South Boston Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to maintain a complete clinical record for one resident (Resident #63-R63) in a survey sample of 23 residents. The findings included: 1. For R63, the facility staff failed to maintain a complete clinical record to include pharmacy recommendations and the provider's response to the recommendation. On 5/20/25 in the morning, R63 was visited in her room. R63 was observed lying in bed and was noted with significant cognitive impairments and was not able to answer questions appropriately, responded with non-sensical responses. On 5/21/25, a clinical record review was conducted. This review revealed that R63's current and active physician orders included the following medications: Ativan 1 mg twice daily, Citalopram 10 mg/5 ml, give 7.5 ml (15 mg) every day, and Depakote Sprinkles 125 mg, give 2 capsules (250 mg) twice daily. According to the census tab and progress notes, R63 was admitted to the facility on [DATE]. R63 was on Ativan and…

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

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to have evidence of residents being provided education and offered flu and pneumococcal immunizations for two residents (Resident #145-R145 and Resident #146-R146) in a survey sample of five residents reviewed for immunizations. The findings included: For R145 and R146, the facility staff failed to educate residents on the benefits and potential side effects of immunization and offer flu and pneumococcal immunizations as ordered by the physician. On 5/21/25, a sample of five residents was selected for review for immunization status. A clinical record review was conducted for each resident. The review revealed the following: According to the preventative health care tab of R145's clinical record, there was no information regarding R145's flu or pneumococcal vaccination status, that they had received any education or been offered the pneumococcal vaccine. R145's physician orders included orders dated 5/13/25 that read, Immunizations: Offer high dose flu vaccine annually unless…

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, clinical record review and facility documentation review, the facility staff failed to have credible evidence of a complete and thorough investigation being conducted following an incident of sexual assault involving two residents (Resident #8- R8 and resident #9-R9) in a survey sample of 10 residents. The findings included: For R8, who was sexually assaulted by R9, the facility staff failed to have credible evidence of a complete and thorough investigation of the incident. On 10/22/24, the survey team was provided with a listing of current residents, it was noted that R8 and R9, were neither a current resident of the facility and therefore were not able to be interviewed. On 10/22/24, during an entrance conference conducted at 1:45 p.m., the facility administrator was asked to provide all information the facility had with regards to a sexual assault. Following the entrance conference the facility administrator stated that the incident binder with the facility's investigation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, and facility documentation review, the facility failed to provide functional furniture appropriate for resident use in 2 rooms (rooms 208 & 323), on 2 of 4 units. The findings included: On 10/24/24 a tour and observations of the nursing units 2 and 3 was conducted. The observation revealed that the closet door in room [ROOM NUMBER] had a broken hinge, preventing the closet door from closing. The closet door handle was also broken. During the tour, it was also observed that the closet door in room [ROOM NUMBER] was ajar. Closer inspection noted that the hinge was broken, preventing the closet door from being closed. On 10/24/24 at 11:45 a.m., a meeting with the administrator, director of nursing, and the regional director of clinical services was conducted. When these above findings were reported to the facility staff, the administrator stated, We have been painting the building and trying to replace the door handles and hinges as we go along. On 10/24/24 a review of…

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 and staff interview, the facility staff failed to ensure a safe, clean, homelike environment on two of four units. Rooms on unit 1 and unit 3 had damaged call bell panel boxes that were loose and/or pulled from the wall in addition to, a dirty/damaged heat unit panel and scraped wall in room [ROOM NUMBER]. The findings include: On 1/25/22 at 12:51 p.m., the call bell box in room [ROOM NUMBER] above bed #3 was observed damaged. The box near the head of bed #3 was pulled completely from the wall leaving the inside of the wall visible. Conduit and wiring to the panel were visible in the gap between the wall and the displaced box. A stainless panel on the wall above the bedside table adjacent to this bed had an exposed black and yellow wire and a broken piece of plastic loosely attached beside the light switch. The front cover of the heat unit in this room was dislodged with a gap along the top right edge. The cover to the heat unit controls was bent and unable to close. 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 review of employee personnel files, staff interview, and review of facility policy, the facility failed to implement their Virginia Resident Abuse Policy for the screening of new employees, for 11 of 25 personnel files reviewed. Eleven of 25 employee personnel files did not include a Sworn Statement. The findings were: On 1/26/2022, the Director of Nursing (DON) was provided a list of 25 employees who were identified as new employees in the last two years. Information requested for each employee included the Sworn Statement, Criminal Record Check, License (if applicable), and References. Review of the personnel files revealed 16 of 25 did not have a Sworn Statement. The DON was given a list of the 16 employee files that were missing the Sworn Statement. The DON subsequently provided a Sworn Statement for five of the 16 employee files. The DON also provided a copy of an email addressed to the Human Resources Director of the facility's former owner asking for the Sworn Statements. Review of the facility's Virginia Resident Abuse Policy, revised on 7/14/2020, noted 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 resident interview, group interview, facility document review and staff interview, the facility staff failed to ensure call bell response was timely on three of four nursing units. Interviews with residents from unit 1, unit 2 and unit 3 revealed call bell response times greater than 20 minutes. The findings include: 1. Resident #57 was admitted to the facility on [DATE] with diagnoses that included diabetes, anxiety, schizophrenia, bipolar disorder, vertigo, hypertension, major depressive disorder and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed Resident #57 with moderately impaired cognitive skills. On 1/25/21 at 1:49 p.m., Resident #57 requested to speak to a surveyor about poor call bell response on her unit (unit 1). Resident #57 stated she frequently waited from 30 minutes to an hour for staff response to call bells especially at night. Resident #57 stated she required assistance with brief changes and rang the bell frequently when she was wet. Resident #57…

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, clinical record review, and facility document review, the facility staff failed to provide a timely response to pharmacy recommendations for 4 of 36 residents in the survey sample, Residents #87, #110, #14, and #149. The facility staff failed to act upon pharmacy recommendations regarding the need for the shingles vaccine for Residents #87, #110, #14; for the use of the medication Singular with diagnosed psychiatric conditions that included major depression and anxiety for Resident #14; and a recommendation for a dose reduction and/or discontinuation of medications related to falls for Resident #149. The findings include: 1. Resident #87 was admitted to the facility on [DATE] with diagnoses that included healing for lumbar fracture, schizophrenia, edema, hypertension, hypokalemia, and muscle weakness. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #87 as severely impaired for daily decision making with a score of 3 out of 15.…

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 clinical record review, staff interview and facility document review, the facility staff failed to ensure a pharmacy recommendation for a gradual dose reduction (GDR) was completed for one of 36 in the survey sample, Resident #110. Resident #110's physician signed a GDR pharmacy recommendation for the antidepressant, Escitalopram (Lexapro) to be decreased from 15 mg (milligrams) daily to 10 milligrams daily. The order was not completed for over 4 months. The findings include: Resident #110 was admitted to the facility on [DATE] with diagnoses that included hypertension, history of falls, anorexia, dementia, and major depressive disorder. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #110 as severely impaired for daily decision making, having long and short term memory problems. Resident #110's clinical record was on 01/27/2022. A pharmacy recommendation dated September 13, 2021 through September 15, 2021 documented the following: (Resident #102) has…

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, staff interview, resident interview, facility document review and clinical record review, the facility staff failed to follow infection control practices on one of four units, and failed to store respiratory equipment in a sanitary manner for one of 36 residents in the survey sample, Resident #121. Facility staff failed to don required personal protective equipment (PPE) and perform required hand hygiene during meal tray service on the yellow (warm) quarantine section of unit 1. On multiple days of the survey, Resident #121's nebulizer mask was observed on the floor with no protective cover. The findings include: 1. A meal observation was conducted on 1/25/22 at starting at 12:30 p.m. on unit 1. Staff were observed at this time, serving meal trays to residents on the warm COVID-19 quarantine unit. The warm unit included rooms 104 to 109 and had signs stating full PPE (gown, gloves, N95 mask, face shield) was required when going into resident rooms. On 1/25/22 at 12:34 p.m., patient care aid…

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 document review, and in the course of a complaint investigation, the facility staff failed to ensure DNR (Do Not Resuscitate) status was followe for one of 36 residents in the survey sample, Resident # 213. Resident # 213 had an advance directive for a DNR and facility staff initiated emergency services for CPR (Cardiopulmonary Resuscitation). Findings include: Resident # 213 was admitted to the facility [DATE] with diagnoses including but not limited to: dementia, GERD, and hypertension. The annual MDS dated [DATE] had the resident assessed with long term and short term memory, and severely impaired in daily decision making skills. The resident expired in the facility [DATE]. On [DATE] at 3:30 p.m. the DON (director of nursing) was interviewed. The DON stated That absolutely happened. The nurse making rounds (who no longer works here) reported that she thought the resident was choking. It actually was the resident taking her last breath. We did a FRI (Facility Reported…

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, the facility staff failed to respond to a resident grievance regarding lost and/or missing clothing for one of 36 residents in the survey sample, Resident #149. Findings include: Resident #149 was admitted to the facility on [DATE]. Diagnoses for Resident #149 included, but were not limited to: diabetes mellitus type II, high blood pressure, history of tumor on kidney, history of ovarian cancer, history of pulmonary embolism, osteoarthritis, chronic pain, GERD (reflux), and increased lipids (hyperlipidemia). The most recent MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13, indicating Resident #149 was cognitively intact for daily decision making skills. Resident #149 was assessed as requiring extensive assistance of one or two staff members for bed mobility, dressing, and personal hygiene, with total dependence upon staff for toileting,…

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 ensure one of 36 residents was free from verbal/mental abuse, Resident #121. A certified nurses' aide (CNA) made derogatory remarks/comments to and about Resident #121. CNA #1 berated Resident #121 along with use of a hand gesture regarding the resident's slow consumption of breakfast in the presence of a state surveyor and two roommates. The findings include: Resident #121 was admitted to the facility on [DATE] with diagnoses that included diabetes, dysphagia, protein-calorie malnutrition, glaucoma, peripheral vascular disease, left below knee amputation, history of osteomyelitis, hypertension, lymphedema, diabetic retinopathy with impaired vision, anemia, major depressive disorder, neuromuscular disorder of bladder, congestive heart failure and morbid obesity. The minimum data set (MDS) dated [DATE] assessed Resident #121 with moderately impaired cognitive skills. 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, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure physician's orders for care of a central venous access device was in place upon admission, for one of 36 residents, Resident #313. Findings include: Resident #313 was admitted to the facility on [DATE]. Diagnoses for Resident #313 included, but were not limited to: cirrhosis of the liver without ascites, hypotension, collapsed vertebrae/fracture, acute kidney failure, moderate protein calorie malnutrition, hypothyroidism, compression fracture (L-5) secondary to discitis and osteomyelitis, discitis of lumbosacral region, closed compression fracture of sacrum, and IV Ertapenem for prolonged therapy. The most current MDS (minimum data set) was an admission assessment, which was in progress and not complete. An admission assessment dated [DATE] at 7:15 PM documented, .arrival date & time: 01/20/22 7:15 PM from hospital .Reason For admission: IV antibiotic 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 and clinical record review, the facility staff failed to develop a comprehensive plan of care for two of 36 residents in the survey sample, Resident #61 and #18. Resident #61 had no plan of care regarding a colostomy. Resident #18 had no plan of care developed regarding use of insulin. The findings include: 1. Resident #61 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, pneumonia, protein-calorie malnutrition, rectal cancer with colostomy, hypertension, benign prostatic hypertrophy, anemia, major depressive disorder, chronic kidney disease and heart failure. The minimum data set (MDS) dated 11/15/21 assessed Resident #61 with severely impaired cognitive skills. Section H of this MDS documented the resident had a colostomy. Resident #61's clinical record documented physician orders dated 3/10/21 for colostomy care every shift and a wafer change to the colostomy each week. The resident's treatment administration record for January 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 observation, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of 36 residents in the survey sample, Resident #155 and #94. Resident #155's plan of care was not revised to reflect discontinued use of bed/chair alarms. Resident #94's plan of care was not updated to reflect a change in resuscitation status. The findings include: 1. Resident #155 was admitted to the facility on [DATE] with a readmission on [DATE]. Diagnoses for Resident #155 included cerebral palsy, cognitive communication deficit, left wrist contracture, cardiomyopathy, anemia, obstructive sleep apnea, restless leg syndrome, congestive heart failure, chronic kidney disease, atrial fibrillation, seizure disorder, fractured left femur, chest wall abscess and pneumonia. The minimum data set (MDS) dated [DATE] assessed Resident #155 with moderately impaired cognitive skills. Resident #155's clinical record documented the resident had a history of frequent falls.…

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, clinical record review and facility document review, the facility staff failed to ensure physician ordered, IV (intravenous) antibiotic medication was available for administration for one of 36 residents in the survey sample, Resident #313. Findings include: Resident #313 was admitted to the facility on [DATE]. Diagnoses for Resident #313 included, but were not limited to: cirrhosis of the liver without ascites, hypotension, collapsed vertebrae/fracture, acute kidney failure, moderate protein calorie malnutrition, hypothyroidism, compression fracture (L-5) secondary to discitis and osteomyelitis, discitis of lumbosacral region, and closed compression fracture of sacrum. The most current MDS (minimum data set) was the admission assessment, which was in progress and not complete for Resident #313. An admission nursing assessment dated [DATE] at 7:15 PM documented, .arrival date & time: 01/20/22 7:15 PM from hospital .Reason For admission: IV antibiotic…

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 and clinical record review, the facility staff failed to provide dental services for one of 36 residents in the survey sample, Resident #57. Resident #57 had no follow-up dental services provided regarding acquisition of dentures. The findings include: Resident #57 was admitted to the facility on [DATE] with diagnoses that included diabetes, anxiety, schizophrenia, bipolar disorder, vertigo, hypertension, major depressive disorder and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed Resident #57 with moderately impaired cognitive skills. On 1/26/21 at 3:40 p.m., Resident #57 was interviewed about quality of care in the facility. Resident #57 stated she had seen a dentist a couple of months ago and had impressions made for dentures. Resident #57 stated she had heard nothing else about getting her dentures. Resident #57's clinical record documented a dental consultation dated 12/1/21 stating, Patient in need of Dentures. took impressions…

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 document review, the facility staff failed to store and prepare food in a sanitary manner in the main kitchen of the facility. The findings include: On 01/25/2022 at 12:03 p.m., accompanied by the dietary manager, the facility's main kitchen was inspected. Stored in the stand-up cooler #6 was one half-pint carton of Maola reduced fat milk with an expired date of 01/24/22 and one half-pint carton of Maola whole milk with an expired date of 01/22/22. . On 01/25/2022 at 12:15 p.m., the dietary manager was interviewed about the cartons of the expired milk. The dietary manager stated kitchen employees were supposed to check the refrigerators and stand-up coolers units daily for expired items and discard them as needed. The dietary manager was asked for a policy regarding food storage and expired items. A review of the policy Freezers and Refrigerators Policy (revised 06/09/2021) documented the following: .8. Food and Nutrition Services Director and Staff will be responsible for ensuring food items in refrigerators and freezers are not…

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, staff interviews, facility document review, and review of manufacturer's instructions, the facility staff failed to properly calibrate glucometers on two of four nursing units, Butterfly Path and Serenity. The findings include: 1. On 1/27/2022 at approximately 8:50 a.m., during an inspection of a medication cart on the Butterfly Path Unit, LPN (Licensed Practical Nurse) # 1, who was using the cart, was asked about the glucometer in the cart. LPN # 1 said she had not used the glucometer, that Glucometer checks are done on third shift. Asked when the glucometer was calibrated, LPN # 1 said she did not know. At 9:30 a.m. on 1/27/2022, RN (Registered Nurse) # 3, the Unit Manager on the Butterfly Path Unit, was asked about the calibration of the glucometers on the unit. RN # 3 said there were two glucometers on the unit, one on each medication cart, and that glucometer checks are done on the third shift. Asked if she knew how to calibrate the glucometers, RN # 3 said she did not. RN # 3 was asked for the log documenting the calibration of the glucometers, but 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 clinical record review and staff interview, the facility failed to ensure the accuracy and privacy of the resident's clinical record for one of 37 residents in the survey sample, Resident # 76. A nursing Progress Note in Resident # 76's clinical record included the names of three other residents. The findings were: Resident # 76 was admitted to the facility with diagnoses that included atrial fibrillation, aphasia, Non-Alzheimer's dementia, seizure disorder, ataxia, tremors, and hypothyroidism. According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 11/23/2021, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired, with a Summary Score of 00 out of 15. Review of the Progress Notes in the resident's Electronic Health Record revealed the following entry, dated 1/10/2011 at 15:15 (3:15 p.m.): Resident was attempting to take (name of first resident) walker and (name of first resident) was telling her to move and leave it alone but (name of Resident # 76) would not leave it alone,…

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, clinical record review, and facility document review, the facility staff failed to ensure professional standards of practice by a hospice provider for one of 36 residents in the survey sample, Resident #122. Records of weekly hospice visits for Resident #122 were not provided to the facility as required in the hospice services agreement. The findings include: Resident #122 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis, facial weakness, pneumonia, Alzheimer's disease, dementia, anxiety disorder, aphasia, and hospice care. The most recent minimum data set (MDS) dated [DATE] was a significant change and assessed Resident #122 as severely impaired for daily decision making having long and short term memory problems. Under Section O - Special Treatments and Programs, the MDS assessed Resident #122 as receiving hospice services. Resident #122's clinical record was reviewed on 01/26/22. Observed on the order summary report was the following:…

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 facility training record review, the facility staff failed to ensure 2 of 182 employees were up-to-date for abuse, neglect, and exploitation training. Findings include: Beginning 1/27/22/at 4:00 p.m. the facility training records for on abuse, neglect, and exploitation were reviewed for all staff. Two staff did not have proof of the required training. The DON (director of nursing) was present, and asked about the two employees with no record of yearly training for this requirement. The DON stated, The CNA (certified nursing assistant) tells me she has done that; the housekeeping staff doesn't think he completed it. The CNA says she can provide that information, so I told her to have it here as soon as possible. The DON was advised the CNA could provide the proof as soon as possible. The DON was also asked for a copy of the policy for the training. The housekeeping staff electronic signature for the training was dated 10/14/20. The CNA electronic signature was 10/16/20. The policy Virginia Resident Abuse Policy was reviewed and…

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

Based on staff interview and training hours review, the facility staff failed to ensure one of 44 CNA's (certified nursing assistant) had the required 12 training hours per year. Findings include: On 1/27/22 beginning at 4:00 p.m. training records for CNA staff were reviewed for 12 hours of training per year. The DON (director of nursing) was present during the review, and was advised of the CNA with only 10.25 hours of required training. The DON stated the CNA was sure she had documentation of the training, and would provide the documentation. On 1/28/22 at 9:30 a.m. the DON stated (Name of CNA) was not able to provide documentation of the training hours. All I have for her is what I gave you. No further information was provided prior to the exit conference.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on dining observation, resident interview, and staff interview, the facility staff failed to ensure a dignified dining experience in one of three dining room in the facility. Approximately twelve residents residing on the Season's unit (a memory care unit), were seated together at two tables and served at different times. Findings were: On 10/08/2019 at approximately 11:30 a.m., during initial tour of the facility, the dining room/kitchen area of the Season's unit was observed. The dining area contained two rectangular tables. There was a kitchen area with a warming table used to keep food hot when brought from the main kitchen. LPN (licensed practical nurse) #4, was asked how meal time was handled. She stated, The trays for the 'feeders' come down from the kitchen already prepared. We bring them to the dining room first and give them their trays. Then the kitchen brings down pans of food for everyone else. We plate that up and serve it in the dining room. At approximately 1:00 p.m., the trays and food 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to apply physician ordered protective sleeves for one of 37 residents in the survey sample (Resident #13); and failed to follow professional standards of practice for medication administration for one of 37 residents in the survey sample (Resident #345). The findings include: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease, congestive heart failure, dementia, high blood pressure and chronic knee pain. The minimum data set (MDS) dated [DATE] assessed Resident #13 with severely impaired cognitive skills and as requiring the extensive assistance of one person for dressing. On 10/8/19 at 1:45 p.m., Resident #13 was observed in bed. The resident had no protective geri-sleeves on her forearms. The resident was observed again on 10/8/19 at 4:20 p.m. and on 10/9/19 at 2:00 p.m. without geri-sleeves in place. Resident #13's clinical record documented 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview and staff interview, the facility staff failed to ensure a safe, homelike environment on two of five nursing units. A resident room on unit 2 had constantly running water in the sink, a malfunctioning bathroom door, holes in the bathroom wall and a broken air freshener holder. A resident room on unit 1 had a broken/missing toilet paper holder and holes in the bathroom wall. The findings include: On 10/8/19 at 11:30 a.m., the bathroom in room [ROOM NUMBER] was inspected. There were multiple holes in the bathroom wall. The toilet paper bracket was broken and missing on one side with the toilet paper positioned in the floor. A private sitter (other staff #2) working in this room was interviewed about the broken bathroom item. The sitter stated the toilet paper bracket had been broken for about 3 weeks. The sitter stated she previously reported the broken bracket but it had not been fixed. On 10/8/19 at 11:53 a.m., Resident #135 was interviewed about quality of life 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 staff interview and clinical record review, the facility failed to develop a baseline care plan for tube feeding for one of 37 Residents, Resident #396. The findings Include: Resident #396 was admitted to the facility on [DATE]. Diagnoses for Resident #396 included; Alzheimer's disease, dementia, diabetes, and placement of a gastrostomy tube (feeding tube). The most current MDS (minimum data set) was not completed at the time of the survey due to Resident #396 being a new admission. On 10/9/19 Resident #396's medical record was reviewed and indicated that Resident #396 was newly admitted with a feeding tube. Review of Resident #396's baseline care plan documented a check mark beside feeding tube, but did not indicate any goals or interventions for the care of Resident #396's feeding tube. On 10/09/19 at 9:26 AM, MDS coordinator (registered nurse, RN #1) was interviewed. RN #1 stated that an initial MDS had not been completed as Resident #396 was a new admission and that after the MDS was complete then 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to follow physician's orders for treatment and care of skin integrity for two of 37 resident's. Resident #86 did not have heels floated or elbow protector while in bed per physician o5rders, and Resident #13 did not have a properly functioning air matress in place. The Findings Include: 1. Resident #86 was admitted to the facility on [DATE]. Diagnoses for Resident #86 included: Hemiplegia, sepsis, bed confinement status, and cerebrovascular accident. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 8/13/19. Resident #86 was assessed as moderately cognitively intact. On 10/9/19 Resident #86's medical record was reviewed. An active physician's order set dated 10/1/19 through 10/31/19 included orders to use heel protectors on while in bed and to apply an Elbow Protector to LT [left] Elbow While In Bed. On 10/9/19 at 9:30 AM and again at 1:50 PM Resident…

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, staff interview, family interview, resident interview and clinical record review, the facility staff failed to ensure podiatry services for one of 37 residents, Resident #110. Findings were: Resident #110 was admitted to the facility on [DATE], with the following diagnoses, but not limited to: Alzheimer's, Parkinson's, hypertension, and peripheral vascular disease. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 08/19/2019, assessed Resident #110 as severely impaired in his cognitive status with a summary score of 05. On 10/08/2019 at approximately 11:55 a.m., Resident #110 was observed sitting in the day room with his wife. They were interviewed regarding life at the facility. Resident #110's wife stated, It is lovely here, we are very pleased with his care. The staff is wonderful. The only problem I have is that they ordered him new shoes and they haven't gotten here yet. They've been at the foot doctor's office for five weeks .they said his shoes he has are…

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, staff interview, and clinical record review, the facility staff failed to implement fall interventions to prevent accidents for 1 of 37 in the survey sample. Resident #15, who was identified as having a history of falls was observed without a fall mat beside the bed. The findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses that included hypertension, diabetes, Non-Alzheimer's Dementia, left-side hemiplegia, and seizures. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #15 has having long and short term memory problems, severely impaired for daily decision making, and having continuous periods of inattention and disorganized thinking. Further review of the 09/25/19 MDS revealed under Section G - Functional Status, Resident #15 was assessed as not ambulating in his room or on the unit; as being total dependent for transfers, bed mobility, dressing, eating, hygiene, bathing and locomotion on and off the unit.…

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, staff interview, clinical record review and facility document review, the facility staff failed to ensure physician's orders for the care and maintenance of a PICC (Peripherally inserted central catheter) line for one of 37 residents, Resident #346. Findings include: Resident #346 was admitted to the facility on [DATE] with diagnoses including, but not limited to: CAD (coronary artery disease), high blood pressure, cellulitis of the right foot, osteomyelitis of the right foot, positive MRSA (methicillin resistant staphylococcus aureus) screen and diabetes mellitus. The most current MDS (minimum data set) was an entry assessment dated [DATE], this MDS did not provide complete information on the resident. Resident #346's admission assessment dated [DATE] and timed 5:00 PM was reviewed and documented, .reason of admission: therapy/ABT [antibiotics] .osteomyelitis (R) foot, PAD [peripheral artery disease] .MRSA . Resident #346 was assessed as being alert and oriented to person, place, time and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to ensure an accurate clinical record for one of 37 residents in the survey sample. Resident #13's clinical record inaccurately documented a physician's order for restorative dining services. The findings include: Resident #13 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease, congestive heart failure, dementia, high blood pressure and chronic knee pain. The minimum data set (MDS) dated [DATE] assessed Resident #13 with severely impaired cognitive skills. On 10/9/19 at 8:30 a.m., Resident #13 was observed eating breakfast in her room, unattended by staff. Resident #13's clinical record documented a physician's order signed by the physician on 9/30/19 for restorative dining services. The MDS assessment dated [DATE] listed the resident required set up and cueing only for eating. On 10/9/19 at 2:08 p.m., the certified nurses' aide (CNA #3) caring for Resident #13 was interviewed…

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, staff interview, clinical record review and facility document review, the facility staff failed to ensure appropriate infection control practices to identify and control infections for two of 37 residents, Resident #195 and Resident #346. Findings include: Resident #195 was admitted to the facility on [DATE]. Diagnoses for this resident included, but were not limited to: High blood pressure, osteoporosis, history of prostate cancer, high blood pressure, history of colon cancer, BPH (benign prostatic hypertrophy) with obstructive uropathy, chronic indwelling Foley catheter and ESBL (extended spectrum beta-lactamase) infection. The most current MDS (minimum data set) was a 14 day admission assessment dated [DATE]. This MDS assessed the resident as having a cognitive score of 9, indicating the resident had moderate impairment in daily decision making skills. The resident was also assessed as requiring extensive assistance of one for toileting and hygiene. The resident was also assessed as…

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, staff interview, facility document review and clinical record review, the facility staff failed to perform a bed safety inspection prior to installation of a specialty mattress for one of 37 residents in the survey sample. A specialty air mattress was installed and in use by Resident #13 without a prior inspection for bed safety to minimize entrapment risks. The findings include: Resident #13 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease, congestive heart failure, dementia, high blood pressure and chronic knee pain. The minimum data set (MDS) dated [DATE] assessed Resident #13 with severely impaired cognitive skills. On 10/10/19 at 7:50 a.m., Resident #13 was observed in bed with specialty air mattress in use. Quarter length side rails were in the raised position on both sides near the head of the bed. Resident #13's clinical record documented a physician's order dated 10/9/19 to discontinue use of an alternating air pressure pad and initiate…

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.