Waynesboro Post Acute & Rehabilitation

Inspectors wroteBased on policy review, Hospice contract review, medical record review, facility investigation review, Hospital record review, and interview, the facility failed to ensure residents were free from neglect for 1 of 3 (Resident #1) sampled residents reviewed for injury of unknown origin. On 11/10/2022, Resident #1 was found in bed by staff with multiple bruises to her right shoulder and right upper arm. On 11/18/2022, Resident #1 complained of pain in her right shoulder area. On 11/18/2022, the facility obtained an X-ray of the right arm/shoulder that revealed a displaced acute right transverse humerus shaft fracture (broken upper right arm usually caused by trauma/injury). [...]

Inspectors wroteBased on the policy review, Electronic Medical Record (EMR) Provider Transition Checklist memo review, Administrator's email, medical record review, and interview, the facility failed to maintain access and availability to resident's medical records for 10 of 10 (Resident #1, #3, #5, #6, #7, #8, #9, #10, #11, and #12) sampled residents reviewed for medical records prior to 6/18/2024.

Inspectors wroteBased on facility policy review, medical record review, facility investigation review, Hospital record review, and interview, the facility failed to report an injury of unknown origin for 1 of 3 (Resident #1) sampled residents reviewed for abuse and neglect.

Inspectors wroteBased on policy review, medical record review, facility investigation review, Hospital record review, and interview, the facility failed to perform a thorough investigation for injury of unknown origin for 1 of 3 (Resident #1) sampled residents reviewed for abuse and neglect.

Inspectors wroteBased on policy review, observation, and interview the facility failed to ensure medications were stored appropriately and securely when external medications and internal medications were stored together, and expired medications were in 4 of 7 medication storage areas (Treatment Cart, North Hall Medication Cart, [NAME] Hall Medication Cart, and [NAME] Hall Medication Room) reviewed and when 1 of 3 nurses (Licensed Practical Nurse (LPN) #1) gave the South Hall Medication Cart and Medication Room keys to the to an unauthorized staff member (the Housekeeping Supervisor) and left him unattended in the Medication Room.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to promote care that maintained residents' dignity, respect, and quality of care when staff failed to provide dignity bags for 2 of 2 sampled residents (Resident #26 and #63) reviewed for urinary catheters.

Inspectors wroteBased on review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, dated October 2019, medical record review, and interview, the facility failed to ensure Death in Facility tracking assessments were completed for 2 of 23 sampled residents (Resident #2 and #8) reviewed for Minimum Data Set (MDS) assessments.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to timely notify the physician of a change in a resident's condition related to a pressure ulcer for 1 of 2 (Resident #50) sampled residents reviewed for pressure ulcers. The failure of the facility to timely notify the physician of a heel wound and obtain orders for treatment resulted in actual Harm for resident #50 when the wound deteriorated from a reddened area to a deep tissue injury/pressure ulcer.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview the facility failed to revise the care plan to identify the development of a pressure ulcer for 1 of 2 (Resident #50) sampled residents reviewed with pressure ulcers. The failure of the facility to accurately perform skin assessments and revise Resident #50's care plan with updated interventions to address a reddened area when it was identified resulted in actual Harm to Resident #50.

Inspectors wroteBased on National Pressure Ulcer Advisory Panel (NPUAP) reference guide, facility policy review, medical record review, observation, and interview, the facility failed to perform an accurate skin assessment to identify a pressure ulcer, failed to notify the physician of the development of a new pressure ulcer, failed to obtain new treatment orders, and failed to accurately assess a wound before it deteriorated to a Deep Tissue Injury (DTI) for 1 of 2 (Resident #50) sampled residents reviewed for pressure ulcers. The failure of the facility to accurately assess, implement interventions and document the findings before the pressure ulcer progressed into a Deep Tissue Injury (DTI) resulted in actual Harm for Resident #50. [...]

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to implement effective fall prevention interventions for 1 of 8 (Resident #60) sampled residents. The failure of the facility to implement effective fall interventions resulted in actual Harm when Resident #60 fell after the malfunction of a chair alarm, and sustained a hip fracture which required surgical repair.

Inspectors wroteBased on review of the Administrator's Job Description and the Director of Nursing's (DON) Job Description, and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of the residents, when they failed to recognize an ongoing concern with pressure ulcers and falls. The failure of the facility to be effectively and efficiently administered resulted in actual Harm to 1 of 2 (Residents #50) sampled residents with pressure ulcers. The failure of the facility to be effectively and efficiently administered resulted in actual Harm to 1 of 8 (Residents #60) sampled residents reviewed for falls. [...]

Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to have an effective, ongoing quality program that identified, developed, implemented and monitored appropriate plans of action for pressure ulcers and falls. The QAA Committee failure to ensure an effective pressure ulcer prevention and treatment system resulted in actual Harm for Resident #50 when she developed a pressure ulcer to the right heel on 5/28/18, and the facility's Wound Nurse failed to assess the wound, failed to notify the physician, failed to revise the care plan related to the pressure ulcer, and initiated wound treatments without a physician's order. The QAA committee's failure to ensure an effective fall prevention system (an effective process to reduce patient falls) resulted in actual Harm for Resident #60. [...]

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to provide wound assessments for 1 of 1 (Resident #46) residents reviewed for arterial wounds.

Inspectors wroteBased on medical record review, observation, and interview the facility failed to honor the resident's request related to food choices for 1 of 3 (Resident #45) sampled residents reviewed for choices.