Northern Neck Senior Care Community

Inspectors wroteBased on Staff interview, clinical record review, hospital record review, and facility document review, the facility staff failed to obtain and provide appropriate oxygen orders during a change in condition event for one Resident (Resident #100) in a survey sample of 13 residents.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to store medications in accordance with currently accepted professional principles in 1 of 1 medication room inspected.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to care for Residents with dignity and respect for 1 Resident (#3) in a survey sample of 31 Residents.

Inspectors wroteBased on interview, clinical record review, and facility documentation, the facility staff failed to immediately notify the resident representative when there was a significant change in the Resident's condition for 1 Resident (#375) in a survey sample of 31 Residents.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to review and revise the care plan for 2 (Resident #19 & #3) of 31 sampled residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to follow standards of nursing practice for 2 Residents (Resident #70 & #19) in a survey sample of 31 Residents.

Inspectors wroteBased on observation, staff interview, resident interview and clinical record review, the facility staff failed to provide respiratory care consistent with professional standards of practice for one Resident (Resident # 53) in a survey sample of 31 residents.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to provide routine drugs and biologicals to meet the needs of 1 Resident (#19) in a survey sample of 31 Residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to ensure the medication error rate was less than 5%. There were 2 medication errors (medications ordered that were not administered) in 30 opportunities, resulting in an 6.6% error rate.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure foods stored in the kitchen were labeled, dated, not expired, and sealed. These failures had the potential to increase the prevalence and spread of foodborne illness and infection to all 72 facility residents.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to review and update the facility assessment following a change in facility ownership which required substantial modifications.

Inspectors wroteBased on observations, record review, resident interviews, and staff interviews, the facility failed to demonstrate their response to grievances voiced repeatedly by the Resident Council regarding call-light wait times. This deficient practice affected 11 residents who regularly participated in Resident Council meetings and five of 26 initial pool residents (Residents (R) 7, R54, R49, R15, and R20) reviewed for call-light concerns. This failure had the potential to cause accidents, skin breakdown, infection, and/or psycho-social distress related to long wait times.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure that one of nine observed licensed or registered nurses (Licensed Practical Nurse (LPN) 1) received the specific competencies and skill sets necessary to use and clean the glucometer in a sanitary manner. This failure increased the potential to spread blood-borne pathogens among the three residents (Resident (R) 219, R47, and R15), out of seven residents with orders for finger-stick blood glucose testing, who tested with the same multi-use glucometer.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure menus were followed for the 17 residents who received a pureed or mechanical soft diet out of a total census of 72. Specifically, these 17 residents did not receive a dinner roll as called for on the menu, and the five residents on a pureed diet did not receive foods that were on the menu. This failure had the potential to cause weight loss or nutritional deficiencies for these 17 residents on mechanical soft or pureed diets.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure food was prepared in a form designed to meet the individual needs of the 12 residents who received a mechanical soft diet. This failure had the potential to cause coughing, choking, aspiration, or nutritional deficiencies for these 12 residents on mechanical soft diets.

Inspectors wroteBased on observations, interviews, and document review it was determined the facility failed to provide activities of daily living (ADL) care for three of 20 sampled residents (Residents (R) 2, R44, and R63) who were unable to carry out ADL care without assistance. Specifically, the facility failed to provide/assist R2, R44, and R63 with facial grooming. This continued practice had the potential to affect the residents' psychosocial well-being related to self-esteem and dignity.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure one of four residents (Resident (R) 49) reviewed for nutrition received a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet. This failure placed R49 at risk of unplanned weight loss, nutritional deficiency, and choking or aspiration.

Inspectors wroteBased on observations, interviews, and document review, the facility staff failed to ensure a multi-use glucometer was cleaned between residents with an EPA registered disinfectant when performing fingerstick blood glucose testing on one of three residents (Resident (R) 219). This failure had the increased likelihood of transmission of blood borne pathogens between the three residents (R219, R47, and R15) undergoing fingerstick blood glucose [sugar] testing on Dogwood wing. In addition, the facility failed to ensure personnel protective equipment (PPE) was appropriately doffed after caring for a resident on contact and droplet precautions by one staff member in one of three units. This failure increased the potential for transmission of COVID-19 to a resident not on precautions.

Inspectors wroteBased on staff interview, and facility documentation review, the facility failed to train 2 of 2 staff on abuse policies and procedures.

Inspectors wroteBased on observation, staff interviews, and facility documentation review, the facility staff failed to maintain compliance with the Code of Virginia Regulations for the Licensure of Nursing Facilities, 12VAC5-371-140. Policies and Procedures, section H. Policies and procedures were not readily available for staff use at all times, to direct care and services for all 69 residents in the facility.

Inspectors wroteBased on staff interviews and facility documentation review, the facility staff failed to obtain written agreements with outside resources to ensure timely provision of services. Specifically, the facility staff failed to arrange written agreements for the following services (including but were not limited to) since assuming ownership of the facility on 02/01/2021: dental, podiatry, audiology, optometry, radiology, and dialysis services.

Inspectors wroteBased on observation, staff interview, and resident interview, the facility staff failed to provide privacy for a group council meeting with the state agency involving the 13 residents in the meeting. One staff member entered the day room while the meeting was being conducted, and a second staff member stood in front of a large window looking into the room, and pointing at residents.

Inspectors wroteBased on observation, staff interview and facility documentation review, the facility staff failed to prepare and store food in a sanitary manner. The facility staff failed to ensure that the hot box, oven, floor, food containers, and ceiling were clean.

Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure that the professional standards of quality were provided for one Resident (Resident #53) in a survey sample of 26 residents. For Resident #53, the nursing staff left 2 medications in a cup on the bedside table, and left the room without administering them.

Inspectors wroteBased on staff interview and clinical record review the facility failed to ensure 1 Resident (Resident #204) remain free from unnecessary antipsychotic medications in a survey sample of 26 Residents. For Resident #204 the facility failed to ensure the Resident had a diagnosis that supports the use of antipsychotics. Resident # 204 an 80 yr. old female admitted to the facility on [DATE]. She has a diagnosis of but not limited to Alzheimer's disease, Alzheimer's disease, unspecified, mental disorder (dementia) unspecified dementia without behavioral disturbance, Major depressive disorder single episode, Major Depression, Vascular dementia without behavioral disturbance, unspecified psychosis not due to a substance or known physiological condition The most recent Minimum Data Set (MDS) was a quarterly with an Assessment Reference Date (ARD) of 4/12/18. [...]

Inspectors wroteBased on observation and interview the facility failed to properly store and label 1 bulk medication (Pro-Stat), and two open vials of insulin were found with no open date.