Ascension Living Via Christi Village McLean

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 32 residents, with 12 residents sampled for advanced directives (a written document, which indicates the medical decisions for health care professionals when the person could not make their own decisions). Based on observation, interview and record review, the facility failed to ensure one resident's advanced directives were thoroughly completed when Resident (R)34 had a do not resuscitate (DNR- or no code, a legal document or order that means the person does not desire resuscitative measures) which was only signed by two licensed nurses as a verbal order and lacked a physician signature rendering it invalid. This placed the resident at risk for an impaired right to have advance directives honored. Findings included:- R34 's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or…

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.

The facility reported a census of 32 residents. The sample included 12 residents. Based on interview and record review, the facility failed to ensure the correct and complete Beneficiary Protection Notification forms were issued to one of three residents reviewed, Resident (R) 27. This placed the resident at risk for uninformed decisions.Findings included:- On 08/13/25 a review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form CMS-20052 (SNF ABN) revealed the facility lacked a completed form for R27. R27's Notification of Medicare Non-Coverage Form 10123(NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) was signed on 05/21/25. Last covered day of service was 05/23/25. R27 remained in the facility for long-term care.R27's 05/08/25 Progress Note at 01:48 PM documented R27 was admitted from hospital for skilled nursing care/rehab.R27's 05/23/25 Physical Therapy Discharge Summary documented R27 was discharged from physical therapy to reside in this long-term care facility. Goal partially…

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.

The facility reported a census of 32 residents. The sample included 12 residents, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 34's as-needed antianxiety (a class of medications that calm and relax people) medication had a 14-day stop date, or a specified duration, and physician rationale for the extended duration. This deficient practice placed the affected resident at risk for adverse effects associated with the use of psychotropic (alters mood or thoughts) medications.Findings included:R34 's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).The 11/05/24 Annual Minimum Data Set (MDS) documented resident had a Brief Interview for Mental Status (BIMS) score of zero, which…

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.

The facility had a census of 32 residents. The sample included 12 residents, with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide a written bed hold policy and failed to issue a written notification as soon as practicable for transfers of Resident (R) 39. This placed the resident at risk for impaired rights related to returning to the facility. Findings included:Review of the Electronic Health Record (EHR), documented R39 had diagnoses acute hypoxia (a condition characterized by a relatively sudden onset inadequate supply of oxygen that are usually severe), and respiratory failure (a condition where the lungs can't adequately provide enough oxygen to the body or remove enough carbon dioxide, leading to potentially dangerous levels of oxygen and/or carbon dioxide in the blood).R39's 05/17/25 Entry Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R39 was totally dependent on staff for transfers, toileting, and lower-body dressing.…

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.

The facility had a census of 32 residents. The sample included 12 residents. Based on observations, interviews, and record review, the facility failed to provide services to meet professional standards of care when staff signed a treatment order as completed but did not complete the treatment for Resident (R) 15. This placed the resident at risk for delayed healing and infection. Findings included:- R15 's Electronic Health Record (EHR) revealed diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).R15's 05/27/25 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The MDS documented R15 required moderate assistance for bathing, toileting, lower body dressing, and footwear. The MDS documented R15 had one venous stasis ulcer (lesion of the lower leg due to poor circulation) and required a non-surgical dressing…

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.

The facility reported a census of 32 residents. The sample included 12 residents with one dependent resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to provide ADL care including grooming of facial hair for Resident (R) 9. This placed the resident at risk for impaired dignity and poor hygiene. Findings included:- R9's Electronic Health Record (EHR) revealed diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R9's 11/26/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS noted R9 required set-up assistance for personal hygiene and oral care. The MDS noted R9 required moderate assistance with toileting, standing, and transfers. The 12/05/24 Functional Abilities…

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.

The facility reported a census of 32 residents; the sample included 12 with five residents reviewed for unnecessary medications and related monitoring. Based on observation, interview, and record review revealed the facility failed to monitor and respond to Resident (R)14 and R36 for lack of bowel movements. This placed the residents at risk for complications including constipation and bowel obstruction. Findings included:- R14's Electronic Health Records (EHR), under the Physician Orders (POS), documented diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), hypovolemia (abnormally low circulating blood volume), and constipation (difficulty passing stools),R14's 4/15/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment. The MDS noted R14 was frequently incontinent of bowel, without a toileting program, and/or constipation.The Urinary Continence and…

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.

The facility reported a census of 32 residents. The sample included 12 residents. Based on interviews, observation and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to a Resident (R) 42 with a peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart). The facility further failed to ensure adequate hand hygiene during personal care for R3 when staff failed to complete proper hand hygiene. The facility failed to store respiratory equipment in a sanitary manner for R6. These deficient practices had the potential to spread infections to the residents in the facility.Findings included:- Observation on 08/12/25 At 11:54 AM, R6 had oxygen tubing dated 08/03/25 stored in a plastic bag attached to an oxygen concentrator. The plastic bag had a large hole noted on the bottom and…

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.

The facility reported a census of 35 residents. Based on observation, record review and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the kitchen on 11/14/23 at 10:03 AM, the following areas of concern were noted: 1. The white freezer had food debris on the bottom shelf. 2. The ice machine drainage pipe lacked an air gap and rested directly touching on the grate of the floor drain. 3. The stationary can opener had dried, sticky food debris on the tip and on the surrounding holding device. 4. A large fan which blew directly onto the shelf where pots and pans were placed to dry, had a heavy build-up of dust and debris on the cage surrounding the blades. The fan was on and blowing at the time of the initial tour and again on a follow up visit to the kitchen. The facility policy for Sanitation and Infection Prevention/Control, revised 01/2023, included: A basic sanitation inspection is conducted at least…

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 The facility reported a census of 35 residents. Based on observation, interview and record review, the facility failed to maintain an effective infection control program with the failure to ensure sanitary storage of clean linen in the beauty shop, lack of housekeeping staff knowledge of cleaning products for clostridium difficile (a spore producing highly transmissible bacteria), use of expired sanitizing wipes, and unsanitary catheter care for resident (R)33. Findings included: - Observation, on [DATE] at 09:30 AM, during the environmental tour of the facility, revealed the beauty shop contained plastic wrapped clean towels placed directly on the floor. Administrative Staff A stated she would expect all staff to ensure towels were stored off the floor to prevent contamination. Furthermore, interview, on [DATE] at 11:30 AM, with Housekeeping Staff W, revealed she did not know what cleaning solutions were required to clean an isolation room for clostridium difficile and thought the nursing staff would provide…

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.

The facility reported a census of 35 residents. Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff regarding the parameter of the kitchen floor containing trash and debris. Findings included: - During an initial tour of the kitchen on 11/14/23 at 10:03 AM, the following area of concern was noted: The parameter of the kitchen floor contained food and trash debris throughout. On 11/15/23 at 10:01 AM, Dietary staff BB confirmed the kitchen floor needed to be cleaned around the parameter. The cleaning schedule for the kitchen, used as a cleaning policy, revealed the kitchen floor was to be mopped every shift. The facility failed to provide a safe, functional, sanitary and comfortable environment for residents and staff.

The facility reported a census of 35 residents. Based on observation and interview, the facility failed to ensure the beauty shop exhaust ventilation remained in good working order for the residents of the facility. Findings included: - Observation, on 11/14/23 at 02:30 PM, with Beauty Shop Operator V, revealed she did not know if the beauty shop had an exhaust fan, but that she provided very few permanents that would create foul odors. Observation, on 11/15/23 at 09:03 AM, with Maintenance Staff U and Administrative Staff A during the environmental tour, revealed the ventilation exhaust fan was non-working. Administrative Staff A stated the fan was checked once a year and staff did not report that fan was not working, and the damper was probably non-functioning. The facility lacked a policy for maintenance of the beauty shop exhaust fan. The facility failed to ensure the beauty shop exhaust fan was maintained in good working order as required for the residents of the facility who utilize the beauty shop.

The facility reported a census of 35 residents with 15 selected for review which included six residents observed for medication administration. Based on observation, interview and record review, the facility failed to ensure appropriate storage of one Resident (R)19's inhaler of the six residents observed. Findings included: - Review of Resident (R) 19 Physician Order Sheet, dated 11/10/23, instructed staff to administer Advair disckus (an inhaled medication containing a steroid and broncho dilator) 100/50 micrograms one inhalation twice a day for chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). Observation, on 11/14/23 at 08:08 AM, revealed Licensed Nurse (LN) H, prepared to administer morning medications to Resident (R)19. LN H could not find the resident's inhaler in R19's box in the medication cart. LN H looked in the resident's room and was unable to find the inhaler. The resident was sitting at the common dining room table. LN H noted the inhaler in a flower…

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.