Based on record review, staff interview and observations, the facility failed to ensure a comprehensive care plan for fall interventions was developed. The failed failed practice had the potential to affect a limited number of residents. Resident Identifier: #75. Facility census: 128. Findings included: a) Resident #75On 08/25/2025 at 09:19 AM, Resident #75 was observed during the initial interview process. The resident was observed to have a fall mat on the left side of the bed, his bed against the right side of the wall and his bed in a low position. On 08/28/2025 at 08:10 AM, Nursing Assistant #15 confirmed Resident #75 had fall mats, bed in low position and bed against wall on the right side. The nursing assistant reported he usually has these items in place. On 08/28/2025 at 09:23 AM, Registered Nurse (RN) #169 confirmed there was no order for floor mats, and they typically don't order for bed positioning, but they put it in the care plan. On 08/28/2025 at 09:40 AM, RN #169 reported floor mats and bed positioned against the wall were added to the resident's care plan.

Based on observation, staff interview and record review, the facility failed to ensure an accurate medical record for fall intervention orders and provide documentation of the method of bathing. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #75 and #104. Facility Census: 128. Findings included: a) Resident #75 On 08/25/25 at 9:19 AM, Resident #75 was observed during the initial interview process. The resident was observed to have a fall mat on the left side of the bed, his bed against the right side of the wall and his bed in a low position. On 08/28/25 at 8:10 AM, Nursing Assistant #15 confirmed Resident #75 had fall mats, bed in a low position, and bed against wall on the right side. The nursing assistant reported he usually has these items in place. On 08/28/25 at 09:23 AM, Registered Nurse (RN) #169 confirmed there was no order for a floor mat and reported they had just added the order. A copy of the order was given to the state surveyor. b) Resident #104 Review of Resident #104’s medical record on 08/21/25, showed it did not contain the method of bathing provided. During an interview with the Director of Nursing on 08/21/25 around 1:00 PM, she stated that she would have to ask the resident or the nurse aide that was providing care if the resident was given a shower, bath or bed bath. She verified there was no other way to confirm the method of bathing provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observation, the facility failed to ensure food was stored in accordance with professional standards for food service. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 128.Findings included: a) The facility's policy and procedure for Food Storage stated, All foods are to be covered, labeled, and dated. All food items open and not dated will be discarded. Procedures:All foods, including sliced meats (example: lunch meat and bulk cooked meats) are to be re-dated with current date when removed from freezer and placed in the refrigerator. All food is covered, labeled and dated when placed in the refrigerator.All food items in refrigerator open, not dated or outdated will be discarded.b) The facility's policy and procedure for Leftovers stated: All leftover cold food for storage in the refrigerator is put in storage containers and completely covered with plastic or foil wrap. It is then labeled with the name of the item in the container and the date. All leftovers are to be used within 3 DAYS or be discarded. Hazardous foods are Used within 24 hours and then discarded. c) The following items were observed and confirmed during the initial kitchen investigation and investigation of the facility's pantries: The kitchen Investigation was initiated on 08/25/2025 at 11:30 AM. [NAME] #188 reported they date food for seven (7) days when it is opened. 1) The following items in the kitchen were observed and confirmed by [NAME] #188: No received dates on canned items. One dented can of light peaches. Egg noodles - opened with no use by date. Chocolate cake mix - opened with no use by date. Penne pasta - opened with no use by date. [NAME] sugar - opened with no use by date. Whip topping - opened and no use by date. Ham, Pork Loin , pulled pork, roast beef , sausage - in refrigerator to thaw with no use by date - [NAME] #188 reported, Meat is for seven days. Freezer packs of lunch meat in foil - no use by date. Pork chops sliced - opened, not labeled and no use by date.Ground Hamburger - not labeled and no use by date.Fruit and potato salad in a plastic container - not labeled and no use by date.Tomatoes, lettuce, cantaloupe, pineapples, oranges. pudding, egg salad, peaches, ham salad, tuna salad and watermelon - labeled with no use by date. [NAME] #188 reported these items were good for five (5) to seven (7) days.Green beans - no use by date.Stewed tomatoes - no use by date.Biscuits - no use by date.Lettuce - opened with no use by date; [NAME] #188 stated, We usually use the date on the bag.Hard boiled eggs - opened and no use by date. Shredded cheese - opened and no use by date. Swiss cheese - opened and no use by date. Diced potatoes - not labeled. Frozen biscuits - Baked in a Ziploc bag - no use by date. Frozen broccoli - opened with no use by date Frozen carrots - opened with no use by date. Frozen celery - opened and no use by date. Frozen tater tots - opened, not labeled and no use by date. Frozen hashbrown patties - opened, not labeled and use by date. Frozen chicken breasts - opened and no use by date. Frozen chicken tenders - open and no use by date. Frozen Canadian bacon - opened and not dated. Frozen turkey - opened and not dated. Frozen roast beef - opened and not dated. Frozen raisin bread - not labeled and not dated. Frozen pepperoni -not labeled with no use by date. Frozen rye bread - not labeled and not dated. 2) First Floor Pantry items confirmed by Dietary Assistant #26 on 08/27/25 at 9:20 AM. Items included: Freezer - Waffles - not labeled, no use by date. Biscuits - not labeled - open and no use by date. English muffins - no labeled and no use by date. [NAME] Deluxe Chocolate Ice Cream - opened, no open or used by date. Rye bread - opened and no use by date. Refrigerator - Butter - opened and not dated. Cream cheese - no use by date. Sliced cheese - opened , not labeled with no use by date. Lunch meat - open, not labeled and no use by date. Cottage cheese - opened, not labeled no open date. Pudding - opened, not labeled no open date. Applesauce - opened, not labeled, no open date. 3) Second Floor Pantry items were confirmed by Dietary Assistant #64 on 08/27/2025 at 08:53 AM. Items included: Freezer - Sausage - Not labeled or dated. Raisin bagels - Not labeled or dated.Bagels - Not labeled or dated.Waffles - Not labeled and no use by date. English muffins - Not labeled and no use by date. Pancakes - Not labeled and no use by date. Refrigerator - Applesauce - not labeled and no open date. Grapes - not labeled and no open. Lunchmeat - not labeled with no use by date. Cheese - sliced and cheddar - opened, not labeled or dated. Philadelphia cream cheese - No use by date. Butter, individual packages - No use by date. Cream individual packages - No use by date. Wishbone red wine vinaigrette - opened and no dated. Dry Pantry - [NAME] wheat bread - no open date. Sunbeam sandwich bread - no open date Old El Paso Taco Seasoning Mix - opened and not dated. Small plastic container - appeared to be cinnamon (spice) - not labeled and not dated. On 08/27/2025 at 09:53 AM, Dietary Aide #64, stated, I will fix all of that. 4) Third Floor Pantry food items were confirmed by Dietary Assistant #128 on 08/27/2025 at 09:05 AM. Items included: Freezer - Muffins - no use by date Raisin bread - not labeled. French toast - opened and not labeled. Waffles - two (2) packages - not labeled and no use by date. Waffles - two (2) packages - opened, not labeled and no use by date. Pancakes - opened, not labeled and no use by date. Bagels - opened, not labeled and no use by date. Refrigerator - Cream Cheese - no use by date. Slice cheese - not labeled and no use by date. Individual butter - no use by date. Individual creamer - no use by date. Pudding - opened, not labeled and no opened date. Cottage Cheese - opened, not labeled and no date opened. Applesauce - opened, not labeled and no open date. Dry Goods - Bread - opened and no opened date. Dinner rolls - wrappers - no open or use by date. [NAME] sandwich bread - no open date. Raisin bread - not labeled and no open date. Eggs - not labeled and no open date. Dietary Assistant #128 stated, Baker's put end date.

. Based on policy review, record review and staff interview, the facility failed to ensure resident falls resulting in serious bodily injury were reported in a timely manner to the appropriate state agencies. The failure to make a timely report and to report to the correct state agencies was true for two (2) of two (2) sample residents for falls. Resident identifiers: #56 and #14 . Facility census: 115. Findings included: Review of the facility's Mistreatment/Abuse/Neglect Reporting Allegations Policy, with a revision date of January 2023, revealed the facility would report to the Office of Health Facility and Licensure (OHFLAC) and to Adult Protective Services (APS) in accordance with [NAME] Virginia Code 9-6-9. a) Resident #56 A medical record review, completed on 11/28/23 at 12:50 PM, revealed the following: - Resident #56 fell while getting up to the bathroom without staff assistance on 08/21/23 at 10:00 PM. - A Health Status Note, on 08/22/2023 at 10:47 AM, noted Resident #56 was complaining of right elbow pain. Her physician was notified and new orders were given for a portable x-ray of right arm/elbow. - A Health Status Note, on 08/22/2023 at 5:29 PM, noted the physician visited and went over x-ray results with resident. - The Immediate Fax Reporting of Allegations reporting form was faxed to the Office of Health Facility and Licensure (OHFLAC) on 08/23/23 at 2:02 PM. There was no evidence Adult Protective Service (APS) had been notified. During an interview on 11/28/23 at 1:30 PM, the Director of Nursing (DON) acknowledged the serious bodily injury was not reported within the required two (2) hour timeframe. The DON reported it was a facility oversight that the serious bodily injury was not reported to Adult Protective Services (APS). b) Resident #14 An interview with Resident #13 on 11/28/23 at 9:26 AM revealed, she fell out of bed and she broke her arm. She stated that she had to have immediate surgery. A progress notes review revealed an unwitnessed fall on 08/10/23 at 10:10 PM: --Upon arrival to room, found resident sitting on floor on left side of bed sitting upright, head against side of bed with bilateral legs straight out in front. Right anterior foot wedged under bed side table and left arm wedged between the bed and left upper bedside railing. (Transcribed as written.) A review of the Facility Reportable's found that the 08/10/23 unwitnessed fall with injury and outside medical treatment was not reported timely. On 11/29/23 at 8:00 AM documentation was provided the unwitnessed fall with major injury was not reported until 8/21/23 at 6:10 PM. During an interview with the Administrator on 11/29/23 at 8:10 AM, confirmed that Resident #14 was sent to the hospital and had surgery on her left arm. She also stated that the facility did not report the incident timely. She verified the incident wasn't reported until 08/21/23. No further information was provided prior to the end of the survey on 11/29/23 at 5:30 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of one (1) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier #98. Facility census 115. Findings included: a) Resident #98 On 11/28/23, a record review of the resident's electronic medical record (EMR), the resident's admission PASARR, dated 05/01/23, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated None. A continued record review also revealed the resident received a psychistric diagnosis of bipolar disorder on the diagnosis listed on admission [DATE] but did not receive a new PAS to address whether or not specialized services were needed. On 11/29/23 at 1:51 PM, an interview with Social Worker #136 confirmed the admission PAS presented to the surveyor did not indicate a diagnosis of bipolar disorder and a new PAS was not completed for bipolar disorder upon admission.

. Based on observation and staff interview, the facility failed to ensure resident safety and sanitary storage, handling and consumption of food in a personal refrigerator. Resident identifier: #68 Facility census: 115. Findings included: a) Resident #68 On 11/27/23 at 3:14 PM observation of Resident #68's personal refrigerator in the room found three (3) cartons of expired milk. The expiration dates were 04/12/23, 09/30/23 and 10/14/23. This was confirmed on 11/27/23 at 3:25 PM with Licensed Practical Nurse (LPN) #79 who agreed the expired milk should have been thrown out.

. Based on observation and staff interviews, the facility failed to maintain the garbage storage area in a sanitary condition. It was discovered the dumpster had a work glove, a food container and newspaper on the ground around the dumpster. Facility census: 115. Findings included: a) Garbage refuse receptacle During an observation from the loading dock of the outside garbage receptacle on 11/27/23 at 11:55 AM, with the Dietary Manager (DM). She verified the garbage storage area was not maintained in a sanitary manner. There was a work glove, food container and newspaper on the ground around the dumpster. She also reported the area around the dumpster was cleaned early in the morning and again in the afternoon. The DM on 11/27/23 at 12:38 PM, provided the schedule for cleaning of the area around the dumpster. The Dumpster Cleaning Log noted at 6:00 AM and 2:00 PM on 11/01/23 to 11/26/23 the area around the dumpster had been cleaned. There was no time recorded for the early morning cleaning on 11/27/23. During an interview with the Nursing Home Administrator on 11/29/23 at 9:10 AM, verified the Dumpster Cleaning Log did not record a time the area around the dumpster was cleaned on the morning of 11/27/23.

. Based on record review and staff interview, the facility failed to electronically submit to CMS complete and accurate direct care staffing information data by the required deadline for the FY Quarter 3 2023 (April 1 - June 30). This was a random opportunity for discover. Facility census: 115. Findings included: a) Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 3 2023 (April 1 - June 30) Review of the PBJ Staffing Data Report for Fiscal Year Quarter 3 2023 (April 1 - June 30) revealed results for low weekend staffing, Registered Nurse coverage for eight (8) consecutive hours/day, and Licensed Nurses for 24 hours/day were suppressed on the 3rd Quarter of 2023 report. It was noted that a possible reason for suppression may be invalid data. During an interview on 11/28/23 at 3:00 PM, the Administrator reported the facility started using a new payroll system in January 2023. As a result, data had to be extracted from two (2) new systems. The Fiscal Year Quarter 2 2023 (January 1 - March 31) information was submitted successfully. The Administrator reported she ran into unanticipated electronic submission issues (a corrupt file) and failed to meet the reporting time frame for the Fiscal Year Quarter 3 2023 (April 1 - June 30). Once the midnight deadline had passed there was no opportunity to complete a late submission of the data.

. Based on facility documentation and staff interview, the facility failed to have required members sign in at the Quality Assessment and Assurance (QAA) meetings. This failed practice had the potential to affect all residents residing at the facility. Facility census: 115. Findings included: a) QAA Record review of the facility's documentation of QAA Meeting Agenda and Minutes revealed no sign in sheets for staff that attended the meeting quarterly. During an Interview 11/29/23, at 4:08 PM, the Administrator verified the required members did not sing in for the quarterly QAA meetings. No other information was provided prior to the end of the survey on 11/29/23.

. Based on medical record reviews and staff interviews, the facility failed to ensure the physician was notified of changes regarding resident's physical status. This was true for three (3) of 27 sample residents. The physician was not notified of urinalysis results for Resident #112, and for Residents #4 and #98 there was no notice of weight loss/gain. Resident identifiers: #112, #4, and #98. Facility census: 115. Findings included: a) Resident #112 On 11/29/23 at 1:55 PM record review shows Resident #112 had a temperature of 101.7 Fahrenheit (F) on 10/23/23 at 10:16 AM. At 11:40 AM the (in house Physicians name) was notified of the fever, lungs clear but diminished. Denies burning or pain with urination. A new order for a chest X-ray (negative) and urinalysis with a culture and sensitivity was ordered. According to a progress note on 10/24/23 at 5:24 PM the Physician was notified regarding the urinalysis and preliminary results from the urine culture. No new orders were received. Documentation shows the Physician requested to wait on the results of the culture and sensitivity for further orders. On 10/25/23 at 9:02 AM, records show the final urine culture result was received from the laboratory. There is no documentation of the physician being notified of the final urine culture and sensitivity. As a result of the Physician not being notified of the culture and sensitivity, there were no antibiotics ordered for the final urine culture showing Escherichia coli in the urine. This was confirmed with the Director of Nursing on 1/29/23 at 2:15 PM who agreed the Physician should have been notified of the final urine culture. No additional evidence was provided prior to exiting the survey. b) Resident #4 A review of the Nutritional Assessment completed on 11/14/23, the Dietician documented Resident #4 was down 8.8 pounds in one (1) month and noted that was a significant weight loss. Resident #4 receives enteral tube feedings and the physician was not notified of the significant weight loss. In an interview with the Director of Nursing (DON) on 11/29/23 at 3:27 PM, verified the physician should have been notified of the significant weight loss for Resident #4. c) Resident #98 Record review of the facility's policy titled, Weight Chart/Monitoring of weight Loss, revision dated 11/23, showed that the date of weight taken, and the weight is to be written under the appropriate headings on the weight record. If weight signifies loss or gain of plus or minus five (5) pounds, resident should have repeat weight on identical scale. During an interview with Resident #98 on 11/27/23 at 3:05 PM, he stated that he was gaining weigh on his tube feeding. He stated that he does not desire to gain weight. A medical record review on 11/28/23 revealed, significant weight gain. Resident #98 weighed 181.4 pounds (LBS.) on 11/06/23 and weighed 192.4 LBS. on 11/27/23 equaling an 11.0 pound in weight gain. Resident #98s Weight log showed: 11/27/2023 192.4 pounds 11/13/2023 184.4 pounds 11/06/2023 181.4 pounds 11/06/2023 181.8 pounds 10/30/2023 181.4 pounds Continued review revealed a Physician order: --Weekly weights, one time a day every Monday, with a start date 08/07/23. Subsequent review of the resident's medical record showed it did not contain documentation of Resident #98's physician being notified of a significant weight loss. During an interview on 11/29/23 at 1:37 PM with the Dietician, she confirmed that Resident #98's medical record revealed a weigh increase of 11 pounds. She stated that she did not feel it was accurate. She stated that she was recommending that resident #98 be reweighed next week on 12/04/23. She continued to say that the weight policy was just for monthly weights, not weekly weights. No further information was provided prior to the end of the survey on 11/29/23 at 5:30 PM. .

. Based on record review and staff interview, the facility failed to follow physician orders. Medication used to control blood sugar in people with diabetes mellitus was not administered within physician's parameters and documented in accordance with professional standards of practice. Blood glucose levels were not obtained as ordered. High blood sugars were not reported to the physician. The facility failed to have a documented order for a tube feeding. The facility failed to notify the physician when a resident had an abnormal urinalysis culture. This affected 8 (eight) of 27 residents reviewed during the long-term care survey process. Resident identifiers: #10, #22, #47, #15, #4, #68, #112, #5. Facility census: 115. Findings included: a) Resident #10 A record review, completed on 11/27/23 at 2:08 PM, revealed the following physician order, Blood Sugar, two times a day for DM (Diabetes Mellitus). Call dr (doctor) if below 70 or above 300 for further orders. Review of the November 2023 Medication Administration Record, completed on 11/28/23 at 8:46 PM, revealed the following seven (7) times there was no evidence the physician was contacted for further orders when blood sugars were above 300: -11/05/23 at 4:00 PM Blood Sugar was documented as 316 -11/06/23 at 6:00 AM Blood Sugar was documented as 339 -11/06/23 at 4:00 PM Blood Sugar was documented as 365 -11/08/23 at 6:00 AM Blood Sugar was documented as 305 -11/08/23 at 4:00 PM Blood Sugar was documented as 348 -11/09/23 at 4:00 PM Blood Sugar was documented as 340 -11/11/23 at 4:00 PM Blood Sugar was documented as 427 During an interview on 11/29/23 at 9:44 AM, the Director of Nursing confirmed there was no documentation in the medical record to indicate the physician had been notified of the high blood sugars and stated she would need to look into it further. The DON stated she believed the nurses did not contact the physician because he has told them (the nurses) before to just give coverage and to quit calling him with high blood sugars. The DON agreed that if that was indeed the case, a different order should have been obtained to accurately reflect the physician's treatment desires. b) Resident #22 A record review, completed on 11/27/23 at 1:44 PM, revealed the following physician order: HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 140 - 159 = 1 unit; 160 - 179 = 2 units; 180 - 199 = 3 units; 200 - 219 = 4 units; 220 - 239 = 5 units; 240 - 259 = 6 units; 260 - 279 = 7 units; 280 - 299 = 8 units; 300 - 319 = 9 units; 320 - 339 = 10 units; 340 - 359 = 11 units; 360 - 379 = 12 units; 380 - 399 = 13 units; 400 - 419 = 14 units > 420 = Give 15 units, subcutaneously four times a day for Diabetes Further review revealed there was no documentation to indicate the medication had been administered per the sliding scale. -11/11/23 at 8:00 AM Blood Sugar was documented as 449 During an interview on 11/29/23 at 9:37 AM, the Director of Nursing (DON ) stated according to the blood sugar level Resident #22 should have been given 15 units as per physician's sliding scale order and that it appeared it had not been done. On 11/29/23 at 4:04 PM, the DON reported she had spoken to the nurse who had worked on the date in question and the nurse distinctly remembered giving the 15 units to resident as per the physician's sliding scale order but had failed to document it. c) Resident #47 A record review, completed on 11/27/23 at 7:18 PM revealed the following orders: -Check glucometer blood sugar daily -Lantus Solution (Insulin Glargine) - Inject 18 unit subcutaneously one time a day for DM (Diabetes Mellitus) **ONLY HOLD IF BS (blood sugar) < 80 AND NOTIFY PHYSICIAN Further review revealed the following dates where resident's blood sugar was less than 80 and it appeared not only was the physician not notified but Lantus Solution was not held: -11/06/23 at 6:00 AM the Blood Sugar was documented as 66 and the Medication Administration Record (MAR) revealed the Lantus Solution was given at 8:00 AM -11/07/23 at 6:00 AM the Blood Sugar was documented as 73 and the Medication Administration Record (MAR) revealed the Lantus Solution was given at 8:00 AM During an interview on 11/29/23 at 11:13 AM, the Director of Nursing (DON) stated according to the above details the medication should have been held and she would look into it further. On 11/29/23 at 4:06 PM, the DON stated the nurse's reported they had rechecked the resident's blood sugar levels prior to administering the medication. The DON acknowledged that there was no documentation of the rechecks and the nurses had failed to follow the part of the order that directed the nurses to notify the physician if the blood sugar was under 80. d) Resident #15 On 11/28/23 at 2:35 PM record review shows Resident #15 has an order to check the blood glucose twice a day and report to the Physician if it is over 300. Further review shows there were five (5) times in October and November, 2023 that Resident #15's blood glucose was elevated over 300. There was no evidence of the elevated blood glucose being reported to the Physician. The following blood glucose were documented on the Medication Administration Record (MAR). 11/28/2023 21:28 308.0 mg/dL 11/21/2023 19:35 335.0 mg/dL 11/07/2023 11:52 327.0 mg/dL 10/27/2023 20:56 348.0 mg/dL 10/14/2023 21:57 337.0 mg/dL On 11/29/29 at 11:00 AM the above information was confirmed with Director of Nursing who agreed the Physician should have been notified of the above five (5) elevated blood glucose. No additional documentation was provided prior to exiting the survey. e) Resident #4 On 11/28/23 at 12:45 PM observation of Resident #4 showed tube feeding (2 Cal HN) infusing at an ordered rate of 35 milliliters (ml) per hour with water also on the pump and programmed to infuse 50 ml every hour. On 11/29/23 at 8:02 AM record review shows the following order: 2 cal HN 35 ml/hour with 50 ml of water flush every hour. May use Nutren in place of 2 Cal. May be off the tube feeding two (2) hours if out of bed (OOB). The above order was entered to appear on the Treatment Administration Record (TAR) however, it was entered in such a manner that it does not show up on the TAR. Further record review of the November TAR found there is no documentation that the tube feeding had been hung. This was confirmed with the Administrator on 11/28/23 at 3:10 PM when she agreed the order was erroneously entered and not showing as administered daily on the TAR for November, 2023 No additional documentation was provided prior to exiting the survey. f) Resident #68 On 11/29/23 at 9:46 PM record review shows Resident #68 had the following order: Blood sugar checks weekly. No coverage at this time. Notify (Physicians name) for blood sugar greater than 300 or less than 70. Further review shows blood glucose results for October and November, 2023 were not obtained weekly as ordered. Blood glucose checks were due four (4) times in October and five (5) times in November. During the month of October the blood glucose was obtained once. During the month of November the blood glucose was obtained twice. 11/19/2023 20:57 263.0 mg/dL 11/15/2023 05:58 108.0 mg/dL 10/18/2023 06:13 108.0 mg/dL The above information was confirmed with the Director of Nursing on 11/29/23 at 1:00 PM who agreed the blood sugar checks were not completed as ordered. No additional documentation was provided prior to exiting the survey. g) Resident #112 On 11/29/23 at 1:55 PM record review shows Resident #112 had a temperature of 101.7 Fahrenheit (F) on 10/23/23 at 10:16 AM. At 11:40 AM the Dr.(in house Physician name) was notified of the fever, lungs clear but diminished. Denies burning or pain with urination. A new order for a chest X-ray (negative) and urinalysis with a culture and sensitivity was ordered. According to a progress note on 10/24/23 at 5:24 PM the Physician was notified regarding the urinalysis and preliminary results from the urine culture. No new orders were received. Documentation shows the Physician requested to wait on the results of the culture and sensitivity for further orders. On 10/25/23 at 9:02 AM, records show the final urine culture result was received from the laboratory. There is no documentation of the physician being notified of the final urine culture and sensitivity. As a result of the Physician not being notified of the culture and sensitivity, there were no antibiotics ordered for the final urine culture showing Escherichia coli in the urine. This was confirmed with the Director of Nursing on 1/29/23 at 2:15 PM who agreed the Physician should have been notified of the final urine culture. No additional documentation was provided prior to exiting the survey. h) Resident #5 A medical record review on 11/29/23, revealed Resident #5 had an order for the physician to be notified when the resident's blood sugars were over 350. On November 9, 10, 13, 14, 18, 19, 22, and 25, 2023 there were eight (8) instances when Resident #5's blood sugars exceeded the allowable insulin parameters. Also, there was no evidence the physician was notified of the high blood sugars. During interviews The Director of Nursing (DON) and the Manager of Nursing #61 on 11/29/23 at 1:35 PM, verified there was no documentation the physician was notified of the eight (8) instances when the resident's blood sugars exceeded the allowable parameters. Thus agreeing the physician's orders for Resident #5 were not followed for the administration of insulin.

. Based on observation and staff interview, the facility failed to ensure wheelchair arms were in good repair for a resident. This was a random opportunity for discovery. The failed practice was true for one (1) of 22 sampled residents. Resident identifier: #4. Facility census: 113. Findings included: A record review of the facility's policy titled Standards of Nursing Practice revised on 02/2022, stated, It is each nurse's responsibility to monitor patient care equipment to assure equipment is in good working condition. a) Resident #4 An observation on 06/20/22 at 9:37 AM, showed Resident #4's wheelchair arms were cracked and in poor repair. During an interview on 06/21/22 at 11:00 AM, Administrator stated that Resident #4's wheelchair arms were cracked and were in need of repair. .

. Based on medical record review and staff interview, the facility failed to report a fall with major injury for Resident #99. This practice affected one (1) of three (3) residents reviewed for falls during the Long Term Care Survey Process. Resident identifier: #99. Facility census: 113. Findings included: a) Resident #99 A medical record review on 06/21/22 revealed a progress note for 06/05/22, which indicated resident was found in the bathroom and her left leg was noticeably turned outward. The physician was notified and orders were received to send Resident #99 to the emergency room for evaluation. A progress note on 06/09/22 reported Resident #99 was readmitted from the hospital with left hip repair after a fall with fracture. In an interview with the Nursing Home Administrator and the Director of Nursing on 06/21/22 at 10:25 AM reported the fall with major injury on 06/05/22 was not reported to any State entities. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessments for two (2) of 22 residents reviewed during Long-Term Care Survey (LTCSP). The MDS for Resident #3 did not accurately reflect resident was receiving hospice. And Resident #100's MDS did not accurately reflect a diagnosis of an infection. Resident identifier: Resident #3 and Resident #100. Facility Census: 113 Findings Included: a) Resident #3 A Review of the Resident #3 Significant change MDS on 06/20/22 with Assessment Reference Dates (ARD) of 03/19/22 discovered the following: Section O titled Special treatment procedure and programs, Section K Hospice Care was coded as: No. Section J titled Health Conditions, Section J1400 Prognosis was coded No. A review of Resident #3's medical record on 06/20/22, found a physician order dated, 03/10/22 for Admit to Amedisys Hospice-Diagnosis Alzheimer's Disease. During an interview on 06/21/22 at 1:15 PM MDS Coordinator #50 acknowledged the MDS with ARD date 03/19/22 Section J Prognosis was marked No and the section O Other health conditions 1400 prognosis was marked no. She stated Section J and O both need modified they are incorrect. b) Resident #100 Review of Resident #100's medical records showed the resident had a diagnosis of Methicillin-resistant Staphylococcus Aureus (MRSA) upon her admission to the facility on [DATE]. Review of Resident #100's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) 06/03/22 did not document the resident was diagnosed with MRSA. During an interview on 06/22/22 at 12:32 PM, MDS coordinator #50 confirmed the resident had a diagnosis of MRSA that was not documented on the admission MDS. No further information was provided through the completion of the survey. .

. Based on medical record review and staff interview, the facility failed to revise Resident #3's care plan for update medication for dementia with behaviors that was discontinued. This is true for one (1) of 22 residents reviewed for care plans. Resident identifier: Resident #3. Facility Census: 113. Findings included: a) Resident #3 A record review of Resident #3's medical record on 06/22/22 found the following care plan: Focus statement: Cognitive loss/dementia or Alteration in thought processes related to: history of Alzheimer The focus statement was initiated on 04/16/18 and revised on 03/28/19. Goals associated with the this goal included Will provide current level of cognitive function as demonstrated by: knowing self and family by review date. This goals was initiated on 04/16/2018 and revised on 06/17/22. The interventions included Administer medications as ordered by MD. Geodon for Dementia. Ativan for anxiety and restlessness. This intervention was initiated on 04/16/18 and revised on 03/07/22. During a medical record review revealed a physician order dated 05/13/22 Geodon Capsule give 40 mg(milligrams) by mouth two (2) times a day for dementia disturbances for one (1) week Do not crushed or open capsules. Give 20 mg by mouth two (2) times a day for dementia with behavioral disturbances for 1 week. Physician order discontinued on 05/28/22. During an interview on 6/22/22 at 10:44 AM the Care Plan Coordinator #74 acknowledged the Geodon was discontinued on 05/28/22 and was not removed from the care plan on 06/17/22 during the review. During an interview on 06/22/22 at 10:44 AM the Coordinator Social Services #39 stated It was an oversight, I always check the medications to update the care plan. I just missed that one this time. .

. Based on observation, record review, and staff interview, the facility failed to provide oxygen therapy in accordance with professional standards of practice. The oxygen tubing was not labeled to indicate when it was last changed for two (2) of two (2) residents reviewed for the area of respiratory care. Resident identifiers: Residents #53, #71. Facility census: 113. Findings included: a) Resident #53 Review of Resident #53's medical records showed the following physician's order: Change oxygen tubing monthly on the 1st (with labels provided - note date, time and initials). During observation on 06/20/22 at 10:23 AM, Resident #53 was noted to be using supplemental oxygen via a nasal cannula. The oxygen tubing was not labeled to indicate when it was last changed. During an interview on 06/20/22 at 11:15 AM, Licensed Practical Nurse (LPN) #111 confirmed Resident #53's oxygen tubing did not have a label. No further information was provided through the completion of the survey process. b) Resident #71 During a random observation on 06/20/22 at 1:30 PM, it was discovered the oxygen tubing for Resident #71 did not include the date, time, or initials when changed. A medical record review on 06/20/22 revealed an order to change oxygen tubing monthly, on the first of every month and note date, time, and initials with a start date of 06/01/22. On 06/20/22 at 1:37 PM, Registered Nurse (RN) #93 verified there was no date, time or initials on the oxygen tubing. b) Resident #71 During a random observation on 06/20/22 at 1:30 PM, it was discovered the oxygen tubing for Resident #71 did not include the date, time, or initials when changed. A medical record review on 06/20/22 revealed an order to change oxygen tubing monthly, on the first of every month and note date, time, and initials with a start date of 06/01/22. On 06/20/22 at 1:37 PM, Registered Nurse (RN) #93 verified there was no date, time or initials on the oxygen tubing. .

. Based on medical record review and staff interview, the facility failed to develop an order for the care and treatment of a vascular assess catheter for hemodialysis. This was discovered for one (1) of (1) residents reviewed for dialysis during the Long Term Care Survey Process. Resident #163 had no order for the care and treatment of his vascular access catheter for hemodialysis. Resident identifier: Resident #163. Facility census: 113. Findings included: a) Resident #163 During a medical record review on 06/22/22 for Resident #163, it was discovered there was no order for the care and treatment of a vascular access catheter for dialysis. In an interview with the Director of Nursing (DON) on 06/22/22 at 9:38 AM verified there was no order for the vascular access catheter used for dialysis for Resident #163. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed provide pharmaceutical services to meet the needs of each resident. Medication current being received by Resident #26 was expired. This was a random opportunity for discovery. Resident identifier: #26. Facility census: 113. Findings included: a) Resident #26 On [DATE] at 9:19 AM, the 1 North Hallway medication storage room was observed. In the refrigerator was a bottle of Omeprazole liquid for Resident #26 that had expired on [DATE]. Licensed Practical Nurse (LPN) #89 confirmed the medication was expired and needed to be discarded. LPN #89 also said Resident #26 was currently receiving Omeprazole liquid. Review of Resident #26's current orders showed an order for Omeprazole suspension one (1) time a day. No further information was provided through the completion of the survey. .

. Based on record review and staff interview, the facility failed to ensure Resident #207's as needed anti-anxiety medication was limited to 14 days. This is true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier: #207. Facility census: 113. Findings included: a) Resident (R) #207 Review of the medical record found R #207 was prescribed Ativan (antianxiety medication) 0.5 milligrams (mg) as needed every eight (8) hours three (3) days after being admitted . The order written on 06/14/22 states: Ativan Tablet 0.5 mg Give 0.5 mg by mouth every eight (8) hours as needed for anxiety, agitation, restlessness. The order lacks a stop date to identify the 14 day limit. During an interview on 06/22/22 at 9:58 AM, Registered Nurse (RN) #4 reviewed the order for R #207's Ativan and acknowledged the medication order in the computer system lacks a 14 day stop date. RN #4 stated staff must put in the 14 day limit for the as needed Ativan when it is ordered so it will automatically stop on the fourteenth day. .

. Based on observation, record review, and staff interview, the facility failed to provide special eating utensils for Resident #48. This was a random opportunity for discovery. Resident identifier: #48. Facility census: 113. Findings included: a) Resident #48 On 06/20/22 at 12:09 PM, Resident #48 was observed to be eating in the dining room. The resident appeared to be feeding herself well. However, the resident's tray ticket stated the resident was to have built-up utensils. The resident was using regular silverware. On 06/20/22 at 12:19 PM, Dietary Aide #123 confirmed Resident #48 did not have the built-up utensils specified on the tray ticket. Dietary Aide #123 stated she had been told the resident did not need them anymore. Review of Resident #48's current physician's orders showed the following order written on 04/14/22: Patient to have built up utensils with all meals. No further information was provided through the completion of the survey process. .

. Based on observations and staff interview, the facility failed to store food in accordance with professional standards for food service safety. During the kitchen tour it was discovered the bins containing sugar and flour were not dated. This had the potential a limited number of residents receiving nourishment from the kitchen. Facility census: 113. Findings included: a) Kitchen tour It was discovered during the kitchen tour on 06/20/22 at 11:00 AM, the bins containing sugar and flour were not dated. The Dietary Manager was present during the kitchen tour on 06/20/22 at 11:10 AM and verified the bins containing the sugar and flour were not dated. .

. Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Staff failed to don appropriate personal protective equipment (PPE) for a resident in contact isolation. This was a random opportunity for discovery. Resident identifier: #100. Facility census: 113. Findings included: a) Resident #100 Review of Resident #100's medical records showed an order for contact isolation for Methicillin-resistant Staphylococcus Aureus (MRSA). During observation on 06/22/22 at 11:03 AM, Registered Nurse (RN) #134 was observed entering Resident's room wearing only a mask. The resident had PPE consisting of gloves, gowns, and masks outside the room. A sign hanging outside the room indicated the resident was on contact isolation and gloves, gowns, and masks were required for all people entering the room. The sign had folded in on itself and was difficult to read. RN #134 was observed by the resident's bedside and was beginning the administration of the resident's intravenous antibiotic. RN #134 had donned gloves upon entering the resident's room but had not donned a gown. When RN #134 exited the resident's room, she confirmed the resident was on contact isolation. RN #134 stated she had forgotten to put on a gown before entering the room. No further information was provided through the completion of the survey process. .

. Based on record review, staff interview and policy review, the pharmacist failed to identify and report a drug irregularity during the initial medication review and reconciliation. Resident #207's as needed antianxiety medication lacks a 14 day time limit. In addition, the Medication Regimen Review (MRR) policy lacks time frames for the different steps in the review process and does not identify the steps the pharmacist must take when identifying an irregularity that requires urgent action to protect the resident. This is true for one (1) of five (5) reviewed for unnecessary medications and the policy has the potential to more than a limited number of residents residing in the facility. Resident identifier: 207. Facility census: 113. Findings include: a) Resident (R) #207 Review of the medical record found R #207 was prescribed Ativan (antianxiety medication) 0.5 milligrams (mg) as needed every eight (8) hours three (3) days after her admission. The order written on 06/14/22 states: Ativan Tablet 0.5 mg Give 0.5 mg by mouth every eight (8) hours as needed for anxiety, agitation, restlessness. The order lacks a stop date to identify the 14 day limit. The facility pharmacist completed the initial medication review and reconciliation on 06/15/22 and failed to identify the incomplete Ativan order for R #207. During an interview on 06/22/22 at 09:58 AM, Registered Nurse (RN) #4 reviewed the order for R #207's Ativan and reported the medication order in the computer system lacked a 14 day stop date. RN #4 stated staff must put in the 4 day limit for the as needed Ativan when it is ordered so it will automatically be stopped at the end of the 14 day time limit. b) Medication Regimen Review (MRR) Policy The facility policy titled Medication Regimen Review with a revision date of February 2021 was given to the survey team on 06/21/22. The Medication Regimen Review (MRR) policy lacks time frames for the different steps in the review process and does not identify the steps the pharmacist must take when identifying an irregularity that requires immediate action. During an interview on 06/22/22 at 08:10 AM the Administrator confirmed the MRR policy lacks time frames for the specific steps in the review process including irregularities requiring an urgent response. .