Charlottesville Health & Rehabilitation Center

Inspectors wroteBased on staff interviews and facility document review, the facility failed to ensure resident preferences were met regarding showers for one of two units (unit one), which did not provide showers due to low weekend staffing.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure that unnecessary psychotropic medications were not administered to one resident, Resident #5 (R5) out of a survey sample of six residents.

Inspectors wroteBased on staff interviews and facility document review, the facility failed to ensure sufficient staffing in accordance with the facility assessment on one of two units (unit one), which had excessively low weekend staff.

Inspectors wroteBased on staff interviews, clinical record review, and facility document review, the facility failed to ensure an appropriate discharge for one of six residents, resident #6.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review the facility staff failed to follow physician orders for one resident, Resident #5 (R5) out of a survey sample of six residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review the facility staff failed to ensure medication review was performed by physician services on admission for one resident, Resident #5 (R5) out of a survey sample of six residents.

Inspectors wroteBased on staff interviews and clinical record review, the facility failed to ensure a complete and accurate record for two of six residents.

Inspectors wroteBased on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to follow the menu for both meals observed, affecting multiple residents, including Resident #2-R2, Resident #3 - R3, Resident #4 -R4, and Resident #5-R5, who resided on two of two nursing units.

Inspectors wroteBased on observation, resident and staff interviews, and facility documentation review, the facility staff failed to provide liquids consistent with resident needs and preferences affecting multiple residents on two of two units.

Inspectors wroteBased on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to follow the menu for both meals observed, affecting multiple residents who resided on two of two nursing units.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to maintain essential equipment in safe, operating condition the main kitchen.

Inspectors wroteBased on observation, resident interviews, staff interviews, clinical record reviews, and facility documentation reviews, the facility staff failed to provide meals in accordance with resident preference for 2 residents (Resident #2 - R2 and Resident #10 - R10) out of a survey sample of 8 residents.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to notify the responsible party of a change in condition for one of four residents in the survey sample, (Residents #3). Resident #3's (R3) responsible party was not notified of a fall with injury. This was a closed record review.

Inspectors wroteBased on staff interview and facility record review, the facility staff failed to have a surety bond to assure the security of all personal funds of residents deposited with the facility, which affected 72 residents who had funds deposited with the facility.

Inspectors wroteBased on resident interviews, staff interviews, and facility documentation review, the facility staff failed to maintain sufficient nurse staffing to assure resident safety and highest practicable well-being of each resident, to meet their daily needs in accordance with the facility assessment, for 2 of 2 nursing units.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, and serve food accordance with professional standards for food safety in the main kitchen, which has the potential to affect multiple residents on 2 of 2 nursing units.

Inspectors wroteBased on observation, resident interview, staff interviews, facility documentation review and clinical record review, the facility staff failed to assess and determine if a Resident was safe to self-administer medications that were at the bedside, for one Resident (Resident #28) in a survey sample of 26 Residents.

Inspectors wroteBased on family interview, staff interview, facility document review and clinical record review, the facility staff failed to provide advance written notice of a room change for one of twenty-six residents in the survey sample (Resident #77).

Inspectors wroteBased on facility staff interview, clinical record review and facility documentation review, the facility staff failed to obtain and incorporate the recommendations from a level II PASARR (preadmission screening and resident review) into the Resident's assessment and care plan for one Resident (Resident #46) in a survey sample of 26 Residents.

Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure that residents receive devices to prevent accidents for one resident (Resident #28- R28), in a survey sample of 26 residents.

Inspectors wroteBased on observations, staff interviews, facility document review, and clinical record review, the facility staff failed to ensure that each resident received the necessary respiratory care, services, and failed to appropriately store respiratory equipment, in accordance with professional standards of practice for two residents (Resident #84 and Resident #28) in a survey sample of 26 residents.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure prn (as needed) orders for psychotropic medication was limited to 14 days, affecting 1 resident (Resident #82- R82), in a survey sample of 26 residents.

Inspectors wroteBased on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to provide meal substitutions in accordance with resident preferences for one resident (Resident #32- R32), in a survey sample of 26 residents.

Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to provide a therapeutic diet in accordance with physician orders for one resident (Resident #82- R82) in a survey sample of 26 residents.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to provide a complete and accurate clinical record for one of twenty-six residents in the survey sample (Resident #77).

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow infection control practices for one of 26 residents.

Inspectors wroteBased on staff interview and facility documentation review the facility staff failed to ensure CNA's (certified nursing assistant) received 12 hours of in-service training per year for one CNA (CNA #8), in a survey sample of two CNA's reviewed.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to follow posted menus for six of ten residents in the survey sample (Residents #1, #2, #3, #5, #6 and #10).

Inspectors wroteBased on observation, resident interview, staff interview, and facility document review, the facility staff failed to serve food at an appetizing temperature on one of two units (unit 1).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to notify the responsible party of changes in medications for one of ten residents in the survey sample (Resident #7).

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility failed to develop a resident centered care plan for one of 4 resident's. Resident #1 (R1) did not have resident specific interventions for nutrition, vision, activities of daily living (ADL's), and bowel incontinence. The Findings Include: Diagnoses for R1 included; irritable bowel syndrome (IBS), lactose intolerant, chronic diarrhea, and retinopathy with macular edema. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 9/14/23. R1 was assessed with a cognitive score of 15 out of 15, indicating intact cognition. During an interview on 12/4/23 at 11:20 AM, R1 verbalized that he could only see the outline of a person and shapes, but was able to get to the bathroom by counting steps and feeling the wall. [...]

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility failed to provide meals to accommodate food allergies/intolerance for one of 4 resident's. Resident #1 (R1) was served food that exacerbated his medical condition. The Findings Include: Diagnoses for R1 included irritable bowel syndrome (IBS), lactose intolerant, chronic diarrhea, and retinopathy with macular edema. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 9/14/23, which assessed R1 with a cognitive score of 15 out of 15, indicating intact cognition. During an interview on 12/4/23 at 11:20 AM, R1 verbalized that he is lactose intolerant but is served food containing milk, which upsets his stomach and results in needing to use the bathroom right away. [...]

Inspectors wroteBased on observation, clinical record review, and staff interview the facility staff failed to follow physicians orders for the administration of the correct formulation of a multi-vitamin for one of 22 residents in the survey sample, Resident # 9. Resident # 9 was ordered Men's Daily Health Formula and instead was administered a regular multi-vitamin for a period of five months.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control practice during a medication pass observation on one of two units. Thirteen oral medications were touched by the nurse's bare hands/fingers prior to administering them to residents during a medication pass on unit two.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to develop a baseline care plan for one of 22 in the survey sample, Resident #289. Resident #289's baseline care plan failed to include a problems/focus area, goals and interventions for the anticoagulant medication, Apixaban.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for one of 22 in the survey sample, Resident #60. Resident #60's comprehensive care plan did not include a problem/focus area with goals and interventions for the use the anticoagulant medication, Heparin Sodium Solution.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to perform a pressure ulcer dressing change in a manner to prevent infection for one of twenty-two residents in the survey sample, Resident #33. A nurse failed to perform hand hygiene between glove changes during dressing changes to Resident #33's pressure ulcers.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to implement use of safety devices for one of twenty-two residents in the survey sample, Resident #36. Resident #36 was observed in a wheelchair without anti-rollback devices as required in his plan of care for fall/injury prevention.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure two of 23 residents were free from unnecessary medications. Residents #13 and #73 had physician orders for as needed (prn) psychotropic medications in place for greater than 14 days. These as needed prescriptions were continued beyond the 14-day limit without a specified duration. 1. Resident #13 had a physician's order for prn (as needed) Lorazepam in place greater than 14 days. This prescription was continued without a specified duration. 2. Resident #73 was prescribed Ativan (psychotropic medication) on an as needed basis for longer that 14 days without thorough justification.

Inspectors wroteBased on clinical record review and staff interview, the facility failed for one of 23 residents in the survey sample (Resident # 145), to ensure a PASARR, used to screen for a mental disorder or intellectual disability, was completed prior to the resident's admission to the facility. Resident # 145 was admitted to the facility without a PASARR, which prevented the facility from knowing if the resident required specialized treatment or services to address a mental disorder or intellectual disability.

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to develop a baseline care plan for one of 23 residents, Resident #344. Resident #344's baseline care plan failed to include any problems, goals, and/or interventions for ADL assistance (activities of daily living) and dietary instructions.

Inspectors wroteBased on clinical record review and staff interview, the facility failed for two of 23 residents in the survey sample (Resident # 23 and 46), to develop a plan of care that encompassed the resident's total care needs. 1. For Resident # 46, the facility failed to develop a plan of care that addressed the resident's whirlpool treatments for localized edema, and for the refusal of the treatments; and, failed to develop a plan of care to address the resident's use of psychotropic medications. 2. Resident #23 had no care plan developed regarding tooth pain and difficulty chewing due to broken teeth.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 23, Resident #65. Resident #65's care plan was not revised to reflect interventions for skin integrity. The Findings Include: Resident #65 was admitted to the facility on [DATE]. Diagnoses for Resident #65 included: Subdural hemorrhage, hemiplegia affecting the right side, muscle weakness, and schizoaffective disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (Assessment Reference Date) of 1/25/19. Resident #65 had a cognitive score of 15, indicating cognitively intact. On 02/12/19 at 1:48 PM, Resident #65 was interviewed. Resident #65 verbalized he prefered to spend most the day in bed but would like to get out of bed for short periods of time during the day. [...]

Inspectors wroteBased on observation, resident interview, family interview, staff interview and clinical record review, the facility staff failed to assess and implement interventions to maintain and/or improve the ability to carry out activities of daily living (ADLs) for one of 23 residents in the survey sample. Resident #196, with no restricted activities, remained in bed for one week following a re-admission to the facility after a hospitalization. Staff reported they were waiting for a therapy assessment before getting the resident out of bed. There was no assessment by any discipline during the week following the re-admission regarding the resident's transfer and mobility needs.

Inspectors wroteBased on resident interview, staff interview and clinical record review, the facility staff failed to follow physician orders for one of 23 residents in the survey sample. A dose of the medication Neurontin was not administered to Resident #82 as prescribed by the physician.

Inspectors wroteBased on observation, resident interview, 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 23 resident's, Resident #65 and Resident #196. 1. Resident #65 did not have physician ordered heel protectors (prevlon boots) on while in bed. 2. Resident #196 developed a stage 2 pressure ulcer on her left upper buttock after remaining in bed for one week following a re-admission and without application of a specialized mattress as required in her plan of care for pressure ulcer prevention. The Findings Include: 1. Resident #65 was admitted to the the facility on 12/28/18. Diagnoses for Resident #65 included: Subdural hemorrhage, hemiplegia affecting the right side, muscle weakness, and schizoaffective disorder. [...]

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure safety interventions were in place to help prevent accidents and injury for one of 23 residents , Resident #16. Resident #16 was not moved closer to the nurses station as indicated in the Resident's care plan intervention for falls. The Findings Include: Resident #16 was admitted to the the facility on 11/12/18. Diagnoses for Resident #16 included: COPD, Major depression, , anxiety, hypoxemia, bilateral knee replacements. The most current MDS (minimum data set) was an admission assessment with an ARD (Assessment Reference Date) of 11/19/18. Resident #16 had a cognitive score of 14 indicating cognitively intact. On 02/13/19 at 9:01 AM, an interview was conducted with Resident #16. During the interview Resident #16 mentioned she has had a couple of falls recently but without injuries. [...]

Inspectors wroteBased on resident interview, staff interview and clinical record review, the facility staff failed to provide dental services for two of 23 residents in the survey sample. Resident #23 was not provided dental services regarding assessed broken, painful teeth that caused chewing difficulty. Resident #82 was not provided services to replace two dislodged dental crowns.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure notification in writing to the state ombudsman office of a transfer for one of 23 residents in the survey sample. A written notification of Resident #195's transfer to the hospital was not sent a representative of the state ombudsman office. In addition, facility staff reported no discharges and/or transfers in the facility were reported in writing to the ombudsman office unless a resident left against medical advice.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide written notice of the bed-hold policy at the time of transfer for one of 23 residents in the survey sample. No written copy of the bed-hold policy was provided when Resident #195 was transferred to the hospital. In addition, staff reported no practice of providing written bed-hold policy information to residents or their families at the time of transfer out of the facility.