Club Healthcare and Rehabilitation Center at the V

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 of 5 residents reviewed (Residents #11 and #90).

Inspectors wroteBased on interview and record review the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed when a mental illness was identified for 1 of 3 residents, Resident #20, review for PASRR screening.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to ensure assistance with activities of daily living (ADLs) for nail care for 1 of 5 residents, Resident #59, reviewed for ADL (Activities of Daily Living) care.

Inspectors wroteBased on interview and record review the facility failed to ensure blood pressure medication administration per the physician's ordered parameters for 1 of 6 residents, Resident #46, reviewed for medication management.

Inspectors wroteBased on interview and record review the facility failed to provide laboratory and diagnostic testing as ordered for 2 of 6 residents reviewed for laboratory services (Resident #11 and #74). Finding including:1) Review of Resident #11's physician order dated 6/8/2026 read, UA [urine analysis] & culture take sample on 06/11/2026. Review of Resident #11's laboratory documentation did not document a urinalysis and culture and sensitivity dated 6/11/2026. During an interview on 6/17/2026 at 9:33 AM Staff C, Licensed Practical Nurse stated, I spoke to the provider yesterday [6/16/2026]. I saw the order and asked the patient [Resident #11] he had no signs and symptoms and I called the provider. I didn't see any results in the system. Generally, we collect the sample the same day. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the possible spread of infection by not donning personal protective equipment when providing direct care for 1 of 3 residents, Resident #37, reviewed for enhanced barrier precautions and failing to performed hand hygiene during mealtime for Residents #55 and #42. Finding including: 1) During an observation on 6/16/2026 at 8:15 AM on the outside of Resident #37's room door there was an Enhanced Barrier Precaution sign. Staff E, Certified Nursing Assistant (CNA) entered with Resident #37's breakfast tray and placed it on the bedside table. Without wearing gloves or a gown Staff E began to reposition Resident #37 in bed. Staff E reposition Resident #37's pillow and proceeded to readjust the resident's head on the pillow. [...]

Inspectors wroteBased on record review and interview, the facility failed to submit accurate direct care staffing information to CMS for the fourth quarter of 2024.

Inspectors wroteReview of Resident #1's physician order dated 12/25/2024 showed it read, House Nutritional Supplement two times a day for Nutritional Supplement, risk of malnutrition, Offer 240 ml and document amount consumed. Review of Resident #1's physician order dated 12/25/2024 showed it read, House Protein two times a day for risk of malnutrition, Offer 30 ml and document amount consumed. Review of Resident #1's medication administration record for January 2025 showed no entries documented for the amount of House Protein consumed or the amount of House Nutritional Supplement consumed from 1/1/2025 through 1/27/2025. Review of Resident #38's physician order dated 1/1/2025 showed it read, House Nutritional Supplement two times a day for Nutritional supplement, risk of malnutrition, Offer 240 ml and document amount consumed. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident's physician was notified of a change in condition for 1 of 3 residents reviewed for significant weight loss, Resident #38.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 1 of 5 residents reviewed for nutrition, Resident #17.

Inspectors wroteBased on record review and interview, the facility failed to reassess the effectiveness of the interventions, review and revise the resident's care plan when necessary for 1 of 3 residents reviewed for significant weight loss, Resident #38.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received adequate nutrition for 1 of 3 residents reviewed for significant weight loss, Resident #38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater for 2 out of 31 observations of medication administration. The facility had a medication error rate of 6.45%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles (Photographic evidence obtained).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used appropriate personal protective equipment (PPE) while providing direct contact care for 2 of 10 residents reviewed for enhanced-barrier precautions (EBP), Residents #1 and #161, and 1 of 4 residents reviewed for transmission-based precautions, Resident #158, to prevent the possible spread of infection and communicable diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were stored in a safe and sanitary manner in bistro of the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure initial weights were obtained for 4 of 6 residents, Residents #93, #28, #196, and #198, upon admission to the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' medical records were complete and accurately documented for 2 of 7 residents, Residents #4, and #198 reviewed for care treatments.

Inspectors wroteBased on record review and interview the facility failed to provide a bed hold notice to the resident or the resident's representative when the resident was transferred to the hospital for 1 of 4 residents, Resident #195, reviewed for discharge.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure care plan fall precautions were fully implemented for 1 of 4 residents, Resident #18, reviewed for accidents.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure residents received treatment care and services in accordance with professional standards for 1 of 1 resident, Resident #198, with a central venous line catheter, and 1 of 6 residents, Resident #29 reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents' environment was free of accident hazards for 1 of 4 residents, Resident #18, reviewed for accidents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 2 of 4 medication carts, and failed to ensure medications were secure when unattended in 1 of 2 units, the POLO unit.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the possible spread of infection when not performing hand hygiene and following infection control standards during wound care, and failed to ensure transmission-based precautions were followed.