility staff to ensure Resident #15 had a completed DDNR from and the failure of the facility staff to ensure Resident #15's armband had the resident's DNR status indicated with a 'purple star' was discussed for a final time.

Based on staff interview and clinical record review, the facility staff failed to demonstrate a review of pharmacy recommendations for one 1 of 21 residents (Resident #41). The findings included: The facility staff failed to follow up on a pharmacy recommendation for the month of August 2021. Resident #41's clinical record included the diagnosis unspecified psychosis, dementia, depressive disorder, and anxiety disorder. Section C (cognitive patterns) of Resident #41's quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 10/04/2021 included a (BIMS) brief interview for mental status summary score of 12 out of 15 points. Resident #41's clinical record included a drug regimen review dated 08/20/2021. The reviewing pharmacist had marked the box beside the statement that read, Recommendations made, review Pharmacy Report for recommendations. The surveyor was unable to locate a pharmacy report with the date of 08/20/2021 that referenced a recommendation in Resident #41's clinical record. 11/04/2021 11:16 a.m., the (DON) director of nursing was made aware of the missing pharmacy report. 11/04/2021 2:23 p.m., an end of the day meeting was held with the administrator, DON, infection preventionist, and unit manager. The missing pharmacy review recommendation was reviewed with these staff. 11/04/2021 3:14 p.m., the DON stated they were unable to locate anything in regards to the pharmacy review for the month of August 2021 for Resident #41. No further information regarding the pharmacy review for August 2021 was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to ensure residents were free of significant medication errors for 1 of 21 residents in the survey sample, Resident #27. The findings included: For Resident #27, the facility staff failed to follow physician's orders for the administrator of Clonidine, a medication used to treat high blood pressure, on six (6) separate occasions. Resident #27's diagnosis list indicated diagnoses, which included, but not limited to Chronic Combined Systolic and Diastolic Heart Failure, Chronic Kidney Disease Stage 4 Severe, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, and Paroxysmal Atrial Fibrillation. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/22/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15 in section C, Cognitive Patterns. Resident #27's current physician's orders included an active order dated 6/21/21 for Clonidine HCL 0.1 mg tablet by mouth as needed for systolic blood pressure greater than 160 twice daily. A review of Resident #27's October 2021 MAR (medication administration record) revealed Clonidine was administered in error on 10/05/21 at 9:13 pm for a blood pressure of 160/70. A review of Resident #27's October 2021 MAR and blood pressure summary revealed the following systolic blood pressure readings greater than 160 in which Clonidine was not administered: 10/02/21 8:13 am 183/75, 10/02/21 8:28 pm 161/72, 10/11/21 10:33 am 180/79, 10/24/21 9:09 pm 161/71, and 10/28/21 6:09 am 162/72. On 11/04/21 at 10:06 am, surveyor spoke with the UM (unit manager) who verified the above surveyor findings for Resident #27. Resident #27's current comprehensive person-centered care plan included a focus area stating (Resident #27) is at risk for altered cardiovascular status r/t (related to) CHF (congestive heart failure), atrial fibrillation, cardiomegaly, hx (history) of hypertension, MI (myocardial infarction), ASCVD (atherosclerotic cardiovascular disease) with an intervention stating check blood pressure every shift, administer meds as indicated. On 11/04/21 at 2:31 pm surveyor met with the administrator, director of nursing, UM, social worker, and the infection preventionist and discussed the concern of Resident #27 not receiving Clonidine as ordered by the physician on six (6) separate occasions. No further information regarding this issue was provided to the survey team prior to the exit conference on 11/04/21.

Based on clinical record review and staff interview, facility staff failed to ensure that residents receive treatment and care in accordance with the comprehensive person-centered care plan as evidenced by failure to obtain daily weights for 1 of 20 residents in the survey sample, Resident #23. For Resident #23, facility staff failed to obtain daily weights as ordered by the physician. Resident #23's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease Stage 4, Unspecified Systolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, and Essential Primary Hypertension. The most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 11/20/19 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive Patterns. A review of Resident #23's medical record revealed an active physician's order dated 10/02/18 stating Lasix 20 mg (milligrams) (Furosemide) give 20 mg by mouth every 24 hours as needed for weight gain, check daily weights, if weight 2-3 lbs. (pounds) in 24 hours or 5 lbs. in one week, give Lasix. Resident #23's comprehensive care plan included the problem area of (Name omitted) is at risk for fluid imbalance, approaches included, but were not limited to administer medications as ordered, refer to MAR (Medication Administration Record) and weigh and record as ordered, notify physician of significant findings. A review of the TAR (Treatment Administration Record) and the resident's Weights and Vitals Summary Report revealed weights were being obtained weekly. February 2020 weights were obtained on 2/03/20, 2/10/20, and 2/17/20. On 2/20/20 at approximately 10:00am, surveyor notified the DON (director of nursing) of the above findings. The DON did not provide any additional information. On 2/20/20 at approximately 3:30pm, the administrative team consisting of the administrator and the DON were made aware of staff not following the physician's order to obtain daily weights for Resident #23. No further information regarding this issue was presented to the survey team prior to the exit conference on 2/21/20.

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections as evidenced by a failure of a staff member to cleanse an injection site prior to the administration of a subcutaneous injection for 1 of 20 residents in the survey sample (Resident #40). The findings include: On 2/20/20 at 8:00 a.m., Staff Member (SM) #21 was observed to administer Humolog (insulin) 10 unit via subcutaneous injection to Resident #40. SM #21 did not cleanse the injection site prior to administering the medication. SM #21 confirmed the injection site was not cleansed prior to the injection. SM #21 reported always cleansing an injection site prior to administering an injection and was unsure why he/she did not cleanse the injection during the aforementioned observation. Resident #40's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 1/11/20, had the resident assessed as requiring assistance with eating, hygiene, and dressing. Resident #40's diagnoses included, but were not limited to: diabetes, dysphagia, respiratory disease, and high blood pressure. The following information was found in facility infection control and/or injection procedure documents provided to the survey team by the facility's Director of Nursing on 2/20/20 at 10:25 a.m.: Subcutaneous Injection . 12. Examine the patient's skin to select an appropriate injection site . 15. Clean the intended injection site with an alcohol swab or facility approved antiseptic solution and allow it to air-dry 16. Uncap the needle and administer the injection . Resident #40's care plan included Diabetes Mellitus as a focus area. This focus area had administer diabetes medication as an intervention. During a meeting on 2/20/2020 at 3:20, the failure of SM #21 to cleanse Resident #40's injection site prior to a subcutaneous injection was discussed with the facility's Administrator and Director of Nursing.