Kempsville Health & Rehab Center

Inspectors wroteBased on interviews, record review, document review and facility policy review, the facility failed to ensure allegations of staff-to-resident abuse were reported timely, and in accordance with federal reporting requirements, to the State Survey Agency (SSA) for one of four sample residents (Resident (R) 101) reviewed for allegations of abuse or neglect. The facility's failure to promptly report allegations of abuse limited regulatory oversight and had the potential to delay protective interventions for residents.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to investigate a potential injury of unknown origin for one of four sample residents (Resident (R) 101) reviewed for allegations of abuse. The facility's failure to thoroughly investigate the injury had the potential to delay protective interventions for residents.

Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to ensure that a person-centered baseline care plan was developed within 48 hours of admission, and provided to the resident or their representative, for five of five residents (Resident (R) 105, R113, R59, R67, and R100) out of 20 sampled residents. This failure to establish initial care instructions for nursing staff placed newly admitted facility residents at risk of not receiving critical care needs, and residents and representatives to be poorly informed of anticipated plans of care.

Inspectors wroteBased on observation, interview and review manufacturer's instructions for use, the facility failed to maintain a medication error rate below five percent. Out of the 27 opportunities for error, two errors occurred during medication administration with one of one Licensed Practical Nurse (LPN)3. The facility's medication error rate was 7.41%.

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to ensure that two of two residents' insulin pens (Resident (R) 110 and R69) were labeled with the date they were opened. This failure had the potential for medications to be administered past their use by date and affect the residents' quality of life.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to follow appropriate infection prevention practices for two of six residents (Resident (R) 69 and R110) observed during medication administration. This failure had the potential to expose the residents to contaminants in the environment.

Inspectors wroteBased on observation, staff interviews, and clinical record review, the facility staff failed to provide care and services to prevent pressure ulcer development and to identify a pressure ulcer prior to progression to an advanced stage for 1 of 37 residents, (Resident #15) and the facility staff failed to ensure the necessary assessment, treatment, care, and services was provided for 1 of 37 Residents (Resident #278) impaired skin to prevent deterioration, necessitating surgical debridement which constituted harm.

Inspectors wroteBased on observations, resident interview, staff interviews, clinical record review, and facility document review the facility staff failed to reassess resident for self-administration of medication for 1 of 37 residents (Resident #46) in the survey sample.

Inspectors wroteBased on complaint investigation, observation, staff interviews, clinical record review and facility documentation, the acuity staff failed to ensure 1 of 37 residents (Resident #277) to be free from misappropriation of the resident's narcotic medication.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to implement their abuse policy regarding the screening of employees for 2 employees, Dietary Employee #3 and LPN #2, in a sample of 20 employee records reviewed.

Inspectors wroteBased on clinical record review, staff interviews and facility documentation, the facility staff failed to develop a baseline care plan and/or ensure the indwelling catheter was addressed in the admission orders for Resident #281 and the facility staff failed to provide a baseline care plan to Resident #47 within 48 hours out of a sample of 37.

Inspectors wroteBased on staff interview, clinical record review and facility document review the facility staff failed to develop a care plan for 1 of 37 residents (Resident #1) in the survey sample.

Inspectors wroteBased on staff interviews, clinical record review and facility documentation the facility staff failed to revise 1 of 37 residents (Resident #47) comprehensive personal centered care plan in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure a Resident dependent in activities of daily living received good grooming, personal hygiene and dressing care for 1 of 37 residents (Resident #281), in the survey sample.

Inspectors wroteBased on resident interview, staff interviews and clinical record review, the facility staff failed to ensure a recommended referral from the Ophthalmologist for cataract extraction was provided for 1 of 37 residents (Resident #46) in the survey sample.

Inspectors wroteBased on clinical record review, staff interviews and facility documentation, the facility staff failed to obtain an order for use of an indwelling catheter including a valid medical justification for 1 of 37 Resident's (Resident #281), in the survey summary.

Inspectors wroteThe facility staff failed to ensure one resident with a potential for weight loss received adequate protein, portion sizes, and preferences at each meal, and to obtain weights as a means of measuring weight management for Resident #15, failed to obtain weekly weights for Resident #47 and failed to record meal consumption for Resident #127.

Inspectors wroteBased on observation, resident interview, staff interviews, clinical record review, facility documentation review, the facility staff failed to provide 1 of 37 residents (Resident #1) in the survey sample with respiratory care in accordance with professional standards of practice.

Inspectors wroteBased on observation, staff interviews and facility documentation review the facility staff failed to ensure medications were stored in a secured location, accessible to designated staff for 1 of 37 residents (Resident #46) in the survey sample.

Inspectors wroteBased on record review, observation and staff interview the facility staff failed to obtain one visitor's temperature during the screening process and failed to screen one vendor. On 1/13/22 at approximately 3:50 PM a vendor was seen entering the facility through the rear entrance to drop off a package. He was let inside of the building, walked up to the nurse's station and was directed by the facility staff where to leave a package. No screening process was initiated. On 01/13/22 at approximately 3:53 PM an interview was conducted with CNA (Certified Nursing Assistant) #7 concerning the above. She stated, The delivery people usually come through the storage area. [NAME] Wing (Unit 100 and 200 unit). I didn't screen him because we normally don't. Usually around 5:00 PM the visitors come to the back of the building to be screened. [...]

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to have an ongoing review of antibiotic stewardship and monitor the effectiveness of 1 resident, Resident #47's, antibiotic therapy out of a sample of 37 residents.

Inspectors wroteBased on observation and staff interviews the facility staff failed to protect resident from public view during wound care for 1 resident (Resident #21), of 36 residents in the survey sample. The facility staff failed to ensure privacy was maintained during a wound care dressing change for Resident #21.

Inspectors wroteBased on observations, resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to ensure for 1 resident (Resident #44) out of 36 residents in the survey sample was free from physical restraint. The facility staff failed to ensure that Resident #44 was free of physical restraint.

Inspectors wroteBased on staff interviews and clinical record reviews the facility staff failed to send comprehensive care plan goals for 2 residents (Resident #45, Resident #78) out of 36 residents in the survey sample when discharged to the hospital. 1. The facility staff failed to send comprehensive care plan goals for Resident #45 when discharged to the hospital on [DATE]. 2. For Resident #78, facility staff failed to evidence that the comprehensive care plan goals were sent with the resident upon transfer to the hospital on 9/1/18.

Inspectors wroteBased on resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 2 of 36 residents (Resident #83 and #45) in the survey sample. 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #83 discharge to the hospital on [DATE]. 2. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #45's discharge to the hospital on [DATE].

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide written bed hold notification for 2 of 36 residents in the survey sample, Residents #78 and #45. 1. For Resident #78, facility staff failed to provide the Resident and/or Resident Representative a written bed hold notification upon transfer to the hospital on 9/1/18. 2. For Resident #45 the facility staff failed to provide the Resident and/or Resident Representative a written bed hold notice when discharged to the hospital on [DATE].

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to implement the comprehensive care plan for one of 36 residents in the survey sample, Resident #6. For Resident #6, facility staff failed to implement her plan of care and ensure a fall mat was in place to prevent injury from falls.

Inspectors wroteBased on resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to invite 1 of 36 residents in the survey sample to attend his person centered care plan meeting (Resident #54) in the survey sample.

Inspectors wroteBased on resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to maintain professional standards for 1 resident (Resident #1) in the survey sample of 36 residents. The facility staff failed to communicate an ongoing assessment with the dialysis center for Resident #1 who attended outpatient dialysis three days per week on Monday, Wednesday and Friday; And, the facility staff failed to obtain weights on Resident #1 per the comprehensive care plan and physician's order.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to conduct a thorough skin assessment of a pressure ulcer prior to it advancing to an unstageable pressure ulcer, and failed to evidence that a barrier cream was implemented per the plan of care, for one of 36 residents in the survey sample, Resident #6; and the facility staff failed to follow physician's orders for a wound care dressing for one of 36 residents, Resident #21.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that facility staff failed to implement interventions to reduce the potential for accidents/hazards for one of 36 residents in the survey sample, Resident #6. For Resident #6, facility staff failed to ensure her fall mat was placed on the floor while she was in bed per physician's order to prevent injuries.

Inspectors wroteBased on resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to communicate an ongoing assessment for one resident (Resident #1) of 36 residents in the survey sample for monitoring of complications after dialysis treatment; and failed to check weights on Resident #1. The facility staff failed to communicate an ongoing assessment with the dialysis center for Resident #1 who attended outpatient dialysis three days per week on Monday, Wednesday and Friday. The facility staff failed to obtain weights on Resident #1 when she returned from dialysis on most days.

Inspectors wroteBased on a complaint investigation, staff interviews and facility documentation review, the facility staff failed for one (Resident #181) of 36 residents in the survey sample, to assist with transportation arrangements in order to attend an appointment with an outside physician.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to maintain infection control practices for two of 36 residents in the survey sample (Residents #33 and #21); and facility staff failed to ensure annual review of the infection control policies. 1. For Resident #33, facility staff failed to maintain infection control practices during breakfast on 7/10/19. 2. The facility staff failed to ensure infection control measures were implemented during wound care to Resident #21's left heel pressure ulcer. 3. The facility staff failed to ensure the Infection Prevention & Control policy was reviewed annually.