Mechanicsville Specialty Care

Based on observations, clinical record review, staff interviews, and facility policy review the facility failed to provide dignity with cares for 1 out of 3 residents reviewed (Resident #2). The facility reported a census of 29 residents. Finding include:1. The Minimum Data Set (MDS assessment for Resident #2 dated 6/8/25 revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderate cognitive impairment. The MDS assessment for Resident #2 dated 8/22/25 listed diagnoses of neurogenic bladder, spastic quadriplegic cerebral palsy, and urinary tract infection. The Care Plan for Resident #2 dated 4/10/25 identified a urinary catheter related to neurogenic bladder. On 9/03/25 at 9:58 AM, Resident #2 laid on his bed while the catheter drainage bag hung uncovered on the left side of his bed. The catheter bag held amber colored urine. On 9/04/25 at 9:11 AM, Resident #2 laid in his bed while his uncovered catheter bag hung on the left side of his bed. The empty dignity bag hung beside the uncovered drainage bag. On 9/04/25 at 12:57 PM, the Director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview and facility policy review the facility failed to administer the correct amount of water flush before the administration of the tube feeding for 1 of 1 resident reviewed (Resident #2). The facility reported a census of 29 residents. Finding include: The Minimum Data Set (MDS) assessment for Resident #2 dated 6/8/25 revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderate cognitive impairmentThe Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses of spastic quadriplegic cerebral palsy and urinary tract infection. The Care Plan for Resident #2 dated 2/24/25 directed he will remain free of side effects or complications related to tube feeding.The Physician's Orders Review History Report dated 8/4/25 directed enteral feed order every shift flush feeding tube with at least 70 milliliters (ML) of water before and after administration of feedings.The Medication Administration Record (MAR) for Resident #2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews and facility policy review, the facility failed to prevent exposure for cross contamination during meal service and failed to follow safe food handling practices. The facility identified a census of 33 residents. Findings include: On 08/06/24 at 12:19 PM, observed Staff C, [NAME] leave the meal serving area to go to the dining room. The cook left the serving scoops in the potatoes, corn, rice casserole and the tongs in the chicken and did not cover any of food items on the steam table before leaving. At 12:23 PM Staff C returned to the kitchen, scratched her face and resumed plating resident's food without washing her hands. On 08/07/24 at 12:35 PM, The Dietary Manager advised the test tray would be the last tray on the cart with the room trays and then placed the thermometer and alcohol wipes on the test tray. The cook took the thermometer off the test tray to check the temperature of the chicken noodle soup. The thermometer was not cleaned before or after temping the soup and being placed back on the test tray. Staff D, Dietary aid then took…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, clinical record review, resident, and staff interviews, the facility failed to treat a resident with respect and dignity for one reported interaction with a nurse for one out of one residents reviewed (Resident#7). The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) Assessment for Resident # 7 dated 7/5/24, included diagnoses of Parkinson's disease, and non Alzheimer's dementia. The Brief Interview for Mental Status (BIMS) reflected a score of 13, intact cognition. The MDS identified Resident#7 independent with toileting, transfers, ambulation, and dressing. The Care Plan for Resident#7 listed an intervention dated 7/18/24, at times I can have an outburst and yell at my family or staff. Attempt to redirect me when I have an outburst or give me some alone time so I can settle down and proceed with my day. Resident #7's Nurses Behavior Progress Note dated 7/31/2024 at 11:15 PM, reflected Resident#7 wanted Staff A, Registered Nurse (RN) to send her to emergency room (ER) after Staff A found her slipping out of her recliner…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, test tray, resident and staff interviews, the facility failed to provide food at an appropriate temperature to ensure the food was safe and appetizing. The facility also failed to serve pureed food that was attractive in appearance. The facility reported a census of 37 residents. Findings Include: On 9/26/23 at 9:45 AM, Resident #10 reported the food on his room trays were cold most of the time. Resident #10 stated he doubted the facility would do anything about the food being cold. On 9/26/26 at 1:00 PM, Staff C, Dietary Manager served two pureed meals that consisted of fish, wax beans, and potatoes. The pureed food items were white in color, appeared bland and served together on the same plate, with the pureed food items blending into each other on the plate. On 9/26/23 at 1:29 PM, Staff C reported there was one resident (Resident #10) that complains all the time that his food was not warm enough. On 9/26/23 at 1:31 PM, a test tray was received from Staff C. The test tray consisted of crumb topped fish, oven browned potatoes, green peas and apple crisp.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff and resident interviews and facility policy review, the facility failed to ensure food was discarded after product expiration date, that leftovers were discarded after 3 days, prevent cross contamination during meal service and serve the meal on time. The facility identified a census of 37 residents. Findings include: 1. An initial kitchen tour conducted on 9/25/23 at 11:00 AM, revealed the following items were stored in the refrigerator ready for service: a. Vanilla Yogurt 32 ounces- best by date 9/18/23. b. Leftovers covered and dated: - [NAME] beans - prepped/dated 9/21. - Baked beans - prepped/dated 9/15. - Noodle for Resident's Name - prepped/dated 9/17. - Egg Salad - prepped/dated 9/20. - Spaghetti sauce - dated 9/17. On 9/25/23 at 11:45 AM, Staff C, Dietary Manager reported she had left a note for the night cook to go through the refrigerators and throw away outdated items. Staff C stated her expectation was for leftovers to be thrown away after three days. Staff C acknowledged and verified the leftovers identified needed to be discarded. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, document review, resident and staff interviews, the facility failed to set up resident funds over $50 in an interest bearing account and failed to provide the resident or their legal representative with quarterly balance statement for 1 of 4 residents sampled (Resident #25). The facility documented a census of 37 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. On 9/25/23 at 1:50 p.m., Resident #25 reported he had money locked up in the front business office that he could access whenever he wanted. Resident #25 didn't recall getting any quarterly statements detailing his balance of funds at the facility. During an interview on 9/26/23 at 9:43 a.m., the Business Office Manager (BOM) reported Resident #25's daughter leaves money in the front office for him for hair cuts and outings. He can come to the office and get money whenever he wants. She…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility policy review, the facility failed to provide a notice of bed hold for 2 of 2 residents reviewed (Resident #32 and #139) for discharge to the hospital. The facility reported a census of 37 residents. Findings include: 1. Resident #32's Minimum Data Set (MDS) dated [DATE] assessment identified Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Resident #32's MDS included diagnoses of cancer, coronary artery disease, end stage renal disease and malnutrition. The Clinical Census revealed Resident #139 was admitted to the facility on [DATE]. A Progress Note dated 8/29/23 at 4:10 PM, revealed Resident #32 was transferred to the emergency room (ER) from the cardiovascular clinic due to low blood pressure. A Progress Note dated 8/29/23 at 9:00 PM, documented Resident #32 was admitted to the hospital for hypokalemia (low potassium) and hypotension (low blood pressure). The Clinical record lacked documentation the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, electronic census record, document review, Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) Assessment across multiple MDS assessments for 1 of 2 residents reviewed for Hospice services (Resident #15). The facility identified a census of 37 residents. Findings Include: A Order Review History Report signed by the Provider on 9/01/23 documented a physician order for Hospice care services for pancreatic cancer effective 2/21/22. A Medicare Hospice Election form detailed Resident #15 signed himself into hospice care on 2/21/22. A review of the Electronic Census Record on 9/26/23 revealed Resident #15 resided on Hospice care at the facility since 2/21/22. A review of the Care Plan on 9/26/23 documented Resident #15 had chosen hospice care and directed to coordinate his care with hospice. The Care Plan had an initiation date of 3/09/22. A review of the Hospice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interview and facility policy review, the facility failed to develop a Care Plan to address pressure reduction interventions for a chronic left heel pressure ulcer for 1 out of 13 residents (Resident #36) reviewed for Comprehensive Care Plans. The facility reported a census of 37 residents. Findings Include: Resident #36's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS identified Resident #36 required extensive assistance of two persons with bed mobility, transfer and toilet use. The MDS documented Resident #36 did not walk during the assessment period. The MDS identified Resident #36 at risk for developing pressure ulcer and indicated that he had an unhealed pressure ulcer during the seven day lookback period. The MDS also identified the facility had placed a pressure reducing device in the resident's chair, provided pressure ulcer care,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interview, the facility failed to have physician insulin orders that matched insulin administration and failed to follow the manufacturer's directions regarding safety for product use for administration for 1 of 2 residents observed for insulin administration (Resident #15). The facility identified a census of 37 residents. Findings Include: Resident #15 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive loss. The MDS listed a diagnosis of diabetes mellitus, hyperlipidemia and detailed Resident #15 received insulin injections seven days a week. The Care Plan revised [DATE] documented a focus problem of diabetes mellitus and directed Resident #15 had chosen to have his blood sugars assessed per medical doctors orders and receive diabetes medications for treatment for better control and comfort while on Hospice services. The Order Review History Report signed by the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.