Every finding on record at Virginia Gay Nursing & Rehab, LLC

Based on facility record review, interview, the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year (FY) Quarter 2, 2026, and the Centers for Medicare & Medicaid Services Electronic Staffing Data Submission PBJ Long-Term Care Facility Policy Manual (CMS PBJ Manual) the facility failed to submit accurate staffing data to CMS for 1 of 1 quarter reviewed. The facility reported a census of 31 residents. Findings include:The facility PBJ Staffing Data Report dated FY Quarter 2 2026 (January 1 - March 31) documented the facility triggered for a one star staff rating, no RN (Registered Nurse) hours, and failure to have licensed nursing coverage for 24 hours per day. RN hours were flagged on 2/11/2026, 2/12/2026, 2/17/2026, and 2/18/2026. Nursing coverage for 24 hours was flagged on 1/15/2026, 1/27/2026, 1/28/2026, 1/29/2026, 2/3/2026, 2/4/2026, 2/5/2026, 2/10/2026, 2/11/2026, 2/18/2026, and 3/25/2026. Time cards provided by the facility dated 1/15/2026 through 3/25/2026 revealed the facility maintained adequate RN coverage as well as 24 hour nursing coverage. An email from the Administrator dated 7/14/2026 at 4:32 PM documented she was not sure why it did not register on the PBJ report. She noted the facility was short a few minutes for 8 hours of RN coverage on 2/11/2026 so that one was accurate but she was unable to determine what happened the other days. On 7/15/2026 at 8:19 AM the Administrator followed up and stated she still could not say why the hours were not registering. She stated that until a couple of months ago she didn't know there was a way to look up the errors. On 07/16/2026 at 1:14 PM the Administrator stated there were still errors showing up in the data she submitted this month, and she and another staff member continued to try to correct it. She reported she had not had training in this area and it was a work in progress. The CMS PBJ Manual, Version 2.7 dated June 2025, documented staffing information was required to be an accurate and complete submission of a facility's staffing records. Facilities should run the staffing and census reports available in the system to verify the accuracy and completeness of their final submission and the accuracy of their resident census prior to the submission deadline. Facilities that did not meet accuracy and deadline requirements were considered noncompliant and subject to enforcement actions by CMS.

Based on facility records, interviews, and the facility Quality Assurance Performance Improvement (QAPI) Plan the facility failed to ensure all required staff or a designee attended quarterly QAPI meetings and that the Infection Preventionist provided relevant infection control information to the committee. The facility reported a census of 31 residents. Findings include:A document titled N & R (Nursing and Rehabilitation) QAPI Meeting dated 8/11/2025 documented the Medical Director and the Interim Administrator were absent from the meeting. The list of attendees did not include designees for these roles. A document titled Nursing and Rehabilitation QAPI Meeting Minutes dated 2/19/2026 documented the Director of Nursing/Infection Preventionist (DON/IP) attended the meeting. The section titled infection control indicated no new concerns were identified during the 4th quarter. No infection control tracking information was documented in the minutes. A document titled Nursing and Rehabilitation QAPI Meeting Minutes dated 5/21/2026 indicated the Administrator and the Medical Director were absent from the QAPI meeting. There was not a designee assigned to attend the meeting by the Administrator or Medical Director. The attendees listed included the DON/IP. There was not documentation to indicate the committee discussed infection control tracking. During an interview with the DON/IP on 7/16/2026 at 9:08 AM, she stated there was a COVID outbreak in January. She stated she was the Infection Preventionist and responsible for giving updates to the QAPI committee. At 12:13 PM when asked about the notes in the QAPI minutes that indicated there were no new concerns, the DON/IP confirmed that if the minutes documented no new concerns were reported then the committee did not discuss infection control tracking or the COVID outbreak. During an interview with Staff B, Quality Improvement on 7/16/2026 at 12:19 PM, she stated meetings should include the Medical Director, the Administrator, the DON/IP, and department heads. She stated she thought the Medical Director could miss a meeting a year and sometimes they couldn't replace their attendance with someone else. They have held meetings without the Administrator. Staff B stated some infection control was discussed at QAPI but not every time. She stated they mostly discussed falls and medication errors. On 7/16/2026 at 12:42 PM, the Administrator stated she didn't know if the Medical Director had a designee to send to QAPI meetings and the Medical Director had never said she could send someone else. When asked how information got to the committee if she (the Administrator) or the Medical Director did not attend, she said she might send an email. She was not aware of the Medical Director sending information ahead of time. The Administrator stated the DON/IP mostly discussed falls and medication errors. When asked if the minutes report documented 'no new information' that meant there was not an infection prevention tracking report given to the committee, she stated she assumed there was not. The facility QAPI plan titled Quality Assurance and Performance Improvement plan, revised 2/12/2024, documented the QAPI committee should meet at least quarterly and consisted of, but was not limited to: The Director of Nursing Services, the Medical Director or his/her designee, the Nursing Home Administrator, and the Infection Preventionist. If any member of the committee was unable to attend for any reason either their supervisor or a delegate would present their data. The document was signed by the Medical Director, the Administrator, and Staff B.

Based on clinical record review, policy review, and staff interviews, the facility failed to obtain consent and provide information about the risks and benefits of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for 3 of 5 residents reviewed for psychotropic medications (Residents #1, #3, #7). The facility reported a census of 31 residents.Findings include: 1. Review of the Minimum Data Set (MDS) assessment, dated 6/10/26, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated severe cognitive impairment. The MDS assessment listed a diagnosis of non-Alzheimer's dementia for the resident. The MDS indicated that Resident #1 took an antipsychotic medication. Review of the Care Plan, initiated 10/10/25, revealed a Focus care area for Resident #1's use of antipsychotic medication related to agitation. An intervention instructed educate the Power of Attorney (POA) on side effects on black box warning for antipsychotic medication as needed (initiated on 10/10/25). Review of the Order Summary, dated 7/16/26, revealed the following active order:a. Rexulti (Brexpiprazole) oral tablet 0.5 milligrams (mg) (antipsychotic medication used alongside antidepressants for major depressive disorder (MDD), to treat schizophrenia, and for agitation associated with Alzheimer's dementia) with instructions to give one tablet by mouth one time a day related to unspecified dementia, unspecified severity, with anxiety. Start date: 5/20/26. Review of Resident #1's clinical records lacked documentation that the facility informed the resident or the resident's representative of the risks and benefits of the medication, the treatment alternatives, or other options so the resident could make an informed choice. 2. Review of the MDS assessment, dated 6/29/26, revealed Resident #3 had a BIMS score of 9 out of 15, which indicated moderate cognitive impairment. The list of diagnoses included non-Alzheimer's dementia, Traumatic Brain Injury (TBI), seizure disorder, and depression. The MDS indicated that Resident #3 took antidepressant and anticonvulsant medications. Review of the Care Plan, initiated on 7/01/26, revealed a Focus care area for Resident #3's use of anti-anxiety medications related to end of life comfort. Interventions instructed the following, in part: a. Monitor the resident as needed for safety. The resident is taking anti-anxiety medications which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs. Date initiated: 7/01/26. b. Monitor, document, report as needed any adverse reactions to anti-anxiety therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 7/01/26. c. Monitor and record occurrence of target behavior symptoms and document per facility protocol. Date initiated: 7/01/26. Review of the Order Summary, revealed the following active order for Ativan (lorazepam) oral concentrate 2 mg/milliliter (mL) (benzodiazepine, anti-anxiety medication used to treat anxiety disorders, severe agitation, insomnia, and active seizures), with instructions to give 0.25mL by mouth every 2 hours as needed for anxiety/restlessness. Start date: 6/21/26. Review of Resident #3's clinical records lacked documentation that the facility informed the resident or the resident's representative of the risks and benefits of the medication, the treatment alternatives, or other options so the resident could make an informed choice. 3. Review of the MDS assessment, dated 6/03/26, revealed Resident #7 had a BIMS score of 15 out of 15, which indicated intact cognition. The MDS lacked mood or behavioral symptoms and lacked mood disorder diagnosis. The MDS identified that Resident #7 utilized antidepressant medication.Review of the Care Plan, initiated 6/03/26, revealed a Focus care area for Resident #7 's use of antidepressant medications. Interventions instructed to monitor/document/report as needed adverse reactions to antidepressant therapy. Adverse reactions listed as follows: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, withdrawal, decline in activities of daily living ability, no voiding/constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea/vomiting, dry mouth, and dry eyes.Review the Order Summary, revealed an active order for Sertraline (Zoloft) hydrochloride (antidepressant medication used to treat depression, anxiety disorders) 25mg oral tablet, with instructions to give 50mg by mouth one time a day for anxiety. Start date: 6/09/26. During an interview on 7/16/26 at 12:08 PM, the Director of Nursing (DON) stated consent for psychotropic medication use should be obtained upon admissions and with any new psychotropic medication orders. The DON confirmed that Resident #1, Resident #3, and Resident #7 were prescribed and administered psychotropic medications and lacked documentation of consent for psychotropic medication. During an interview on 7/16/26 at 1:00 PM, the facility Administrator denied having facility policy or procedures for obtaining psychotropic medication consents.

Based on clinical record review, staff interview, and facility record review, the facility failed to notify the State Ombudsman office of resident hospital transfers for 1 of 1 resident reviewed for transfers (Resident #9). The facility reported a census of 31 residents.Findings include:The clinical record for Resident #9, admitted on [DATE], documented diagnoses that included unspecified atrial fibrillation, cardiomyopathy, and chronic congestive heart failure.A Social Service Structured Progress Note dated 4/30/26 documented Resident #9 had a hospital stay on 4/18/26 due to cellulitis requiring intravenous (IV) medications.A Health Status Note dated 4/19/26 at 12:50 PM documented Resident #9 returned to the facility following a discharge from the hospital at 12:35 PM after receiving treatment for a skin infection.An email from the Administrator, dated 7/14/26 at 5:34 PM, confirmed that the facility lacked Ombudsman notification records for the month of April 2026.In an interview on 7/15/26 at 3:15 PM, the Administrator stated she was responsible for notifying the Ombudsman of resident admissions, discharges, hospitalizations, and deaths at the end of each month. The Administrator confirmed she had never completed this task before because she was new to her role, and admitted she forgot about it. She acknowledged that the facility had not submitted the required Ombudsman notifications since January of 2026. She further acknowledged that the facility should have notified the Ombudsman of Resident #9's hospitalization on 4/18/26.When asked for a copy of the facility's notification policy during the interview on 7/15/26 at 3:15 PM, the Administrator stated that the facility did not have a policy regarding Ombudsman notifications.

Based on observation, policy review, and staff interview, the facility failed to maintain appropriate food holding temperatures at or above 135 degrees Fahrenheit. The facility identified a census of 35 residents. Findings include: Resident #9 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. During the initial pool interview 7/29/24 at 1:07 PM Resident #9 reported she dines in her room and many times the food is cold. Observation on 7/30/24 at 10:40 AM revealed the pre-meal temperatures as follows: a. Potatoes - 184 degrees b. Ground barbecue pork 211 degrees. Staff A, [NAME] placed the food items in the steam table with each steam table well noted at setting 3. On 7/30/24 at 11:40 AM Staff A plated the last room tray for the first hallway and set up a test tray. As soon as the last room tray had been delivered the Surveyor and the Dietary Manager performed a temperature check of the food on the test tray. The testing revealed the loaded potato temperature at 124.7 degrees. Post food temperatures completed at 11:52 AM at the conclusion of the meal service revealed the potato at 126 degrees and the ground barbecue pork at 130 degrees on the steam table. During an interview on 7/30/24 at 11:57 AM Staff A reported the potatoes and ground barbecue pork did not temp correctly at 135 degrees. He verbalized food is to be held above 135 degrees on the steam table. Staff A confirmed all the steam table wells were set on setting #3. During an interview on 7/30/24 at 12:35 PM the Dietary Manager reported the staff are to take food temperatures prior to the meal to ensure correct serving temperatures. She expects food to be maintained at 135 degrees. If the food is not held at 135 degrees, she expects staff to reheat the food above 165 degrees before serving. The Serving Line Food Temperature Record Policy revised 4/20/23 provided by the facility documented the temperature of all hot and cold food items will be taken prior to every meal and at the end of service on days that require test trays. The Policy Procedure directed potatoes and hot entrees would be held at 135 degrees or above. If not hot enough, food will be reheated in the oven or the microwave to be at proper temperature.

Based on clinical record review, facility document review, former staff interviews and staff interviews, the facility failed to respect each resident's dignity and privacy by taking pictures of staff with the resident for 1 of 6 residents reviewed (Resident #1). The facility reported a census of 35 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) of 0, indicating severe cognitive impairment. The MDS identified the resident needed extensive assistance for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. A Progress Note written on 10/18/23 at 6:56 PM, documented Resident #1's Power of Attorney (POA) was made aware a picture of Resident #1 was taken by a staff member and requested a copy. A Progress Note written on 10/22/23 at 11:44 AM, documented the POA was provided with written documentation of the investigation and a copy of the picture. Facility documents titled Orientation Information directed staff to have personal phones on vibrate and not use in patient care areas. During an interview on 11/20/23 at 12:54 PM, Staff A, former Certified Nursing Assistant (CNA) admitted he took a picture of Resident #1. He stated the picture was taken on 10/7/22 at 7:02 PM. He explained he took the picture to show to management but didn't show it to management until 10/14/23. When asked about the delay he explained the picture was saved in his phone and it moved down in his pictures list and he forgot it was there. During an interview on 11/20/23 at 1:23 PM, Staff B, CNA, stated Staff A had entered the room while she was cleaning up after caring for Resident #1. She stated she knew Staff A had been taking pictures and sending Snap Streaks (Social media platform where users send pictures back and forth daily for several consecutive days) that evening but she was unaware he had taken a picture of the resident. During an interview on 11/21/23 at 11:37 AM, the Administrator stated she expected CNA's to not be taking pictures of residents in their room.

Based on staff interview, facility policy and employee record review, the facility failed to provide dignity and respect for 1 of 13 residents reviewed. (Resident #77) The facility reported a resident sample of 26. Findings Include: The Discharge Return Anticipated Minimum Data Set (MDS) Resident assessment dated [DATE] documented that Resident#77 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident had moderately impaired cognitive skills for daily decision making, short term memory loss, disorganized thinking, and difficulty focusing. The Nursing Admission Screening/History dated 4/15/21 documented the resident with normal gait control, and normal range of motion in all extremities. The Nursing Admission Screening documented the resident had been independent with transfers, bed mobility, toilet use, personal hygiene, and walking with a walker. The Nursing Admission Screening documented the resident had no pain. During an interview on 3/14/22 at 6:14 p.m., Staff B, Certified Nurse Aide (CNA) reported the resident very disruptive and would not quiet down on the night shift at about 11:00 p.m. the resident had been brought out to the nurses station. Staff B reported the staff had ambulated the resident with his walker, and he had a gait belt on. Staff B reported she asked the nurse if the resident had any anti-anxiety medication, and the nurse said no, all he had was Tylenol. Staff B reported as the shift went on, the resident became agitated, and he wanted to leave. Staff B reported the resident said he had been held hostage, and the resident had been taken to the bathroom. Staff B reported that at about midnight Staff A, Licence Practical Nurse (LPN) yelled at the resident that he may have been a corporal, but she was the Sergeant and he needed to sit his ass down. Staff B reported that Staff A had made the statement to the resident in a crabby and mean way. Staff A even called the resident a curse word later in the shift after the resident had fallen. During an interview on 3/15/22 at 6:34 p.m., Staff D, CNA reported at the beginning of the shift the resident had been assisted in the hallway with walking the resident had still been awake, Staff D reported later in the shift the resident became agitated and wanted to go home. Staff A, LPN had used foul language towards the resident, and stated to the resident that he may have been a corporal, but she was a Sergeant and told the resident to sit his ass down. Staff D reported that Staff A had been very rude towards the resident, and called the resident a curse word. During an interview on 3/14/22 at 3:00 p.m., the Nurse Manager reported that Staff A had been terminated due to her unprofessional verbal behavior, and also her lack of assessment and intervention after the resident had fallen. The facility Abuse Prevention, Identification, Investigation, and Reporting Policy with revised review date of 2/11/21 documented the following Policy Statement: All residents have the right to be free from physical abuse, sexual abuse or exploitation, financial exploitation including misappropriation of resident property, denial of critical care (neglect) personal degradation (verbal abuse), abuse through social media, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. An Employee Warning Notice with signature dated by Staff A on 4/16/21 documented a the type of violation as follows: unprofessional. The Warning documented that Staff A called a resident a curse word and told the resident to sit his ass down. The Employee Warning Notice documented that Staff A had been terminated.

Based on clinical record review, staff interviews, and employee record review the facility staff failed to provide assessment and intervention in a timely manner for 1 of 4 residents reviewed for falls (Resident#77). The facility reported a census of 26. Findings Include: The Discharge Return Anticipated Minimum Data Set (MDS) Resident assessment dated [DATE] documented Resident#77 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident with moderately impaired cognitive skills for daily decision making, short term memory loss, disorganized thinking, and difficulty focusing. The Nursing Admission Screening/History dated 4/15/21 documented the resident had normal gait control, and normal range of motion in all extremities. The Nursing Admission Screening documented the resident had been independent with transfers, bed mobility, toilet use, personal hygiene, and walking with a walker. The Nursing Admission Screening documented the resident had no pain. The residents Care Plan with initiated date of 4/15/21 documented the resident with a Focus Area as follows: impaired cognition due to Alzheimer's disease. The Care Plan directed staff to monitor for behavior problems as needed, evaluate behavior problems as needed and document and report to Nurse/Doctor. The Care Plan also identified a Focus Area as follows: the resident is at risk for falls due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan directed staff as follows: observe for skin swelling, discoloration, guarding, facial grimacing, moaning, external rotation or shortening of leg, decreased range of motion, after any fall and report to Nurse/Doctor as needed. The Order Summary Report with active orders as of 4/15/21 documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/14/22 at 6:14 p.m., Staff B, Certified Nurses Aide (CNA) reported that on 4/15/21, Resident#77 had been very disruptive and would not quiet down, so the staff brought the resident up to the Nurse's Station at about 11:00 p.m. Staff B reported that the resident had been agitated as the shift went on and he wanted to leave, he said that they had been holding him hostage. Staff B reported staff ambulated with the resident, and took him to the bathroom. Staff B reported that she had asked Staff A, Licence Practical Nurse (LPN) if the resident had anything for anxiety, and Staff A reported that the resident only had Tylenol. Staff B reported that the resident went to sit down on a roller chair that had no locks, and Staff A told us to get the resident before he sat, but when the staff approached the resident he swung his walker at me, and he fell . Staff B reported that she thought they must have startled him. Staff B reported the fall happened at about 1:00 a.m. on 4/16/21. Staff B stated the resident screamed out in pain when they transferred the resident to a chair. Staff B reported, Staff A did do an initial assessment of the resident. Staff B reported that she thought the residents leg had been twisted inward. Staff A reported that the resident kept rubbing his leg throughout the shift, so she placed an ice pack on it, which did not seem to help. Staff B reported that other staff members took the resident to the bathroom and the resident had difficulty standing. During an interview on 3/15/22 at 6:33 a.m., Staff B reported all the staff had reported to the nurse several times about the resident's request to go to the hospital, and she also did not call the doctor, or do another assessment on the resident after being notified of the resident complaint about more pain. During an interview on 3/15/22 6:34 a.m., Staff D, CNA reported the resident had been able to walk independently with his walker in the hallway, and staff assisted him in the hallway. Staff D stated the resident became agitated later in the shift. Staff D reported that the resident went to sit down on a stool with rollers, and he landed on his hip when Staff A, LPN told us to stop him. Staff D reported that Staff B, CNA got to the the resident first, we must have startled him and he swung his walker, and fell on his hip. Staff D reported all the night shift staff saw his fall. Staff D stated that Staff A instructed the CNA's to move the resident to a chair then Staff A assessed him. Staff D reported that the resident yelled out in pain during the transfer and had trouble standing. Staff D had the CNA's stand the resident she then, pulled his pants down, and moved his lower leg. Staff D thought the resident's foot had been internally rotated. Staff D reported after the resident put in a recliner close to the Nurses Station, she sat with him until 2:00 a.m., then it took all four CNA's to toilet him as he could not stand on his leg. Staff D reported that Staff A did not observe us toilet him or reassess him to her knowledge. Staff D reported that the staff kept telling Staff A that he asked to go to the hospital, and that he had pain. Staff D reported that the resident complained of pain way above 10 when asked about a pain scale from 0 to 10. Staff D reported that she had been relieved by another staff member at 2:10 a.m. During an interview on 3/15/22 at 9:19 a.m., Staff C, CNA reported she arrived at work on 4/16/21 at 2:00 a.m., and the resident had already fallen. Staff C had been instructed to keep a close eye on the resident. Staff C reported that the resident had been yelling out in pain, and had been in the main dinning room area in a wheelchair. Staff C reported that she knew the resident had been up ambulatory on his own before he fell , and would accept visual supervision when walking with his walker. Staff C reported that the residents leg had been bent backwards, and curled under the wheelchair. Staff C reported the staff reported to the nurse that the resident had been in pain, and the nurse did nothing. Review of a Progress Note dated 4/16/21 at 12:49 a.m., documented the following; Resident had been ambulating in the dinning room with front wheeled walker and gait belt, then started to swing walker at staff and he fell to the floor on his left hip. Resident rolled himself to his hands and knees, and then assisted with two staff to standing, and then was seated in a chair. Vitals were; temperature: 98.4, pulse: 80, respiration: 20, blood pressure: 111/71 while sitting and oxygen saturation 96 percent. Resident reported pain to left hip at a 5 for a 0 out of 10 scale. Resident left hip is normal in skin color with no internal or external rotation no lengthening or shorting of the leg. Resident given Tylenol at 1:38 a.m. The resident's Clinical Record lacked any further assessment to the resident. The resident's Clinical Record lacked further contact with a Physician to obtain further interventions to assess the resident's continued complaints of pain . During an interview on 3/15/22 at 9:43 a.m., Staff E, LPN reported that the resident had been up ambulatory with stand by assist prior to his fall. Staff E stated that she came in the morning after he had fallen. Staff E reported the CNA's had told her that the resident could hardly stand on his feet, and in a lot of pain. Staff E reported the resident did get his scheduled pain med. Staff E explained a transfer of the resident did not go well, so she completed a full assessment on the resident and called the Primary Care Physician, and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/15/22 at 10:22 a.m. Staff F, LPN reported if he had a resident that fell , and continued to complain of pain he would contact the Nurse Manager, and also call the doctor for an update. Staff F reported that, if you are working second shift you can call and talk to the Doctor-On-Call for the emergency room as the hospital is just next door and they will give you guidance. Staff F explained there are Standing Orders for Tylenol, also ice and heat packs for pain that Nursing Staff could utilize. Staff F stated he would notify the Nurse Manager if a resident had been ambulatory before a fall, and then had a change of not being able to bear any weight on the legs. The Employee Warning Notice dated 4/16/21 for Staff A documented the type of violation as refusing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA's repeatedly told Staff A concerns of left hip pain, resident not able to bear weight, and not standing, also signs and symptoms of a hip injury without Staff A sending the resident for a further medical evaluation. Staff A's documentation did not describe a true picture of the incident that happened. .

Based on a Resident Group Interview, observations, staff interview and record review the facility failed to offer bedtime snacks to residents daily. The facility identified a census of 35 residents. Findings include: 1. During a Resident Group Interview on 10/3/16 at 1:30 p.m. 4 out of 5 residents reported bedtime snacks are not offered to the residents. 3 of the 4 residents stated they had not been offered a bedtime snack and would take one if offered. 1 of 5 residents reported he/she was not offered a bed time snack and stated never knew a snack was available. The group also remarked no snack cart observed pushed around at night to offer any snacks. Observation on 10/4/16 at 7:15 to 8:15 p.m. noted staff assisting residents with p.m. cares and no snacks being passed and no snacks observed at the Nurse's Station. During an interview on 10/4/16 at 7:41 p.m., Staff A, Registered Nurse (RN) reported certain residents with specific dietary needs get snacks that come up on a tray from the kitchen. Staff A indicated they do have snacks in the kitchenette if the residents ask for one. Staff A stated the Certified Nurse Aides (CNA's) do not go room to room and offer snacks to the residents. During an interview on 10/4/16 at 7:50 p.m., Staff B CNA, Staff C CNA, and Staff D CNA report they were not told snacks need to be offered to each resident in the evening. During an interview on 10/5/16 at 12:40 p.m., the Nurse Manager stated each resident is assessed by the Dietary Department in regards to their individual needs and wants. The residents who chose a snack are care planned and the snacks come up on a tray per Dietary with the resident's name on it. The CNA's do not go around to each individual resident and offer them a snack. There are items available in the kitchenette for anybody who is hungry. Review of the Between-Meal Feedings (Snacks) Policy with a revision date of 1/12/12 stated the between-meal feedings will be available at established intervals, upon request or when prescribed to meet the specialized nutritional needs of the resident. Review of the undated form titled- 7:00 Nursing & Rehab Snacks 9/9/16, (most current) revealed the dietary department sends 15 resident snacks each evening to the unit. The facility reported a census of 35.

Based on observation and interview, the facility failed to secure hazardous chemicals with an operational lock. The facility reported a census of 37 residents. Observation on 11/9/15 at 11:10 a.m. revealed the keypad lock on the supply closet was not functioning leaving the following hazardous chemicals unsecured. Cid-a-L- II Apollo one gallon times five. Turbo Clean pre-disinfectant chelating detergent, one gallon times three. PDI Super sani-cloth Germicidal disposal wipe one pound tub times eight. McKesson Medicpak instant cold compress size 6 x 9 time five. Ecolab Quik-Care Aerosol Foam Hand Sanitizer 15 ounces time seven. Ecolab Total Body Shampoo 18 ounces time twenty seven. Ecolab Quik-Care Nourishing Foam Hand Sanitizer times five. Ecolab Quik-Care Sensitive Skin Foam Hand Soap times seven. ALL Stainlifter detergent 60 ounces times one. ALL Stainlifter powder 3 pounds times one. Product label review of all products revealed a cautionary label to read Keep out of reach of children. During an interview on 11/9/15 at 3:15 p.m., the DON reported staff was unaware the push key lock was not working and the expectation is that the supply room is to be locked at all times.

Based on observation, document review, and staff interview, the facility failed to secure all oxygen tanks in a manner that ensured their safe use and control in the facility. The facility census was 34 residents. Findings include: Observation on 10/16/14 at 9:00 a.m., during the environmental tour, revealed an oxygen/supply room with 2 oxygen tanks standing upright and unsecured. During interview, at the time of the observation, Staff D, maintenance, reported he did not know who was responsible for monitoring the room. Facility policy/procedure titled "Plant Operation and Maintenance" dated 1/11/13 documented the following: Policy: Storage of Oxygen and other cylinders Purpose: The purpose of this policy is to provide guidelines for the safe use and control of oxygen and other tanks in the facility. Procedure: By NFPA life code, all Oxygen and other tanks in the facility must be chained or contained at all times. Regardless of the contents or full or empty, all cylinders must be either chained up, or contained in a rack of some sort, at all times. During an interview on 10/16/14 at 11:40, the Director of Nursing stated, everyone should be monitoring the oxygen storage.

Based on document review and staff interview, the facility failed to provide non-pharmacological interventions prior to administering as needed (PRN) anti-anxiety medication for 2 of 3 residents reviewed. (Resident #"s 6, and 9). The facility reported a census of 43 residents. Findings include: 1. Resident #6's Admission Record Sheet documented [DIAGNOSES REDACTED]. Resident # 6's Care Plan documented the resident had impaired cognitive function/dementia, confusion/forgetfulness, anxiety, and directed staff to provide emotional, intellectual, physical, and social needs related to the resident's physical limitations and cognitive deficit. The Care Plan directed staff to move the resident to another room and provide privacy if they could not redirect the residents behavior. To provide the resident with activities, which did not overly demand cognitive tasks, such as John Wayne movies, and music. To cue, reorient, and supervise the resident as needed, administer medications as ordered and monitor for signs and symptoms of PRN psychoactive medications. Resident #6's medication records and nurses notes showed the resident received PRN [MEDICATION NAME] (medication for anti-anxiety) 16 times, without documentation of facility staffs attempts at non-pharmacological interventions prior to administration of the [MEDICATION NAME] from 3/21/14 to 9/1/14. The Medication Record dated 3/1/14 to 3/31/14 revealed an order for [REDACTED]. Facility policy titled: The [MEDICAL CONDITION] Drug Monitoring dated 12/5/2004, documented it is the policy of the Virginia Gay Nursing and Rehab to evaluate residents that are receiving psychoactive medications for necessity, effectiveness and to monitor for adverse drug reactions. Residents will be maintained at the highest practicable level of functioning at the lowest possible dose of medication required for their specific condition. During an interview on 10/14/14 at 10:10 a.m., Staff C, Licensed Practical Nurse, reported when giving a as needed [MEDICATION NAME] (anti-anxiety) type medication, interventions should be done and documented in the nurses notes prior to administration of the medication. 2. Resident #9's Admission Record documented [DIAGNOSES REDACTED]. Resident #9's Care Plan documented the resident required long term care services due to overall care needs and memory and directed staff to calm the resident if upset/agitated. Interventions included encourage interaction with others, at activities of choice, evaluate for changes in overall health, approach warmly, and positively, provide assist/cues to areas as needed, allow resident to choose routine as able to promote overall well-being, and call a family member as their voice may calm the resident if combativeness or agitation develop. Documentation on the physician's "Order summary Report" showed an order for [REDACTED]. According to the resident's Medication Records and Nurses Notes, the resident received PRN [MEDICATION NAME] ([MEDICATION NAME]) 0.5 milligrams on 10/11/4, 8/16/14, 5/13/14, 3/8/14, and 3/3/14 without documentation of facility staffs attempts at non-pharmacological interventions.

Based on employee record review, staff interview, and nurse aide registry staff interview, the facility failed to ensure that 1 of 3 newly hired employees (Staff B) had fulfilled the education requirements for working independently in the facility. The facility reported a census of 34 residents. Findings include: The Single Contact License and Background Check dated 7/18/14 indicated Staff A, Certified Nurses Aide (CNA) was ineligible to work in a CNA position. The Personnel Action Form dated 7/25/14 documented Staff A was a new employee effective 8/5/14. The Virginia Gay Nursing and Rehab CNA Position Description dated 7/8/14 with the subtitle of education documented the following education requirements, "Current CNA certification or enrolled in an approved certification CNA program. Must become certified within 90 days of first day of employment." Staff A's employee record lacked documentation that showed she had completed the CNA testing requirements. On 10/13/14 at 12:14 p.m. the Director of Nursing reported that Staff A had completed her orientation on 9/9/14, and worked on the floor independently. The Director of Nursing reported that Staff A did pass the written portion of the CNA exam, but needed to retake the skills portion of the exam. During an interview on 10/13/14 at 12:34 p.m., nurse-aide registry staff reported, Staff A is not eligible to work on the floor unsupervised until she passes the skills portion of the CNA exam. The nurse-aide registry staff member also reported, when Staff A did not pass the skills portion of the exam someone should have followed through with information, be it either the facility or the employee as to how to proceed, they could have contacted the CNA registry for guidance.

Based on record review and interview the facility failed to follow the physician orders [REDACTED].#4) residents reviewed. The facility identified a census of 36 residents. Findings include: 1. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE], revealed active [DIAGNOSES REDACTED]. The MDS documented the resident had both short and long term memory problems and moderately impaired cognition. Review of Resident #2's clinical record showed the resident complained of shortness of breath and a chest X-ray had been completed on 6/21/13. The chest X-ray results revealed increased bilateral [MEDICAL CONDITION] infiltrates (fluid, infection, or blood in airspaces in both lungs) and small pleural effusions (a build up of fluid in the space between the outside covering of the lung and the inside lining of the chest wall). The facility notified the physician of the results and the physician instructed staff to obtain a CBC and BMP in 7-10 days. physician's orders [REDACTED]. The attending nursing staff noted the Physician Orders. Nursing staff documented the physician order [REDACTED]. Nursing notes dated 6/21/13 at 6:20 p.m., documented, see new order... CBC and BMP in 7-10 days. Nursing notes dated 7/31/13 at 9:10 documented CBC, BMP not drawn during 6/27-6/30 timeframe. Physician notified, draw today. During an interview on 7/31/13, at 9:00 a.m., the MDS Coordinator confirmed no one had drawn the laboratory tests 7-10 days after 6/21/13 as ordered by the physician. During an interview on 7/31/13, at 12 noon, the Director of Nursing reported laboratory had drawn the blood for the tests this a.m. then provided the laboratory test results. Review of laboratory test results for blood collected on 7/31/13 at 9:33 a.m. showed results verified at 10:14 a.m. for a CBC and results verified at 10:31 a.m. for a BNP (measures the amount of Brain Natriuretic Peptide (BNP) in blood. Physicians use the BNP test to check for heart failure.). The laboratory results did not include a BMP test. The DON explained the following process staff followed when a physician orders [REDACTED]. Staff place a copy of the form used to notify the laboratory in the chart until the facility receives the results. The DON explained, in this case, the physician had not written the order on the facility's physician order [REDACTED]. Telephone order documented on a Provider Order Sheet dated 7/31/13 at 8:57 read, CBC and BMP today. On 7/31/13, at 1:30 p.m., The Director of Nursing reported she had mistaken the order and the laboratory ran a BNP test instead of the BMP test. The Director of Nursing reported following-up with the laboratory regarding the error and laboratory staff would complete the ordered BMP then provide the results to the facility. On 7/31/13, at 3:30 p.m. the Director of Nursing provided the BMP laboratory test results. Review of test results for blood collected on 7/31/13 at 9:33 a.m. showed results verified at 12:33 for a BMP. 2. Review of Resident #4's Minimum Data Set (MDS) assessment dated [DATE], revealed active [DIAGNOSES REDACTED]. The MDS documented the resident had intact cognition. Review of Resident #4's clinical record showed the facility failed to obtain a physician's orders [REDACTED]. Review of Interdisciplinary Progress Notes dated from 6/20/13 12:20 p.m. through 6/20/13 11:15 p.m. lacked documentation that showed nursing staff notified the physician that Resident #4 was going to the hospital. Review of Nursing Statement and Provider Order Sheet showed nursing staff made a late entry dated 7/31/13 at 11:10 that documented in the section titled Nursing Statement, " Call made to ER depart on residents request to be seen" Additional documentation in the section titled Provider Order Sheet read, "Ok to transfer to Emergency Department of hospital." Nursing staff noted the order on 7/31/13 at 11:10 a.m. During an interview on 7/31/13, at 11:45 a.m. the Director of Nursing confirmed the resident's clinical record lacked a physician's orders [REDACTED]. On 7/31/13, at 3:30 p.m. The Director of Nursing provided a transfer policy titled Transfer and Discharge Policy, dated 1/1/86. Review of the policy revealed the following, in part. "...II Process for Transfer-for Voluntary, Involuntary, and for Admission to Acute Care Facility: "No resident will be transferred to another nursing home or to any kind of medical facility without a written physician's orders [REDACTED]. In that case, a telephone call or letter from the doctor will be accepted and countersigned within forty-eight (48) hours...."