Sitter and Barfoot Veterans Care Center

Inspectors wroteBased on observation, interview, and facility document and policy review, the facility failed to ensure expired food items were discarded, food items were labeled with the date opened, and an industrial fan in the kitchen was free of dust. This failure created the potential for foodborne illness for 167 residents who received food from the kitchen of 170 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure 4 of 4 washing machines were maintained in safe and proper working condition.

Inspectors wroteBased on observation, interview, and facility documentation the facility staff failed to ensure the reasonable accommodation of resident needs and preferences for 1 resident (#122) in a survey sample of 54 residents.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure residents were free from chemical restraints for 2 Residents (#123 and #47) in a survey sample of 54 residents. 1. For Resident #123 the facility staff failed to ensure that the PRN order for the anxiolytic medication, Lorazepam, was not administered for more than 14 days without proper documentation of indication for usage and duration of therapy. Resident #123 was admitted to the facility on [DATE] Gout, Parkinsons disease, unspecified dementia with psychotic disturbance, neurocognitive disorder, major depressive disorder, insomnia visual hallucinations, benign prostatic hyperplasia, and vitreous degeneration. Resident #123's most recent BIMS (Brief Interview of Mental Status) score of 11/15 indicating moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to provide respiratory care according to professional standards of practice for 1 resident (#108) in a survey sample of 54 residents.

Inspectors wroteBased on observation, interview, clinical record review, and facility documentation review, the facility staff failed to ensure 1 of 3 sampled residents (resident #1) received care and services to prevent pressure ulcers from developing.

Inspectors wroteBased on observation, interview, record review, and review of policies and procedures, and of medical device and product user information, the facility failed to: A.) ensure the nursing staff cleaned and disinfected multi-use glucometers per the device manufacturer's instructions and per the Environmental Protection Agency (EPA)-registered (approved) disinfectant's instructions for use when performing fingerstick blood glucose (sugar) (FSBS) testing between residents. Specifically, five of five Licensed Practical Nurses, (LPN) 21, LPN22, LPN23, LPN25, and LPN26) on three of four units (Richmond, Bay Side, and Blue Ridge) failed to effectively clean and disinfect five of five glucometers used to perform FSBS testing for five of 30 sampled residents, (Resident (R) 4, R51, R82, R135, and R352), plus five supplemental residents, (R11, R79, R91, R112, and R199). [...]

Inspectors wrote495393_F578-IJ Based on interview, record review, and review of the facility's policy, the facility failed to ensure a resident's advance directive was executed per the resident's wishes related to code status for one of 47 sampled residents (Resident (R) 24). R24 formulated an advance directive prior to being admitted to the facility; however, the resident's family member signed a Do Not Resuscitate (DNR) form without being educated about the form or it's implications. This failure had the potential to affect all residents of the facility who had, or who wished to formulate an advance directive. On [DATE] at 3:55 PM, the facility's Assistant Administrator was notified and issued an Immediate Jeopardy at F578, the right to formulate an Advance Directive. [...]

Inspectors wroteBased on resident and staff interviews, review of financial records pertaining to resident accounts, and review of the facility Resident Trust Fund Policy the facility failed ensure that one resident (Residents (R)57) of 47 sampled residents had access to his petty cash fund on weekends. This failure had the potential to impact all 112 residents for whom the facility manages personal fund accounts.

Inspectors wroteBased on resident and staff interview, and review of facility polices, the facility failed to implement written policies and procedures that thoroughly address misappropriation of resident property. This failure placed all 153 residents in the facility at the time of the survey at an elevated risk for theft/misappropriation of their property. (Refer to F602-L)

Inspectors wroteBased on staff interview, record review, policy review, and review of guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to offer and administer the pneumococcal and /or influenza vaccination in a manner consistent with CDC recommendations and professional standards. The failure affected four of five residents (Resident (R)30, R82, R141and R352) reviewed for immunizations. This failure had the potential to increase the potential transmission of pneumonia and influenza for residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to promote and enhance each resident's dignity for one of 47 sampled residents (Resident (R) 94). Observation revealed in R94's room, four signs related to the resident's required personal care displayed on the closet and wall, in plain view.

Inspectors wroteBased on resident and staff interviews, and review of facility policies, the facility failed to identify potential and reported misappropriation of resident property. Specifically, two of 47 sampled residents (R) 135 and R4, reported personal items missing to the facility without resolution.

Inspectors wroteBased on record review, resident and staff interviews, and review of facility policies, the facility failed to thoroughly investigate and report to the State Agency (and law enforcement when necessary) alleged and/or potential misappropriation of resident property. This failure potentially placed all 153 residents in the facility at an increased risk for misappropriation of their personal items. (Reference F602-L).

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the resident's dental status. One (Resident (R) 51) of 32 residents reviewed for MDS assessments had an issue with an inaccurate Oral/Dental assessment. The resident's poor dentition was not known or cared for by facility staff. (see F791).

Inspectors wroteBased on observation, record review and interviews s, the facility failed to ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good oral hygiene. One of two residents (Resident (R) 51) reviewed for activities of daily living had an issue with staff not ensuring that the resident had good oral hygiene.

Inspectors wroteBased on observation, interview, record review, and review the facility's policy, the facility failed to ensure residents remained free from preventable accidents and hazards for one of 47 sampled residents (Resident (R) 48). This failure had the potential to elevate the hazard/accident risk for all 51 residents who resided on the Blue Ridge Unit.

Inspectors wroteBased on observation, record review and staff and resident interviews, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care. One (Resident (R)51) of two residents reviewed for dental services needed dental services for broken and missing teeth, inflamed gums and copious amounts of plaque. R51 had resided in the facility since 06/19/19 without receiving any dental services. This deficient practice has the potential to affect 73 residents residing in the facility who could receive dental services approved by Medicaid.

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed, for 1 resident (Resident #56) of the survey sample of 59 residents, to mitigate accident hazards to prevent burns. This resulted in harm. Resident #56 spilled hot coffee prepared by staff causing a second degree burn (harm). The facility failed to monitor hot liquid temperatures or assess the resident for hot liquid safety before and after the burn.

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed, for one Resident, (Resident #56) of the survey sample of 59 residents, to ensure that hot liquids were served at a safe temperature, resulting in a second degree burn (harm). Resident #56 spilled hot coffee prepared by staff causing a second degree burn (harm). The facility failed to monitor hot liquid temperatures.

Inspectors wroteBased on observation, the facility staff failed to serve food in accordance with professional standards for food safety. Dietary staff in the main kitchen and Richmond Unit were observed to use hand sanitizer as a substitution for hand washing during meal service.

Inspectors wroteBased on Resident Interview, Staff Interview, Clinical Record Review, facility failed to ensure level 1 screening tools were completed prior to admission for residents 5 residents, 171, 136, 133, 124, 155. 1. Resident #171 did not have a Level I PASARR completed prior to or upon admission to the facility. 2. Resident #136 did not have a Level I PASARR completed prior to or upon admission to the facility. 3. For Resident # 133 the facility failed to ensure Resident #133 had PASARR Level I screening prior to or on admission to facility. 4. Resident #124 did not have a Level I PASARR completed prior to admission to the facility. 5. Resident # 155 did not have a Level I PASARR screening completed prior to admission.

Inspectors wroteBased on interview and record review, facility failed to ensure, that one resident (#69) was treated with respect and dignity while providing personal care.

Inspectors wroteBased on observation, staff interview and clinical record review the facility staff failed for 1 resident (Resident #64) of 59 residents in the survey sample to assess for the safe self administration of medications. For Resident #64, 11 unopened tablets of Gas-ex tablets were found on the bedside table and the resident had not been assessed to self administer medications.

Inspectors wroteBased on observations, resident interviews, staff interviews, and clinical record review, the facility staff failed to accommodate needs for one resident (Resident # 80) in a sample of 59 residents. The facility staff failed to provide Resident # 80 with a specialized call bell to accommodate Resident's physical limitations. Resident # 80 was admitted to the facility on [DATE]. Diagnoses for Resident # 80 included depression, Parkinson's disease, aphasia, unspecified dementia without behavioral disturbances, and chronic pain syndrome. Resident # 80's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/10/2018, was coded as an annual assessment. Resident # 80 was coded with a Brief Interview Mental Status (BIMS) score of 13 out of possible 15 indicative of no cognitive impairment. [...]

Inspectors wroteBased on resident interview and staff interview, the facility staff failed to give access to one resident's medical record. (Resident #186)

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (form CMS 10055) for one resident (Resident #44). On 09/12/2018 a review of Skilled Nursing Facility Beneficiary Protection Notification was conducted. The review showed Resident #44 did not receive an Skilled Nursing Facility Advance Beneficiary Notice (form CMS 10055). On 09/12/18 at 10:35 AM, an interview was conducted with Employee B. Employee B stated that a form CMS 10055 was not issued but a form CMS 10123-NOMNC was issued to the resident. Employee B stated that she did not know that a form CMS 10055 needed to be issued. The facility staff was made aware of the concern during a briefing on 9/12/2018.

Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review the facility failed to maintain a catheter in a manner to prevent the spread of infection for 1 resident (Resident #107) of 59 residents in the survey sample. Resident #107's catheter bag was observed on the floor on two occasions.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed for 1 resident (Resident #64) of 59 residents in the survey sample to ensure safekeeping of hard scripts for controlled medications. For Resident #64, the facility staff failed to send a hard copy script dated 7/12/17 for Tramadol (narcotic pain medication) 50 milligrams 1 tab three times per day to the Pharmacy.

Inspectors wroteBased on observation and staff interview, facility document review, facility failed to ensure proper labeling of opened insulin vials.

Inspectors wroteBased on observation, staff interview, and resident interview, the facility failed to post survey signage and survey results in a readily accessible manner for residents that use wheelchairs.