Farmville Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for four of 43 residents in the survey sample, Residents #57, #85, #31, and #10. The findings include: 1a. For Resident #57 (R57) the facility staff failed to follow the care plan for diabetes. R57 was admitted to the facility with a diagnosis of diabetes mellitus (1). A review of R57's physician orders revealed the following order dated 9/8/22: Trulicity (2) Solution Pen-injector 1.5 MG/0.5ML (Dulaglutide). Inject 1.5 mg subcutaneously week every Fri related to TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY (E11.42). A review of R57's MAR (medication administration record) for September 2022 revealed R57 received two doses of Trulicity on 9/9/22. A review of R57's progress notes revealed the following: 9/9/22 8:26 p.m. Writer was phoned about resident receiving an extra dose of Trulicity. Writer spoke with both daughters about this. Writer…

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 staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for three of 43 residents in the survey sample, Residents #41, #63 and #103. The findings include: 1.a. For Resident #41 (R41), the facility staff failed to review and revise the resident's comprehensive care plans for pressure ulcer/injuries that were acquired on 2/1/23. A review of R41's clinical record revealed weekly wound assessments that documented the resident acquired the following pressure injuries: -a pressure injury on the left thigh that was acquired on 2/1/23. -a pressure injury on the left foot that was acquired on 2/1/23. -a pressure injury on the right ischium that was acquired on 2/1/23. A review of R41's comprehensive care plan dated 9/23/22 failed to reveal the care plan was reviewed and revised for the above acquired pressure injuries. On 5/22/23 at 3:21 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated the purpose of the care plan is that…

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, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for four of 43 residents in the survey sample, Residents #57, #10, #349, and #38. The findings include: 1. For Resident #57 (R57) the facility staff failed to correctly transcribe a physician's order for Trulicity (1), resulting in the resident receiving a double dose of the medication on 9/9/22. R57 was admitted to the facility with a diagnosis of diabetes mellitus (2). A review of R57's physician orders revealed the following order dated 9/8/22: Trulicity Solution Pen-injector 1.5 MG/0.5ML (Dulaglutide). Inject 1.5 mg subcutaneously week every Fri related to TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY (E11.42). A review of R57's MAR (medication administration record) for September 2022 revealed R57 received two doses of Trulicity on 9/9/22. A review of R57's progress notes revealed the following: 9/9/22 8:26 p.m. Writer…

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 resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide ADL care for dependent residents, for three of 43 residents in the survey sample, Residents #38, #101 and #85. The findings include: 1. For Resident #38, the facility staff failed to provide bathing/baths/showers. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/9/2023, in Section G - Functional Status, the resident was coded as being totally dependent upon two or more staff members for bathing. The ADL (activities of daily living) documentation for March 2022, revealed the resident did not receive any form of bathing on 3/2/2022, 3/5/2022 and 3/27/2022. The blocks on the form where documentation would be were blank. The ADL (activities of daily living) documentation for April 2022, revealed the resident did not receive any form of bathing on 4/5/2022, 4/6/2022, 4/7/2022, 4/10/2022, 4/23/2022,…

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 resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a pain management program for one of 43 residents in the survey sample, Resident #31. The findings include: On the most recent MDS (Minimum Data Set), an annual assessment dated [DATE], Resident #31 was coded as being cognitively intact in ability to make daily life decisions. On 5/21/23 at 2:52 PM, in an interview with Resident #31, they stated that the facility runs out of their pain meds (medications) and they don't get it. A review of the physician's orders revealed one dated 10/31/22 for Hydrocodone-Acetaminophen (1) 5-325 mg (milligrams) tablet, 1 tablet every 4 hours when awake, for moderate pain of gastric polyp. A review of the MARs (Medication Administration Record)s for March 2023, April 2023 and May 2023, and the progress notes revealed the following: 1. On 3/26/23 at 2:00 PM, Resident #31 did not get the scheduled medication. A nurse's note…

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 staff interview, facility document review and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for one of 43 residents in the survey sample, Resident #63. The findings include: For Resident #63 (R63), the facility staff failed to monitor the resident for side effects (bleeding) from the anticoagulant (blocks the activity of certain clotting substances in the blood) medication Eliquis (1). A review of R63's clinical record revealed a physician's order dated 4/7/23 for Eliquis 5 mg (milligrams) twice a day (for a history of pulmonary embolism). A review of R63's March 2023 and April 2023 MARs (medications administration records) revealed the resident was administered Eliquis twice a day from 4/7/23 (the date of admission) until 5/20/23 (except for the days the resident was on a leave of absence from the facility). Further review of R63's clinical record (including the MARs and nurses' notes for April 2023 and May 2023) failed to reveal the resident was monitored for side effects (bleeding) from the Eliquis. R63's…

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 staff interview and facility document review, it was determined the facility staff failed to arrange timely outside medical appointments as ordered for one of 43 residents in the survey sample, Resident #85. The findings include: The facility failed to evidence outside neurology and dry needling medical appointments were made timely as ordered for Resident #85. Resident #85 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: traumatic spinal cord injury, neurogenic bladder, quadriplegia and hypertension. Resident #85's most recent MDS (minimum data set) assessment, a quarterly Medicare assessment, with an assessment reference date of 5/9/23, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the physician orders revealed the following: -Refer to Neurology related to spasticity on 10/7/22 and 10/12/22. -2/16/23 order: Physical Therapy outpatient referral…

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 staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to promote a resident's right to respect and dignity, for one of 43 residents in the survey sample, Resident #85. The findings include: The facility staff failed to ensure Resident #85 was treated with respect and dignity during interactions with the nurse practitioner (NP). Resident #85 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: traumatic spinal cord injury, neurogenic bladder, and quadriplegia. Resident #85's most recent MDS (minimum data set) assessment, a quarterly Medicare assessment, with an assessment reference date of 5/9/23, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the facility grievance log revealed the following: 1/4/23: wants to speak to NP about medications, NP rushes past him and states 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 observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide personal privacy for one of 43 residents in the survey sample, Resident #349. The findings include: For Resident #349 (R349), the facility failed to offer interventions to prevent other residents from wandering into R349's room. The MDS (minimum data set) assessment was not due at the time of the survey. On the admission nursing assessment dated [DATE] R349 was assessed as being alert and oriented to person, place, time and situation. The resident was assessed as having a speech impairment, as speaking in a whisper voice, requiring two person assistance for bed mobility, dressing, eating, transfers and toileting. On 5/21/2023 at 2:54 p.m., an interview was conducted with R349 in their room. R349 stated that they were new to the facility and had two residents wander into their room on different occasions. R349 stated that once they were in 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, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to maintain a clean, comfortable, homelike environment for three of 43 residents in the survey sample, Residents #3, #6 and #31. The findings include: 1. For Resident #3 (R3), the facility staff failed to maintain the resident's wheelchair in good repair. The vinyl covering on both armrests was torn with foam exposed. On 5/21/23 at 2:15 p.m., R3 was observed sitting in a wheelchair. On the right armrest, a section (approximately 12 inches in length by 0.5 inches in width) of the vinyl covering was torn with foam exposed. On the left armrest, a section (approximately four inches in length by 0.5 inches in width) of the vinyl covering was torn with foam exposed. Approximately four inches at the end of the arm rest was wrapped in medical tape. On 5/22/23 at 2:23 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that usually the therapy…

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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to report an injury of unknown origin in a timely manner for one of 43 residents in the survey sample, Resident #149. This is cited at past non-compliance. The findings include: For Resident #149 (R149), the CNA (certified nursing assistant) failed to report to the nurse, a bruise on R149's face in a timely manner. A facility synopsis of event with an injury of unknown origin was sent to the State Agency on 10/25/2022. The synopsis documented in part, On 10/25/2022 during afternoon rounds, DON (director of nursing) noted a hematoma to the forehead. No falls had been reported. The resident is under hospice care at this time. An investigation is underway and outcome to follow. The facility synopsis of the event dated 11/1/2022, documented, An investigation was launched. Upon interviewing staff and roommate, it was discovered that on the previous night (10/24/2022) the resident had been assisted back to bed by staff using a Hoyer lift. The staff accidentally bumped…

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 resident interview, staff interview, facility document review and clinical record review it was determined the facility staff failed to assess and monitor the resident's range of motion for the appropriateness of a restorative program, for one of 43 residents in the survey sample. Resident #38. The findings include: For Resident #38 (R38), the facility staff failed to assess and monitor the restorative program used for range of motion. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/9/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. An interview was conducted on 5/21/2023 at 3:04 p.m. with R38. When asked if they participated in any form of therapy, R38 stated they were getting range of motion exercises. The comprehensive care plan dated, 12/6/2022, documented in part, Focus: Able to participate in a Splint Restorative program. The Interventions documented in part, Splint/brace to…

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 staff interview and clinical record review, the facility staff failed to provide colostomy care and services for one of 43 residents in the survey sample, Resident #41. The findings include: For Resident #41 (R41), the facility staff failed to obtain a physician's order for how often the resident's colostomy bag should be changed. R41's comprehensive care plan dated 9/23/22 documented, Alteration in elimination r/t (related to) colostomy. Change colostomy bag per orders and prn (as needed) . A review of R41's clinical record revealed a physician's order dated 9/30/22 for colostomy care every shift but failed to reveal a physician's order for how often the colostomy bag should be changed. On 5/23/23 at 10:45 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated a resident with a colostomy should have a physician's order for how often to change the bag, to make sure this is done frequently. On 5/23/23 at 2:37 p.m., ASM (administrative staff member) #1, the director of nursing, and ASM #2, the regional vice president of operations were made…

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, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for two of 43 residents in the survey sample, Resident #349 and Resident #63. The findings include: 1. For Resident #349 (R349), the facility failed to assess for bed rail use, obtain consent for use and review risk and benefits of the use of bed rails prior to use. The MDS (minimum data set) assessment was not due at the time of the survey. On the admission nursing assessment dated [DATE] R349 was assessed as being alert and oriented to person, place, time and situation. The resident was assessed as requiring two person assistance for bed mobility, dressing, eating, transfers and toileting. R349 was assessed as not using bed rails. On 5/21/2023 at 2:54 p.m., an interview was conducted with R349 in their room. R349 was observed in bed with a bed rail raised on the right side of the bed. R349 stated that they used 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.

Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide timely laboratory services for one of 43 residents in the survey sample, Resident #87. The findings include: For Resident #87 (R87), the facility staff failed to obtain an ordered urine specimen in a timely manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/7/2023, the resident scored six out of 15 on the BIMS (brief interview for mental status) assessment, indicating that the resident was severely impaired for making daily decisions. Section H documented R87 always incontinent of urine. The physician orders for R87 documented in part: - Urinalysis flex to culture, may I/O (in and out) cath (catheterization) if needed r/t (related to) incontinence. Order Date: 05/05/2023. - Urinalysis flex to culture, may I/O cath if needed r/t incontinence. Order Date: 05/10/2023. - Keflex Oral Capsule 750 MG (milligram) (Cephalexin) Give 1 capsule by mouth every 12 hours for for [sic] UTI…

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, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to accommodate dietary preferences and allergies for two of 43 residents in the survey sample, Resident #85 and Resident #57. The findings include: 1. Resident #85 had documented lactose intolerance but was served a cheese product. A review of the facility grievance log dated 1/17/23 for Resident #85, revealed, Resident not happy with dinner tray. Unit manager went to kitchen to replace meal and was told they did not have any more food and that resident or staff could go out and get him something. When unit manager asked for sandwich option, they only had sliced ham which resident declined. (unit manager spoke to dietary manager). The unit manager is no longer employed at the facility. Resident #85 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: traumatic spinal cord injury and quadriplegia. Resident #85's most recent MDS (minimum data…

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 resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of 43 residents in the survey sample, Resident #38. The findings include: For Resident #38 (R38), the facility staff failed to document the restorative program activities the resident was participating in. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/9/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. An interview was conducted on 5/21/2023 at 3:04 p.m. with R38. When asked if they participated in any form of therapy, R38 stated they were getting range of motion exercises. Review of the physician orders failed to evidence documentation of a restorative program. An interview was conducted with CNA (certified nursing assistant) #13, the restorative aide, on 5/23/2023 at 11:31 a.m. When…

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 observation, staff interview, facility document review and clinical record review, the facility staff failed to implement infection control practices for one of 43 residents, Resident #3, and on one of two units, the North unit. The findings include: 1. For Resident #3 (R3), the facility staff failed to maintain the resident's wheelchair armrests free from torn areas, exposing foam that was unable to be sanitized. On 5/21/23 at 2:15 p.m., R3 was observed sitting in a wheelchair. On the right armrest, a section (approximately 12 inches in length by 0.5 inches in width) of the vinyl covering was torn with foam exposed. On the left armrest, a section (approximately four inches in length by 0.5 inches in width) of the vinyl covering was torn with foam exposed. Approximately four inches at the end of the arm rest was wrapped in medical tape. On 5/22/23 at 2:23 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that usually the therapy department handles the repair or replacement of wheelchair armrests, but the nursing staff will report to 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.

Based on observation, interview, and review of facility policy, the facility failed to ensure each resident received food and drink that was palatable and served at an appropriate temperature. The failure to assure that that hot and cold foods were served at a palatable temperature had the potential to affect 91 of 92 residents residing on the facility's two wings (North and East) who consume food by mouth. Findings include: 1. Review of R83's Minimum Data Set (MDS) located in the electronic medical record (EMR) under the MDS tab with an Assessment Reference Date (ARD) of 12/10/21 revealed a Brief Interview for Mental Status (BIMS) score of 14/15, indicating the resident was cognitively intact. During an interview on 01/04/22 at 10:22 AM with R83, the resident stated the food was served cold at every meal. During this interview, R83 was observed to reside on the East Wing of the facility. 2. Review of R3's MDS located in the EMR under the MDS tab with an ARD of 12/17/21 revealed a BIMS score of 15/15, indicating the resident was cognitively intact. During an interview on 01/04/22 at…

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 observation, interview, and review of facility policy, the facility failed to store and/or serve food in accordance with professional standards for food safety. Foods were not labeled/dated when stored. Equipment such as the nozzle used for serving juice was not clean. Scoops used to serve food from the steam table were not sanitized. This failure had the potential to affect 91 of 92 residents in the facility who consume food by mouth. Findings include: 1a. Observation of the walk in refrigerator in the main kitchen on 01/03/22 at 9:10 AM revealed a metal pan used on the steam table was full of spaghetti and meat balls covered in clear cellophane without a date. Interview with the Dietary Food Service Supervisor (DFSS) who was present at the time of the observation verified the food item lacked a storage date and stated, It was from last night. b. Observation of the walk in refrigerator in the main kitchen on 01/03/22 at 9:10 AM revealed a small metal container from the steam table full of macaroni and cheese, covered in clear cellophane without a date. Interview with 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.

Based on observation, interview, record review, review of facility policy, and review of specifications for the use of a bed frame, the facility failed to ensure that mattresses fit snugly within the bed frame and side rails and/or that side rails were maintained in a fixed (tightened) position for two residents (Resident (R) 69 and R45). In addition, the facility failed to conduct regular inspections to assure that all bed frames, mattresses, and side rails (if present) were inspected as a part of a regular maintenance program. The failure to conduct regular inspections to identify possible entrapment hazards as part of the routine maintenance program had the potential to affect all 92 residents using beds in the facility. Findings include: Review of the facility policy titled, Bed Rail Policy, revised 08/12/21, revealed that the facility will ensure appropriate dimensions of the bed based on the resident size and weight. The policy also noted the requirement to, Ensure scheduled maintenance of any bed rail in use according to manufacturer's specifications. 1. Review of R69's Face…

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 interview, record review, and facility policy review, the facility failed to provide written information to the resident and/or resident's representative regarding the right to formulate an advanced directive for 12 of 31 residents sampled (Resident (R) 73, R83, R93, R77, R3, R68, R79, R64, R35, R94, R195, and R81). Findings include: 1. Review of R73's admission Record located in the Electronic Medical Record (EMR) under the Profile tab, revealed an admission date of 10/18/19 and full code status. There was no evidence in the medical record that written information regarding the right to formulate an advanced directive was provided to the resident and/or resident's representative. 2. Review of R83's admission Record located in the EMR under the Profile tab, revealed an admission date of 02/19/20 and Do Not Resuscitate (DNR) status. There was no evidence in the medical record that written information regarding the right to formulate an advanced directive was provided to the resident and/or resident's representative. 3. Review of R93's admission Record located in the EMR…

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 interview, review of facility incident files, and review of facility policy, the facility failed to ensure that reports related to allegations of abuse and/or neglect were immediately reported to the State Survey Agency (SSA). The facility failed to assure that allegations of abuse and/or serious injury were reported in no more than two hours, while allegations of neglect were reported in no more than 24 hours for four of 11 facility-reported allegations, which involved Resident (R) 65, R90, R145, R50, R32, R41, and R146. In addition, the facility failed to assure that results of an investigation into an injury of unknown origin sustained by R245 were reported to the SSA within five working days. Findings include: 1. a. Review of Facility Incident Report (FRI) 51726, dated 04/14/21 at 11:43 AM, revealed an allegation of unknown injury-resident to resident abuse. The allegation was identified on 04/11/21 at 11:59 PM, when staff observed that R65 had a bruise and the resident alleged being hit by R90. Review of the report revealed the allegation of abuse was not reported to…

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 interview, record review, and review of the facility abuse policy, the facility failed to ensure that a thorough investigation was completed for four allegations (involving Resident (R) 245, 65. R90, R145, R50, R32 and R41) of eleven reportable incidents and/or complaints. The facility failed to assure that allegations of resident-to-resident abuse and/or injuries of unknown origin were thoroughly investigated, with all potential witnesses interviewed, to assure that investigations had sufficient information to form an accurate conclusion in response to the allegation. Findings include: 1. Review of R245's Facility Reported Incident (FRI), reported to the Virginia Department of Health (State Survey Agency - SSA) on 09/11/21, revealed R245 had an injury of unknown origin that occurred on 09/10/21. The FRI indicated an investigation into the injury of unknown origin was underway; however, the facility could not provide evidence that a thorough investigation into this allegation was conducted. Review of R245's Quick Response incident note, dated 09/10/21, located in the EMR…

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 interview and record review, the facility failed to ensure medication use was accurately recorded on Minimum Data Set (MDS) assessments for three (Resident (R) 44, R68, and R81) of 32 residents reviewed during the initial resident pool of the survey process. The facility inaccurately documented that the residents received anticoagulant (blood-thinner) medications. Findings include: 1. Review of R44's admission Record in the facility's electronic medical record (EMR) showed an original admission date of 09/13/17, with a readmission date of 02/21/20, with medical diagnoses that included cerebral infarction, adult failure to thrive, and metabolic encephalopathy. Review of R44's MDS quarterly assessment, with an Assessment Reference Date (ARD) of 11/09/21 revealed that the assessment documented that he received an anticoagulant medication seven of seven days of the assessment period. R44's quarterly MDS assessment with an ARD of 08/09/21 and annual assessment with an ARD of 02/06/21 were also both coded as showing that R44 received an anticoagulant medication seven of seven…

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 interview, record review, and facility policy review, the facility failed to implement an effective discharge planning process that focused on the resident's expressed discharge goals and failed to document referrals to local housing agencies for one (Resident (R) 83) of two residents sampled for discharge. Findings include: Review of R83's admission Record located in the Electronic Medical Record (EMR) under the Profile tab, revealed an admission date of 02/19/20. Review of R83's Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/10/21 revealed a Brief Interview for Mental Status (BIMS) score of 14/15, indicating the resident was cognitively intact. Review of R83's Social Services Note located in the EMR under the Progress Notes tab, dated 11/10/20, revealed the following: Resident approached SS [Social Services] if we could assist in helping him find an apartment in the Roanoke area. SS reached out to transition coordinator via email. Review of R83's Social Services Note located in the EMR under the Progress Notes…

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 interview, record review, and facility policy review, the facility failed to ensure one (Resident (R) 83) of two residents reviewed for pain out of 31 sampled residents received needed treatment and care in accordance with professional standards of practice. The facility failed to provide R83 pain medication as ordered. Findings include: Review of R83's admission Record located in the Electronic Medical Record (EMR) under the Profile tab, revealed an admission date of 02/19/20 with diagnoses including, but not limited to, chronic pain, wedge compression fracture of first and fifth lumbar polyosteoarthritis, and chronic kidney disease. Review of R83's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/10/21 revealed a Brief Interview for Mental Status (BIMS) score of 14/15, indicating the resident was cognitively intact. Per the MDS, R83 was on a scheduled pain medication regimen. Review of R83's current Care Plan, dated 04/09/21 and located in the EMR under the Care Plan tab, revealed the following interventions…

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.