Hanover Health and Rehabilitation Center

Inspectors wroteBased on staff interviews, record reviews and the Virginia Board of Nursing guidance, the facility failed to ensure competent nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of all 110 residents. This failure had the potential to affect the completion of nursing duties, including incident management, assessments, and fall monitoring and prevention, infection prevention and control, and medication administration.

Inspectors wroteBased on observations, policy review, and interviews, the facility failed to discard six two-pound cartons of liquid eggs located in the walk-in cooler that were beyond the manufacturer's use by date of 02/09/26.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure that each resident's medication regimen was free from unnecessary medications through monthly pharmacist review, physician oversight, and monitoring for adverse effects, and implementation of gradual dose reductions when appropriate for four of four residents, Resident (R)2, R4, R68, and R128, reviewed in the sampleFindings include:1. Review of R2's admission Record, located in the resident's electronic medical record (EMR) under the Resident Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis' to include but not limited to anxiety disorder, depression, chronic kidney disease, and personal history of other mental and behavioral disorders, unspecified dementia and unspecified severity behavioral disturbance, and psychotic disturbance. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to use appropriate infection control practices, specifically, to ensure Personal Protective Equipment (PPE) was utilized appropriately by housekeeping staff while providing environmental cleaning and disinfecting objects and surfaces in the resident rooms with contact precautions and when moving between resident rooms . who was on Enhanced Barrier Precautions (EBP) for two of two residents (Resident (R) 115) and in room [ROOM NUMBER] reviewed for EBP of 25 sample residents. This failure had the potential to cause the spread of infection to other residents who resided on the hall.

Inspectors wroteBased on observation, interview, clinical record review, and facility documentation review, the facility staff failed to ensure that staff have the appropriate competencies and skill sets to provide adequate nursing care for one (1) Resident #1 in a survey sample of 5 residents, resulting in immediate jeopardy and harm to Resident #1.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to notify the physician that medications were not available for administration for four of 30 residents, Resident #303, Resident #304, Resident #306, and Resident #307.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility failed to develop a baseline care plan and provide a summary of the care plan to the resident responsible party for four of 30 resident's, Resident's #202, #207, #349, and #249. The findings Include: 1. Resident #202 was admitted with diagnoses that included: fractured femur, muscle weakness, reflux, and difficulty walking. The most current MDS (minimum data set) was an entry assessment with an ARD (assessment reference date) of 4/21/22. Resident #202's cognitive score had not been assessed at time of survey. On 4/27/22 Resident #202's medical record was reviewed and evidenced a baseline care plan was created for Falls on 4/23/22, but no additional care areas. On 04/27/22 at 11:20 a.m. [...]

Inspectors wroteBased on a medication pass and pour observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow professional standards of practice for one of 30 residents in the survey sample, Resident # 210. Resident # 210 was administered the incorrect dose of a medication.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow physician orders regarding medication administration for four of 30 residents, Resident #303, Resident #304, Resident #306, and Resident #307. The facility also failed to do an admission skin assessment and provide treatment for an aterial wound for one of 30 residents, Resident #210.

Inspectors wroteBased on clinical record review, staff interview, and facility document review, the facility staff failed to develop a comprehensive care plan (CCP) for 1 of 30 residents in the survey sample, Resident #5. Resident #5's CCP did not include a focus area with goals and interventions for the use of anticoagulants.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to review and revise a comprehensive care plan (CCP) for 1 of 30 in the survey sample, Resident #15. Resident #15's CCP was not reviewed and revised for the discontinuation of enteral feedings (tube feedings).

Inspectors wroteBased on observation, staff interview, and resident interview, the facility staff failed to ensure a dressing was in place for a Stage III pressure ulcer for one of 30 residents, Resident #306.

Inspectors wroteBased on medication pass and pour observation, staff interview, clinical record review, and facility document review the facility staff failed to ensure a medication error rate less than 5 percent. There were three errors out of 41 opportunities resulting in a medication error rate of 7.32 percent.

Inspectors wroteBased on observation, staff interview, and facility document review the facility staff failed to ensure medications and biologicals were labeled and stored correctly on one of 3 medication carts inspected, and in one of 2 medication rooms. The East wing refrigerator included a vial of tuberculin solution (PPD), and a bottle of Vancomycin; both were open and not dated. The medication cart on the 400 north hall contained 5 open vials of insulin, which were not dated.

Inspectors wroteBased on clinical record review, resident interview, and staff interview, the facility failed to obtain routine dental care for two of 30 residents in the survey sample, Residents # 13 and 47, who were assessed as having dental problems. During the Group Meeting, Residents # 13 and 47 expressed a desire to see a dentist.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of 30 residents, Resident #303.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff neglected to provide goods and services to prevent and promote the healing of pressure ulcers for one resident (Resident #5) in a survey sample of 46 Residents, resulting in harm for Resident #5. Immediate Jeopardy was identified on 8/6/19 at 6:17pm and the facility was notified. After verification, Immediate Jeopardy was abated on 8/7/19 at 6:55pm and the scope and severity was lowered to level three, isolated.

Inspectors wrote8. For Resident # 54, the facility staff failed to administer physician ordered, and scheduled medications in a timely manner. Resident #51 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #54's diagnoses included Chronic Heart Failure, Dementia, Depression, Asthma, Diabetes Mellitus Type 2, and Constipation. The Minimum Data Set, which was an Annual Assessment with an Assessment Reference Date of 3/12/19 was reviewed. Resident #54 was coded as having a Brief Interview of Mental Status Score of 10, indicating moderately impaired cognition. On 7/16/19 a review was conducted of Resident #54's clinical record. The signed physician orders for the medications, and Medication Administration Records (MAR) were reviewed for the month of July. According the MAR, the following medications were administered approximately 2 hours late: [...]

Inspectors wrote5. For Resident # 62 the facility staff failed to follow their Pressure Ulcer Treatment Guide and applied barrier cream to a pressure ulcer instead of a Hydrocolloid dressing. Resident #62 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Cerebral infarction (stroke) affecting left side, Hemiplegia and Hemiparesis following stroke, Diabetes and heart failure. Resident #62's most recent MDS (minimum Data Set) with an ARD (Assessment Reference Date) of 6/24/19 coded Resident as being extensive assistance with physical assistance of 1 person for bathing, and dressing and for bed mobility, transfer and toileting she is coded as total dependence staff assistance of 2. Resident was coded as having a (Brief Interview of Mental Status) BIMS of 15. [...]

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility failed to ensure nursing staff have the appropriate skills and competencies to conduct assessment and treatment of pressure injuries which resulted in deterioration of the injuries and/or hospitalization for one resident (Resident #5) in a survey sample of 46 Residents, resulting in harm for Resident #5. Immediate Jeopardy was identified on 8/6/19 at 6:17pm and the facility was notified. After verification, Immediate Jeopardy was abated on 8/7/19 at 6:55pm and the scope and severity was lowered to level three, isolated.

Inspectors wroteBased on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility has failed to ensure the Medical Director has coordinated medical care in the facility and implemented resident care policies for one resident (Resident #5) in a survey sample of 46 Residents, resulting in harm for Resident #5. Immediate Jeopardy was identified on 8/6/19 at 6:17pm and the facility was notified. After verification, Immediate Jeopardy was abated on 8/7/19 at 6:55pm and the scope and severity was lowered to level three, isolated.

Inspectors wroteBased on observation, staff interview, and facility documentation review the facility staff failed to store food in accordance with professional standards for food service safety for 1 of 1 kitchens.

Inspectors wrote4. For Resident # 57 the facility staff failed to ensure the Resident was provided privacy and dignity when providing care. Resident #57, an [AGE] year old man admitted to the facility on [DATE] with diagnoses of but not limited to acute kidney failure, muscle weakness, gout and hereditary Lymphedema. The Resident's most recent MDS codes resident as having BIMS (Brief Interview of Mental Status) of 14 indicating mild cognitive impairment. The resident was coded as needing extensive assist and 1 person physical assist for transfers. On 7/14/19 at approximately 5:30 PM Resident #57 was observed sitting in his wheelchair at the entrance to the [NAME] Wing dining room. The DON, ADON, as well as CNA I and CNA J were observed each had one of Resident #57's extremities and were re-positioning him in his wheelchair in full view of the Residents and visitors in the dining room and hallway. [...]

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed for 8 residents (Resident #503, #87, #502, #203, #254, #252, #253, and #48) of the survey sample of 46 to ensure a Preadmission Screening and Resident Review (PASARR) was conducted prior to admission to the nursing facility.

Inspectors wroteBased on observation, staff interview, facility documentation review and clinical record review, the facility failed to provide respiratory care therapy consistent with infection control measures for 4 Residents (Resident # 68, #503, #92, and #58) in a survey sample of 46 Residents.

Inspectors wroteBased on staff interviews and facility documentation review the facility staff failed to ensure that certified nursing assistants (CNA's) receive regular in-service education for four CNA's (CNA O, CNA P, CNA Q, CNA R) of 15 CNA records reviewed.

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review and clinical record review the facility staff failed to transport linens so as to prevent the spread of infection and failed to store medical respiratory equipment in a manner to prevent the development and transmission of communicable diseases and infections concerning linens and 7 Residents (Resident #58, Resident #79, Resident #95, Resident #92, Resident #3, Resident #68, Resident #503 in a survey sample of 46 Residents.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review the facility staff failed to have reasonable accommodation of resident needs for three Residents (Resident #95, Resident #101, and Resident 91) in a survey sample of 46 Residents.

Inspectors wroteBased on observation, staff interview, clinical record review, facility documentation, and in the course of a complaint investigation, the facility staff failed to implement their abuse policies for 1 resident (Resident #8) in a sample size of 46 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, facility documentation, and in the course of a complaint investigation, the facility staff failed to report injuries of unknown origin to the state agency for 2 residents (Resident #35, Resident #8) in a sample size of 46 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, facility documentation, and in the course of a complaint investigation, the facility staff failed to investigate injuries of unknown origin for 2 residents (Resident #35, Resident #8) in a sample size of 46 residents.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to notify Ombudsman of a transfer to hospital for one Resident (Resident #79) in a survey sample of 46 residents.

Inspectors wroteBased on observation, clinical record review, and staff interview, the facility staff failed to develop a comprehensive care plan for oxygen use for one Resident (Resident #58) in a survey sample of 46 residents. For Resident #58 the facility staff failed to develop a careplan to include poor oxygen saturation and use of oxygen.

Inspectors wroteBased on observation, Resident interview, spouse interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to review and revise the care plan for 2 Residents (#58 and #79) in the survey sample of 46 Residents.

Inspectors wroteBased on observation, staff interview, clinical record review, facility documentation, and in the course of a complaint investigation, the facility staff failed to maintain activity participation for one resident (Resident #35) in a sample size of 46 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, facility documentation, and in the course of a complaint investigation, the facility staff failed to adequately supervise and assist to prevent injury for one resident (Resident #101) in a sample size of 46 residents.

Inspectors wroteBased on observation, resident interview, family interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide services and assistance to maintain continence status for one resident (Resident #91) in a sample size of 46 residents.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to obtain physician ordered medications for 1 resident (#63) in a survey sample of 46 residents.

Inspectors wroteBased on Resident interview, staff interview clinical record review and facility documentation the facility staff failed to ensure Residents are free from unnecessary psychotropic medications for 3 Residents (#253, #79, and # 95) in a survey sample of 46 Residents.