Yanceyville Rehabilitation and Healthcare Center

Inspectors wroteBased on record review, and staff and Psychiatric Nurse Practitioner (NP) interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation after a new serious mental illness disorder was identified for residents previously determined to have a Level I PASRR status for 4 of 8 residents reviewed for PASRR (Residents #10, #79, #120, #145). 3. Resident #120's Level I PASRR Determination Notification document dated 6/12/25 revealed the document was valid for his stay at the facility. The document further indicated no further PASSR screening was required unless a significant change occurred. Resident #120 was admitted on [DATE] with a diagnosis of major depressive disorder. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to store dry food away from moisture, keep dry goods covered, failed to label and date leftover food stored for use, and discard expired food. This was for 1 of 1 dry goods storage room, 1 of 1 walk-in cooler, 1 of 1 walk-in freezer and 1 of 1 reach-in refrigerator. The facility also failed to maintain the walk in refrigerator floor in a clean and sanitary condition, keep 1 of 4 ice machines clean, and failed to maintain the ceiling above the steam table to prevent peeling paint. These failures had the potential to affect food served to residents.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to develop a person-centered care plan for 1 of 4 residents reviewed for activities (Resident #9).

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to provide an on-going activity program that met the individual interests and needs for 3 of 4 cognitively impaired residents reviewed for activities (Residents #32, Resident #44 and Resident #9).

Inspectors wroteBased on observation, record review, resident and staff interview, and Resident Representative (RR) interview, the facility failed to identify hearing aides were missing and determine whether an appointment was needed to maintain hearing abilities for a resident with reported hearing difficulties for 1 of 1 resident reviewed for communication (Resident #81).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to provide pureed food items with a pudding like consistency as required. This failure had the potential to affect 11 of 11 residents who had orders for a pureed texture diet.

Inspectors wroteBased on observations and staff interviews, the facility failed to keep food preparation areas and food service equipment clean, free from debris, grease buildup, and/or dried spills during two kitchen observations. The facility failed to clean the ceiling vents located over the food preparation and food service areas. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, and staff interviews, the facility failed to ensure the garbage and refuse was contained in 3 of 3 dumpsters and 1 of 1 grease interceptor container and failed to ensure the surrounding area clean and free from debris. This practice had the potential to attract pests and rodents.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to provide an on-going activity program that met the individual interests and needs for 4 of 5 cognitively impaired residents reviewed for activities (Residents #29, Resident #52, Resident #137 and Resident #68).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to promote care in a dignified manner for 3 of 3 residents who were assisted with meals. Staff were observed standing beside the side of the residents' beds while feeding assistance was provided (Resident #62, Resident #14 and Resident # 68).

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to facilitate a resident's participation in the development of their plan of care for 1 of 29 residents reviewed for comprehensive care plans (Resident #110).

Inspectors wroteBased on record review, and staff, Adult Protective Services Social Worker (APS-SW), family and the Arresting Officer interviews, the facility failed to protect a resident's right to be free from misappropriation of property leading to a suspected monetary loss of $11,670.68. The deficient practice was for 1 of 1 resident reviewed for misappropriation of resident property (Resident #400).

Inspectors wroteBased on record review, and Resident Representative and staff interviews, the facility failed to provide the resident and Resident Representative with a written notification of transfer or discharge including notification of appeal rights when the resident was discharged for 1 of 2 residents reviewed for hospitalization (Resident #200).

Inspectors wroteBased on record reviews, and Resident Representative (RR), hospital Case Manager, Physician, and staff interviews, the facility failed to permit a resident to remain in the facility after the hospital assessed Resident #200 as returning to her baseline and discharged her back to the facility for 1 of 2 residents reviewed for discharge (Resident #200).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to complete an admission Minimum Data Set (MDS) and failed to complete the Care Area Assessments (CAA) within 14 days of admission for 1 of 3 sampled residents reviewed for comprehensive assessments (Resident #15).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to complete a significant change Minimum Data Set (MDS) within 14 days of the Assessment Reference Date for 1 of 3 sampled residents reviewed for significant change assessments (Resident #61).

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to secure smoking materials, specifically, a lighter for 1 of 4 residents (Resident #16) reviewed for safe smoking.

Inspectors wroteBased on observations and staff interviews, the facility failed to keep food preparation areas, food storage areas and food service equipment clean, free from debris, grease buildup, and/or dried spills on the floor during two kitchen observations. The facility failed to clean the ceiling vents and air condition units located over the food prep and food service area. This practice had the potential to affect food served to all residents.

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to resolve repeated concerns with scheduled smoking and diet preferences voiced during 2 of 5 months of consecutive Resident Council Meetings reviewed May 2023, thru October 2023.

Inspectors wroteBased on observations, resident and staff interviews and record reviews, the facility to follow the menu for 1 of 1 meal observations for 4 of 4 residents(Resident #7, #58, #109 and #49). During the lunch meal the facility ran out of chicken thighs.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to remove an expired multi-dose vials of insulin or put the date of opening on multi-dose containers of insulin and inhalers in the medication cart drawer for 2 of 7 medication administration carts (100 hall and 400 hall). Findings Included: 1. On 11/14/23 at 10:00 AM, an observation of the medication administration cart on 100 hall with Nurse #5, revealed one opened and undated Novolog insulin pen injector. A review of the manufacturer's literature indicated to discard the insulin multi-dose vial 28 days after opening; one multi-dose vial of Lantus insulin opened on 9/25/23. A review of the manufacturer's literature indicated to discard the insulin multi-dose vial 28 days after opening, which would be on 10/23/23; one Insulin Lispro multidose vial opened on 10/15/23. [...]

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to obtain and honor food likes/dislikes and to provide an alternative meal of similar nutritive value for 4 of 5 sampled residents, (Resident #88).

Inspectors wroteBased on staff interview, and record review of the Facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor interventions that the committee put into place following the 12/14/21 annual recertification survey. This was for one recited deficiency in the areas of dietary services (F 812). This deficiency was cited again on the annual recertification survey on 11/17/23. This continued failure of the facility during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QAA program.