Daleville Health and Rehabilitation

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility kitchen and 2 of 2 nourishment rooms.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the correct code status was in place for 1 of 19 residents in the survey sample, Resident #46.

Inspectors wroteBased on observation, Resident interview and staff interview the facility staff failed to provide a clean, comfortable, and homelike environment for 1 of 19 residents, Resident #63.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to implement a comprehensive person-centered care plan to meet the needs of the resident for 1 of 19 residents in the survey sample, Resident #2.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for 2 of 19 residents, Resident #31 and #63.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to follow the medical provider orders for 1 of 19 residents in the survey sample, Resident #62.

Inspectors wroteBased on staff interview and clinical record review, facility staff failed to provide treatment as ordered for pressure ulcers for 2 of 19 residents in the survey sample (Residents #68 and #35). Resident #68 was admitted to the facility with diagnoses including, but not limited to, hypertension, seizures, pressure ulcers, pain, anxiety, and depression. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the brief interview for for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The electronic clinical record contained orders for daily dressing changes to a sacral wound. The Treatment Administration Record was blank for 4/4/2024. The nursing progress note dated 4/4/2024 at 2:10 AM documented the resident refused a shower at that time but agreed to a bed bath. There were no wound care notes on that date. [...]

Inspectors wroteBased on staff interview, clinical record review and facility document review the facility staff failed to complete a safe smoking assessment for 1 of 19 residents, Resident #20.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide the health care provider ordered therapeutic diet for 2 of 19 residents, Resident #54 and #25.

Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to obtain a provider ordered medication for 1 of 19 residents in the survey sample, Resident #46.

Inspectors wroteBased on staff interview, clinical record review and facility document review the facility staff failed to review and act upon a monthly medication regimen review for 1 of 19 residents, Resident #234.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a complete and accurate clinical record for 2 of 19 residents in the survey sample, Resident #46 and #21.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a Quality Assurance and Performance Improvement (QAPI) Program to meet the needs of the facility and failed to monitor and revise as needed the plan of correction for the standard recertification surveys dated 4/11/19, 5/27/21, and 2/16/23 in order to maintain compliance as evidenced by repeated deficiencies in the area of Pharmacy Services.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to distribute and serve food in accordance with professional standards for food service safety as evidenced by a final rinse temperature below 180 degrees Fahrenheit (F) for a high temperature (heat sanitization) dishwasher in the facility kitchen.

Inspectors wroteBased on interviews and document reviews, the facility staff failed to maintain complete and accurate clinical records for five (5) of 24 residents, Resident #50, Resident #68, Resident #70, Resident #125, and Resident #176.

Inspectors wroteBased on resident representative interview, staff interview, clinical record review, and facility document review, the facility staff failed to notify the resident representative of significant changes in the resident's physical condition for 1 of 24 residents in the survey sample, Resident #61.

Inspectors wroteBased on interviews and document review, the facility staff failed to complete a Significant Change Minimum Data Set (MDS) assessment for one (1) of 24 residents, Resident #68.

Inspectors wroteBased on interviews and document reviews, the facility staff failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents' conditions for two (2) of 24 residents, Resident #68 and Resident #70.

Inspectors wrote3. The facility staff failed to develop a care plan to address Resident #68's hospice needs. Resident #68's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/11/23, was signed as completed on 1/11/23. Modification to this MDS assessment were documented on 2/14/23 and 2/16/23. Resident #68 was assessed as rarely or never able to make self understood and as rarely or never able to understand others. Resident #68 was assessed as the Brief Interview for Mental Status should not be completed due to the resident being rarely/never understood. Resident #68 was documented a being dependent on others for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #68 had an order for consult for hospice care and to treat if approved dated 11/29/22. [...]

Inspectors wroteBased on interviews and document review, the facility staff failed to ensure clinical documentation supported new diagnoses for two (2) of 24 residents, Resident #68 and Resident #50.

Inspectors wroteBased on facility document review and clinical record review, and staff interview facility staff failed to provide treatment as ordered for one of 24 current residents in the survey sample (Resident # 176). Resident #176 was admitted to the facility on [DATE]. The resident's diagnoses included primary adrenocortical insufficiency, ployneuropathy, chronic obstructive pulmonary disease, polymyalgia rheumatica, common variable immunodeficiency, morbid obesity type 2 diabetes mellitus, chronic pancreatitis, depression, anxiety, muscle spasms, nausea, allergies, edema, primary adrenocortical insufficiency, hypertension, and insomnia. At the time of the survey, the resident did not yet have a minimum data set assessment. [...]

Inspectors wroteBased on staff interview and clinical record review, facility staff failed to provide pressure ulcer treatment as ordered for one of 24 current residents in the survey sample (Resident #5). Resident #5 was admitted to the facility with diagnoses including hypertension, peripheral vascular disease, gastroesophageal reflux, muscle weakness, major depression, osteoarthritis, cognitive communication deficit and polyneuropathy. On the minimum data set assessment with assessment reference date 12/8/2022, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting treatment. The resident was assessed as having one unhealed stage two pressure ulcer and application of non-surgical dressing. [...]

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure that residents maintain acceptable parameters of nutritional status for 1 of 24 residents in the survey sample, Resident #61.

Inspectors wrote2. The facility staff failed to assess respiratory status for Resident #125. Resident #125 was COVID-19 positive at the time of admission. On the afternoon of 2/13/23, Resident #125 was observed to be resting in bed, coughing. Resident #125's Minimum Data Set (MDS) assessment had yet to be completed at the time of the survey. Review of Resident #125's clinical documentation failed to reveal evidence of a respiratory exam until approximately 38 hours after the resident's arrival to the facility. The following information was found in a facility policy titled Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents (with a revised date of September 20212): - Residents are monitored daily for signs of respiratory infection and/or symptoms of COVID-19, including: a. fever (temperature (greater than or equal to) 100.0 (degrees Fahrenheit) and/or chills; b. cough; c. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure that residents who require dialysis receive services consistent with the comprehensive person-centered care plan for 1 of 24 residents in the survey sample, Resident #42.

Inspectors wroteBased on interviews and document review, the facility staff failed to ensure Medication Regimen Reviews (MRRs) were addressed by a medical provider for two (2) of 24 residents, Resident #68 and Resident #61.

Inspectors wroteBased on resident representative interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents are free of any significant medication errors for 1 of 24 residents in the survey sample, Resident #61.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide laboratory services to meet the needs of the resident for 1 of 24 residents in the survey sample, Resident #61.

Inspectors wrote7. For Resident #11, the facility staff failed to provide assistance with showers per the resident's preference of twice weekly. Resident #11's diagnosis list indicated diagnoses, which included, but not limited to Spondylolisthesis Lumbar Region, Bipolar II Disorder, Hereditary Motor and Sensory Neuropathy, Muscle Wasting and Atrophy, and Epilepsy Unspecified not Intractable without Status Epilepticus. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 4/22/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15 in section C, Cognitive Patterns. Resident #11 was coded as being totally dependent in bathing. On 5/26/21 at 9:19 am, surveyor spoke with Resident #11 who stated that they did not get their shower on Monday because there was not enough staff. Resident further stated that this happens often on Mondays. [...]

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to accurately code a MDS (minimum data set) assessment to reflect the resident's status for 1 of 22 residents, Resident #61.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure the residents receive treatment and care in accordance with the comprehensive person-centered care plan for 2 of 22 residents, Residents #31 and #19.

Inspectors wrote2. For Resident #31, the facility staff failed to report the February 2021 drug regimen review to the attending physician, the facility medical director, and the DON (director of nursing). Resident #31's diagnosis list indicated diagnoses, which included, but limited to Muscle Wasting and Atrophy not Elsewhere Classified Other Site, Unspecified Injury at Unspecified Level of Cervical Spinal Cord, Functional Quadriplegia, Generalized Anxiety Disorder, and Major Depressive Disorder Recurrent Mild. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 4/27/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive patterns. Upon review of Resident #31's clinical record on 5/26/21, surveyor was unable to locate the February 2021 drug regimen review completed by the pharmacist. [...]