Rappahannock Westminster Canterbury

Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 2 kitchens/food preparation/service areas inspected. The findings included: 1. The facility staff failed to store food in a manner consistent with professional standards for food service safety with regard to, labeling and protection from contaminates. On 8/8/23 at 12:45 PM, observations were made in the facility's main kitchen. The facility's dietary manager was present and accompanied Surveyor C. In the storage bin for the dry goods, a foreign object was observed in the seafood breading. The item was scooped out using a scoop and the dietary manager sifted the dry seafood breading into a bowl. Once the object was reached, the dietary manager put on a pair of gloves and was able to remove the breading from the object. The dietary manager and Surveyor C both confirmed that it was a brown bug with wings that was approximately 1/2 inch long. The dietary manager instructed 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, staff interviews, and facility documentation review, the facility staff failed to maintain an effective pest control program ensure the facility is free of pests in the main kitchen, which has the ability to affect multiple Residents within the facility. The findings included: On 8/8/23 at 12:45 PM, a preliminary inspection was conducted in the main kitchen. Observations were made with the dietary manager present. The following observations were noted: Throughout the entire kitchen an abundance of flies was noted in all food preparation areas. Flies were noted to be on the food prep tables, in the dry storage room and in the dish machine area. In the bin where the seafood breaded was stored, something was noted to be in the breaded. The dietary manager scooped the item out of the bin and sifted it into a bowl to make closer observations. It was noted that a small bug, approximately 3/4 of an inch long, tan in color with wings was noted. The dietary manager instructed the kitchen staff to discard the entire contents of the bin, as it was contaminated. On 8/10/23…

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, clinical record review and facility documentation the facility staff failed to immediately inform the Resident's physician, and Resident representative of change in condition for 1 Residents (#14) in a survey sample of 19 Residents. The findings included: For Resident #14, who had a decline in condition, the facility staff failed to notify the physician of the Resident's inability to accept administered medications on several occasions. On 8/8/23-8/9/23, a record review was conducted. This review revealed: A progress note dated 08/04/2023 at 11:17 PM, read, Resident received in bed this evening. Has been resting, refused HS meds and fluids offered, nurse attempted to moisten mouth and resident closed and pursed lips. Did not open eyes however did begin to moan in song like manner which is a normal behavior for her indicating desire to be left alone. Skin warm pink and dry. No outward sign or evidence of discomfort. VS 97.1- 84- 18-137/86-96%. Offered Ensure as well which she also refused. On 08/04/2023 at 11:50 PM, a nurse wrote, Resident received in…

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, clinical record review and facility documentation review, the facility failed to ensure that a Medicare Advanced Beneficiary Notice (ABN) was completed and issued to 2 Residents (#81, and #82) in a survey sample of 3 ABN Residents. The findings included; For Resident #81, and #82, the facility failed to ensure an effective date of insurance coverage loss was documented on the ABN prior to the loss of coverage. On 8-9-23 during the course of the survey, the Administrator was asked for ABN records for three skilled nursing discharged individuals. The documents were received and revealed that two of the three documents had not been correctly completed. Resident's #81, and #82 received the Advanced Beneficiary notices and signed them without the required area being filled out for Effective date coverage of your current services will end being documented on the notices. This indicated both Residents would be unaware of insurance coverage loss date, and thus have no ability to enact their right to appeal. On 8-9-23 at 5:00 p.m., during the end of day debrief, 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 staff interview, facility documentation review, and clinical record review the facility staff failed to complete an assessment that accurately reflects the Resident's status for one Resident (Resident #30) in a survey sample of 19 Residents. The findings included: For Resident #30 the facility staff failed to accurately record on the MDS (Minimum Data Set) (an assessment) where the Resident #30 was admitted from and that a discharge plan was in process. On 8/9/23, a closed clinical record review was conducted of Resident #30's chart. This review revealed that Resident #30 had a discharge minimum data set (MDS) assessment, which was completed 7/27/23. This assessment indicated in section A0310. G., that Resident #30 was an unplanned discharge. Section A1800, was coded that Resident #30 had been admitted from an acute care hospital. Review of the Nursing admission Comprehensive Assessment for Resident #30 was reviewed. This document read, .Entered From: 01. Community (private home/apt, board/care, assisted living, group home) . The nursing notes didn't indicate any details…

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 follow professional standards of nursing for 1 resident (Resident #3) in a sample of 19 residents. The findings include: For Resident #3 the facility staff failed to clarify an order for a PRN laxative. On 8/8/23, during clinical record review, it was noted that Resident #3 had orders that included the following PRN laxative. NATURAL LAXATIVE (30cc) Oral as Needed Starting 08/07/2015 Order Date: 8/7/2015 - CONSTIPATION NOS Notes: For complaint of constipation. On 8/9/23 at 1:00 pm, an interview was conducted with RN D who was asked how many times she could give the Natural Laxative she stated she did not know, as the order did not specify. On 8/10/23 at 3:00 PM, an interview was conducted with the DON who was asked if the facility has standing orders and she indicated that they did. When asked if the nurses knew the protocol for using the standing orders, she stated that they did. When asked if the Natural Laxative order was clear as to how many doses could be administered and she stated that it was…

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 and physician failed to complete a discharge summary to include recapitulation of stay for 1 resident (Resident #30) in the survey sample of 19 residents. The findings included: For Resident #30, the facility staff failed to complete a recapitulation of stay and discharge summary upon the Resident's discharge from the facility. Resident #30 was discharged from the facility on 07/17/23. The Resident's closed record was reviewed on 8/9/23. No discharge summary, nor recapitulation of stay was included in the closed record. On 8/9/23, the survey team requested for the facility to provide the discharge summary and recapitulation of stay for Resident #30. The director of nursing notified the survey team she had no such records available to provide the survey team. The Administrator and Director of Nursing (DON) were notified of the missing discharge summary at the end of day meeting on 8/10/23. No further information was provided by the facility.

Based on observation, interview, clinical record review and facility documentation facility staff failed to provide treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection for 1 Resident (#19) in a survey sample of 19 Residents. The findings include: For Resident #19 the facility staff failed to provide adequate monitoring and treatment to prevent infection from developing in venous stasis wound. On 8/8/23, during clinical record review, it was found that Resident #19 had a document entitled Wound Assessment, excerpts are as follows: Date wound Identified - 3/2/23 Type of Wound - Vascular - Facility Acquired. Right Anterior Foot. Closed dark purple red in color. 2.1 cm x 0.8 cm The wound was documented weekly and by 7/13/23 the wound was 2.2 cm x 1 cm and opened at the base. The wound was not documented again until 7/27/23 (14 days later) when it was measured at 5.0 cm x 5.0 cm. Described as Vascular other description of wound color, drainage or progress was given. The next measurement was during survey on 8/10/23 (14…

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 accurately account for controlled medication for 1 resident (Resident #7) in a survey sample of 19 residents. The findings included: For Resident # 7 the facility staff failed to accurately account for controlled medication. On 8/9/23 at approximately 9:00 AM during med pass it was observed that Resident #7's controlled count sheet for morphine was not accurate. The controlled sheet reflected 24.75 ml (milliliters) of liquid morphine and the bottle contained 30 ml. A review of the controlled sheet revealed that on 7/25/23 at 10:34 AM, the initial dose was given from the bottle. There was no nurse's signature; only date, time, amount given, and the quantity left in the bottle were filled in. Upon closer inspection the controlled sheet was found to have a mathematical error that only accounted for an overage of 1 m. On 7/26/23 at 9:45 PM the nurse signed out 0.25 ml and that left 29.25 in the bottle. On 7/27/23 at 9:58 PM the nurse gave 0.25 ml and instead of writing that there was 29 ml left 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.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from unnecessary psychotropic's for 1 Resident (#3) in a survey sample of 19 Residents. The findings included: For Resident #3, the facility staff failed to ensure the As Needed (PRN) Ativan was only ordered for 14 days without proper documentation. On 8/8/23 a review of the clinical record revealed that Resident #7 had orders for PRN Ativan (an anti-anxiety medication) the order read as follows: Lorazepam 2 mg (milligrams)/mL(milliliter) oral concentrate (.25 ml) PRN Every 4 Hours for 60 Days. Order Date: 7/25/2023- ICD-10: F41.9 - ANXIETY DISORDER, UNSPECIFIED Notes: For agitation, psychotic disturbance, anxiety, and/or mood disturbance. On 8/9/23 at approximately 10 AM, an interview was conducted with the Director of Nursing (DON) who was asked how long a PRN order for Psychotropic medication should be, the DON stated it should be only for 14 days then reevaluated. The DON stated that Resident #3 got an order from hospice for 14 days then Resident #3 got…

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 and facility documentation review, the facility staff failed to store food in a manner to identify the food item and the date opened or to be used by, in 2 of 4 food storage areas inspected. The findings included: On 1/11/22 at 2:59 PM, observations were made in the facility kitchen. Surveyor C was accompanied by Employee F, the dietary manager. In the walk-in freezer, two bags of mixed vegetables and a bag of green peas were open to air, not secured in a manner to protect from environmental contaminates, and had no date. A bag of green beans were observed to be wrapped in saran wrap and had no date. Observations of the walk-in freezer labeled as #4 contained an item in a zip lock bag that Surveyor C was not able to identify. It had no labeling and no date. Employee F, the dietary manager identified the item as, Muffin mix dough. Employee F confirmed all of the observations as they were being made and stated .I expect every item opened to be labeled and dated, properly wrapped and sealed after each use. The potential risks of not doing this is,…

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, resident interview, staff interviews and clinical record review, the facility staff failed to ensure the environment was free of accident hazards by allowing Resident access to medication/treatment and sharps for 1 Resident (Resident #6) in a survey sample of 27 Residents. The findings included: A clinical record review for Resident #6 was conducted. This review revealed that Resident #6 had the following diagnosis: Alzheimer's disease with late onset, visual hallucinations and auditory hallucinations. Resident #6's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 10/7/21, was coded as an annual assessment. On this assessment Resident #6 was coded as having had a BIMS (brief interview for mental status) score of 6, which indicated severe cognitive impairment. Resident #6 was also coded on this assessment as having had hallucinations and delusions. Resident #6 required extensive assistance of one staff person for personal hygiene. Resident #6's clinical record revealed no physician orders for self-administration…

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, facility documentation and clinical record review the facility staff failed to ensure freedom from accident hazard for 1 Resident in a survey sample of 18 Residents. For Resident # 91 the facility failed to ensure foot rests were in place on wheelchair while transporting Resident in wheelchair. The findings include: Resident #91 a [AGE] year old woman was admitted to the facility on [DATE] with diagnoses of but not limited to Dementia, osteoporosis, Atrial Fibrillation, Chronic Kidney Disease, HTN, and generalized weakness. According to last (Minimum Data Set) MDS (screening tool) with an (Assessment Reference Date) ARD date of [DATE], Resident #91 was coded as having a (Brief Interview of Mental Status) BIMS score of 3 indicating severe cognitive impairment. She was also coded as requiring extensive assistance of 2 person physical assistance with all aspects of (Activities of Daily Living) ADL care to include transfers and bed mobility. The Resident used a wheelchair for locomotion in…

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.