Fayetteville Healthcare Center

Inspectors wroteBased on record review and staff interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments. This deficient practice had the potential to affect one (1) of three (3) closed records reviewed during the survey process. Resident Identifier: #60. Facility Census: 57.

Inspectors wroteBased on record review and staff interview, the facility failed to revise the resident's comprehensive care plan to reflect the resident's choices of long term care goal. This had the potential to affect one (1) of 30 residents reviewed in the Long-Term Care Survey Process. Resident Identifier: #6. Facility Census: 57. Findings Included:a) On 03/11/26 at 10:15 AM, a document review revealed resident's care plan stated the following: Page one (1), Patient with plans to discharge to home when there is an overall improvement in abilities. Date Initiated: 02/08/19Revision on: 02/08/19 Page 14, Resident has no plans for discharge secondary to long term care placement in the facility. Date Initiated: 08/28/24 Revision: 08/28/24 b) Interview with Social Worker, on 03/11/26 at 10:18 AM, who reported the initial focus should have been resolved but continues to show up on care plan as active. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to honor a resident's Physician's Orders for Scope of Treatment (POST) form indicating the resident did not want cardio-pulmonary resuscitation. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the closed record category of death. This was determined to be past non-compliance beginning on [DATE] and ending [DATE]. Resident Identifier: #61. Facility Census: 57. Findings Included:a) Resident #61 The facility's policy titled Emergency Procedures, with no implementation or revision dates given, stated cardio-pulmonary resuscitation (CPR) would not be provided for residents having a valid physician order to withhold CPR per the resident's or resident's representative's request. Review of Resident #61's medical records showed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to resident hand sanitation before meals. This was true for Resident #53 and Resident #6. Facility census: 57.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain an infection control program for removal of dirty dishes, old food and drinks from the dining room for Resident #31 and storage of the oxygen cannula and tubing and a soiled bath basin for Resident #47. These were random opportunities for discovery. Resident Identifiers: #31 and #47. Facility Census: 57. Based on observation and staff interview, the facility failed to maintain an infection control program for removal of dirty dishes, old food and drinks from the dining room for Resident #31 and storage of the oxygen cannula and tubing and a soiled bath basin for Resident #47. These were random opportunities for discovery. Resident Identifiers: #31 and #47. Facility Census: 57. Findings Include: [...]

Inspectors wroteBased on observation and staff interview, the facility failed to provide a dignified experience during activities of daily living (ADL) care for Resident #55. This was a random opportunity for discovery. Resident Identifier: #55. Facility Census: 57. Findings Include: a) Resident #55 On 07/01/25 at 3:25 AM, an observation of Resident #55 sitting in a wheelchair with no shirt on and brief on in front of the bathroom with the door to the hallway was open. Nurse Aide (NA) #15 was emptying the urinary catheter bag. Resident #55 was interview at this time. The resident was asked, are you getting the assistance you need? The resident stated, she is getting my catheter emptied and getting ready to put me on the pot. On 07/01/25 at 3:40 AM, the Director of Nursing (DON) was advised of the observation. The DON confirmed the door to the hallway should have been closed.

Inspectors wroteBased on record review and staff interview, the facility failed to complete discharge planning and permit Resident #58 to return to the facility after an acute care transfer. This was true for one (1) of one (1) residents reviewed under the care area of transfers/discharges. Resident identifier: #58. Facility census: 57. Based on record review and staff interview, the facility failed to complete discharge planning and permit Resident #58 to return to the facility after an acute care transfer. This was true for one (1) of one (1) residents reviewed under the care area of transfers/discharges. Resident Identifier: #58. Facility Census: 57. Findings Include: a) Resident #58 On 07/01/25 at 5:00 AM, a review of a facility-reported incident (FRI) dated 12/27/24 was completed. The review found Resident #58 had been admitted to the facility on [DATE]. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide an accurate and complete record for Resident #58. This was true for one (1) of nine (9) residents reviewed during the survey process. Resident Identifier: #58. Facility Census: 57. Findings Include: a) Resident #58 On 07/02/25 at 8:40 AM, a record review was completed for Resident #58. The review found the resident had been transferred to an acute care facility on multiple occasions. The transfer form dated 02/02/23 was incorrect and the correct date was 03/26/24. An additional transfer form dated 03/26/24 was incorrect and the correct date was 08/09/24. On 07/02/25 at 8:55 AM, the Director of Nursing (DON) was notified regarding the incorrect dates on the transfer forms. The DON confirmed the dates were incorrect. The DON stated, sometimes the nurses get in a hurry and do not review the transfer form dates.

Inspectors wroteBased on observation and staff interview the facility failed to ensure hallways were free from clutter and allowed resident a direct access down the hallway. This was a random opportunity for discovery and had the potential to affect a minimal number of residents residing in the Long-Term Care Facility. Facility census:

Inspectors wroteBased on record review and staff interview the facility failed to implement their antibiotic stewardship program. Resident #44's attending physician received the urine culture results which indicated the resident's infection was resistant to Macrobid. However, the physician ordered Macrobid to treat the urinary tract infection (UTI). The resident did not improve and when questioned the facility reviewed the culture again and discovered the wrong antibiotic was ordered. This resulted in actual harm for Resident #44. Her UTI symptoms persisted and she was later hospitalized with sepsis. This was discovered during the completion of the infection control task during the long term care survey process. Resident Identifier: #44 Facility Census: 56 Findings Included: [...]

Inspectors wroteBased on observation and staff interview the facility failed to dispose of garbage and refuse properly by not ensuring the lid on the dumpster was closed. This was found while completing the facility task of the Kitchen and has the potential to affect all residents currently residing in the facility. Resident Census: 56.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the safe food handling practices was used. A glass was held barehanded by the rim during mixing for a thickened diet. This was a random opportunity for discovery identified during the long term care survey process and had the potential to affect a limited number of residents. Facility Census: 56.

Inspectors wroteBased on medical record review and staff interview the facility failed to formulate an advance directive by not obtaining the signature of the Medical Power of Attorney. This was true for one (1) of four (4) residents whose advanced directives were reviewed during the long term care survey process. Resident identifier: Resident #10. Facility Census: 56.

Inspectors wroteBased on observation and staff interview the facility failed to provide a homelike environment. This was true for two (2) of fifty-six (56) residents observed during the long term care survey process. Resident Identifiers: #21, #112 Facility Census:

Inspectors wroteBased on a review of the facility policy and procedure for Abuse, Neglect and Misappropriation, facility record review, medical record review and staff interview the facility failed to implement and ensure actions were in place to prevent further potential abuse. This was a random opportunity of discovery during the long term care survey process. This had the ability to affect a limited number of residents. Resident Identifier: Resident #34. Facility Census: 56.

Inspectors wroteBased on record review and staff interview, the facility failed to report an alleged incident of resident to resident abuse involving Resident #3 and an unknown resident. This was true for one (1) of three (3) residents reviewed for abuse during the survey process. Resident identifier: #3. Facility census: 56.

Inspectors wroteBased on record review and staff interview, the facility failed to accurately complete the Minimum Data Set (MDS) Assessment for Resident #60 upon discharge. This was true for one (1) of one (1) residents reviewed for discharge during the survey process. Resident identifier: 60. Facility census: 56.

Inspectors wroteBased on medical record review and staff interview the facility failed to update the [NAME] Virginia Department of Health and Human Resources Pre-admission Screening (PASARR) with new qualifying diagnoses of major depressive disorder. This was true for two (2) of three (3) residents whose PASSARR's were reviewed during the long term survey process. Residents identifiers: #34, #39. Facility Census: 56.

Inspectors wroteBased on record review and staff interview the facility failed to ensure a Preadmission Screening and Review (PASARR) form had the appropriate diagnoses present. This was true for one (1) of three (3)PASSr's reviewed during the long term care survey process. Resident Identifier: #20 Facility Census: 56 Findings Include: a) Resident #20 On 08/20/24 at 10:29 AM record review of the transfer PASARR provided by Social Worker #77, dated 04/15/24 found that the only diagnosis listed was dementia. A review of Resident #20 medical diagnosis found the following diagnosis: Dementia, upon admission Bipolar, upon admission Depression, upon admission Generalized Anxiety Disorder, upon admission On 08/20/24 at 3:10 PM this was confirmed with Social Worker #77 who agreed all the listed diagnosis should be on the PASARR.

Inspectors wroteBased on record review, family interview, observation and staff interview the facility failed to develop a comprehensive care plan for Resident #44 related to diet restrictions associated with a medical condition. This was true for one (1) of four (4) residents reviewed for the care area of nutrition during the long term care survey process. Resident Identifier: # 44. Facility Census: 56. Findings Include: a) Resident #44 Observation of the noon time meal on 08/21/24 at 12:47 PM found Resident #44 was sitting in the dining room. She was served her meal and on her plate was a serving of corn. Resident #44 immediately stated, I can not eat corn, they know that. She then pushed her plate to the side. A few minutes later Resident #44's family member entered the dining room and said, oh we can just take that corn off your plate. She then helped Resident #44 remove the corn from her plate. [...]

Inspectors wroteBased on record review and staff interview the facility failed to revise the comprehensive care plan in a timely manner. Revisions required for new diagnosis and medication changes. This was true for three (3) of twenty three (23) residents reviewed during the long-term care survey process. Resident Identifier: Resident #34, Resident #14 and Resident #24. Facility Census: 56. Findings Include: a) Resident #34 During a medical record review 08/21/24 at approximately 12:21 PM, it was found Resident #34 diagnosis includes a diagnosis of major depression disorder with the onset date of 03/20/24. Further review of the residents care plan the diagnosis of major depression disorder is not identified. [...]

Inspectors wroteBased on record review and staff interview the facility failed to act on a Physician's order which caused a delay in treatment. This was true for one (1) of twenty three (23) resident records reviewed during the long term care survey process. Resident Identifier: #53 Facility Census: 56 Findings Include: a) Resident #53 On 08/20/24 record review found Resident #53 had an active order dated 07/26/24 to hemoccult stools (a screening test that checks for hidden blood in stool) X 3 samples for an abnormal lab result. As of 08/20/24 the staff had only obtained one stool sample. The one sample which was retrieved on 08/17/24 returned with a positive result for blood being present. Upon notifying the off hours physician (Never Alone) new orders were received to continue monitoring. Resident to also follow up with in house physician for a possible Gastrointestinal (GI) referral. [...]

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to ensure sufficient nursing staff was deployed to meet the needs of each resident. This was a random opportunity for discovery. Resident identifiers: #44, #34. Facility census: 56.

Inspectors wroteBased on record review and staff interview, the facility failed to monitor Resident #3 for side effects of antianxiety, antidepressant, and mood stabilizing medications as ordered, as well as monitoring for behaviors as ordered, per shift. This was true for one (1) of one (1) residents reviewed for psych/opioid side effects during the survey process. Resident identifier: #3. Facility census: 56.

Inspectors wroteBased on record review and staff interview the facility failed to ensure significant medication errors did not occur. This was a random opportunity for discovery. Resident identifier: #43 Facility Census:

Inspectors wroteBased on record review, observation, family interview and staff interview the facility failed to provide Resident #44 with a diet that met her special dietary needs related to her ileostomy. This was true for one (1) of four (4) residents reviewed for the care area of nutrition during the long term care survey process. Resident Identifier: 44. Facility Census: 56. Findings Include: a) Resident #44 Observation of the noon time meal on 08/21/24 at 12:47 PM found Resident #44 was sitting in the dining room. She was served her meal and on her plate was a serving of corn. Resident #44 immediately stated, I can not eat corn they know that. She then pushed her plate to the side. A few minutes later Resident #44's family member entered the dining room and said, oh we can just take that corn off your plate. She then helped Resident #44 remove the corn from her plate. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to accurately document the discharge of a resident and the facility failed to accurately complete a residents capacity form. This was true for two (2) of 23 residents reviewed during the long term care survey process. Resident Identifiers: Resident #5, and #35. Census: 56. a) Resident #59 During a review of the medical record review of 08/20/24 at 9:09 AM of Resident #59 a Social Service note identified the resident had went on a therapeutic leave with his daughter. It was further identified the daughter notified the facility he would not be returning to the facility. During this medical record review a physician note entry for the discharge to family could not be identified. [...]

Inspectors wroteBased on record review and resident interview, the facility failed to ensure residents entering into a binding arbitration agreement were able to understand the agreement prior to signing. This was true for two (2) of two (2) residents reviewed for arbitration during the survey process. Facility Census: 56.

Inspectors wroteBased on observation, record review, and resident and staff interview, the facility failed to have sufficient nursing staff available to meet the needs of each resident residing in the facility. This was true for three (3) of three (3) residents interviewed during the survey process, as well as resident council members. This had the potential to affect more than a limited number of residents. Resident identifiers: #8, #32, #36, #41, #52. Facility census: 60.

Inspectors wroteBased on resident and staff interview, the facility failed to ensure each resident received proper hydration due to no water being passed to Resident #52 and other residents present during a resident council meeting. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Resident identifiers: #52, #7, #32, #36, #41, #48, #54. Facility census: 60.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure food was stored and prepared in a manner to prevent the spread of food borne illnesses. The facility failed to ensure food served from the kitchen was cooked thoroughly to an adequate temperature before serving it to residents. In addition, the facility failed to ensure the kitchen was clean and food was stored in the kitchen in a safe and sanitary manner. There were multiple items which were either not labeled or remained available for service past use by dates. Ensuring all food is cooked to an adequate temperature is critical to prevent the spread of food borne illnesses. The state agency found the failure to cook food items to the appropriate temperature placed all 55 residents currently residing in the facility in an immediate jeopardy (IJ) situation. [...]

Inspectors wroteBased on observation, record review, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The facility failed to ensure the door to the janitor's closet located in the dining room remained locked. This failed practice had the potential to affect more than an isolated number of residents currently residing in the facility. Facility Census: 55.

Inspectors wroteBased on record review and staff interview the facility failed to thoroughly investigate an incident of physical abuse between Resident #52 (the victim) and Resident #42 (the perpetrator). The incident occurred on night shift, and the facility failed to obtain statements from staff who were working at the time of the incident. This was a random opportunity for discovery and was true for Resident #52. Resident Identifiers: #52. Facility Census: 55. Findings Include: a) Resident #52 A review of the facility's reportable's for the previous six (6) months found a reportable dated 12/30/23 which reported and incident where Resident #42 entered the room of Resident #52 while he was sleeping. When Resident #52 told Resident #42 that he was in the wrong room Resident #42 began throwing things about the room and struck Resident #52 in the head multiple times. [...]

Inspectors wroteBased on record review and staff interview the facility failed to provide each resident with the goods and services to enable them to maintain and or attain their highest practicable physical and mental well being. The facility failed to initiate neurological assessments on Resident #52 when another resident reportedly hit him in the head more than once. This was a random opportunity for discovery for Resident #52. Facility Census:

Inspectors wroteBased on observation and staff interview, facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The central supply, clean utility, and dirty utility rooms were found unlocked. This had the potential to affect more than a limited number of residents. Additionally, Resident #39 was observed eating a table decoration. These were random opportunities for discovery. Resident identifier: #39. Facility census: 53. a) unlocked clean and dirty utility rooms On 10/17/22 at 11:17 AM, the clean utility room located in the C hallway was found to be unlocked. The room contained resident hygiene items, including razors. Nursing Assistant #18 verified the clean utility room was unlocked and she locked the door. On 10/17/22 at 11:35 AM, the clean utility room located in the C hallway was again found to be unlocked. [...]

Inspectors wroteBased on resident and staff interviews, the facility failed to ensure that resident has the right to personal privacy of not only his or her own physical body, but of his or her personal space. This was true for one (1) of (1) resident reviewed for the care area of privacy during the long term care survey. Resident identifier: #14. Facility census: 53.

Inspectors wroteBased on record review, observation and staff interview the facility failed to ensure Resident #49's care plan was implemented in the area of accident hazards and fragile skin this was true for one (1) of one (1) residents reviewed for the care area of accident hazards and one (1) of three (3) residents reviewed for skin conditions non pressure related during the long term care survey process. Resident Identifier: #49. Facility Census: 53. Findings Included: a) Resident #49 1) Accident Hazards A review of resident #49's care plan on 10/18/22 found the following care plan focus statement: -- Ms. (Last name of Resident #49) is at risk for falls r/t (related to) Deconditioning, weakness, history of falls, hospice and actual falls. The goal associated with this focus statement read as follows: -- Patient will be free of falls with major injury through the review date. [...]

Inspectors wroteBased or resident interview, staff interview, and record review, the facility failed to include the resident in the care plan meetings and/or provide an explanation in the resident's medical record as to why the participation of the resident was determined not practicable for the development of the resident's care plan. This was true for one (1) of one (1) resident reviewed for participation in care plan during the long -term care survey process. Resident identifier: 34. Facility census: 53.

Inspectors wroteBased on observation, resident interview and staff interview the facility failed to ensure respiratory services were being provided in accordance with professional standards of practice. This was true for one (1) of one (1) residents reviewed for respiratory care. Resident identifier: #50. Facility census: 53.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure medications were stored in accordance with currently accepted professional principles. A multi-use medication vial stored in the medication preparation room had not been discarded after opening in the time frame recommended by the manufacturer. This was a discovery during the facility task of medication storage. Facility census: 53.