The Laurels of Charlottesville

Inspectors wroteBased on observations, resident and staff interviews, and facility documentation, the facility staff failed to appropriately inform residents-both orally and in writing-of their rights and all rules and regulations governing resident conduct and responsibilities during their stay, as required. Additionally, the facility did not have resident rights visibly posted for easy access by all residents.

Inspectors wroteBased on observation, resident interview, staff interview and facility documentation, the facility staff failed to resolve a grievance in a timely manner, failed to post the identification of the grievance officer, and failed to post the grievance procedure in the facility.

Inspectors wroteBased on staff interview, facility document review, employee record review and clinical record review, the facility staff failed to follow abuse prevention policies for pre-employment screening for thirteen of twenty-five employee records reviewed and failed to identify abuse as defined in the abuse policy following an investigation for one of thirty-three residents in the survey sampled (Resident #43).

Inspectors wroteThe facility failed to review and revise comprehensive care plans for four of thirty-three residents in the survey sample. Resident numbers: 1, 9, 17, and 43. The Findings Include: 1. Resident 1's (R1) care plan was not revised to reflect the residents' inability to self- position in bed. R1 was admitted to the facility with diagnoses that included bilateral above knee amputation, acute respiratory failure, peripheral vascular disease, and diabetes. The most recent minimum data set (MDS) was a significant change assessment dated [DATE] and assessed R1as being moderately conatively impaired. Section GG of the MDS indicated R1 was dependent for bed mobility indicating R1unable to self-position in bed. [...]

Inspectors wroteBased upon observations, resident & staff interviews, clinical record review, and facility documentation review, the facility failed to follow physician's orders for seven of thirty-three residents in the survey sample, Resident #134 (R134), Resident #41 (R41), Resident #49 (R49), Resident #22 (R29), Resident #31 (R31), Resident #38 (R38), and Resident #43 (R43). The Findings Include: 1. Resident #134 (R134) did not receive Cefazolin (antibiotic) as ordered. R134 was admitted to the facility with diagnoses that included cellulitis, right toes amputation, congestive heart failure, MRSA, and diabetes. The most recent minimum data set (MDS) was a 5-day assessment dated [DATE], R134 was assessed as being conatively intact. Review of R134’s clinical record indicated an order for “Cefazolin sodium inject 2 grams IM three times a day.” The order was written on 3/12/25 to start 3/13/25. [...]

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents are free from significant medication errors for one resident (Resident #22-R22) in a survey sample of thirty-three residents.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to properly label and store medications on two of three units (unit 1 and unit 2) and for one of thirty-three residents in the survey sample (Resident #31).

Inspectors wroteBased on observation, staff interviews, resident interviews and facility documentation reviews the facility staff failed to provide meals that were palatable and at appetizing temperatures for one of three units.

Inspectors wroteBased on observations and staff interviews the facility staff failed to store, label and distribute food in a sanitary manner in the main kitchen.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the COVID-19 vaccines to four of five residents reviewed for immunizations (Resident #17-R17, Resident #13-R13, Resident #2-R2, and Resident #14-R14).

Inspectors wroteBased on observation, resident and staff interviews, the facility staff failed to uphold resident rights and knock before entering residents rooms on one of three resident care units (200 unit).

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide written notice for a room change prior to the move, affecting two residents, Resident #17 (R17) and Resident #38 (R38) out of a survey sample of 33 residents.

Inspectors wroteBased on observation, resident interview and facility documentation the facility staff failed to provide a private area without staff interference for the Resident council meeting.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility failed to protect the resident's right to be free from verbal abuse by staff for one resident (Resident #43- R43) in a survey sample of 33 residents.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for one of thirty-three residents in the survey sample (Resident #132)

Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to develop a baseline care plan within 48 hours of admission for one resident (Resident #31-R31) in a survey sample of thirty-three residents.

Inspectors wroteBased on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of nurse practice for three residents (Resident #22-R22, Resident #35-R35, and Resident #132-R132) in a survey sample of thirty-three residents.

Inspectors wroteBased on observations, resident interviews, staff interviews, clinical record and facility documentation the facility staff failed to provide activity of daily living (ADL) assistance for three residents Resident #131 (R131), Resident #89 (R89) and Resident #35 (R35) out of a survey sample of 33 residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to administer oxygen at the physician ordered rate for one resident (Resident #35-R25) and failed to store respiratory equipment in a manner to prevent contamination for one resident (Resident #22-R22) in a survey sample of thirty-three residents.

Inspectors wroteBased on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to serve meals in accordance with resident preference for one resident (Resident #22-R22) in a survey sample of thirty-three residents.

Inspectors wroteBased on observations, staff interview, clinical record review and facility documentation review the facility staff failed to provide a therapeutic diet per physician orders.

Inspectors wroteBased on staff interview, and clinical record review the facility failed to ensure a complete and accurate record for one of thirty-three residents, Resident #134. The findings Include:The facility did not document wound care on the Treatment Administration Record (TAR) for Resident #134 (R134). R134 was admitted to the facility with diagnoses that included cellulitis, right toes amputation, congestive heart failure, MRSA, and diabetes. The most recent minimum data set (MDS) was a 5-day assessment dated [DATE], R134 was assessed as being conatively intact. Review of R134's clinical record indicated an order dated 3/12/25 to complete wound care and dressing change to R134's root foot every day and evening shift starting on 3/13/25. Review of R134's TAR indicated on 3/16/25 day shift and 3/17/25 evening shift was not signed off to indicate the dressing change was completed. [...]

Inspectors wroteBased on observations, staff interview, clinical record review and facility documentation review the facility staff failed to implement their infection prevention and control program for one resident out of a survey sample of 33 residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the flu and pnuemococcal vaccines to two of five residents reviewed for immunizations (Resident #17-R17 and Resident #110-R110).

Inspectors wroteBased on staff interviews and facility documentation review the facility staff failed to ensure that staff received required training related to the care of residents with cognitive impairments, including dementia, for two of five staff reviewed for training.

Inspectors wroteBased on observations, staff interview, clinical record and facility documentation the facility staff failed to follow physician's orders for tube feeding flushes for one resident, (Resident #1, R1) in a survey sample of 4 residents.

Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed, during transport in the facility's van, to secure safety restraints for one of four residents in the survey sample (Resident #1). Upon sudden braking during a transport, Resident #1 was thrown from the wheelchair onto the van floor, and was found with an unattached lap/shoulder safety belt. Resident #1 experienced a painful right ankle fracture and left lower leg fracture that required hospitalization, surgical treatment, and a blood transfusion (harm) as a result of the accident.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of six residents in the survey sample (Resident #6). Resident #6's communication forms for dialysis were incomplete.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to assess and implement interventions for prevention/care of pressure ulcers for three of twenty-nine residents in the survey sample, Resident #215, #216, and #5. Resident #215 developed a pressure ulcer initially identified at a stage 3 status. There were no skin assessments in the weeks prior to the stage 3 ulcer and no follow up assessment of the pressure injury for sixteen consecutive days. Resident #215's pressure ulcer developed necrotic tissue, foul odor/drainage resulting in hospitalization due to sepsis from the infected wound. Resident #216 was admitted with a stage 2 pressure ulcer. There was no thorough assessment or interventions implemented for treatment of the ulcer. [...]

Inspectors wroteBased on clinical record review, resident interview, and staff interview, the facility staff failed to follow physician's orders for catheterization for one of 29 residents in the survey sample, Resident # 5. Facility staff failed to catheterize the resident as scheduled according to physician's orders.

Inspectors wroteBased on review of the facility's personnel files, facility policy and procedures, and staff interviews, the facility staff failed to implement the policy and procedure to ensure applicants for employment completed a Sworn Disclosure Statement disclosing .any criminal convictions or pending criminal charges . and also failed to ensure a criminal background check was obtained within 30 days of hire for one of 25 records reviewed.

Inspectors wroteBased on staff interview and clinical record review, the facility failed to document a discharge to the hospital in the clinical record for one of 29 residents, Resident #42. The Findings Include: Resident #42 was admitted to the facility with diagnoses that included: Spleen rupture, congestive heart failure, acute on chronic hypoxic respiratory failure, and muscle weakness. The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 2/16/22. Resident #42 was assessed with a cognitive score of 14, indicating cognitively intact. On 4/13/22 Resident #42's medical record was reviewed. The MDS list indicated Resident #42 had been discharged to the hospital on 1/31/22. Review of the progress notes documentation dated 2/1/22 and 2/2/22 read pt (patient) still in hosp (hospital). [...]

Inspectors wroteBased on clinical record review, staff interview, and resident interview, the facility failed to accurately complete a Minimum Data Set (MDS) for two of twenty-nine (29) residents in the survey sample, Residents # 28 and 29. The facility failed to accurately assess Section C (Cognitive Patterns), Section D (Mood), and Section E (Behavior) for both residents.

Inspectors wroteBased on staff interview and clinical record review, the facility failed to review and revise a comprehensive care plan for two of 29 residents, Resident #64 and #92. Resident #64 did not have an ADLs (activities of daily living) care plan updated and Resident #92 did not have code status updated. The Findings Include: 1. Diagnoses for Resident #64 included: Parkinson's disease, urinary tract infection, anxiety, and muscle weakness. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of [DATE]. Resident #64 was assessed with a cognitive score of 15 indicating cognitively intact. Under Section G, Functional Status, Resident #64 was assessed for bed mobility, transfer, eating, and toileting use at a 3-2 for all areas indicating extensive assistance with one person assist. [...]

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to assess and initiate treatment for a wound for one of twenty-nine residents in the survey sample, Resident #216; and failed to follow physician orders for one of twenty-nine residents in the survey sample, Resident #49. Resident #216, assessed with a leg wound upon admission, had no treatment orders implemented or ongoing monitoring of the wound. Resident #49 did not have a medication dosage change as ordered by the physician.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide a therapeutic diet as ordered by the physician for one of twenty-nine residents in the survey sample, Resident #53. Resident #53 was not provided a double-portioned meal as ordered by the physician due to weight loss.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure medications were available for administration to one of five residents in the medication pass, Resident #84. Calcium carbonate and Natural Balance Tears were not available for administration to Resident #84 during a medication pass.

Inspectors wroteBased on a medication pass and pour observation, staff interview, and clinical record review the facility staff failed to ensure a medication error rate of less than 5 percent. There were three errors out of twenty-six opportunities for an error rate of 11.54 percent.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure drugs and biologicals were labeled appropriately on one of three nursing units, Unit 2 medication room. The facility failed to appropriately label one, multi dose vial of Tuberculin on Unit 2.

Inspectors wrote2. Resident #46 was admitted to the facility with diagnoses that included cerebrovascular accident (stroke) with hemiplegia, hypertension, diabetes, depression and bipolar disorder. The minimum data set (MDS) dated [DATE] assessed Resident #46 as cognitively intact. On 4/12/22 at 11:45 a.m., Resident #46 was interviewed about quality of life in the facility. Resident #42 stated he was not pleased with the food. Resident #46 stated the food doesn't taste good and was most all the time served cold. Resident #42 stated he ate meals in his room and meals more times than not were lukewarm. A test tray was conducted during dinner on 4/12/22 at 6:00 p.m. The test tray evaluation determined that food items were inadequate with temperature and taste at the time of service to residents. [...]

Inspectors wroteBased on resident interview and staff interview the facility staff failed to ensure food preferences were honored for one of 29 resident's in the survey sample, Resident #71.

Inspectors wroteBased on observation, staff interview and facility document review, the facility failed to ensure food in the main kitchen was stored prepared, distributed and served in a safe and sanitary manner.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure an accurate clinical record for one of twenty-nine residents in the survey sample, Resident #216. Resident #216's record had conflicting documentation of her resuscitation status.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to ensure waste was properly disposed of in garbage and refuse containers located outside of the main kitchen.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure the right to retain and use of personal property for one of 27 residents in the survey sample, Resident #209. Resident #209's cell phone was locked in the medication cart for over a week without the resident's permission or knowledge and without identifying the phone as the resident's property.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, facility staff failed to develop a baseline care plan for a PICC (peripherally inserted central catheter) line, for one of 27 residents in the survey sample, Resident #318.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, facility staff failed to develop a comprehensive care plan for one of 27 residents in the survey sample, Resident #318, for care of a PICC (peripherally inserted central catheter) line.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, facility staff failed to obtain a physician order for use of Aspercreme, for one of 27 residents in the survey sample, Resident #321; and failed to coordinate with Hospice services for one of 27 residents, Resident #214.

Inspectors wroteBased on observation, resident interview and staff interview, the facility staff failed to ensure sufficient staffing on one of three nursing units (Unit 1) in the facility.

Inspectors wroteBased on observation and staff interview, facility staff failed to procure, store and prepare food in a sanitary manner in the main kitchen.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, facility staff failed to assess one of 27 residents in the survey sample, Resident #321, for self administration of a medication, Aspercreme.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to implement their abuse prevention policies regarding reporting of an allegation of mistreatment/abuse for one of 27 residents in the survey sample. Resident #209's allegations of mistreatment/abuse/misappropriation of property reported to a therapist and a physician were not immediately reported to the administrator as required in their abuse prevention policies for abuse prevention.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to immediately report to the administrator allegations of mistreatment and potential misappropriation of property for one of 27 residents in the survey sample. Resident #209's report of mistreatment/misappropriation of property to a therapist and a physician were not reported to the administrator. Nursing staff locked Resident #209's personal cell phone in a medication cart without consent and without any report to nursing or facility administration.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to safely store portable oxygen cylinders for one of 27 residents (Resident #214).

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to ensure a medication was properly labeled on one of three nursing units. An insulin pen was stored in the medication cart on unit one with no resident name or date opened.

Inspectors wroteBased on resident interview, family interview, clinical record review, and staff interview, the facility staff failed to ensure one of 27 residents received restorative nursing services. Restorative services for Resident #21 was not provided per the PT (Physical Therapist) recommendations and physician's order.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, facility staff failed to ensure proper infection control practices for contact isolation were implemented for one of 27 residents in the survey sample, Resident #318.