**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews during a recertification survey on 10/16/24, the facility did not ensure timely notification to the physician of Resident's significant weight loss. This is true for one (1) of three (3) Resident's reviewed for weight loss. Resident identifiers: Resident #2. Facility census: 15. Findings included: a) Resident #2 Resident #2 had diagnoses of Polyosteoarthritis, Heart failure, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Type 2 diabetes, hypertension, and age-related physical debility. Record review on 10/15/24 at approximately 2:18 PM revealed the following: Resident had been weighed on 08/06/24 at 11:58 AM, and the weight recorded as 218.2 pounds. A nursing note on 08/07/24 at 10:28 PM by Licensed Practical Nurse (LPN) #21, which stated: Resident alert and oriented to person, place, time and situation. Speech clear. Resident able to make her needs known. Resident independent, set-up to supervision for ADL's, has been requiring staff assistance on occasion with ADLs depending on ability that day. Resident able to feed herself meals after tray set up. Resident wears upper and lower dentures. Resident takes care of her own dentures. Denies oral pain or discomfort at this time. No issues with chewing or swallowing noted. Resident continent of bladder and bowel but does have occasional incontinence episodes. Resident has bilateral hearing aids but usually does not wear them. Resident wears PRN oxygen at 2L via nasal cannula to maintain oxygen saturations above 92%. Resident walks with rollator walker independently in room and hallway. Has been using wheelchair for longer distances at times depending on ability that day. Resident participates with unit activities. Enjoys watching television, playing Bingo and participates with some unit activities. A nursing note on 08/08/24 at 6:50 PM by Registered Nurse (RN) #1 which stated: Resident with increased weakness and dyspnea with exertion. Resident is experiencing some confusion and states she feels shaky. Upon assessment, resident's vital signs WNL for resident. Blood glucose is 319. Resident does have tremors to hands and is having difficulty staying awake, even while conversing with staff. Lung sounds diminished to right side; fine crackles auscultated to left base. Resident required 2 staff assist to ambulate from the bathroom and reported fear of falling due to weakness. [Physician] was notified of change in condition. New orders for ER evaluation. POA, called and updated. POA and resident agreeable to transfer to ER. A note by LPN #21 on 08/08/24 at 7:00 PM which stated: Resident left floor via wheelchair with staff to ER. A follow up note on 08/08/24 at 10:26 PM by LPN #21 which stated: Spoke with ER nurse, resident admitted to (local hospital). MPOA, made aware. A note on 08/12/2024 at 10:23 AM by RN #5 which stated: Resident returned to unit via wheelchair on 2L portable oxygen from (local hospital) unit. VS were taken and are WNL for resident. Last BM reported on 8/11. Bowel sounds active in all 4 quads. Resident lung sounds are clear. Bilateral lower leg swelling +1 pitting edema noted. Resident c/o right knee pain 6/10 that is alleviated with Tylenol. Multiple bilateral arms bruising due to blood draws and IVs. Resident is currently sitting in recliner with call bell in reach. POA notified of residents return to unit. Plan of care ongoing. Resident's weight upon re-admission to the facility on [DATE] at 10:08 AM was documented as 201.4 pounds. This was a loss of 16.8 pounds in six (6) days, which correlates to a 7.7% weight change. During an interview with the Director of Nursing (DON) #34 on 10/16/24 at approximately 10:55 AM, she revealed a patient weighing policy. Review of the policy revealed that residents were to be re-weighed if resident's weight had increased or decreased by five (5) pounds, per physician's order, or at the request of the RN or Dietitian. Record review further revealed that facility staff were compliant with the policy. Resident #2 was re-weighed multiple times on 08/12/24: At 10:45 AM, her weight was again recorded as 201.4 pounds. At 11:15 AM she had been weighed once again and her weight was recorded as 201.4 pounds. On 08/13/24 at 10:31 AM resident's weight was recorded as 201.6 pounds. A progress note on 08/16/24 at 6:24 PM by DON #34 stated: [Resident] triggered for significant change in status (decline) in urinary incontinence this assessment period. On state assessment, [Resident] triggered for significant change in status (decline) in mood this assessment period. [Resident] has episodes of bladder incontinence and mood fluctuates from day to day and times throughout the day, therefore, will not complete a significant change in status this assessment period. During the seven days look back period (ARD 08/02/24), POC documents [Resident] as independent for bed mobility, transfer, toilet use, and supervision for eating. [Resident] was occasionally incontinent of bladder and always continent of bowel this assessment period. [Resident] has no behavior problems. [Resident] has no pressure injuries. Skin is intact. Current weight is 217.6 pounds (08/01/2024). [Resident] attends activities of her choosing and also participates in self-directed activities (television, music, crocheting, talking on the phone). [Resident] had no falls this assessment. [Resident's] family (son and family) live out of state and are supportive. [Resident] has no concerns for care conference and does not wish to participate in care conference. Letter regarding care conference was mailed to MPOA, with no response back. [Resident] requested a copy of her care plan be mailed to her MPOA, per pre request, a copy of care plan was mailed to [Resident's] MPOA. [Resident's] plan of care will continue. A review of Resident #2's care plan revealed the following note: NUTRITIONAL STATUS: [Resident] has the potential for nutritional problem related to Obese II BMI. Diet order Regular Consistency/Regular Diet with regular liquids. [Resident] has Type II Diabetes. Date Initiated: 03/18/19 Revision on: 08/16/24 GOALS: [Resident] will be free from any sign/symptoms of hyperglycemia through next review date. Date Initiated: 06/05/18 Revision on: 06/07/19 Target Date: 11/07/24 [Resident] will be free from any sign/symptoms of hypoglycemia through the next review date. Date Initiated: 06/05/18 Revision on: 06/07/19 Target Date: 11/07/24 [Resident] will have no complications related to Diabetes through the next review date. Date Initiated: 06/05/18 Revision on: 06/07/19 Target Date: 11/07/24 [Resident] will maintain adequate nutritional status as evidenced by maintaining weight within +/- 5%, no s/sx of malnutrition, and consuming at least 76-100% of each meal daily through the next review date. Date Initiated: 06/05/18 Revision on: 06/07/19 Target Date: 11/07/24 INTERVENTIONS: Administer medications (Lantus Insulin, 20 units SQ at bedtime x 1 week) as ordered. Monitor for adverse effects and effectiveness. Notify MD as indicated. Date Initiated: 08/13/24. Dietician offered education to resident due to excessive snacking at times, [Resident] declined education. She verbalized I know exactly what I am doing. Dietician will provide education to [Resident] as requested or indicated. Date Initiated: 03/18/19. Record review revealed a dietitian's note on 09/03/24 at 1:36 PM by Dietitian #27 which stated: Weight loss verified after re-weight. Significant weight loss noted. Current weight on 9/2/24 204.6 Lbs -5.0% change [ Comparison Weight 8/6/2024, 218.2 Lbs. -6.2%, -13.6 Lbs] Discussed POC with RN and [Resident] who are aware of weight loss. During recent acute care hospitalization, they removed fluid. Weight loss was expected. Skin intact at this time. No concerns noted during morning meal rounds. Feeds herself. Normally consumes 100 % of meals. An attempt was made to interview the Dietitian #27 on 10/16/24 at approximately 5:18 PM. The dietitian was not available for interview at that time. Further record review revealed no physician's orders, or progress notes, documenting or addressing the weight loss. An interview with RN #5 on 10/16/24 at approximately 8:55 AM revealed that she was aware of Resident #2's weight loss. During a follow-up interview with DON #34 on 10/16/24 at approximately 1:55 PM, she was asked whether she could produce any record that the facility notified the physician of the resident's 16.8-pound weight loss. DON #34 stated that she would review the facility records. At approximately 3:30 PM on 10/16/24 the DON #34 produced a handwritten physician's order dated 08/13/24 concerning Resident #2's diagnosis, and treatment, but did not refer to the resident's weight loss. She stated That's all I've got.

. Based on record review, review of facility grievances, policy review, and staff interview, the facility failed to ensure that all allegations of neglect were reported within 24 hours to appropriate state agencies as required. This was a random opportunity for discovery. Resident identifier: #7. Facility census: 16. Findings included: a) Resident #7 On 11/02/22 at 9:04 AM, a review of the facility grievance log from May 2022 through October 2022 found the following resident complaint: -Resident #7 reported, on 10/05/22, that she had asked the Certified Nurse Aide (CNA) to hand her oxygen to her. The CNA asked if she could say, Please? Resident also reported the CNA would not assist her with washing her bottom. A subsequent medical record review revealed the following details: -The annual Minimum Data Set (MDS) for Resident #7, with an assessment reference date of 08/29/22, reflected resident was cognitively intact and had a BIMS [Brief Interview for Mental Status] score of 15. -Resident #7 had experienced a fall in her room on 09/29/22 and sustained a broken right arm. Review of the facility's Abuse Prevention and Reporting policy, dated July 2022, indicates the facility will support all residents in reporting any suspected acts of abuse, neglect, or exploitation in accordance with [NAME] Virginia State Law without the fear of reprisal or retribution. Further, the facility policy defines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. During an interview on 11/02/22 at 9:25 AM, the Director of Nursing (DON) agreed that the concerns mentioned in the resident grievance should have been considered an allegation of neglect and it should have been reported according to state guidelines. The DON also acknowledged Resident #7 may have required more help with her routine following her broken arm. .

. Based on medical record review and staff interview, the facility staff failed to accurately complete an annual comprehensive assessment of a resident's psychiatric/mood disorders. This is true for one of five reviewed for unnecessary medications. Resident identifiers: 7. Facility census: 16. Findings include: a) Resident #7 Review of the medical record on 11/01/22 revealed R #7 diagnoses includes anxiety. A physician order dated 03/11/22 notes Celexa (antidepressant used to treat depression and anxiety) 30 milligrams once a day for depression and anxiety. The annual Minimum Data Set (MDS) comprehensive assessment with an assessment reference date of 08/29/22 is not marked to reflect the diagnosis of anxiety under section I5700 titled Psychiatric/Mood disorder. The Director of Nursing confirmed R #7's annual MDS assessment was coded incorrectly and does not reflect her diagnosis of anxiety during an interview on 11/01/22 at 4:00 PM. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure physician orders and care plans matched the resident and/or medical power of attorney's requests documented on the [NAME] Virginia Physician Orders for scope of treatment (POST) form. This is true for four (4) of four (4) residents reviewed. Resident identifiers: 3, 8, 13, 16. Facility census: 16. Findings include: a) Resident (R) #3 Review of the medical record on [DATE], revealed R #3 completed a POST form with his medical power of attorney and physician on [DATE]. The form states Do Not Attempt Resuscitation if found without a pulse and not breathing. Limited interventions include intravenous fluids (IV) for a trial period of no longer then three days and no feeding tube. The physician orders state DNR (Do not resuscitate) but lack any information related to the requested limited interventions. The care plan acknowledges his request to be a DNR but lacks information related to limited interventions of IV fluids for a trial period and no feeding tube. The Director of Nursing (DON) reviewed the medical record during an interview on [DATE] at 2:00 PM. The DON confirmed the physician's order and the care plan do not address R #3's requests listed on the POST form for limited interventions of IV fluids and no tube feedings. b) Resident (R) #8 Review of the medical record on [DATE], revealed R #8 completed a POST form with his physician on [DATE]. The form states Do Not Attempt Resuscitation if found without a pulse and not breathing. Limited interventions include IV fluids for a period of seven days and no feeding tube. The physician's order states DNR (Do not resuscitate) but is silent for the requested limited interventions of IV fluids for seven days and no feeding tube. The care plan identifies his request to be a DNR but lacks information related to limited interventions of IV fluids for a trial period and no feeding tube. The Director of Nursing (DON) reviewed the medical record during an interview on [DATE] at 2:00 PM. The DON confirmed the physician's order and the care plan do not address R #8's limited intervention requests listed on the POST form. c) Resident #13 A medical record review, completed on [DATE] at 3:00 PM, revealed the following details: -A Physician Orders for Scope of Treatment (POST) form, signed on [DATE], indicating the resident wanted to be considered a DNR, wanted to receive limited additional interventions, requested to receive IV fluids for a trial period of no longer than 10 days, and did not want to have a feeding tube. -Resident's Care Plan, dated [DATE], stated [Resident's First Name] is a DNR per MPOA and physician order. -A physician order, dated [DATE], stated, Physician Order: CODE STATUS: DNR. During an interview, on [DATE] at 3:17 PM, the DON stated the physician order and care plan only reflected the resident's desire to be considered a DNR. They did not match the resident's POST form which reflected limited additional interventions, a desire to receive IV fluids for a trial period or the desire to not have a feeding tube. d) Resident #16 A medical record review, completed on [DATE] at 3:13 PM, revealed the following details: -A Physician Order for Scope of Treatment (POST) Form, signed on [DATE], indicating resident wanted to receive CPR, wanted to receive full interventions, requested to receive IV fluids for a trial period of two (2) weeks, and did not want to have a feeding tube. -Resident's Care Plan, dated [DATE], stated, CODE STATUS: [Resident's First Name] is a Full Code per resident and physician order. -A physician order, dated [DATE], stated, Physician Order. Code Status: FULL CODE. During an interview, on [DATE] at 3:19 PM, the DON stated the physician order and care plan only reflects the resident's desire to receive CPR. They did not match the resident's POST form which reflected full interventions, a desire to receive IV fluids for a trial period or the desire to not have a feeding tube. .

. Based on facility documentation and staff interview, the facility failed to meet at least quarterly to conduct required Quality Assurance and Performance Improvement (QAPI) activities. This practice had the potential to affect more than a limited number of residents at the facility. Facility census 16. Findings included: a) QAPI meetings Review of the facility's Quality Assurance and Performance Improvement (QAPI) plan revealed that the Medical Director, [NAME] President of Medical Affairs/designee, [NAME] President, DON, Dietician, Pharmacist, Infection Control Preventionist, Director of Activities, and the Director of Housekeeping were on the committee. A request was made for the attendance sheet from the QAPI meetings for the previous 12 months. Attendance sheets from April 2022 - November 2022 were provided. During an interview, on 11/01/22 at 2:30 PM, the Director of Nursing (DON) reported the facility did not have any QAPI meetings from October 2021 - March 2022. The DON reported she had participated in meetings on the acute care side of the hospital but failed to have meetings for the long-term care unit. The DON reported she had misinterpreted CMS guidance and had erroneously believed the QAPI meetings were waived altogether. The DON confirmed there were no meetings for the October 2021 - December 2021 quarter and the January 2022 - March 2022 quarter. .

. Based on record review and interview, the facility failed to report a resident's major injury to the appropriate state entities, in a timely manner. This is true for one (1) of one (1) resident reviewed for accidents. Resident identifier: #6. Facility census: 16. Findings included: a) Resident #6 On 07/17/21 at 5:10 PM, Resident #6 had an unwitnessed fall. Vital signs were obtained. The resident complained of right hip pain and was immediately sent to the Emergency Department of a local acute care hospital. The resident returned to the facility at 8:45 PM on this same date. X-rays showed no evidence of a broken bone. A Computed Tomography Scan (CT) was ordered by the physician. This scan found an Acute nondisplaced right inferior pubic ramus fracture. This is a stable pelvic fracture. This acute fracture is difficult to see on yesterday's x-ray of the pelvis. According to federal regulations serious bodily injuries should have been reported within two (2) hours of discovery. On 07/27/21 at 4:40 PM, the Director of Nursing (DON) explained she was not aware this regulation. .

. Based on record review and staff interview, the pharmacist failed to recommend a gradual dose reduction (GDR) for a Resident #14 related to the use of an antidepressant. This is true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #14. Facility census: 16. Findings included: a) Resident #14 A medical record review for Resident #14 revealed Zoloft (antidepressant) with a start date of 06/07/20 received the same dose of Zoloft for greater than one (1) year. Continued review of the medical records found no evidence the pharmacist made a GDR for this antidepressant in the prior year, as required by federal Medicare and Medicaid regulations. On 07/28/21 at 10:00 AM, the Director of Nursing (DON) confirmed the pharmacist did not complete the GDR. .