Staunton Health and Rehab Ctr

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain resident safety by failing to implement fall interventions and performing safe transfers. for 4 of 6 residents (R4, R5, R13, R500) reviewed for resident safety in the sample of 31. This failure resulted in R4 being hospitalized for fractures resulting in surgery and R500 being hospitalized for subdural hematoma, and spinal fractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was in reach and residents had a means to call for help for 1 of 3 (R11) residents reviewed for accommodation of needs in a sample of 31. This failure resulted in R11 unable to receive help. It also resulted in R11 feeling frightened, frustrated, embarrassed, helpless and disposed of.

Inspectors wroteBased on interview, observation, and record review, the facility failed to identify, treat, and prevent pressure ulcers for 3 of 5 residents (R4, R9, R13) reviewed for pressure ulcers in the sample of 31. This failure resulted in R4 and R13 having new pressure sores that were not discovered or treated.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide residents with a working call light system for 22 (R2, R4, R6 - R25) out of 23 residents investigated for physical environment in a sample of 25.

Inspectors wroteBased on interview and record review the facility failed to revise a resident's care plan with progressive interventions for 2 of 3 (R2, R5) residents investigated for falls in a sample of 25.

Inspectors wroteBased on interview and record review the facility failed to provide progressive interventions to prevent falls for 2 of 3 (R2, R5) residents investigated for falls in a sample of 25.

Inspectors wroteBased on observation, interview,and record review, the facility failed to properly store and discard expired medication. This failure has the potential to effect all 48 residents residing in the facility.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to date nasal cannulas, oxygen humidification containers and nebulizer administration equipment for 5 out of 5 residents (R24, R19, R30, R7, R37); reviewed for respiratory care in a sample of 41.

Inspectors wroteBased observation, interview and record review, the facility failed to perform hand hygiene after touching clothing, hair and cellular phone during meal service for 18 of 18 (R1, R3, R4, R5, R10, R11, R12, R13, R16, R22, R26, R27, R29, R32, R34, R36, R38, R40) residents reviewed for infection control in a sample of 41.

Inspectors wroteBased on interview and record review, the facility failed to provide notice of Medicare non coverage to 3 for 3 (R24, R99, and R100) residents reviewed for beneficiary notices in a sample of 43.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician's orders for a resident with a rash for 1 of 3 residents (R3) reviewed for pharmacy services in a sample of 4.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure there was an air gap in the ice machine between the floor sewage drain and the ice machine and there were no signs of water damage from sewage lines and or/pipelines. This has the potential to affect all 45 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to adequately develop an ongoing infection control program that adequately collected data to calculate and analyze infection rates and failed to operationalize infection control policies to adequately define infection control practice in the facility. This has the potential to affect all 45 residents living in the facility. Findings Include: On 5/2/2024 at 10:22 AM, an infection control log was provided but did not have any dates or organisms listed or documented. On 5/2/2024 at 10:33 AM, V2, Director of Nursing (DON), stated, I was just hired and just finished taking the ICP (Infection Control Preventionist) course. I am new to this position, and this is the only surveillance I have. I will look and see what else I can find. I do not have a book, but I will call corporate and see what she has. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents were given the correct antibiotics for the organism causing infection for 4 of 4 residents (R8, R25, R31 and R150) reviewed for antibiotic stewardship, in the sample of 33.

Inspectors wroteA. Based on interview and record review the Facility failed to ensure residents were being supervised to prevent wandering for 2 of 8 residents (R36, R41) reviewed for supervision to prevent wandering in the sample of 33. B. Based on observation, interview and record review, the facility failed to respond to a pressure alarm for a resident with a high risk of falling and a recent hip fracture in 1 of 8 residents (R29) reviewed for supervision to prevent falls the sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely incontinent care for 1 of 9 residents (R8) reviewed for Urinary Tract Infections (UTI) in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers and consistent with professional standards of practice for two of three (R1, R2) residents reviewed for pressure ulcers, in a sample of four.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's physician and family of a fall with an injury for one of three (R1) residents reviewed for notification in a sample of nine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to ensure a safe transfer for one of three residents (R1) reviewed for accidents, in a sample of nine.

Inspectors wroteBased on interview, observation, and record review, the facility failed to administer/apply a pain patch as ordered for 1 of 3 residents reviewed for medications in a sample of 9.

Inspectors wroteBased on interview and record review, the facility failed to prevent employee to resident verbal abuse for 1 of 3 residents (R3) reviewed for abuse in the sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to immediately report abuse for 1 of 3 residents (R3) reviewed for reporting of abuse allegations in the sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was thoroughly investigated timely and the alleged perpetrator of abuse was removed from direct patient contact while the allegation was investigated for 1 of 3 residents (R3) reviewed for abuse in the sample of 8.

Inspectors wroteBased on observation, interview and record review, the facility failed to label a Tubersol (used to aid diagnosis of tuberculosis infection) vial when opened per standards of practice. This has the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain appropriate infection control practices while administering medications to 4 of 7 residents (R8, R15, R24, R89) reviewed for infection control in the sample of 30.

Inspectors wroteBased on interview and record review, the facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use for 4 of 5 residents (R32, R238, R240, R241) reviewed for antibiotic stewardship in the sample of 30.