Every finding on record at APPOMATTOX HEALTH & REHABILITATiON CENTER

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide proper medical treatment for abnormal lab values resulting in hospitalization for one of six residents in the survey sample (Resident #4).The findings include:Resident #4 (R4) was admitted to the facility with diagnoses that included chronic kidney disease, bacteremia, endocarditis, congestive heart failure, liver cirrhosis, obesity, diabetes, anemia, atrioventricular block, thrombocytopenia, hypertension, non-alcoholic steatohepatitis (NASH), and diverticulosis. R4's most recent minimum data set (MDS) assessed the resident as cognitively intact.R4's clinical record documented lab test results dated 8/10/23 listing R4 had a low sodium level of 125 mEq/L (reference range of 136 to 145) and normal potassium level of 4.8 mEq/L (reference range of 3.5 tot 5.1). The PA's progress note dated 8/14/23 referenced review of the 8/10/23 lab results and documented under diagnosis/plan that the resident had hypopotassemia (low potassium level) with orders entered for potassium chloride ER, 20 mEq (milliequivalents) daily for the low potassium. The progress note made no mention of a diagnosis or treatment for the low sodium level.R4's medication administration record (MAR) documented the potassium chloride 20 mEq was administered as ordered on 8/15/23 and 8/16/23.R4's nursing notes documented the resident left the faciity on 8/16/23 for an appointment with an infectious disease specialist. A nursing note dated 8/16/23 at 4:16 p.m. documented R4 was assessed at the infectious disease appointment with a critical lab value of potassium at 6.5 with a recheck done with results of 6.6 mEq/L. The note documented the resident was sent as a direct admit to the hospital for treatment of the critically high potassium.R4's hospital Discharge summary dated [DATE] documented the resident was hospitalized from [DATE] until 8/18/23 and treated for hyperkalemia (high potassium level) and acute kidney injury with the medication Lokelma and discontinued use of diuretics. The Discharge summary dated [DATE] documented, .Patient has an enterococcal bacteremia with VRE. She has endocarditis and has been receiving IV daptomycin every 24 hours at a rehab facility. She [R4] went to [infectious disease physician's] office for follow-up appointment today had laboratory findings which showed acute kidney injury as well as hyperkalemia [high potassium level]. Patient direct admitted to [hospital] .In discussions with the patient's [family member] .she states that the director of nursing at the [nursing facility] had called her stating that the patient had been incorrectly prescribed potassium supplementation recently at that facility instead of an apparently intended sodium chloride supplementation for concerns about hyponatremia. This certainly could have led to the patient's hyperkalemia .A facility reported incident form dated 8/17/23 to the state agency documented R4 was hospitalized for a critically high potassium level after the resident was prescribed and administered a potassium supplement by the physician's assistant (PA). The director of nursing (DON) at that time documented on 8/17/23, that she was notified that R4 was admitted to the hospital for hyperkalemia and upon review of the resident's medications, noted that the PA had recently prescribed potassium chloride. The form documented the PA was asked to review the order. The DON's note documented that the PA informed her that she had ordered potassium in error and should have ordered sodium to address the low sodium lab results.A written statement dated 8/17/23 by the PA (other staff #1) documented, I was handed lab results by nurse .I transcribed the abnormal values into my note .paying attention to a sodium of 125 . I did not place orders at this time. After seeing the patient I placed my orders. I had a different pt [patient] that day that I increased their potassium supplementation, it is my belief that when I placed [R4's] orders, my brain was thinking 'potassium' and so I placed an order for 1 tab [tablet] po [oral] daily of Potassium Chloride 20 meq [milliequivalents] instead of sodium .The facility's investigation of this incident dated 8/22/23 documented the PA erroneously ordered potassium for R4 when she meant to order a sodium supplement that resulted in R4's hospitalization for treatment of hyperkalemia.The PA that prescribed the potassium in error was not available for interview as she no longer worked at the facility. The DON at the time of the incident was not available for interview as she no longer worked at the facility.On 8/12/25 at 9:15 a.m., R4 was interviewed about the potassium error and hospitalization. R4 stated the PA gave her potassium when she was supposed to get sodium. R4 stated she had to go to the hospital for treatment of the high potassium. R4 stated, It just knocked me out. The doctor said my potassium was out the roof. R4 stated nothing like that had happened before or since and she got ok after discharge from the hospital. R4 stated regarding the PA, I think she [PA] just made a mistake.On 8/12/25 at 3:22 p.m., the administrator was interviewed about R4's medication error. The administrator stated R4 went out for a physician's appointment and labs were done that indicated a high potassium level. The administrator stated the PA ordered potassium in error when she intended to order sodium. The administrator stated R4 was admitted and treated at the hospital for high potassium and that the medical director at that time was notified.On 8/13/25 at 9:50 a.m., the current medical director (other staff #2) was interviewed about R4 and the prescription/medication error with potassium. The medical director stated a potassium level of 6.5 was considered critical and required immediate treatment. The medical director stated an untreated high potassium level could cause the body to shut down and heart problems including arrythmias, in addition to kidney problems. The medical director stated there were ways to quickly bring potassium levels down that included medications. The medical director stated that potassium levels above 6 (mEq/L) required hospital treatment to quickly bring down the potassium levels. The medical director stated hospital treatment for critically high potassium allowed for heart monitoring during treatment and intravenous medications that allowed for quick reduction of potassium levels. On 8/13/25 at 11:07 a.m., the former medical director (other staff #3) was interviewed about R4's potassium error. The former medical director stated the PA had assessed several residents prior to entering orders that day and that the PA ordered potassium for R4 instead of sodium in error. The former medical director stated R4 got a couple of doses of potassium that resulted in high potassium lab results with the resident hospitalized for treatment. The former medical director stated he did not feel the PA had lack of knowledge but that the PA just made an error.These findings were reviewed with the administrator and regional nurse consultant on 8/13/25 at 12:10 p.m. with no further information presented prior to the end of the survey.

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure one of six residents (Resident #4) was free from a significant medication error resulting in hospitalization for treatment of hyperkalemia.The findings include:Resident #4 (R4) was admitted to the facility with diagnoses that included chronic kidney disease, bacteremia, endocarditis, congestive heart failure, liver cirrhosis, obesity, diabetes, anemia, atrioventricular block, thrombocytopenia, hypertension, non-alcoholic steatohepatitis (NASH), and diverticulosis. R4's most recent minimum data set (MDS) assessed the resident as cognitively intact.R4's clinical record documented lab test results dated 8/10/23 listing R4 had a low sodium level of 125 mEq/L (reference range of 136 to 145) and normal potassium level of 4.8 mEq/L (reference range of 3.5 tot 5.1). The PA's progress note dated 8/14/23 referenced review of the 8/10/23 lab results and documented under diagnosis/plan that the resident had hypopotassemia (low potassium level) with orders entered for potassium chloride ER, 20 mEq (milliequivalents) daily for the low potassium. The progress note made no mention of a diagnosis or treatment for the low sodium level.R4's medication administration record (MAR) documented the potassium chloride 20 mEq was administered as ordered on 8/15/23 and 8/16/23.R4's nursing notes documented the resident left the faciity on 8/16/23 for an appointment with an infectious disease specialist. A nursing note dated 8/16/23 at 4:16 p.m. documented R4 was assessed at the infectious disease appointment with a critical lab value of potassium at 6.5 with a recheck done with results of 6.6 mEq/L. The note documented the resident was sent as a direct admit to the hospital for treatment of the critically high potassium.R4's hospital Discharge summary dated [DATE] documented the resident was hospitalized from [DATE] until 8/18/23 and treated for hyperkalemia (high potassium level) and acute kidney injury with the medication Lokelma and discontinued use of diuretics. The Discharge summary dated [DATE] documented, .Patient has an enterococcal bacteremia with VRE. She has endocarditis and has been receiving IV daptomycin every 24 hours at a rehab facility. She [R4] went to [infectious disease physician's] office for follow-up appointment today had laboratory findings which showed acute kidney injury as well as hyperkalemia [high potassium level]. Patient direct admitted to [hospital] .In discussions with the patient's [family member] .she states that the director of nursing at the [nursing facility] had called her stating that the patient had been incorrectly prescribed potassium supplementation recently at that facility instead of an apparently intended sodium chloride supplementation for concerns about hyponatremia. This certainly could have led to the patient's hyperkalemia .A facility reported incident form dated 8/17/23 to the state agency documented R4 was hospitalized for a critically high potassium level after the resident was prescribed and administered potassium supplement by the physician's assistant (PA). The director of nursing (DON) at that time documented on 8/17/23, that she was notified that R4 was admitted to the hospital for hyperkalemia and upon review of the resident's medications, noted that the PA had recently prescribed potassium chloride. The form documented the PA was asked to review the order. The DON's note documented that the PA informed her that she had ordered potassium in error and should have ordered sodium to address the low sodium lab results.A written statement dated 8/17/23 by the PA (other staff #1) documented, I was handed lab results by nurse .I transcribed the abnormal values into my note .paying attention to a sodium of 125 . I did not place orders at this time. After seeing the patient I placed my orders. I had a different pt [patient] that day that I increased their potassium supplementation, it is my belief that when I placed [R4's] orders, my brain was thinking 'potassium' and so I placed an order for 1 tab [tablet] po [oral] daily of Potassium Chloride 20 meq [milliequivalents] instead of sodium .The facility's investigation of this incident dated 8/22/23 documented the PA erroneously ordered potassium for R4 when she meant to order a sodium supplement that resulted in R4's hospitalization for treatment of hyperkalemia.The PA that prescribed the potassium in error was not available for interview as she no longer worked at the facility. The DON at the time of the incident was not available for interview as she no longer worked at the facility.On 8/12/25 at 9:15 a.m., R4 was interviewed about the potassium error and hospitalization. R4 stated the PA gave her potassium when she was supposed to get sodium. R4 stated she had to go to the hospital for treatment of the high potassium. R4 stated, It just knocked me out. The doctor said my potassium was out the roof. R4 stated nothing like that had happened before or since and she got ok after discharge from the hospital. R4 stated regarding the PA, I think she [PA] just made a mistake.On 8/12/25 at 3:22 p.m., the administrator was interviewed about R4's medication error. The administrator stated R4 went out for a physician's appointment and labs were done that indicated a high potassium level. The administrator stated the PA ordered potassium in error when she intended to order sodium. The administrator stated R4 was admitted and treated at the hospital for high potassium and that the medical director at that time was notified.On 8/13/25 at 9:50 a.m., the current medical director (other staff #2) was interviewed about R4 and the prescription/medication error with potassium. The medical director stated a potassium level of 6.5 was considered critical and required immediate treatment. The medical director stated an untreated high potassium level could cause the body to shut down, heart problems including arrythmias, in addition to kidney problems. The medical director stated there were ways to quickly bring potassium levels down that included medications. The medical director stated that potassium levels above 6 (mEq/L) required hospital treatment to quickly bring down the potassium levels. The medical director stated hospital treatment for critically high potassium allowed for heart monitoring during treatment and intravenous medications that allowed for quick reduction of potassium levels. On 8/13/25 at 11:07 a.m., the former medical director (other staff #3) was interviewed about R4's potassium error. The former medical director stated the PA had assessed several residents prior to entering orders that day and that the PA ordered potassium for R4 instead of sodium in error. The former medical director stated R4 got a couple of doses of potassium that resulted in high potassium lab results with the resident hospitalized for treatment. The former medical director stated he did not feel the PA had lack of knowledge but that the PA just made an error.These findings were reviewed with the administrator and regional nurse consultant on 8/13/25 at 12:10 p.m. with no further information presented prior to the end of the survey.

Based on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of six residents in the survey sample (Resident #1).The findings include:Resident #1's care plan was not revised to include a preference for no male caregivers.Resident #1 (R1) was admitted to the facility with diagnoses that included metabolic encephalopathy, dysphagia, anemia, protein-calorie malnutrition, asthma, cognitive communication deficit, hypothyroidism, myocardial infarction and hypertension. The minimum data set (MDS) dated [DATE] assessed R1 with severely impaired cognitive skills.R1's clinical record documented a nursing note dated 4/29/25 stating, .spoke with [family member] today regarding patient care concerns. resident to not have male caregivers if at all possible .R1's plan of care (revised 7/21/25) documented the resident required total assistance from staff for activities of daily living. The care plan made no mention of a preference for no male caregivers.On 8/13/25 at 8:36 a.m., the registered nurse MDS coordinator (RN #2) responsible for updating care plans, was interviewed. RN #2 reviewed R1's care plan and stated she found nothing added about the preference for no male caregivers. RN #2 stated to her knowledge, the nurses and aides were aware of this preference but that the preference had not been added to the care plan. RN#2 stated the preference for caregivers should have been added to the care plan.This finding was reviewed with the administrator and regional nurse consultant on 8/13/25 at 12:10 p.m. with no further information presented prior to the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to submit investigation findings regarding an abuse allegation to the state agency for one of six residents in the survey sample (Resident #1).The findings include:Resident #1 (R1) was admitted to the facility with diagnoses that included metabolic encephalopathy, dysphagia, anemia, protein-calorie malnutrition, asthma, cognitive communication deficit, hypothyroidism, myocardial infarction and hypertension. The minimum data set (MDS) dated [DATE] assessed R1 with severely impaired cognitive skills.A facility reported incident form was sent to the state agency on 4/27/25 documenting an allegation of sexual misconduct between R1 and certified nurse's aide (CNA) #1. The initial report was sent to the state agency on 4/27/25. The state agency received no final report of the facility's investigation/findings regarding this allegation. Review of the facility's investigation on 8/12/25 revealed a final investigation report dated 4/30/25 summarizing the facility's investigation and findings that did not substantiate sexual assault. The investigation documents included no evidence that the final report was sent to the state agency.On 8/12/25 at 3:22 p.m., the administrator was interviewed about the investigation of abuse allegations regarding R1. The administrator stated he thought the former director of nursing (DON) had sent the findings to the state agency. The administrator reviewed the investigation folder and did not present any evidence that the investigation findings were sent to the state agency. The facility's policy titled Abuse/Neglect Misappropriation/Crime - Reporting Requirements/Investigations (effective 2/5/23) documented under section 5, .The Administrator must thoroughly investigate and file a complete written report of the investigation of the submitted FRI [facility reported incident] to the State Agency within five (5) working days of the incident .This finding was reviewed with the administrator, director of nursing and regional nurse consultant on 8/12/25 at 3:30 p.m. and on 8/13/25 at 12:10 p.m. with no further information presented prior to the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of six residents in the survey sample (Resident #1).The findings include:There was no documentation in Resident #1's clinical record regarding a physical assessment and actions taken in response to allegations of rough handling/sexual abuse.Resident #1 (R1) was admitted to the facility with diagnoses that included metabolic encephalopathy, dysphagia, anemia, protein-calorie malnutrition, asthma, cognitive communication deficit, hypothyroidism, myocardial infarction and hypertension. The minimum data set (MDS) dated [DATE] assessed R1 with severely impaired cognitive skills.A facility reported incident form to the state agency dated 4/27/25 documented investigation of an allegation of sexual misconduct between R1 and a staff member.R1's clinical record documented a skin assessment dated [DATE] following the allegations but included no mention of any actions taken in response to the allegations.On 8/12/25 at 11:00 a.m., the registered nurse (RN#2) that received the allegations from R1's family member was interviewed. RN #2 stated on 4/27/25 that R1's family member reported that R1 had been changed during the night against her wishes and that the aide was rough providing care. RN #2 stated R1's roommate reported that she heard the resident yell out in the night and reported that it sounded like she was getting raped. RN #2 stated with the family member's permission, and accompanied by the floor nurse, she performed a thorough assessment of the resident, including the genital area, that revealed no evidence of redness, bruising or trauma. RN #2 stated the allegations were immediately reported to the director of nursing (DON) who came to the facility along with notification to the administrator, physician and the police. RN #2 stated she wrote a statement about the incident and entered notes into the clinical record. RN #2 stated she reviewed the clinical record and did not see anything documented about the incident. RN #2 stated she thought she entered the notes and thought the DON at the time had entered notes about the incident.On 8/12/25 at 3:22 p.m., the administrator was interviewed about lack of documentation regarding the care concerns/allegations in R1's clinical record. The administrator stated the DON at that time indicated that she was entering notes into the clinical record. The administrator stated the actions taken should have been included in the clinical record and that he did not know why the incident was not documented. On 8/12/25 at 4:45 p.m., the former DON at the time of the incident (RN #1) was interviewed about the lack of documentation in the clinical record regarding the abuse allegations. The former DON stated that RN #2 should have documented her assessment and actions taken in the nursing notes. The former DON stated the notes were not in the record because RN #2 did not enter them into the electronic health record. The DON stated her notes were documented in the investigation.This finding was reviewed with the administrator, DON and regional nurse consultant on 8/12/25 at 3:30 p.m. with no further information presented prior to the end of the survey.

Based on observation, staff interview and clinical record review, the facility staff failed to provide fall mats for injury prevention as required in the plan of care for one of six residents in the survey sample (Resident #3).The findings include:Resident #3 (R3) was admitted to the facility with diagnoses that included psychotic disorder with delusions, depression, hypertension, anorexia, dementia with behavioral disturbance and dysphagia. The minimum data set (MDS) dated [DATE] assessed R3 with severely impaired cognitive skills.On 8/12/25 at 5:05 p.m., R3 was observed in bed. The bed was in low position with no floor mats on either side of the bed. On 8/13/25 at 8:10 a.m., R3 was observed in bed. There were no protective floor mats on either side of the bed.R3's plan of care (revised 8/6/25) documented the resident was at risk of falls/injury due to history of falls, cognitive impairment, muscle weakness, poor vision and use of psychoactive medications. Interventions for fall/injury prevention included, Fall mats bilaterally.On 8/13/25 at 8:12 a.m., the certified nurse's aide (CNA #2) caring for R3, was interviewed about fall mats. CNA #2 stated she was not aware that R3 required floor mats by the bed. CNA #2 stated nurses usually told the aides if fall mats were implemented or required.On 8/13/25 at 8:32 a.m., CNA #2 stated the nurse checked R3's care plan and the fall mats were supposed to be in place when the resident was in bed.On 8/13/25 at 8:36 a.m., registered nurse (RN #3) was interviewed about R3's need for fall mats. RN #3 stated R3's care plan required fall mats in place when the resident was in bed for injury prevention.This finding was reviewed with the administrator and regional nurse consultant on 8/13/25 at 12:10 p.m. with no further information presented prior to the end of the survey.

Based on staff interview and clinical record review, the facility staff failed to provide a complete and accurate minimum data set (MDS) for one of six residents in the survey sample (Resident #1).The findings include: Resident #1 (R1) was admitted to the facility with diagnoses that included metabolic encephalopathy, dysphagia, anemia, protein-calorie malnutrition, asthma, cognitive communication deficit, hypothyroidism, myocardial infarction and hypertension. The minimum data set (MDS) dated [DATE] assessed R1 with severely impaired cognitive skills.R1's clinical record documented a MDS assessment dated [DATE]. Section C. of this MDS for assessment of cognitive patterns was not completed. Each category of section C., including the brief interview for mental status (BIMS) and staff assessment of mental status, was marked not assessed.On 8/13/25 at 9:40 a.m., the registered nurse MDS coordinator (RN #2) was interviewed about R1's incomplete assessment. RN #2 reviewed the MDS and stated the cognitive section had not been completed. RN #2 stated the assessment required for section C. of the MDS was not completed during the designated 7-day look back time, so it was marked as not assessed. RN #2 stated the assessment was required to be completed during the designated look back time.The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual on page C-2 documents concerning completion of Section C, Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) and is not contingent upon item B0700, Makes Self Understood . (1) This finding was reviewed with the administrator and regional nurse consultant on 8/13/25 at 12:10 p.m. with no further information presented prior to the end of the survey.(1) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1, Centers for Medicare & Medicaid Services, Revised October 2024.

Based on staff interview, facility document review and clinical record review, the facility staff failed to complete a thorough investigation regarding an injury of unknown origin for one of six residents in the survey sample (Resident #3).The findings include:Resident #3 (R3) was admitted to the facility with diagnoses that included psychotic disorder with delusions, depression, hypertension, anorexia, dementia with behavioral disturbance and dysphagia. The minimum data set (MDS) dated [DATE] assessed R3 with severely impaired cognitive skills.R3's clinical record documented a nursing note dated 4/4/25 listing the resident was observed with an abrasion area on the left forehead and an abrasion over the right eyebrow. The note documented that the resident was unable to verbalize the cause of the injuries. The director of nursing (DON) documented a note on 4/4/25 at 6:39 p.m. of notification to the family about the assessed abrasions.Notification of R3's injury of unknown origin was sent to the state agency on 4/4/25 with investigation findings sent to the state agency on 4/7/25.On 8/12/25, the facility's investigation of R3's injury of unknown origin was reviewed. The investigation included written statements from a licensed practical nurse and a CNA (certified nurse's aide) that worked on 4/4/25 starting at 7:00 p.m., after the abrasion was identified. One statement was from a CNA that worked 4/3/25 starting at 7:00 p.m. until 4/4/25 at 7:00 a.m. The other statement obtained documented no employee name, job title or when they worked compared to the incident. There were no written statements obtained from staff working the shift when the abrasion was found (4/4/25 from 7:00 a.m. to 7:00 p.m.). On 8/12/25 at 3:30 p.m., the administrator was interviewed about the investigation of R3's abrasion of unknown source. The administrator stated the previous DON obtained the statements. The administrator stated, I think she [former DON] interviewed the night shift. When asked about why shift employees working immediately prior to the injury were not interviewed, the administrator stated, Those [statements] were the only ones I saw in the folder.On 8/12/25 at 4:45 p.m., the former DON (RN #1) was interviewed about the lack of employee statements obtained regarding R3's abrasion of unknown source. The former DON stated, I got as many [statements] as I could. The facility's policy titled Abuse/Neglect Misappropriation/Crime - Reporting Requirements/Investigations (effective 2/5/23) documented, .The Administrator and/or Director of Nursing will immediately initiate a thorough internal investigation of the alleged/suspected occurrence. The investigative protocol will include, but not be limited to, collecting evidence, interviewing alleged victims and witnesses, and involving other appropriate individuals, agents, or authorities to assist in the process and determinations .This finding was reviewed with the administrator, DON and regional nurse consultant on 8/12/25 at 3:30 p.m. with no further information presented prior to the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow abuse prevention policies for three of six residents in the survey sample (Residents #1, #3 and #4).The findings include:1. For Resident #1, facility staff failed to follow abuse prevention policies for submitting investigation findings within five days to the state agency and failed to report an allegation of abuse involving a certified nurse's aide to the department of health professions per facility policy.Resident #1 (R1) was admitted to the facility with diagnoses that included metabolic encephalopathy, dysphagia, anemia, protein-calorie malnutrition, asthma, cognitive communication deficit, hypothyroidism, myocardial infarction and hypertension. The minimum data set (MDS) dated [DATE] assessed R1 with severely impaired cognitive skills.A facility reported incident form was sent to the state agency on 4/27/25 documenting an allegation of sexual misconduct between R1 and certified nurse's aide (CNA) #1. The initial report was sent to the state agency on 4/27/25. The state agency received no final report of the facility's investigation/findings regarding this allegation. The initial report to the state agency documented no report of the allegation to the department of health professions.Review of the facility's investigation on 8/12/25 revealed a final investigation report dated 4/30/25 summarizing the facility's investigation and findings that did not substantiate sexual assault. The investigation documents included no evidence that the final report was sent to the state agency and no evidence that the allegations regarding CNA #1 were sent to the department of health professions.On 8/12/25 at 3:22 p.m., the administrator was interviewed about the investigation of abuse allegations regarding R1. The administrator stated he thought the former director of nursing (DON) had submitted the findings to the state agency. The administrator reviewed the investigation folder and did not present any evidence that the investigation findings were sent to the state agency. The administrator stated the abuse allegations should have been sent to DHP and he did not know why DHP was not notified.The facility's policy titled Abuse/Neglect Misappropriation/Crime - Reporting Requirements/Investigations (effective 2/5/23) documented, .Immediately upon notification of any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, the Administrator will immediately report to the State Agency, but no later than 2 hours after the allegation is made, if the events that caused the allegation involves abuse or results in serious bodily injury . This policy under section 1.b. documented, .Notify within 24 hours the Department of Health Professions (DHP) for incidences involving nurse aides, RNs, LPNs, Physicians, or others licensed or certified by DHP . This policy documented under section 5., .The Administrator must thoroughly investigate and file a complete written report of the investigation of the submitted FRI [facility reported incident] to the State Agency within five (5) working days of the incident . 2. Facility staff failed to thoroughly investigate an injury of unknown for Resident #3 as required in the facility's abuse prevention policies. Statements were not obtained from staff members caring for Resident #3 prior to and/or during the shift when the resident was found with an injury of unknown origin. Resident #3 (R3) was admitted to the facility with diagnoses that included psychotic disorder with delusions, depression, hypertension, anorexia, dementia with behavioral disturbance and dysphagia. The minimum data set (MDS) dated [DATE] assessed R3 with severely impaired cognitive skills.R3's clinical record documented a nursing note dated 4/4/25 listing the resident was observed with an abrasion on the left forehead and an abrasion over the right eyebrow. The note documented that the resident was unable to verbalize the cause or source of the injuries. The director of nursing (DON) documented a note on 4/4/25 at 6:39 p.m. of notification to the family about the assessed abrasion.Notification of R3's injury of unknown origin was sent to the state agency on 4/4/25 with investigation findings sent to the state agency on 4/7/25.On 8/12/25, the facility's investigation of R3's injury of unknown origin was reviewed. The investigation included written statements from a licensed practical nurse and a CNA (certified nurse's aide) that worked on 4/4/25 starting at 7:00 p.m., after the abrasion was identified. One statement was from a CNA that worked 4/3/25 starting at 7:00 p.m. until 4/4/25 at 7:00 a.m. The other statement obtained listed no employee name, job title or when they worked compared to the incident. There were no written statements obtained from staff working the shift when the abrasion was found (4/4/25 from 7:00 a.m. to 7:00 p.m.). On 8/12/25 at 3:30 p.m., the administrator was interviewed about the investigation of R3's abrasion of unknown source. The administrator stated the previous DON obtained statements. The administrator stated, I think she [former DON] interviewed the night shift. When asked about why shift employees working immediately prior to the injury were not interviewed, the administrator stated, Those [statements] were the only ones I saw in the folder.The facility's policy titled Abuse/Neglect Misappropriation/Crime - Reporting Requirements/Investigations (effective 2/5/23) documented, .The Administrator and/or Director of Nursing will immediately initiate a thorough internal investigation of the alleged/suspected occurrence. The investigative protocol will include, but not be limited to, collecting evidence, interviewing alleged victims and witnesses, and involving other appropriate individuals, agents, or authorities to assist in the process and determinations . 3. Facility staff failed to report a medication error incident with Resident #4 made by a physician's assistant (PA) to the department of health professions as required in their abuse prevention policies.Resident #4 (R4) was admitted to the facility with diagnoses that included chronic kidney disease, bacteremia, endocarditis, congestive heart failure, liver cirrhosis, obesity, diabetes, anemia, atrioventricular block, thrombocytopenia, hypertension, non-alcoholic steatohepatitis (NASH), and diverticulosis. R4's most recent minimum data set (MDS) assessed the resident as cognitively intact.A facility incident investigation report dated 8/22/23 documented that on 8/14/23, a physician's assistant (other staff #1) prescribed R4 potassium 20 mEq (milliequivalents) per day with the potassium administered as ordered on 8/15/23 and 8/16/23. R4 was assessed at a local physician's office on 8/16/23 with critically high potassium levels and was admitted to the hospital for treatment of the high potassium. Investigation revealed that the PA ordered potassium instead of sodium to address 8/10/23 labs indicating low sodium levels. The facility's investigation of this error documented notification to state agency, medical director/physician, responsible party, and adult protective services. There was no notification to the state department of health professions of the prescription/medication error.The facility's policy titled Abuse/Neglect Misappropriation/Crime - Reporting Requirements/Investigations (effective 2/5/23) documented under section 1.b., .Notify within 24 hours the Department of Health Professions (DHP) for incidences involving nurse aides, RNs, LPNs, Physicians, or others licensed or certified by DHP . On 8/12/25 at 3:22 p.m., the administrator was interviewed about reporting the PA's prescription error with R4. The administrator stated he was not sure why the medication error involving the PA was not reported to DHP.The director of nursing at the time of this medication error was not available for interview as she no longer worked at the facility.These findings were reviewed with the administrator, DON and regional nurse consultant on 8/12/25 at 3:30 p.m. and on 8/13/25 at 12:10 p.m. with no further information provided prior to the end of the survey.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement safety interventions consistent with the individualized needs and standards of practice for one of sixteen residents (Resident #4). Staff failed to appropriately position the safety interventions (bilateral floor mats) identified in Resident #4's care plan. In addition to the ongoing monitoring of effectiveness, Staff failed to perform a risk/safety assessment prior to implementing devices. The findings include: Resident #4 was observed in bed without protective floor mats being positioned properly as required in the plan of care for injury prevention. Resident #4 had bed bolster cushions in use for over six weeks without having a safety assessment prior to implementation. Resident #4 was admitted to the facility with diagnoses that included congestive heart failure, chronic kidney disease, hypertension, anemia, aphasia, cardiomyopathy, adult failure to thrive, dementia, psychotic/mood disturbance and anxiety. The minimum data set (MDS) dated [DATE] assessed Resident #4 with severely impaired cognitive skills and as requiring the extensive assistance of two people for bed mobility. On 5/8/23 at 2:05 p.m., Resident #4 was observed in bed. There were cushioned bolsters on each side of the resident positioned between the resident and bed rails. No floor mats were positioned on the floor on either side of the bed. One mat was observed rolled up by the bedside table and the other mat was under the resident's bed. Resident #4 was observed again in bed on 5/8/23 at 2:50 p.m. and 3:43 p.m. with the bolster cushions in use and no floor mats on either side of the bed. Resident #4's clinical record documented a history of falls from the bed. Nursing notes documented the following falls. 1/07/23 - .Resident experienced a witnessed fall .located in resident room. No injuries noted . 1/23/23 - .Resident rolled out of bed on to floor in room. No injury noted . 2/19/23 - .found resident lying on the left side of the bed on his right side (on the side of the fall mat) .booster [bolster] to right side of bed in place, booter [bolster] to left side of bed in floor. grip socks in place .unwitnessed fall to right side, c/o [complained of] hip pain and was sent to hospital . 3/10/23 - .Roommate of resident was yelling that resident had fallen out of the bed. Resident was found in room .w/ [with] upper half of body outside of the bed and on the floor, w/ feet remaining in the bed. His head was off of the floor .no injuries . 3/12/23 - .residnet [resident] was found lying next to bed on the floor, no injuries noted and no pain noted . 3/20/23 - Resident experienced witnessed fall . no apparent injuries . 5/02/23 - .Nurse went to check on this Resident, He was noted to be on the Fall Mat laying on His Left Side . Resident #4's plan of care (revised 5/5/23) documented the resident was at risk for falls related to cognitive impairment, had a fall history, assistance required for transfers and poor safety awareness. Interventions listed to prevent falls/injuries included, .fall mats to side of bed .place bed in lowest position while resident is in bed .place common items within reach of the resident .remind the resident to use their call light .Bed bolsters PRN [as needed] .Ensure positioning in middle of bed after ADL care . Resident #4's clinical record documented the bed bolster cushions were added to the care plan on 3/21/23. The clinical record documented no device assessment for use of the bolster cushions. On 5/9/23 at 2:13 p.m., CNA #5 caring for Resident #4 was interviewed about the floor mats and bolster cushions. CNA #5 stated that the protective mats were supposed to be on the floor, on each side of the bed, when Resident #4 was in bed. On 5/9/23 at 2:16 p.m., CNA #3 that cared for Resident #4 during the day shift on 5/8/23 was interviewed. CNA #3 stated that the floor mats were supposed to be by Resident #4's bed because the resident had frequent falls. CNA #3 stated that he did not place the mats by the bed yesterday (5/8/23) because there was lots of coming and going in his room. When asked to explain, CNA #3 stated staff were in and out of the resident's room and he had not placed the mats by the bed. On 5/9/23 at 2:18 p.m., licensed practical nurse (LPN #6) caring for Resident #4 on 5/8/23 was interviewed. LPN #6 stated that she did not notice that the mats were not in place yesterday (5/8/23). LPN #6 stated that the mats were used for injury prevention because the resident had experienced multiple falls from the bed. LPN #6 stated the bolsters were used to help prevent the resident from rolling out of bed, but she was not sure how long they had been in use. On 5/9/23 at 2:45 p.m., the unit manager (LPN #2) stated the bolster cushions were a nursing intervention added in attempt to prevent falls from the bed. LPN #2 stated the mats were supposed to be in place when the resident was in bed for injury prevention in case of a fall. On 5/9/23 at 3:47 the director of nursing (DON) was interviewed about an assessment for the bolsters. After investigating, the DON stated the bolster cushions were added for fall prevention and no assessment had been completed for the resident's use of the cushions. The facility's policy titled Device Assessment/Bed Safety (effective 11/1/19) documented, The Device Assessment will be completed to provide documentation of the needs, and risk factors involved in the use of a restraint or device used by the patient .The assessment is to be completed by a licensed nurse before initiation of any restraint or device. The assessment will be reviewed and revised quarterly, annually, and with any significant changes .The specific type and reason for use of the device or restraint will be documented on the Device Assessment . This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 5/9/23 at 4:15 p.m. The facility provided no further information regarding the out of place mats or a bolster cushion assessment.

Based on observation, staff interview, and review of facility policy and procedure, the facility failed to ensure medications were properly dated on two of two medication carts. Undated multi-dose medication bottles were observed in the East Unit medication cart and the Central Unit medication cart. The findings include: 1. At 3:20 p.m. on 5/9/2023, an observation of the East Unit medication cart was conducted in the presence of RN # 2 (Registered Nurse). The medication cart included the following medications: A 32 oz (ounce) bottle of Milk of Magnesia (MOM) appeared to be nearly empty, but had no open date. A 16oz bottle of Geri Tussin Guaifenessin oral solution, with a punctured inner seal, but had no open date. A 16 oz bottle of Pro Stat, Wild Cherry flavor, that appeared to be nearly empty, but had no open date. Asked about expiration dates for the multi-use bottles of pills, RN # 2 said, I'm not sure. RN # 2 then turned to LPN # 2 (Licensed Practical Nurse), who was standing nearby, and asked what the open date meant on the multi-use bottles of pills. Oh, that's just the date we opened it. Everything has to have an open date, LPN # 2 said. Calling her attention to the open and nearly empty bottle of MOM, LPN # 2 said, Oh, this has to be discarded. No date. LPN # 2 then discarded the bottle in the trash. When asked what the expiration date would be for the mediction bottles, LPN # 2 said, I guess we just use the expiration date already on the bottle. Wait, I don't want to tell you the wrong thing. LPN # 2 walked away but did not return to offer any further explanation or clarification. Pointing to the bottle of Pro Sat, RN #2 was asked when it had been opened. Picking up the bottle and turning it around to examine all surfaces, RN #2 shrugged and stated, I don't know. There's no open date on it. I guess I have to throw it in the trash. RN #2 also threw away the bottle of Geri Tussin when she was unable to find an open date. 2. At 3:50 p.m. on 5/9/2023, an observation of the Central Unit medication cart was conducted in the presence of LPN # 5. The medication cart included the following medications: A 16 oz bottle of Lactulose was half-full and open, but had no open date or expiration sticker A 414 ml (milliliter) bottle of Sucralfate was open, half full, but had no open date or expiration sticker. A 16 oz bottle of MOM, that was nearly empty, but had no open date or beyond use date sticker. A bottle of Vitamin B12 500mg 100 tab bottle had an open date of 8/24/22, but no expiration sticker. The remaining medications in the cart had an open date, as well as an expiration sticker with a Beyond Use Date. Asked what the Beyond Use Date meant, LPN # 5 said, I'm not sure. I guess it means that you throw it away after that date. Concerning the undated bottle of MOM, LPN # 5 said, Yes, it should have been dated when it was opened, but I'll throw that away now. Anything without an open date should be thrown away. After confirming that the bottles of MOM and Sucralfate were also opened and undated, LPN #5 discarded them. At 10:00 a.m. on 5/10/2023, LPN # 4 was asked her understanding of the Beyond Use Date. Meds [Medications] should be discarded on this date. I mean, it's ok to use it on that date, but you can't use it afterwards, LPN # 4 said. When asked how the discard date is identified if there is no Beyond Use Date, LPN #4 stated, You go by the manufacturer's date. LPN #4 pointed to the manufacturer's expiration date of 4/24 on the Vitamin B12 bottle. At 10:22 a.m. on 5/10/2023, the Director of Nursing (DON) was shown the open bottle of Prostat from the East Unit medication cart. When asked what should be done with the bottle, the DON said, I would throw it away. It wasn't dated. You don't know when it was opened. Review of the facility's Storage of Medications policy noted the following: III. Expiration Dating (Beyond-Use Dating) 5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. a. The nurse shall place a 'date opened' sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating. The findings were discussed at a 10:30 a.m. meeting on 5/10/2023 that included the Administrator, Director of Nursing, Corporate Nurse Consultant, and the survey team.

Based on observation, staff interview, and clinical record review, the facility staff failed to provide dental services to one of 16 residents, Resident #1. Findings were: Resident #1 was admitted to the facility with the following diagnoses, including but not limited to: encephalopathy, diabetes mellitus, COPD (chronic obstructive pulmonary disease), major depressive disorder, vascular dementia, hypertension, and hypothyroidism. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 04/26/2023, assessed Resident #1 as moderately impaired with a cognitive summary score of 09 out of 15. During initial tour of the facility on 05/08/2023 at approximately 12:15 p.m., Resident #1 was observed in his room. While speaking, Resident #1's mouth was observed with no front upper or lower teeth. On 05/09/2023 at approximately 11:00 a.m., Resident #1 was about having a partial plate or dentures at the facility. Resident #1 stated, When I grew up, we didn't have much money, I still don't. These are all the teeth I have. Resident #1 opened to reveal approximately four teeth on the top row, two on each side, and four teeth on the bottom row, two on each side. When asked about the presence of pain with eating, Resident #1 stated, No, I guess you just get use to it. When asked about desire to see a dentist, Resident #1stated, I don't think I have the money for that, but teeth would be good. The clinical record was reviewed at approximately 11:15 a.m. The physician order section contained an order for Dental Consult PRN (as needed). There were no progress notes or office visit notes observed in the record from a dentist. At approximately 11:30 a.m., the administrator was asked if the social worker was available for interview. The Administrtor stated, We don't have one right now, we are dividing up the duties. When asked who would be responsible for referring residents to a dentist, the Administrator stated, We have a dentist that comes here .I believe he was here last month. When asked if Resident #1 had been seen by a dentist, the Administrator stated he didn't know but would check. The above information was discussed during an end of the day meeting with the DON (director of nursing), the administrator, and the regional nurse consultant on 05/09/2023 at approximately 4:00 p.m. On 05/10/2023 the unit manager, LPN (Licensed practical nurse) #2 brought information to the conference room and stated, We ordered a dental consult .here are his oral assessments that we have done. The documentation presented three Oral Assessments completed on 12/28/2022, 01/24/2023, 04/26/2023. All three assessments documented that there were no issues with Resident #1's oral health. When asked if she thought the assessments were accurate, LPN #2 stated, I would have marked either 'no natural teeth or tooth fragments' or 'Obvious or likely cavity or broken natural teeth' .I did a dental exam on [Resident #1] last night .[Resident #1] doesn't have very many teeth, but said the only thing that bothers him when eating is the tremors he has in his hands. [Resident #1] did agree to a dental consult, so we have him on the list. No further information was obtained prior to the exit conference on 05/10/2023.

Based on observation, and staff interview, the facility staff failed to store, serve, and prepare food in a sanitary manner in the main kitchen. Findings were: Initial tour of the facility kitchen was conducted on 05/08/2023 at approximately 11:15 a.m., with the DM (dietary manager-other staff #1). Observed in the refrigerator next to the tray line was a plastic bag. When asked what was in the bag, the DM stated, Her lunch, nodding towards the staff member plating food on the tray line. Also observed in the refrigerator were canned sodas. When asked if those belonged to residents, the DM stated, No, employees .they shouldn't be in here and the lunch shouldn't be either. The bins storing flour, sugar, and thickening were observed. Scoops for each bin were to be stored inside the bin, affixed to the top, away from the food ingredients. The scoop for the sugar was observed out of place and laying down in the stored sugar. The can opener which was affixed to a table in the kitchen, was observed with dark, dried debris on the blade area that punctures the cans. When asked how often the can opener was washed, the DM stated, About three times a week or as needed. A rack in the kitchen was identified as containing stacked, dried, and clean pans, with a smaller rack of bowls stationed beside it. The DM was asked to separate the pans to ascertain if they were clean on the inside. Two quarter-sized pans and one full-size pan were observed to be wet nested with water droplets on the interiors of the pans. Three white bowls were observed with dried debris on the inside. All of the dishes identified as compromised were removed from the area by the DM, as she stated, They are suppose to be clean and dry before they are put over here. The above information was discussed with the DON (director of nursing), the administrator, and the regional nurse consultant during an end of the day meeting on 05/09/2023 at approximately 4:00 p.m. No further information was obtained prior to the exit conference on 05/10/2023.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate clinical record for three of sixteen residents in the survey sample (Residents #24, #30 and #41). The findings include: 1. Resident #24's clinical record inaccurately documented a physician's order for enhanced barrier precautions when the precautions had been discontinued since 4/20/23. Resident #24 was admitted to the facility with diagnoses that included chronic kidney disease, atrial fibrillation, atherosclerotic heart disease, hypertension, diabetes, COPD (chronic obstructive pulmonary disease), and anemia. The minimum data set (MDS) dated [DATE] assessed Resident #24 as cognitively intact. Resident #24's clinical record documented a current physician's order dated 3/29/23 for Enhanced Barrier Precautions for infection control. The clinical record documented the precautions were implemented due to the resident's PICC (peripherally inserted central catheter). The clinical record documented the PICC was discontinued on 4/20/23. On 5/9/23 at 2:52 p.m., the licensed practical nurse unit manager (LPN #2) was interviewed about Resident #24. LPN #2 stated Resident #24 was on enhanced barrier precautions because of the PICC. LPN #2 stated no order had been entered to discontinue the precautions. LPN #2 stated the precautions should have been discontinued when the PICC was removed. 2. Resident #30's clinical record inaccurately documented a physician's order for enhanced barrier precautions when the precautions had been discontinued since 4/26/23. Resident #30 was admitted to the facility with diagnoses that included dislocated hip, femur fracture, atherosclerotic heart disease, major depressive disorder, atrial fibrillation, and Alzheimer's dementia. The minimum data set (MDS) dated [DATE] assessed Resident #30 with severely impaired cognitive skills. Resident #30's clinical record documented a current physician's order dated 3/7/23 for Enhanced Barrier Precautions for infection control. The clinical record documented the infection precautions were ordered due to a diagnosed urinary tract infection. On 5/9/23 at 2:32 p.m., the licensed practical nurse (LPN #6) caring for Resident #30 was interviewed about any precautions. LPN #6 stated that Resident #30 was not currently on any type of infection control precautions. LPN #6 stated it was possible the order was not discontinued timely. On 5/9/23 at 3:55 p.m., the unit manager (LPN #2) was interviewed about Resident #30. LPN #2 stated Resident #30 had a urinary tract infection and the infection precautions should have been discontinued when the infection cleared. LPN #2 stated the infection cleared on 4/16/23 and the precautions should have been removed ten days after that on 4/26/23. LPN #2 stated that no order was entered to discontinue the precautions after the infection cleared. 3. Resident #41's clinical record inaccurately documented a current physician's order for enhanced barrier precautions when the catheter for which is was ordered had been discontinued since 3/22/23. Resident #41 was admitted to the facility with diagnoses that included vertebra compression fractures, atrial fibrillation, sepsis, pneumonitis, urinary tract infection, atherosclerotic heart disease, anxiety, asthma, congestive heart failure, urine retention, and kidney failure. The minimum data set (MDS) dated [DATE] assessed Resident #41 as cognitively intact. Resident #41's clinical record documented a current physician's order dated 3/7/23 for Enhanced Barrier Precautions for infection control. The clinical record documented the resident previously had a Foley urinary catheter and had been placed on enhanced barrier precautions when providing catheter care. The clinical record documented the catheter was discontinued on 3/22/23. On 5/8/23 at 3:14 p.m., the registered nurse (RN #5) caring for Resident #41 was interviewed about infection control precautions. RN #5 stated Resident #41 did not currently require any type of infection control precautions and had not recently been on enhanced barrier precautions. On 5/8/23 at 3:20 p.m., the licensed practical nurse unit manager (LPN #2) was interviewed about order for enhanced barrier precautions. LPN #2 stated that Resident #41 was ordered precautions due to a urinary catheter. LPN #2 reviewed the clinical record and stated the catheter was discontinued on 3/22/23 but no order was entered to discontinue the infection control precautions. LPN #2 stated that an order should have been entered to discontinue the precautions when the catheter was discontinued. On 5/9/23 at 9:45 a.m., the registered nurse infection preventionist (RN #3) was interviewed about current orders for Residents #24, #30 and #41 for infection precautions. RN #3 stated she expected nursing to obtain an order to discontinue the precautions when the devices and/or infections were discontinued and/or cleared. These findings were reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 5/9/23 at 4:15 p.m. No further information was presented prior to exit about the inaccurate physician orders.

Based on observation , resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to ensure adequate nutritional needs for the prevention of weight loss for one of 16 residents, Resident #1. Findings were: Resident #1 was admitted to the facility with the following diagnoses, including but not limited to: encephalopathy, diabetes mellitus, COPD (chronic obstructive pulmonary disease), major depressive disorder, vascular dementia, hypertension, and hypothyroidism. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 04/26/2023, assessed Resident #1 as moderately impaired with a cognitive summary score of 09 out of 15. 05/08/2023, Resident #1 was observed while finishing lunch in his room. Resident #1 had eaten 100% of the meal tray. When was asked about still being hungry, Resident #1 stated that he would like some milk. Resident #1 added, I like milk, but they don't give it to me. The clinical record was reviewed on 05/08/2023 at approximately 3:00 p.m. The weight section was reviewed and contained the following: 12/01/2022: 204.3 12/06/2022: 205.1 12/26/2022: 192.6 01/04/2023: 195 01/16/2023: 196.2 01/23/2023: 181.3 01/23/2023: 180.9 01/30/2023: 180.6 02/01/2023: 182.6 03/31/2023: 183.5 04/03/2023: 183.5 05/01/2023: 183.5 Resident #1's weight on 12/01/2022 was listed as 204.3 pounds. His most recent weight was 183.5 pounds on 05/01/2023, a loss of 20.8 pounds or 10.18% in six months. The physician order section was reviewed and contained a diet order for Heart Healthy Diet, dysphagia, mechanically altered texture, Regular liquids consistency, weighted utensils. Also observed was an order for House supplement two times a day for prevention of malnutrition and history or weight loss, dated 01/26/2023. On 05/09/2023 at approximately 8:15 a.m., Resident #1 was observed with his breakfast tray. His tray contained pureed eggs and oatmeal. He had a small Styrofoam cup of orange juice. His tray card was observed and contained the following: Heart Healthy Dysphagia Diet Mechanically Altered Orange Juice: 4 oz Scrambled Egg Substitute: 2 ounces Slivered Green Onions: 1 tablespoon Grits: 8 oz 2% Milk: 8 ounces Hot Coffee or Hot Tea: 6 ounces When asked if the coffee, tea, or milk had been on his tray, Resident #1 stated, No. When asked what he would like, Resident #1 stated, Milk. CNA (certified nursing assistant) #4 was in the hallway and was asked if she knew why Resident #1 didn't have any milk. CNA #4 stated, The drinks come on a separate cart. When asked if she had looked at Resident #1's tray card, CNA #4 stated, No, I just get them what they tell me they want. When asked to provide Resident #1 with some milk per his request, CNA #4 returned to the room with a Styrofoam cup containing milk. There was no lid on the cup. Attempting to drink, Resident #1 was observed with marked shaking of both his right and left hands, spilling more than half of his milk in his lap as he tried to drink it. Resident #1 stated, I'm making a mess, I am sorry. On 05/09/2023 at approximately 11:00 a.m., the RD (registered dietitian) was interviewed When asked about Resident #1's weight loss, the RD stated that Resident #1 had broken his hip in December and was hospitalized for surgical repair. The RD stated that Resident #1 had also had pneumonia in January that required a couple of days in the hospital. The RD stated, I put him on supplements in January when he got back and his weight came up some he has stabilized. When asked what was the ordered diet, the RD stated, Heart healthy, mechanically altered. Meats should be ground with gravy on them .bread and and bread products should be pureed. Asked if that should include the pureed eggs served that morning, the RD stated, No, he can have scrambled eggs. When asked why the diet specified 2% milk following the apparent weight loss, the RD stated, I didn't intend for that .I will liberalize his diet and get him whole milk, large portions, and a regular dysphagia mechanically altered diet. An end of the day meeting was held on 05/09/2023 at approximately 4:00 p.m Concerns were voiced regarding Resident #1's weight loss and lack of additional interventions since January. On 05/10/2023 Resident #1 was observed eating breakfast, while the occupational therapist was in the room. the occupational therapist stated, I am recommending cups with lids for him .I also think he might benefit from a plate guard to help him eat. The breakfast tray card was observed and contained the following: Regular Dysphagia Mechanically Altered Diet Orange Juice: 4 ounces Scrambled eggs: 3 ounces Slivered Green Onions: 1 tablespoon Pureed Buttered Biscuit Grits: 9 ounces Whole Milk: 8 ounces Hot Coffee or Hot Tea: 6 ounces Sausage Gravy: 4 ounces It was observed that Resident #1 had eaten 100% of his breakfast, but did not have any milk on the tray. When asked if he was full, Resident #1 stated. I don't want to be a pig but I would like a cake or something sweet. Resident #1's CNA was notified and stated that she would get something. At approximately 8:35 a.m., the CNA came and reported that Resident #1 had eaten 2 cups of ice cream after breakfast. At approximately 8:40 a.m., the nurse practitioner caring for Resident #1 was interviewed. When asked if she was aware of Resident#1's weight loss, the nurse practitioner stated, I was made aware of that yesterday .I ordered labs on him, a TSH, Free T4, CBC, and CMP he hasn't labs since January. They were fine then, but in light of his weight loss, I will repeat them and see where we need to go from there. When asked what she would have done if she had known about the weight loss sooner, the nurse practitioner stated, I would have ordered the labs sooner .I can't address what I don't know about. When asked if the residents weights when rounding, the nurse practitioner stated,No, I don't have time to review every patient's weights when I come in .I rely on the nurses and the RD to tell me if there is a problem with those .no one mentioned anything about him to me until yesterday. The above information was discussed during an end of the day meeting on 05/10/2023. No further information was provided prior to the exit conference on 05/10/2023.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a baseline care plan for the care of suprapubic catheter was in place for one of 16 residents, Resident #257. Findings were: Resident #257 was admitted to the facility with the following diagnoses including but not limited to: hypertension, pulmonary edema, protein-calorie malnutrition, anemia, pneumonia, urethral stricture, and pseudomonas pneumonia. Due to his recent admission, no MDS (minimum data set) information was available. When interviewed, regarding his care at the facility Resident #257 answered questions appropriately. During initial tour of the facility on 05/08/2023 at approximately 12:15 p.m., Resident #257 was observed lying supine on his bed. His pajama top was not pulled all the way down and a suprapubic catheter was observed. The clinical record was reviewed on 05/08/2023 at approximately 2:30 p.m. The physician order section contained the following orders for the care of the suprapubic catheter: Cleanse and apply split sponge to suprapubic site daily . The care plan was reviewed. A focus area, The resident requires an urinary suprapubic catheter related to : Obstructive uropathy. Interventions listed were to provide catheter care each shift. An end of day meeting was held on 05/09/2023 at approximately 4:00 p.m. with the DON (Director of Nursing), the administrator, and the regional nurse consultant. The DON was asked if the facility was changing Resident #257's catheter or was he going out of the facility. She stated she didn't know but would check. Concerns were voiced that there were no immediate care orders on the clinical record regarding the care of the catheter nor were there any interventions regarding replacement listed on the care plan. The DON stated that she would find out what was supposed to be done. On 05/10/2023 the facility staff presented an updated care plan that included care of the catheter, and physician orders that included, Nursing staff not to change suprapubic catheter, urology will manage. No further information was obtained prior to the exit conference on 05/10/2023.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to identify and report an injury of unknown origin to the appropriate facility staff for one of 16 residents, Resident #258. Findings were: Resident #258 was admitted to the facility with the following diagnoses, including but not limited to, Atrial fibrillation, dementia, psychotic disturbance, mood disturbance, anxiety, and urinary tract infection. Due to her recent admission, no MDS (minimum data set) information was available. Upon attempted interview with Resident #258, her speech was nonsensical and she was unable to answer questions. On 05/08/2023 at approximately 12:15 p.m., the initial tour of the facility was conducted. Resident #258 was observed sitting in a wheelchair outside of her room. An elongated area was observed on the right side of her head, from her scalp, down her forehead, running parallel to her hair line. The area was bluish/purple in color. When asked what had happened to her head, Resident #258 answered, I don't know it's [Name redacted]'s choir .they know. CNA (certified nursing assistant) #3 was in the hallway with Resident #258 and was asked about the bruise. CNA #3 stated that Resident #258 was a fall risk and that she falls. When asked if she had hit her head during a fall, Resident #258 again answered the question with a reference to [Name redacted]'s choir. The clinical record was reviewed on 05/09/2023 at approximately 11:00 a.m. There was no documentation observed regarding the discolored area on Resident #258's forehead. The admission assessment completed on 05/01/2023 was reviewed. The section Skin Observations assessed Resident #258 as having no skin issues. At approximately 3:00 p.m., LPN (licensed practical nurse) #1 was interviewed regarding the area of discoloration on Resident #258's forehead. LPN #1 stated that she had done the admission assessment and documentation for Resident #258 and had not seen the area at that time. LPN #1 and this surveyor went to Resident #258's room. Resident #258 was lying supine on her bed. The area on her forehead was observed with more green coloring with the same elongated shape described above. LPN #1 stated, I haven't seen that before .it wasn't there when she came in. At approximately 3:15 p.m., the DON (director of nursing), the administrator, and the regional nurse consultant were all in the DON's office. They were asked if anyone had reported the area on Resident #258's forehead to them. The administrator and the DON both stated that they had not been made aware of any discoloration. During an end of the day meeting with the DON, the administrator, and the regional nurse consultant the above information was discussed. The DON stated they were still investigating to see if they could find out what had happened. When asked if the area should have been reported to him by they facility staff, the Administrator stated, Yes. On 05/10/2023 at approximately 8:50 a.m., CNA #3 was interviewed regarding the area on Resident #258's forehead. When asked if he had noticed the area when he was taking care of her, CNA#3 stated, Yes, I saw it. When asked if he had reported it to his charge nurse when he first noticed it, CNA #3 stated, No, I thought it looked old, so I thought they already knew about it. At approximately 9:00 a.m. the DON and the regional nurse consultant were interviewed regarding Resident #258. The regional nurse consultant stated, We are still looking into it .the therapist said he noticed it last Friday .her son said he noticed it on Saturday .she had a fall here on May 5th .the documentation is that she fell on her bottom . When asked if the therapist or the resident's son had told any one about the area, the regional nurse consultant stated, No. At approximately 10:25 a.m., a skin observation tool completed on 05/09/2023 at 6:21 p.m. was presented by the unit manager, LPN #2. The skin observation tool contained the following: Top of Scalp: Bruising Left hand (back): Bruising Right knee (front): Bruising Left knee (front): Bruising Right top foot: Bruising Notes: Head to toe Skin sweep Resident noted to have a bruise to her right temple area blue, yellow greenish in color. Yellowish bruise noted to left wrist, yellowish bruise noted to left shin area, blue bruise noted to right knee and a reddened area noted to the top of her right foot under metatarsals no open area noted, nor drainage noted. Dr [name redacted] called and notified at this time of head-to-toe skin sweep and finding. LPN #2 stated, I did the skin sweep last night, I called the doctor to let him know about the bruises that I saw the staff should have reported what they were seeing. The facility policy, Injuries of Unknown Origin contained the following: Injuries of unknown origin will be handled the same as an allegation of mistreatment, neglect, or abuse and must be reported to the center Administrator. Procedure: Injuries of unknown origin to a patient are to be reported to a licensed nurse. The staff educator, RN (registered nurse) #3 was interviewed at approximately 10:30 a.m. regarding staff education about injuries of unknown origin. RN#3 presented an Inservice/Educational Record that education had occurred on 03/09/2023 with nursing staff and included information regarding injuries of unknown origin. The above information was discussed with the DON, the administrator, and the regional nurse consultant during a meeting at approximately 11:30 a.m. No further information was presented prior to the exit conference on 05/10/2023.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure admission orders were in place for the care of suprapubic catheter for one of 16 residents, Resident #257. Findings were: Resident #257 was admitted to the facility with the following diagnoses including but not limited to: hypertension, pulmonary edema, protein-calorie malnutrition, anemia, pneumonia, urethral stricture, and pseudomonas pneumonia. Due to his recent admission, no MDS (minimum data set) information was available. When interviewed, regarding his care at the facility Resident #257 answered questions appropriately. During initial tour of the facility on 05/08/2023 at approximately 12:15 .pm., Resident #257 was observed lying supine on his bed. His pajama top was not pulled all the way down and a suprapubic catheter was observed. The clinical record was reviewed on 05/08/2023 at approximately 2:30 p.m. The physician order section contained the following order for the care of the suprapubic catheter: Cleanse and apply split sponge to suprapubic site daily . The care plan was reviewed. A focus area, The resident requires an urinary suprapubic catheter related to : Obstructive uropathy. The interventions listed was to provide catheter care each shift. An end of day meeting was held on 05/09/2023 at approximately 4:00 p.m. with the DON (Director of Nursing), the administrator, and the regional nurse consultant. The DON was asked if the facility was changing Resident #257's catheter or was he going out of the facility. The DON stated that she didn't know but would check. Concerns were voiced that there were no immediate care orders on the clinical record that addressed what to do if the catheter became clogged or dislodged, nor were there interventions on the care plan to address these concerns. The DON stated that she would find out what was supposed to be done. On 05/10/2023 the facility staff presented an updated care plan that included care of the catheter, and physician orders that included, Nursing staff not to change suprapubic catheter, urology will manage. No further information was obtained prior to the exit conference on 05/10/2023.

Based on complaint investigation, closed clinical record review, and staff interview, the facility staff failed for one of 16 residents in the survey sample, Resident # 107, to forward a notice of discharge to the local Ombudsman. Resident # 107 was transferred to the hospital without a notice of discharge being sent to the local Ombudsman. The findings were: Resident # 107, who was her own Responsible Party, was admitted to the facility with diagnoses that included status post left femur fracture, history of malignant neoplasm of the breast, hypothyroidism, depression, hypertension, difficulty walking, generalized muscle weakness, anxiety disorder, peripheral vertigo, chronic obstructive pulmonary disease, right hip pain, chronic respiratory failure with hypoxia, and COVID-19. The Progress Notes in the resident's Electronic Health Record included the following entries: 12/30/2022 - 1930 (7:30 p.m.) - O2 (oxygen) sat (saturation) reported @ 75% on 5L/M (5 liters per minute). Resident positioned sitting up, alert and oriented. Administered prn (as needed) Duoneb treatment and titrated oxygen to 8L/M via nasal cannula. O2 sat increased to 88%. TC (Telephone Call) to on call MD, (name), and received order to transfer Resident to ED. Resident left facility via EMS transport to Lynchburg General @ 2020 (8:20 p.m.). Daughter notified of Resident's change in condition approx(imately) 2000 (8:00 p.m.). 12/31/2022 - 0431 (4:31 a.m.) - Spoke with (name) at Centra Lynchburg ER resident being admitted for Acute respiratory failure. Resident # 107 did not return to the facility. At approximately 2:30 p.m. on 5/9/2023, the facility Administrator was asked for a copy of the resident's transfer notice sent to the local Ombudsman. The Administrator stated that the Discharge Planner/Social Worker who handles that process was no longer employed at the facility, but that he would try to locate the notice. At 10:50 a.m. on 5/10/2023, the Administrator reported that he was unable to find the transfer notice sent to the local Ombudsman. The lack of a transfer notice was discussed at a 10:30 a.m. meeting on 5/10/2023 that included the Administrator, Director of Nursing, Corporate Nurse Consultant, and the survey team.

Based on observation, staff interview and clinical record review, the facility staff failed to maintain floor mats and positioning cushions in clean/intact condition for one of sixteen residents in the survey sample (Resident #4). The findings include: Resident #4's floor mats were dirty, and the surfaces were heavily torn with frayed edges. The coverings on the bolster cushions in Resident #4's bed had torn corners with exposed foam visible. Resident #4 was admitted to the facility with diagnoses that included congestive heart failure, chronic kidney disease, hypertension, anemia, aphasia, cardiomyopathy, adult failure to thrive, dementia, psychotic/mood disturbance and anxiety. The minimum data set (MDS) dated [DATE] assessed Resident #4 with severely impaired cognitive skills and as requiring the extensive assistance of two people for bed mobility. On 5/9/23 at 10:02 a.m., floor mats were observed on Resident #4's side of the room. One mat was observed rolled up by the bedside table and the other mat was under the resident's bed. The covers of both mats were dirty and worn with visible cracks over the entire mat surface. The edges of both mats were tattered and frayed. On 5/9/23 at 2:18 p.m., the licensed practical nurse (LPN #6) caring for Resident #4 was interviewed about the condition of the floor mats. LPN #6 stated, They [mats] are in pretty bad shape. LPN #6 stated that she was not sure if new mats were kept in the supply room. On 5/9/23 at 2:29 p.m., accompanied by LPN #6, two bolster cushions on Resident #4's bed were observed. The coverings on both cushions were torn on the corners with exposed foam visible. LPN #6 stated at this time that the floor mats were ragged and the torn cushion covers needed replacing. On 5/9/23 at 2:45 p.m., the unit manager (LPN #2) was interviewed about the floor mats and bolster cushions being in poor condition. LPN #2 stated any mats and/or cushions with hole or rips were supposed to be immediately replaced. LPN #2 stated that it was not sanitary to use cushions with torn coverings. LPN #2 stated Resident #4's mats and the bolster cushions needed to be discarded and replaced. This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 5/9/23 at 4:15 p.m. The facility provided no further information about the torn/tattered mats/cushions prior to the end of the survey.