Virginia Beach Healthcare and Rehab Center

Inspectors wroteBased on observation, interview, clinical record review and facility documentation, the facility staff failed to protect the residents right to be free from abuse and neglect by facility staff for one resident (R4) in a survey sample of five Residents. This deficient practice resulted in the identification of Immediate Jeopardy (IJ), which constituted substandard quality of care. Following the verification of removal of the IJ, the scope and severity was lowered to a level three isolated.

Inspectors wroteBased on interview, clinical record review and facility documentation, the facility staff failed to implement their abuse/neglect policy and take measures to protect a resident during an allegation of abuse/neglect, failed to report the allegation and failed to conduct a thorough investigation for one resident (Resident #4-R4) in a survey sample of five residents. This failure resulted in R4 sustaining psychosocial harm and the identification of immediate jeopardy (IJ) and resulted in substandard quality of care.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure residents on four of four units had snacks available to them.

Inspectors wroteBased on clinical record review, facility document review, and staff interview, facility staff failed to develop a comprehensive plan of care for Hemorrhoids with internal treatment with a medication for one Resident (Resident #1-R1) in a survey sample of five Residents.

Inspectors wroteBased on Clinical record review, facility document review, and staff interview, the facility staff failed to clarify a physician's order which was written without a specific dosage, and with a contraindicated route for a significant medication, for one Resident (Resident #1/R1) in a survey sample of five Residents.

Inspectors wroteBased on interview, clinical record reveiew and facility documentation, the facility staff failed to provide necessary services to maintain good grooming and personal hygiene for one resident, (Resident #5-R5) in a survey sample of five residents.

Inspectors wroteBased on observation, interview and clinical record review the facility staff failed to ensure residents received proper treatment and care to maintain good foot health for one resident in a survey sample of five residents, (Resident #5- R5).

Inspectors wroteBased on observation, staff interview, and review of facility documents, the facility staff failed to assure that a medication cart was not kept locked or under direct observation of authorized staff in an area where residents could access it.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to prevent the elopements for two (2) residents out of 24 residents. Resident #217 and Resident # 223, in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to provide the necessary supervision to prevent an elopement for two (2) out of 24 residents. Resident #217 and Resident # 223, in the survey sample.

Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to prevent, assess, identify and treat an avoidable pressure ulcer resulting in harm for one Resident (Resident #73) in a survey sample of 55 Residents.

Inspectors wroteBased on observations, resident interviews, staff interviews, facility document reviews, and review of the facility's policy, the facility staff failed to provide a sanitary, comfortable, and homelike environment on four of four units and some common areas, which resulted in Substandard Quality of Life.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation, the facility staff failed to serve food that is palatable, attractive, and an appetizing temperature for Residents on 4/4 units.

Inspectors wroteBased on observation, staff interview, facility documentation review, the facility staff failed to ensure the facility was administered effectively to maintain the highest practicable well being of each resident.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to devise a facility-specific facility assessment

Inspectors wroteBased on observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the facility maintained a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases, infections, Legionnaires', and other potentially transmissible waterborne pathogens, on 4 of 4 Resident living units and communal spaces.

Inspectors wroteBased on observation, interview, and facility documentation the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Inspectors wroteBased on information obtained during the Resident Group interview, observations, staff interviews, and Resident Group meeting minutes, the facility staff failed to demonstrate their response, action and/or a rationale for not taking action to the Resident Group grievances.

Inspectors wroteBased on staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse and neglect, failed to report the abuse to the state agency, failed to fully investigate the abuse, failed to protect the victims during the investigation, and further failed to implement their abuse and neglect policies for four known Residents (Residents #68, #20 and #521, ) in a survey sample size of 55 residents.

Inspectors wroteBased on staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to implement their abuse policies to prevent repeated willful abuse and neglect, in so doing, failed to report the abuse to the state agency, failed to fully investigate the abuse,and further failed to protect the victims during the investigation, for four known Residents (Residents #68, #20, #521, and #325) in a survey sample size of 55 residents.

Inspectors wroteBased on staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse and neglect, failed to report the abuse to the state agency, failed to fully investigate the abuse, failed to protect the victims during the investigation, and further failed to implement their abuse and neglect policies for four known Residents (Residents #68, #20, #521, and #325) in a survey sample size of 55 residents.

Inspectors wroteBased on staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse and neglect, failed to fully investigate the abuse, failed to report the abuse to the state agency, failed to protect the victims during the investigation, and further failed to implement their abuse and neglect policies for four known Residents (Residents #68, #20, #521, and #325) in a survey sample size of 55 residents.

Inspectors wroteBased on Resident staff interview, facility documentation review, and clinical record review, the facility staff failed to provide a comprehensive care plan for care and services to maintain the highest practicable well being for two residents, (Resident #73, and #521) in a survey sample of 55 residents.

Inspectors wroteBased on observations, Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to follow the professional standards of nursing practice for 2 residents, (Residents #89, and #161) in a survey sample of 55 residents. The Findings Included: 1. For resident #89 the facility staff failed to apply a Cardiac Monitor, to the Resident for the required time frame to capture and diagnose the cause of repeated syncopal episodes from suspected heart arrythmias (irregular heart beats). Resident #89 was admitted to the facility on [DATE], and readmitted on [DATE], after a 6 day hospitalization. Diagnoses included; Chronic Kidney disease, sick sinus syndrome after syncope and collapse on 7-12-24, dementia, hypertension, malnutrition, stroke, and anemia. [...]

Inspectors wroteBased on observation, staff interview, facility documentation and clinical record review, the facility staff failed to ensure two Residents (Resident #89 and #68) received ADL (activities of daily living) care to include hygiene and showers in a survey sample of 55 residents.

Inspectors wroteBased on Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to identify and address necessary behavioral health services, and failed to devise and implement a comprehensive person centered care plan for identified responses to stressors for one Resident with non-Alzheimer's type dementia with a language barrier (Resident #521) in a survey sample of 55 Residents.

Inspectors wroteBased on observations, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to ensure significant medication was administered for 5 of 55 residents (Resident #47, Resident #57, Resident #424, Resident #372 and #161), in the survey sample.

Inspectors wroteBased on observation and staff interview, the facility staff failed to remove expired medications and provide the date medications were opened on 2 of 4 facility units.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to maintain an effective pest control program so that the facility is free of pests for the facility.

Inspectors wroteBased on staff interview the facility failed to maintain a training program for all new and existing staff based on the facility's assessment.

Inspectors wroteBased on review of facility documents and staff interview the facility staff failed to ensure that all staff members were educated on Resident's rights and facility responsibilities.

Inspectors wroteBased on review of facility documents and staff interview the facility staff failed to ensure that all staff members were educated regarding the Quality Assurance and Performance Improvement

Inspectors wroteBased on review of facility documents and staff interview the facility staff failed to ensure that all staff members were educated on Compliance and Ethics.

Inspectors wroteBased on review of facility documents and staff interview the facility staff failed to ensure that all Certified Nurses Aides (CNA) completed the mandatory twelve (12) hours of education each year.

Inspectors wroteBased on review of facility documents and staff interview the facility staff failed to ensure that all staff members were educated on Behavioral health.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff has failed to determine that Residents are clinically appropriate to self-self-administer medication for 1 Resident (#142) in a survey sample of 55 Residents.

Inspectors wroteBased on observation, Resident interview, staff interview and clinical record review, the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 2 Residents (# 161 and # 107) in a survey sample of 55 Residents.

Inspectors wroteBased on a clinical record review and staff interview the facility staff failed to thoroughly and accurately complete the Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability (PASARR) for 2 of 55 residents (Resident #56 and #28), in the survey sample.

Inspectors wroteBased on family interview, staff interviews, and clinical record review, the facility staff failed to have an ongoing discharge planning process which focused on the resident's/resident representative discharge goals for 1 of 31 residents (Resident #119), in the survey sample.

Inspectors wroteBased on observation, family interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to apply the correct size Ostomy appliance and failed to provide care to an ostomy according to the physician's order for 1 of 31 residents in the survey sample.

Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to prevent significant weight loss and malnutrition for one Resident (Resident #73) in a survey sample of 55 Residents.

Inspectors wroteBased on information obtained during the as worked nursing schedule nursing staff, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week which could potentially affect all residents. The facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week.

Inspectors wroteBased on staff interview, facility record review, and clinical record review, the facility staff failed to provide specific and adequate treatment services for mental health and psychosocial concerns for one Resident with depression, and anxiety (Resident #126) in a survey sample of 30 Residents. Resident #126 did not receive adequate psychosocial, psychiatric, nor psychoactive medication care and services while in the facility after multiple falls, a hospitalization with fracture and head injury, and after return to the facility with behavioral issues complicated by new onset confusion. Further the facility failed to reinstitute long standing medication therapy for depression and anxiety after the hospitalization return.

Inspectors wroteBased on resident interviews, staff interview, clinical record review, and facility document review, it was determined that the facility social worker failed to provide services for one resident (Resident #521) in the survey sample of 55 Residents

Inspectors wroteBased on observation, interview, clinical record review, the facility staff failed to procure routine medications as ordered by the physician for 2 Residents (#142, #161) in the survey sample of 55 residents and establish a system of records of receipt and disposition of all controlled drugs.

Inspectors wroteBased on observation, interview, and facility documentation the facility staff failed to ensure food was prepared, in accordance with professional standards for food service safety for 1 of 4 kitchen staff.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to Maintain all mechanical, electrical, and patient care equipment in safe operating condition

Inspectors wroteBased on observation, resident, family and staff interview, clinical record review, and review of facility documents, the facility staff failed to administer analgesics to treat and manage pain which constituted harm for 2 of 55 residents (Resident #473 and Resident #325), in the survey sample.

Inspectors wroteBased on family interview, a clinical record review and staff interviews, the facility staff failed to notify the resident's Emergency Contact of his transfers to the emergency room (ER) for 1 of 55 residents (Resident #473), in the survey sample.

Inspectors wroteBased on family interviews, clinical record review, and staff interviews, the facility staff failed to provide a resident with a discharge summary at the time of discharge for 1 of 55 residents (Resident #472), in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to provide the necessary supervision to prevent an elopement for two (2) out of 24 residents, Resident #217 and Resident # 223, in the survey sample.

Inspectors wroteBased on resident interview, staff interview, and review of facility documents, the facility staff failed to provide sufficient nursing staff to provide nursing and related services to meet the resident's needs for 2 of 55 residents (Resident #47, #472), in the survey sample.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to provide requested medical records for 1 of 55 residents (Resident #171), in the survey sample.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to meet professional standards for one of five residents in the survey sample, Resident #4.

Inspectors wroteBased on observations, staff interviews, facility document review and clinical record review, it was determined the facility staff failed to provide evidence of ADL (activities of daily living) care for one of five residents in the survey sample, Resident #1.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to meet provide catheter care for one of five residents in the survey sample, Resident #4.

Inspectors wroteBased on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide feeding assistance to prevent weight loss for one of five residents in the survey sample, Resident #1.

Inspectors wroteBased on resident and staff interview, resident observation, facility document review and clinical record review, it was determined that the facility staff failed to provide sufficient staffing to meet resident needs for two of five residents in the survey sample, Resident #1 and Resident #4.

Inspectors wroteBased on observations, staff interview, and facility document review, it was determined that the facility staff failed to provide snacks at bedtime and meals in a timely manner.

Inspectors wroteBased on review of facility's documentation and staff interview, it was determined that the facility failed to promote and enhance each resident's right to a dignified existence and being respected for one of five residents in the survey sample, Resident #1.

Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to respect the resident's and RP's (responsible party) right to participate in care planning for one of five residents in the survey sample, Resident #1.

Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to notify the RP (responsible party) of a change in condition for one of five residents in the survey sample, Resident #1.

Inspectors wroteBased on interviews, clinical record review, and facility documentation the facility staff failed to notify the physician of not of medications not being administered to 20 Residents (the entire Unit 3 B Assignment) in a survey sample of 28 Residents.

Inspectors wroteBased on interviews, clinical record review, and facility documentation, the facility staff failed to provide services that meet professional standards of care for 20 Residents in a survey sample of 28 Residents.

Inspectors wroteBased on interviews, clinical record review, and facility documentation, the facility failed to ensure the necessary care and services are provided consistent with the resident's physical status and immediate needs upon admission to the facility for one (1) Resident (#1) in a survey sample of 28 Residents.

Inspectors wroteBased on interview, record review, and facility policy, the facility failed to ensure advanced directives were offered and periodically reviewed; and Do Not Resuscitate (DNR) forms were completed and accurate for ten residents out of 34 sampled residents (Resident (R) 51, R11, R33, R114, R67, R85, R407, R412, R126, and R107).

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed ensure food was stored safely for three of four unit refrigerators. This failure could possibly lead to cross contamination and food-borne illness for the residents on three units.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to maintain a complete and accurate medical record for six of thirty-four sampled residents (Resident (R) 107, R126, R199, R402, 407, and 412). Specifically, the nursing staff failed to document the completion of physician orders on the resident's medication administration records (MAR). Findings Include: Review of facility policy titled Documentation Summary dated 11/01/19 indicated Licensed Nurses and CNAs [Certified Nurse Aides] will document all pertinent nursing assessments, care interventions, and follow up actions in the medical record. Review of facility policy titled Monitoring dated 11/01/19 indicated Licensed nurses will complete blood glucose monitoring as ordered by the physician .4. Blood glucose checks will be documented on the eMAR [Electronic Medication Administration Record]. 1. [...]

Inspectors wroteBased on observation, record review, interview, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases for six residents of nine residents (Resident (R) 403, R404, R405, R406, R407, and R408) reviewed for transmission-based precautions; three of seven residents (R37, R51, and R105) observed during the observation of medication administration; and three of seven residents (R3, R138, and R144) reviewed for catheter care. Specifically, enhanced droplet precautions were not followed for R403, R404, R405, R406, R407, and R408. Staff did not perform hand hygiene between R37, R51, and R105. [...]

Inspectors wroteBased on observation, record review, interview, and review of facility policy the facility failed to ensure dignity was maintained for one of thirty-four sample residents (Resident (R) 404)). Specifically, R404's foley catheter bag was uncovered and within view of individuals in the corridor.

Inspectors wroteBased on observation, interview, record review, and facility policy, the facility failed to ensure one of 34 sampled residents (Resident (R) 85) had a physician's order and was screened/assessed for the self-administration of medications prior to medications being stored at the bedside and self-administered.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure an accurate Level 1 pre-screening of the resident for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility was completed for two of three residents (Resident (R) 13 and R133) reviewed for Level 1 Pre-admission Screening and Resident Review (PASRR).

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission to the facility for one resident of eight residents (Resident (R)404) reviewed for baseline care plans in a total sample of 34 residents.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to develop, assist, and follow through to completion with discharge plans for one of 34 sampled residents (Resident (R) 133) reviewed for discharge planning. The facility did not have a person-centered discharge plan for R133.

Inspectors wroteBased on observation, interview, record review, and review of facility policy the facility failed to provide an individualized activity program for two of 34 sampled residents (Resident (R) 33 and R51).

Inspectors wroteBased on interview and record review the facility failed to ensure treatment and care in accordance with professional standards of practice was provided for two of 34 sampled residents (Resident (R) 51 and R47). Specifically, the staff failed to ensure R51 was transported to her cardiologist follow up appointment on two different occasions. In addition, the staff failed to follow physician's orders for R47.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed provide treatment as ordered for prevention for pressure ulcer/skin injury for one of nine residents (Resident (R) 138) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure one of four residents (Resident (R) 67) reviewed for limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, staff did not apply R67's right hand splint per physician's orders to maintain range of motion.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed prevent accidents by failing to safely transfer a resident and perform neurological assessments for one of three residents reviewed for accidents (Resident (R) 42).

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to follow physician's orders to maintain the suprapubic urinary catheter for one resident of two residents (Resident (R) 404) reviewed for catheters. Specifically, the facility failed to ensure R404's suprapubic urinary catheter was flushed every shift and daily dressing change per physician's orders.

Inspectors wroteBased on observation, interview, record review, and facility policy the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for one of one resident (Resident (R) 58) reviewed for dialysis. The facility failed to ensure R58 had reliable transportation to and from dialysis and the facility did not demonstrate ongoing communication to the dialysis center and assessment of the resident prior to dialysis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide alternatives to residents who did not like what was served and failed to provide alternatives of similar nutritive value when alternatives were provided for three of 34 sampled residents (Resident (R)131, R405, R412).

Inspectors wroteBased on Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to follow physician orders for 9 of 36 Residents, Residents #141, 170, 366, 467, 115, 20, 11, 126, and 38.

Inspectors wroteBased on observation and staff interview, the facility staff failed to ensure physician ordered medications were available for administration, failed to date opened medication, and failed to properly store medications for 5 of 36 Residents (#38, 11, 126, 20, and 7) and on 2 of 5 medication carts.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure a complete DNR (do not resuscitate) form for 1 of 36 Residents, Resident #129.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to notify the physician of medication refusals for 3 of 36 residents in the survey sample (Resident #'s 126, 35 and 41).

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to protect the private healthcare information of residents on 1 of 4 units in the nursing facility (Unit 2).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to review and revise the resident's comprehensive care plan for 1 of 36 residents in the survey sample (Resident #35).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to administer pain medications for 2 of 36 Residents, (Residents #38 and #41) 1. For Resident #38, facility staff failed to consistently administer pain medications per physician orders. Resident #38 was admitted to the facility on [DATE] with diagnoses including paraplegia, muscle weakness, chronic pain, neurogenic bowel, hypertension, diabetes mellitus, anxiety, and depression. On the quarterly minimum data set assessment with assessment reference date 12/27/18, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. During an interview on 3/13/19 at 12:56 PM, the resident mentioned that during her stay, robaxin and gabapentin had both run out with no quick replacement. [...]

Inspectors wrote2. The facility staff failed to coordinate care with dialysis for Resident #316. Resident #316 was admitted to the facility 3/7/19 with the following diagnoses of, but not limited to end stage renal disease. The resident did not have an admission MDS (Minimum Data Set) completed at the time of this survey. However, it was noted by the surveyor that the resident was .alert and oriented X4 . as documented in the nursing notes for 3/7/19 at 23:49 (11:49 pm). On 3/13/19, the surveyor could not find any documentation of communication between the facility and the dialysis center. The resident was noted to be receiving dialysis on Monday, Wednesday and Friday of every week. At 10:45 am on 3/13/19, the surveyor asked the director of nursing (DON) where to locate the documentation of communication between the facility and dialysis for Resident #316. [...]

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to identify irregularities related to medications for 1 of 36 Residents, Resident #129.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure 1 of 36 Residents was free of unnecessary psychotropic medications, Resident #129.

Inspectors wroteBased on staff interview, clinical record review and facility document review the facility staff failed to ensure 3 of 36 Residents were free of significant medication errors, Resident #88, Resident #90, and Resident #7.

Inspectors wroteBased on staff interview, clinical record review and facility document review the facility staff failed to ensure a complete and accurate clinical record for 3 of 36 Residents, Resident #129, Resident #1 and Resident #11.

Inspectors wroteBased on observation, resident and staff interview, facility document review and clinical record review it was determined the facility staff failed to coordinate services with hospice to include a hospice plan of care for 1 of 36 residents (Resident #122.)

Inspectors wroteBased on observation and staff interview, the facility staff failed to maintain a hazard free environment.