Essentia Health Virginia Care Cent

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to date opened products, dispose of expired products, and failed to have a process to ensure stored food was labeled with an expiration date that staff could understand. This deficient practice had the potential to affect all 15 residents who received food from facility kitchen.Findings include:During the initial kitchen tour on 3/23/26 at 1:27 p.m., nutrition services manager (NSM) stated products were dated when opened. The following was observed during the tour:Dry storage:6 cans of pasta sauce had no discernible expiration date.6 cans of tomato paste had no discernible expiration date.5 cans of carrots had an expiration date of 12/28/25.Cold storage:In cooler 3, there was an open, undated half gallon of heavy cream.In freezer 1, beef stew tray had no expiration date.Kitchen cooking line:Small fridge on kitchen line had an open, undated liquid egg carton.7 open, undated spices. In addition, there were no discernable expiration dates on 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 observation, interview, and document review the facility failed to only leave medications at bedside when there was order to and the resident wanted to self adminster medications. This affected 1 of 1 residents (R5) reviewed for self administration of medication.Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact. Diagnoses included diabetes and cerebral vascular accident (CVA)(stroke). R5's Assessment for Resident Self-Administration of Medications/Treatments dated 3/16/26, indicated R5 did not want to self-administer medications and/or treatments (SAM). R5's Physician Order Report (POR) dated 3/26/26 indicated R5 received acetaminophen 500 milligrams (mg), 2 tablets three times a day by mouth. The POR lacked orders for Tums antacids. No staff were in the room. R5's care plan undated, lacked a care plan related to self-administration of medication. During an observation on 3/23/26 at 2:13 p.m., two tylenol were observed in a medicine cup sitting 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 observation, interview, and record review the facility failed to wear appropiriate personnal protective equipment (PPE) for a resident on contact precautions. This affected 1 of 1 resident (R11) reviewed for infection control. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 as cognitively intact. R11's diagnoses included ataxia following cerebral infarction, diabetes mellitus type 2, paroxysmal atrial fibrillation, hypertension, and legal blindness. R11's care plan revised 2/24/26, identified left eye blepharoconjunctivitis infection: will resolve infection incurred and not spread same to others. It instructed to implement contact precautions. R11's provider orders dated 3/25/26 identified contact precautions through duration of eye drops and duration of left eye symptoms. During dining observations on 3/23/26 at 5:10 p.m., R11's door had an isolation sign on it which indicated R11 was on contact precautions. The sign indicated gown, and gloves had to always be worn…

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, interview, and document review, the facility failed to ensure nebulizer tubing/canister was cleaned and allowed to air dry after each use for 1 of 1 resident (R16) reviewed for oxygen therapy. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], identified R16 had moderate cognitive impairment and diagnoses included chronic obstructive pulmonary disease (COPD) and respiratory failure. R16's provider order dated 4/12/24, identified orders for ipratropium-albuterol solution for nebulizer: 0.5 milligram (mg) - 3mg(2.5mg) base/3mililiter (ml) every four hours as needed for shortness of breath. On 1/6/25 at 1:52 p.m., a nebulizer canister was observed in R16's room. The canister was observed to have condensation built around the inside of the canister with water drops also noted in the base of the canister. There was no date on the canister. R16 stated a nebulizer treatment had not been taken since some time on 1/5/25. On 1/7/25 at 1:42 p.m., a nebulizer canister was again…

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, interview and document review the facility failed to ensure the completed Minimum Data Set (MDS) was accurately coded for 4 of 6 residents (R4, R13, R16 and R19) reviewed for resident assessment. Findings include: R4's quarterly MDS dated [DATE], did not identify the following diagnoses hyperlipidemia (excess fat in blood), idiopathic gout (recurrent attacks of [NAME] arthritis in joints), esophageal mass, or atherosclerotic heart disease (narrowing of heart arteries). R4's physician order report, identified R4 was diagnosed with and receiving treatment for hyperlipidemia starting on 4/10/2023, idiopathic gout starting on 6/23/2023, esophageal mass starting on 8/10/2023, and atherosclerotic heart disease starting on 1/6/2023. R13's quarterly MDS dated [DATE], did not identify the diagnosis of atrial fibrillation (abnormal heartbeat). Additionally, R13's quarterly MDS did not indicate R13 was taking the high-risk hypoglycemic (lower's blood glucose) medication metformin or the high-risk…

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 interview and document review, the facility failed to ensure timely completion of all Minimum Data Set (MDS) sections prior to submission, and to ensure completion of a Care Area Assessments (CAA) worksheet for a significant change in condition assessment (SCSA) for 1 of 6 (R5) residents reviewed for MDS completion. The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2023, identified section C's intention was to determine the resident's attention, orientation, and ability to register and recall new information. These items were crucial factors in making care planning decisions. The Manual identified section F's intention was to obtain information regarding the resident's preferences or his or her daily routine and activities. Nursing homes should use this as a guide to create an individualized plan for the resident's preferences. Care Areas are triggered by MDS item responses that indicated the need for additional assessment based 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 observations, interviews and record review, the facility failed to review and revise the care plan to reflect resident preferences for 1 of 2 residents (R5) reviewed for care planning. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 was rarely if ever understood and had diagnoses of dementia and congestive heart failure. R5 was dependent on staff for all activities of daily living (ADLs) and was non-ambulatory. R5's care plan dated 1/9/24 identified it was important to R5 to be awake at 9 a.m. During a continuous observation on 2/27/24 starting at 8:09 a.m. to 10:42 a.m., R5 was in bed sleeping with the covers on. During this time staff were not observed to enter the room. During an observation on 2/27/24 at 10:42 a.m., nursing assistant (NA)-B and NA-A worked together to provide R5 with a bed bath, dressing and grooming. R5 was not resistive to the care throughout this observation. During an interview on 2/28/24 at 9:08 a.m., NA-A stated R5 used to have breakfast,…

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, interview and record review, the facility failed to follow care plan interventions for pressure ulcer prevention and wheelchair positioning for 1 of 3 residents (R5) reviewed for pressure ulcer care and prevention. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 was rarely if ever understood and had diagnoses of dementia, congestive heart failure (CHF), chronic peripheral vascular disease, pre-diabetes, and morbid obesity. R5 was dependent on staff for bed mobility, hygiene, incontinent care, transfers and was at risk for pressure ulcer development. R5's care plan dated 9/2/19, identified R5 was at risk for alteration in skin integrity related to her Braden (a skin risk-assessment) score, impaired mobility, and incontinence. Interventions included licensed nurses to do weekly skin assessments, to provide a foam mattress, encourage turning and repositioning, clean and dry skin promptly after incontinent episodes, perform Braden assessment quarterly, turn…

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 interview and document review, the facility failed to ensure a rationale was documented for the extended order of an as needed (PRN) psychotropic (effecting the chemical makeup of the brain) medication beyond 14 days for 1 of 5 residents (R19) reviewed for unnecessary medications. Findings include: R19's significant change Minimum Data Set (MDS) dated [DATE], identified R19 was severely cognitively impaired and had diagnoses of malignant neoplasm of endometrium (cancer that begins in the lining of the uterus) and glaucoma. R19's care plan last revised on 2/27/24, identified diagnoses that included type 2 diabetes mellitus, malignant neoplasm of endometrium, hyperlipidemia, depression, and glaucoma. R19's physician orders dated 1/15/24, identified lorazepam (antianxiety medication) oral tablet 0.5 milligrams (mg) 1/2 tablet dose of 0.25 mg give by mouth every 4 hours PRN anxiety. Order did not have rationale to extend beyond 14 days, nor did it have an end date from the provider. Attempted to reach…

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.