Walnut Cove Health and Rehabilitation

Inspectors wroteBased on record reviews, and staff, resident and resident RP (Responsible Party) interviews, the facility failed to protect a resident's right to be free from misappropriation of property leading to a monetary loss of $1309.99 for 1 of 3 residents reviewed for misappropriation of resident property (Resident #23).

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to develop a person-centered care plan in the areas of diabetes management (Resident #13) and smoking status (Resident #23). This deficient practice was for 2 of 29 residents whose care plans were reviewed.

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to revise the care plan in the areas of use of a wander/elopement alarm (Resident #13) and smoking status (Resident #39) for 2 of 29 residents whose care plans were reviewed.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a discharge Minimum Data Set (MDS) assessment within 14 days of the discharge date for 3 of 3 residents reviewed for resident assessment (Resident #55, Resident #81, Resident #85).

Inspectors wroteBased on observation, record review, and interviews with facility staff including Transport Aide/Driver #1, the facility failed to ensure the lift gate/platform was in the elevated position before unloading a resident from the back of the facility van for 1 of 3 residents sampled for accidents (Resident #1). On 10/24/24 Transport Aide Driver #1 pushed Resident #1 backwards out of the van and he fell approximately 17 and ½ inches out of the transport van to a lift platform that was located on the ground. Resident #1 fell out of his wheelchair and landed on his left side with half of his body on the lift platform and the other half of his body on the asphalt, and he struck his head on the asphalt. Resident #1 was prescribed and administered a blood thinner twice a day which increases the risk of bleeding. [...]

Inspectors wroteBased on observation, record review, staff and resident interviews and a life safety surveyor interview the facility failed to ensure the safety of residents in the designated smoking area of the facility when a staff member supervising the residents who smoked lit Resident #78's cigarette and allowed the resident to smoke with a combustible tank of compressed oxygen attached to the back of her wheelchair while she sat in the wheelchair. Residents who were also smoking were seated near the oxygen tank. The oxygen tank was turned off while the residents smoked. Even if turned off, it is not safe to smoke around an oxygen tank, oxygen-enriched levels can remain on tubing, clothing, hair, and skin increasing the risk for fire and/or explosion. Supplemental oxygen can make fires burn faster and hotter. [...]

Inspectors wrote3. a) An observation of the long hall nourishment room on 6/24/24 at 10:37 am in the presence of Nurse Aide (NA) #2 revealed black dried powdery substance on a white blanket crammed behind the ice machine. The same black dried powdery substance was noted on the wall behind the pipes that were attached to the ice machine. The plastic baseboard under the pipes behind the ice machine was peeling off the wall. The black dried powdery substance was observed between the wall and the baseboard that was peeling off. The floor tiles in the nourishment room were dull and had debris. NA #2 stated she did not know what the black stuff was. b) An observation of the corner wall opposite the ice machine on 6/24/24 at 10:37 am in the presence of NA #2 revealed black dried powdery substance under the refrigerator and behind it. [...]

Inspectors wroteBased on observations, record reviews, residents and staff interviews, the facility failed to honor 1 resident (Resident #30) of 2 residents reviewed for safe smoking the right to take smoking breaks at their preferred times.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to document the steps taken to investigate a complaint/grievance expressed on behalf of a resident, the findings or conclusions reached based on the investigation, and whether the investigation results were reported to the complainant with a written grievance decision. This occurred for 1 of 1 resident reviewed for grievances (Resident #284).

Inspectors wroteBased on record review and staff interviews the employee file was missing evidence of pre-employment screening documents for history of abuse, neglect, exploitation, or misappropriation of residents on a staff reviewed for allegation of staff to resident abuse (Nurse Aide #1).

Inspectors wroteBased on record review and staff interviews, the facility failed to report an initial allegation of staff to resident abuse to Adult Protective Services (APS) for 1 of 5 residents reviewed for abuse (Resident #71).

Inspectors wroteBased on staff interviews and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment at least every 12 months for 1 of 34 residents (Residents #29) whose MDS assessments were reviewed.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment to reflect the use of an anticoagulant and antipsychotic medication for 1 of 5 residents (Resident #54) reviewed for unnecessary medications and failed to accurately complete a Minimum Data Set (MDS) assessment to reflect a resident's cognitive mental state for 1 of 23 residents (Resident #59) reviewed for MDS accuracy.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to incorporate a resident's Preadmission Screening and Resident Review (PASRR) Level II determination and recommendations into the resident's care planning for 2 of 3 residents (Resident #4 and Resident #72) who were reviewed for PASRR.

Inspectors wroteBased on record review and staff interviews, the facility failed to review and revise a care plan after a resident's antipsychotic medication was discontinued and after fall mats were no longer used. This occurred for 2 of 5 residents (Resident #54 and #59) whose care plans were reviewed for accuracy.

Inspectors wroteBased on observation, record reviews, resident and staff interview, the facility failed to provide dental services to 1 of 1 sampled resident (Resident #30) with several missing and/or chipped teeth who requested dental services.

Inspectors wroteBased on record review, observations. and interviews with facility staff, the Dietary District Manager, and an Appliance Service Technician, the facility failed to notify the Administration of a concern related to the ignition of the stovetop burners, turn off the gas to the pilot lights of the malfunctioning gas burners and oven, and provide the maintenance required to keep 1 of 1 gas stove/oven combination appliance in safe operating condition.

Inspectors wroteBased on observations, record review, and resident, family, staff, Psychiatric Nurse Practitioner and Law Enforcement interviews the facility failed to protect a resident's right to be free from physical abuse when Nurse Aide (NA) #1 and NA #2 forcefully turned Resident #1 causing her forehead and left knee to hit the wall. The two NAs continued to provide incontinence care after the resident yelled and screamed for them to stop. Resident #1 reported she no longer felt safe when new staff came in to provide care to her. One of three sampled residents were affected by the deficient practice (Resident #1).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete and submit an Initial Report within 2 hours to the state regulatory agency for staff to resident abuse (Resident #1) for 1 of 3 residents reviewed in facility reported incidents.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to maintain a resident's dignity by dressing the resident in a gown with a brown stain across the neckline that extended below the chest area for 1 of 3 residents (Resident #38) reviewed for dignity. A reasonable person would expect to be treated with dignity and be dressed in apparel that was not stained.

Inspectors wroteBased on resident and staff interviews and record reviews, the facility failed to accurately code cognition and fall history on the Minimum Data Set (MDS) assessments for 2 of 20 residents (Residents #79, and #23) reviewed for MDS accuracy.

Inspectors wroteBased on observation, resident and staff interviews and record review, the facility failed to secure medications for 1 of 1 resident (Resident #40) observed with medications at bedside.

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey dated 12/2/2021. This was for four deficiencies that were cited in the areas of resident rights (F550), notice requirements (F623), accuracy of assessments (F641), and label/store drugs and biologicals (F761). The four areas were recited on the current recertification and complaint survey of 3/30/2023. The duplicate citations during two federal surveys of record demonstrate a pattern of the facility's inability to sustain an effective QAA program.