Westminster-Canterbury Of Richmond

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for documentation for one of four residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to document assessments, interventions, and vital signs in the clinical record on 10/19/24. A review of R1's nurses' progress notes revealed the following: 10/19/24 19:44 (7:44 p.m.) Resident remains lethargic. BP remains low 88/43. Resident responds to tactile and verbal stimuli. Has declined PO (by mouth) this evening. [Name of attending physician] updated. No new orders. 10/19/24 19:57 (7:57 p.m.) Per [name of attending physician] change Morphine to 15 mg (milligrams) every 8 hours and hold Metoprolol tonight. 10/20/24 01:15 (1:15 a.m.) Resident continues with lethargy, night medications of Morphine, Metoprolol held. Resident blood pressure decline 70/56 and repeat was 56/31. On call NP (nurse practitioner) notified. Gave order for transfer. This note was written by RN (registered…

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 maintain a complete, accurate clinical record for one of four residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed maintain a complete, accurate medical record by documenting assessments, interventions, and vital signs in the clinical record on 10/19/24. A review of R1's nurses' progress notes revealed the following: 10/19/24 19:44 (7:44 p.m.) Resident remains lethargic. BP remains low 88/43. Resident responds to tactile and verbal stimuli. Has declined PO (by mouth) this evening. [Name of attending physician] updated. No new orders. 10/19/24 19:57 (7:57 p.m.) Per [name of attending physician] change Morphine to 15 mg (milligrams) every 8 hours and hold Metoprolol tonight. 10/20/24 01:15 (1:15 a.m.) Resident continues with lethargy, night medications of Morphine, Metoprolol held. Resident blood pressure decline 70/56 and repeat was 56/31. On call NP (nurse practitioner) notified. Gave order for transfer. This 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.

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 ensure an assessment was completed for medication self-administration for one of 20 residents, Resident #30. The findings include: The facility staff failed to ensure Resident #30 was assessed for self-administration of medication. Resident #30 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: osteoarthritis, spondylosis and bipolar disorder. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/21/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 7/19/23, which revealed, FOCUS: The resident has pain due to osteoarthritis and gout. INTERVENTIONS: Assess need for pain medication on each contact. Assess…

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 implement the comprehensive care plan for one of 20 residents in the survey sample, Resident #76. The findings include: For Resident #76, (R76), the facility staff failed to implement the resident's comprehensive care plan for diabetic medication administration. A review of R76's clinical record revealed a physician's order dated 1/31/24 for Basaglar KwikPen U-100 insulin, 100 units/milliliter- 10 units once daily for diabetes. The order further documented to hold the insulin if the resident's blood sugar was less than 100. R76's comprehensive care plan dated 4/5/24 documented, (Name) is at risk for hypo/hyperglycemia and complications of diabetes will be minimized. Administer diabetic meds per MD (medical doctor) order. A review of R76's June medication administration record revealed that on 6/1/24, the insulin was administered although the resident's blood sugar was 94. On 6/12/24 at 10:07 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1…

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 record review and staff interviews, the facility failed to monitor the neurological status post unwitnessed falls putting the residents at risk for undetected neurological deterioration. This failure affected 2 of 6 residents reviewed for falls (Residents (R) #50 and #68). This deficient practice was evidenced by the following: 1. A review of the medical record revealed, R#50 was originally admitted to the facility on [DATE] with a current admission date of 01/26/2022. The diagnoses including but not limited to fractured shaft of right fibula, pain in right ankle and joints of right foot, Parkinson's Disease, unspecified dementia with unspecified severity, history of repeated falls, unspecified cerebral infarction (stroke) and abnormal posture. R#50's Minimum Data Set (MDS), Brief Interview for Mental Status (BIMS) score was 4 (The BIMS test presents a scoring scale that guides the interpretation: 0 to 7 points indicates severe cognitive impairment, 8 to 12 points indicates moderate cognitive…

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 20 residents in the survey sample, Resident #76. The findings include: For Resident #76, (R76), the facility staff failed to hold the resident's insulin on 6/1/24, per a physician's order. A review of R76's clinical record revealed a physician's order dated 1/31/24 for Basaglar KwikPen U-100 insulin, 100 units/milliliter- 10 units once daily for diabetes. The order further documented to hold the insulin if the resident's blood sugar was less than 100. A review of R76's June medication administration record revealed that on 6/1/24, the insulin was administered although the resident's blood sugar was 94. On 6/12/24 at 10:07 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that if a resident has a physician's order to hold insulin for a blood sugar less than 100 and the resident's blood sugar is 94 then the resident's insulin should be held because that is the physician'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.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure that Residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion, for 1 Resident (#122) in a survey sample of 37 Residents. The findings included: For Resident # 122 the facility staff failed to ensure that the Resident's elbow protectors and resting hand splint were applied correctly as ordered by the physician. On 5/23/23 at approximately 11:30 am, an observation was made of Resident #122 in her wheelchair. Resident #112 was asleep, fully dressed, and she had elbow protectors on both elbows and a resting left hand splint applied over the elbow protector. A cork board in her room displayed written directions for the correct application of the splint as well as a photo Resident #122's left arm with the splint correctly applied. The instruction sheet and photo indicated that the elbow protector was to be over the splint not under the splint as it was observed. 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.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure an accurate medical record for 1 Resident (#69) in a survey sample of 37 Residents. The findings included: For Resident #69 the facility staff failed to correctly enter an order for morphine. On 5/25/23 during the clinical record review it was noted that on 12/11/22 an order was put in the system for Morphine 20 mg every hour PRN. The order stayed on the MAR (Medication Administration Record) as a valid order until 1/4/23 when a pharmacy review was conducted. At the time of the pharmacy review the pharmacy sent a notice that read: *Clinically Urgent Recommendation Prompt Response Requested [Resident #69 name redacted] medication administration record (MAR) or prescriber order sheets (POS) items that need clarification: Current order on the MAR for PRN Morphine = 20 mg every hour PRN. Pharmacy records indicate Morphine 20 mg / ml give 0.25 ml q hour PRN. Recommendation: Please clarify with MD and adjust the dose on the MAR. The facility corrected the dose on 1/4/23 after…

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 interviews and record reviews, it was determined the facility failed to ensure residents were provided a written notice which specified the duration of the bed-hold policy at the time of transfer to the hospital for one of 25 sampled residents (Resident (R) 33). On 12/29/21, R33 was transferred to the hospital because she developed paralysis and hematuria; however, she was not given the written notice that addressed holding the resident's bed during her absence. Findings include: Review of R33's Physicians Progress Note, dated 12/29/21, located in the resident's EMR under the progress notes tab, revealed the resident was sent to the hospital per her physician's recommendation due to a change in condition. It was documented that the Physician notified the resident's' daughter. Review of R33's EMR showed a written notice of transfer to the emergency room was sent to the family by the Director of Nursing (DON). During an interview with the DON on 3/24/21 at 4:00 PM the bed hold notification was requested for R33's transfer to the hospital; however, the DON was not able 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and review of the facility menus, it was determined the facility failed to prepare menus to include portion sizes to ensure residents received adequate amounts of menu items to meet their nutritional needs. This failed practice had the potential to affect the nutritional status of the 125 residents in the facility. The facility also failed to ensure menus were not repetitive in food items. Review of the menus revealed chicken in some form was on the menu for lunch and dinner daily four of four residents (Resident (R) 12, R68, R19, and R110) who ccomplained about the lack of variety if food options. Findings include: 1. On 03/22/21 at 10:45 AM, during observation and interview with R12, the resident indicated she was unhappy with the menu. R12 stated they have chicken at every meal. The resident stated she was tired of the baked chicken and chicken entrées like casseroles. 2. On 03/22/21 at 12:10 PM, observation and interview of R68 revealed he was eating a…

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

Based on observations, interviews, and review of facility policies, the facility failed to date foods in the refrigerators according to the facility policy. The facility failed to air dry dishes and pans before being stacked and stored. The facility also failed to date food in resident refrigerators located in the nursing lounge on three of three floors. These failed practices had the potential to affect the 125 residents in the facility. Findings include: 1. Labeling and Dating Review of facility's undated policy titled, Proper Labeling and Dating, all items in refrigerators were to have a date sticker on them. Also, the item must include the open date or prepared date, use by date, time opened or prepared, name of item, and initials of person opening or preparing. This facility had a main kitchen where all food is prepared and then brought to the three floors in large pans. Each floor, except the first floor, has a North, South, East, and [NAME] wing with their own kitchen. The first floor does not have a South wing. There are 11 kitchens on the three floors. On 03/22/21 at 9:00…

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, interviews, and record review, the facility failed to provide activities of daily living (ADL) care for one of two sampled residents reviewed for hospice care (Resident (R) 32). This failure has the potential of other residents in hospice care to not receive assistance with ADLs. Findings include: Review of R32's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/07/21, located in the resident's electronic medical record (EMR) under the MDS tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia, and legal blindness. Continued review of the MDS revealed R32 was totally dependent on staff for bathing and all personal hygiene. R32's MDS also revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine out of 15 which indicated the resident was moderately cognitively impaired. Observation and interview with R32 on 03/22/21 at 11:30 AM, revealed 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.