Vienna Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled residents (Resident 1's) representative was provided timely access to Resident 1's personal funds. This failure resulted in Resident 1's rights regarding financial matters to not be recognized.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper food storage and preparation, as well as maintaining kitchen equipment and food contact surfaces in accordance with professional standards for food safety for 133 residents who consumed facility-prepared meals when:1. Kitchen contained worn and improperly maintained food preparation equipment such as, three blenders were visibly discolored, five cooking sheet trays had dark brown residue buildup in the inside corners, and two cutting boards had multiple scratches on both sides; and2. A container of cheddar cheese dated 1/29/26 and a container of mozzarella cheese dated 2/4/26 were not properly labeled and were stored in the walk-in refrigerator without clear identification to ensure safe use within appropriate time frames. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 136, when:1. Enhanced barrier precautions (EBP - an infection control intervention that requires staff to wear gowns and gloves during high contact care for residents with wounds, medical devices or known multidrug resistant germs) were not followed while draining Resident 6's foley catheter;2. Staff did not do hand hygiene while passing meal trays for Resident 158, Resident 152, Resident 115, and Resident 31, and;3. Oxygen tubing for Resident 148 and Resident 149 did not have protective storage bags. These failures in infection prevention and control measures had the potential to spread the infection to staff and other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for two of 35 sampled residents (Resident 4 and Resident 152) when:Staff stood while assisting Resident 4 with meals and did not position themself at Resident 4's eye level. Resident 152's urinary catheter bag (a bag that collects urine from the bladder through a urinary catheter - a soft tube that drains urine from the bladder) was exposed and not placed in a dignity bag (a cover used to hold and hide the catheter bag to maintain privacy). These failures had the potential to negatively impact Resident 4 and Resident 152's psychosocial well-being (emotional and social health, including how a person feels and interacts with others).

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of two of 35 sampled residents (Resident 17 and Resident 147) when Resident 17 and Resident 147 had call lights (devices used to contact staff for assistance) that were not within their reach. This deficient practice placed Resident 17 and Resident 147 at increased risk for unmet care needs, delayed staff response, falls, and potential for accidents or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate resident choices and preferences for care in accordance with professional standards of practice for 1 of 35 sampled residents (Resident 86) when, Resident 86's hair was cut against his wishes. This failure had the potential to negatively impact Resident 86's dignity and well-being due to not being able to make decisions regarding his care.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 35 sampled residents (Resident 6) rights related to treatment choices were known and protected when Resident 6's code status was not available on the electronic health record (EHR). This failure had the potential for Resident 6's wishes regarding emergency treatment to not be followed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a comfortable and homelike environment for six of 136 residents (Resident 6, Resident 12, Resident 54, Resident 67, Resident 105, Resident 126 ), when the hot water temperature in the bathroom of rooms A and B were found to be less than the required temperature range of 105 degrees Fahrenheit ( F - unit of measure) to 120 F.This failure has the potential to negatively impact on the hygiene and comfort of the residents who used the bathroom in rooms A and B.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the use of physical restraint (equipment used to limit a resident's movement) was safe to use and medically necessary for one of 35 sampled residents (Resident 147) when Resident 147, who had the ability to walk with assistance, was placed in a Geri chair (a reclining chair used when a resident cannot safely sit in a regular chair or wheelchair and can prevent a resident from rising independently) without informed consent (resident or resident's representative was informed and agreed to its use), or a Geri chair care plan. This failure removed Resident 147's ability to move freely and placed Resident 147 at risk for physical decline and psychosocial harm (effects on feelings, comfort, and dignity) related to restraint use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free of accidents or hazards for one of 35 sampled residents (Resident 131) when Resident 131's smoking assessment was not completed quarterly by the required due date, no smoking care plan was initiated, and Resident 131 was allowed to smoke without supervision. This failure had the potential to place Resident 131 and other residents in the facility at risk for accidental burns and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess pain and provide timely pain relief for one of 35 sampled residents (Resident 2) when Resident 2 reported moderate (medium level) pain, waited for 10 minutes for non-pharmacological interventions (comfort measures that do not involve medication), and was not reassessed for pain. This failure resulted in Resident 2 experiencing ongoing, uncontrolled pain, which affected Resident 2's comfort and emotional well-being (the ability to feel calm, comfortable, and free from distress).

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the safe use of bed rails (side rails) for one of 35 sampled residents (Resident 80) when Resident 80 did not have a completed bed rail assessment to determine whether bed rails were needed and safe to use. This failure placed Resident 1 at risk of entrapment and serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rate was less than 5% (% or percentage is a fraction of a number out of 100) during medication administration. The facility had a total of three errors out of 28 opportunities which resulted in a facility wide medication error rate of 10.71%. Medication observations were conducted over multiple days, at varied times, in random locations throughout the facility. The three medication errors were identified in two residents (Resident 93 and Resident 83) out of eight residents observed for medication administration observation as follows:1. Resident 93 was given medication without a doctor's order.2. Resident 93's ordered medication was not given.3. Resident 83's medication that was ordered to be given with food was not given as ordered. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication storage and labeling practices in one out of two medication rooms and two out of three medication carts when:1. An expired bottle of ocular vitamins (specialized supplements containing high concentrations of nutrients designed to support vision and reduce the risk of age-related eye disease) was found in the Station 2 Medication Storage Room and an expired bottle of ocular vitamins was found in the Station 1 Medication Cart 3; and2. Two pill cutters (a device used to safely and accurately divide medication tablets, vitamins, and supplements) were found with white and grayish residue in two different medication carts (Medication Cart 5 and Medication Cart 3). These failed practices could contribute to unsafe medication use, medication error, and risk of contaminated products or supplies.

Inspectors wroteBased on interview and record review, the facility's Resident Care/Quality Assurance Committee (a mandatory, internal group within a nursing home or skilled nursing facility. Its purpose is to identify, monitor, and improve the quality of care and life for residents, as required by federal law for facilities receiving Medicare or Medicaid funding) failed to meet quarterly with all required members, when the Infection Preventionist (IP) did not attend the quarter 2 meeting on 4/24/25. This failure had the potential of leading to staff lacking knowledge and coordination of care for a census of 136, thereby resulting in risk for safety, spread of infection, and hospitalization.

Inspectors wroteBased on observation and interview, four rooms (rooms 24, 33, 43 and 68 ) in the facility did not meet the required 80 square feet per resident. This failure placed the residents in rooms 24, 33, 43 and 68 at potential risk to impede their care and highest possible level of functioning due to smaller than required square footage.

Inspectors wroteBased on interview and record review, the facility failed to report to the Department an injury of unknown source (an injury which was not observed, cannot be explained by the resident, and is suspicious because of the extent or location) for one of three sampled residents (Resident 1) when Resident 1 had a bruise on the right side of her neck and left clavicle (a bone that connects the breastbone to the shoulder blade) identified on 11/14/24 and 11/15/24 respectively, and the facility did not report this to the Department until 11/21/24. This failure resulted in a delay in the Department investigation into Resident 1' s bruises and had the potential for an occurrence of abuse to go undetected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food storage and service was in accordance with professional standards for food service safety, for the 139 residents who ate facility prepared meals when: 1. The cook's refrigerator was found with the temperature varying anywhere from 42-50 degrees Fahrenheit; 2. The three-door freezer (used for meats) had ice buildup behind the second and third doors, around the top of the door frame; 3. The three-door freezer had an open box of vegetarian meatballs that was exposed to the air; 4. Three fans were found with discolored blades; 5. Two metal shelves in cook's preparation area found with rusted areas; and 6. Four cutting boards found with black staining and deep grooves on cutting surfaces. These failures had the potential of leading to food borne illness for the 139 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide consistent guidance to staff regarding food brought to residents from outside sources. This failure had the potential of unsafe food items being distributed to the 139 residents leading to choking risk, allergic reactions, and food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards of practice were followed for two of 34 sampled residents (Resident 114 and 70) when: 1. Licensed Nurse 3 (LN 3) did not wear gloves during the administration of Resident 114's Paroxetine (medication used to treat depression) per physician's order; and 2. The dose for Resident 70's Zolpidem (medication used to treat insomnia [trouble falling asleep]) was not given but was signed as administered. These failures had the potential to result in contamination of the medication and exposure of Resident 114 and the LN to side effects, and confusion and inaccuracies in Resident 70's medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified in a timely manner of a medication refusal for one of 34 sampled residents (Resident 12). This failure had the potential to cause negative outcomes to Resident 12's physical and mental well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to prevent pressure injuries (localized pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for 2 of 34 sampled residents (Resident 3 and Resident 37) when: 1. Resident 3 did not have a foot cradle (device used to relieve pressure from the lower extremities by preventing blankets and linens from laying directly on the lower extremities) and sheepskin padding in place as ordered by physician; and, 2. Resident 37's foot cradle was used incorrectly when linens and towels were placed on top of the frame allowing bed linens and blankets to lay directly on lower extremities. These failures had the potential to result in Resident 3 and Resident 37 developing pressure injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 34 sampled residents (Resident 45) received care and services to address her right hand contracture (a tightening of the muscles, tendons, and skin, causing resident's fingers to bend and curl towards the palm), when the facility did not implement preventative measures to maintain the resident's hand mobility and prevent worsening of Resident 45's contracture. This failure resulted in Resident 45 experiencing a severe right hand contracture leading to further decline in use of her hand and had the potential to result in pain and skin problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage, usage, handling, and labeling of respiratory care equipment were consistent with the facility's policy and procedures (P&P) for one of 34 sampled residents (Resident 13) when a nebulizer (a machine that turns medicine into a mist) mask and tubing were not properly stored and replaced as ordered, and nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was used and connected to a nebulizer machine. These failures had the potential to result in unsafe and unsanitary delivery of respiratory treatments to Resident 13.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was provided consistent with professional standards of practice for one of 34 residents (Resident 34) when doses of Resident 34's PRN (as needed) pain medication were given without adequate indication. This failure had the potential to increase Resident 34's risk of exposure to side effects and dependence on pain medication.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide 80 square feet of living space per resident in rooms 24, 33, 43, and 68. This failure had the potential to compromise the residents' care and privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to ensure safety for one of three sampled residents (Resident 1), when he was verbally threatened and then hit and kicked by Resident 2. This failure resulted in Resident 1 sustaining skin tears to the bridge of his nose and right arm, large abrasion to his left shoulder, experienced pain, and had the potential to negatively affect his long term emotional well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe environment and ensure one of three sampled residents (Resident 1) was free from verbal abuse by a staff member, by failing to ensure the facility's staff (FS 1), was not raising his voice, arguing with Resident 1, and calling the resident inappropriate names. This failure had the potential for Resident 1 to be fearful and to negatively affect her psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their medication and pain management policy and procedure to ensure standards of professional practice were maintained during Medication Administration for a census of 115 when: 1. Pain was not assessed properly for Resident 66; 2. Glycolax powder (a medication used for constipation) was not administered as ordered for Resident 26; 3. Blood pressure (BP) was not checked as ordered prior to giving medication for Resident 85; 4. Medications administered or held were on not documented in a timely manner for Resident 16; and 5. Resident 16's electronic medical record was not protected during medication administration. These failures had the potential to negatively impact the resident's health outcomes. Additionally, failure to protect health records denied residents their rights to privacy of their information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three residents (Resident 47, Resident 81, and Resident 113) were assisted with Activities of Daily Living (ADL) when fingernails were long and had blackish substance underneath the nails, for a census of 115. These failures increased the potential to result in skin problems or injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services for one of two residents, (Resident 269) who received renal hemodialysis (HD, a treatment necessary for kidney failure to remove unwanted toxins, waste products, and excess fluids by filtering the blood), when the facility failed to communicate and collaborate with the transport agency. This failure resulted in fatigue and frustration when transportation was delayed for an hour or more on multiple occasions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen in sanitary condition by failing to ensure the Quaternary Ammonium sanitizing solution (a chemical agent used to destroy germs) used for sanitizing kitchen surfaces and equipment had the required concentration to be effective and Dietary Aide 2 failed to follow proper hand hygiene between tasks. These failures had the potential to result in foodborne illness to 114 vulnerable residents receiving food from the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper infection control practices were followed for a census of 115 when: 1. Reusable equipment was not sanitized after use and between residents for (Resident 16, Resident 26, and Resident 85) and, proper hand hygiene was not followed during medication administration for Resident 85; 2. Resident 268, who had an infectious condition, shared a room with a vulnerable resident, and 3. There was no Contact Isolation Precautions signage posted informing visitors that the resident was on isolation precautions (measures taken to prevent the spread of germs/infection from one person to another). These failures had the potential to spread infection between and among the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Range of Motion (ROM, the degree of movement that occurs at a given joint during an exercise program) exercises were provided as ordered for one resident (Resident 81), for a census of 115. This failure increased the potential for Resident 81 to experience further reduction in ROM.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide 80 square feet of living space per resident in rooms 24, 33, 43, and 68. This failure had the potential to compromise the residents' care and privacy.