Deficiencies (last 4 years)
Deficiencies (over 4 years)
27 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
197% worse than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Re-Inspection
Deficiencies: 19
Date: Jul 16, 2024
Visit Reason
The revisit inspection was conducted to evaluate the facility's compliance with previously cited deficiencies related to resident rights, quality of care, medication administration, infection control, staff training, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to provide written evidence of advance directive discussions, inadequate bathing and nail care for residents, failure to provide required transfer and bed hold notices, medication administration errors including unavailable medications and exceeding ordered doses, incomplete controlled substance inventory counts, delayed laboratory testing and reporting, incomplete clinical records, failure to offer required vaccinations, and inadequate infection control practices. The facility's Quality Assurance and Performance Improvement (QAPI) program was also found ineffective in preventing repeat deficiencies.
Deficiencies (19)
Facility staff failed to provide written evidence that residents or their representatives were offered or declined to develop advance directives.
Facility staff failed to maintain a clean, comfortable, homelike environment as evidenced by a dried brown substance on a resident's tube feeding pole.
Facility staff failed to ensure written transfer notices included required information for five residents transferred to hospitals.
Facility staff failed to provide written notice of the bed hold policy to residents or their representatives at the time of transfer for five residents.
Facility staff failed to review and revise a resident's comprehensive care plan to include current Do Not Resuscitate (DNR) status.
Facility staff failed to follow professional standards of practice for medication administration for two residents, including signing for medications not available.
Facility staff failed to provide adequate bathing and nail care for three residents, including failure to maintain nail care and provide bed baths twice a week.
Facility staff failed to adhere to provider ordered maximum dose limits for migraine medication for one resident.
Facility staff failed to follow physician's orders for medication administration for four residents, including failure to administer medications and failure to document administration.
Facility staff failed to ensure a resident maintained and/or improved range of motion by failing to apply a provider ordered splint.
Facility staff failed to ensure water temperatures were maintained at a safe level to decrease risk of injury.
Facility staff failed to ensure licensed nursing staff had the competencies and skill sets necessary to provide care for residents, including proper cleaning of glucometers.
Facility staff failed to act on pharmacy recommendations for medication dose reductions for one resident.
Facility staff failed to ensure residents were free from unnecessary medications as evidenced by administration of medication without required vital sign checks.
Facility staff failed to provide timely laboratory services and failed to promptly notify medical providers of critical lab results for residents.
Facility staff failed to maintain complete and accurate clinical records for residents, including accurate weight documentation, duplicate medication orders, and incomplete medication administration records.
Facility staff failed to follow established infection control procedures during finger stick blood glucose monitoring, including improper cleaning and disinfecting of glucometers.
Facility staff failed to ensure residents were offered required pneumococcal and COVID-19 vaccinations.
Facility's Quality Assurance and Performance Improvement (QAPI) program failed to implement effective measures to prevent repeat deficiencies in multiple areas of care.
Report Facts
Deficiencies cited: 18
Residents affected: 5
Residents affected: 5
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Observed during medication pass and pour, failed to properly clean glucometer and signed medication as administered when unavailable |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding unavailable Symbicort inhaler and medication administration |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding medication administration, clinical records, and laboratory results |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication administration, infection control, and training |
| Staff Development Coordinator | Staff Development Coordinator | Interviewed regarding lack of staff competencies and training program |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Mar 29, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations related to resident rights, care planning, assessments, activities of daily living, pressure ulcer care, and laboratory services.
Findings
The facility was found deficient in multiple areas including failure to provide written evidence of advance directive discussions for residents, inaccurate Minimum Data Set (MDS) assessments, incomplete care plan revisions, failure to implement prescribed splints, inadequate bathing and grooming care, failure to provide ordered wound care and skin assessments, and delays and omissions in laboratory testing and filing of lab results.
Deficiencies (8)
Facility staff failed to provide written evidence that residents or their representatives were informed about advance directives and given the opportunity to develop them.
Facility staff failed to accurately complete Minimum Data Set (MDS) assessments for Resident #62, specifically regarding functional limitations in range of motion.
Facility staff failed to revise care plans timely and include residents in the care plan process for Residents #15 and #62.
Facility staff failed to implement prescribed upper extremity splints for Resident #62 as directed by therapy.
Facility staff failed to provide necessary activities of daily living care, including appropriate bathing and grooming, for Residents #1, #52, #59, #62, and #66.
Facility staff failed to provide ordered wound care and consistent skin assessments for Resident #62, including after hospital readmission.
Facility staff failed to provide timely laboratory services, including delayed collection of a urinalysis for Resident #122.
Facility staff failed to maintain complete, dated laboratory records in Resident #122's clinical record, omitting multiple lab results.
Report Facts
Residents sampled: 21
Residents affected: 3
Residents affected: 5
Residents affected: 1
Date of survey completion: Mar 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Services | Director of Social Services | Interviewed regarding advance directive tracking form and facility policy |
| Administrator | Administrator | Met with surveyors to discuss advance directive regulation expectations and other deficiencies |
| Director of Nursing | Director of Nursing | Provided information on care plans, splints, and wound care deficiencies |
| Regional Director of Clinical Services | Regional Director of Clinical Services | Discussed MDS assessment inaccuracies, care plan revisions, ADL care, wound care, and lab result issues |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Reported on resident positioning related to fall risk |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Observed resident toenail condition |
| Director of Rehab | Director of Rehabilitation | Provided Functional Maintenance Program documents and discussed splint orders |
| Director of Respiratory | Director of Respiratory | Reported on resident movement and fall incident |
Inspection Report
Routine
Deficiencies: 27
Date: Mar 26, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including resident rights, quality of care, medication administration, staff training, infection control, and quality assurance. Specific issues included failure to treat residents with dignity, inadequate dining services, restricted resident rights, medication errors, incomplete care plans, insufficient staff competencies, and failure to maintain accurate clinical records.
Deficiencies (27)
Facility staff failed to treat Resident #10 with dignity and respect as evidenced by ignoring the resident's questions about attendance at an off-campus program.
Facility staff failed to ensure residents received services according to expressed preferences including limited dining room availability, inadequate bathing services, and enforcement of a curfew.
Facility staff failed to promote Resident #1's right to leave the building, restricting the resident's ability to go outside unaccompanied.
Facility staff failed to post accessible contact information for the State Survey Agency.
Facility staff failed to post survey results and notices of availability in prominent, accessible areas.
Facility staff failed to notify Resident #72's medical provider of an ordered medication (Pancrelipase) not being available and failed to notify Resident #13's representative of a urinary tract infection requiring treatment.
Facility staff failed to maintain a safe, clean, sanitary, and comfortable environment for Residents #14 and #52, including unclean rooms, broken furniture, and long toenails.
Facility staff failed to implement abuse and neglect screening policies for new hires, with missing background checks and reference verifications.
Facility staff failed to provide timely and complete transfer notices including appeal rights and ombudsman contact information for five residents transferred to hospitals.
Facility staff failed to provide written notice of bed hold policy to residents or representatives upon transfer for five residents.
Facility staff failed to complete a comprehensive Minimum Data Set (MDS) assessment within 12 months for Resident #57.
Facility staff failed to accurately complete MDS assessments for Resident #62, specifically regarding functional limitations in range of motion.
Facility staff failed to develop comprehensive care plans for Residents #10, #79, and #52, including failure to address off-facility programs, nutrition, and sensory stimulation.
Facility staff failed to implement Resident #62's prescribed upper extremity splints as directed by therapy.
Facility staff failed to follow professional standards of practice for medication administration for Residents #123 and #110, including signing medications as given when unavailable.
Facility staff failed to ensure sufficient nursing staff to meet resident needs, resulting in delayed medication administration and missed medications when a nurse left early.
Facility staff failed to complete performance reviews and provide regular in-service education for nurse aides.
Facility staff failed to provide appropriate bathing and grooming care to maintain residents' hygiene for Residents #1, #52, #59, #62, and #66.
Facility staff failed to follow medical provider orders for 10 residents including failure to administer medications, incorrect medication administration, and failure to document medication holds.
Facility staff failed to ensure accurate and complete clinical records for Residents #46, #59, and #72, including documentation of medication administration and wound care.
Facility staff failed to ensure water temperatures were maintained at safe levels to prevent injury.
Facility staff failed to ensure residents were offered influenza and pneumococcal vaccinations.
Facility staff failed to provide evidence of effective communication training for direct care staff.
Facility staff failed to provide evidence of staff education on resident rights for four staff members.
Facility staff failed to provide evidence of staff education on abuse, neglect, exploitation, and dementia management for four staff members.
Facility staff failed to provide evidence of behavioral health training for staff.
Facility staff failed to provide evidence of staff training on the facility's Quality Assurance and Performance Improvement (QAPI) program.
Report Facts
Medication administration delay: 15
Medication administration count: 13
Resident medication errors: 10
Residents with incomplete clinical records: 3
Residents with incomplete staff training records: 4
Residents with missing vaccination offer records: 3
Residents with missing COVID-19 vaccination offer records: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #12 | Licensed Practical Nurse | Applied Biofreeze to Resident #9 causing allergic reaction |
| RN #3 | Registered Nurse | Observed not disinfecting glucometer and signing medication as administered when unavailable |
| LPN #5 | Licensed Practical Nurse | Signed medication as administered when inhaler was not available for Resident #123 |
| LPN #10 | Licensed Practical Nurse | Relieved LPN #3 and reported medications were not administered on 3/26/24 |
| LPN #11 | Licensed Practical Nurse | Knew Resident #9 was allergic to Biofreeze and did not administer it |
Inspection Report
Routine
Census: 33
Deficiencies: 15
Date: Nov 1, 2023
Visit Reason
Routine inspection of Old Southwest Health and Rehabilitation to assess compliance with regulatory standards including resident care, medication administration, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean and homelike environment, incomplete care plans, medication administration errors, missing or unavailable medications, improper infection control practices, and inadequate documentation.
Deficiencies (15)
Facility staff failed to ensure a clean, comfortable homelike environment for 3 residents and in 2 shower rooms.
Failed to develop baseline and comprehensive care plans for Resident #21.
Failed to review and revise care plan for Resident #26 to include isolation status.
Medication administration errors including documenting medications given when resident was not present, borrowing medications between residents, and incorrect medication administration.
Failed to provide ordered pressure ulcer care for Residents #18 and #25 on multiple days.
Failed to provide appropriate foot care for Resident #23.
Facility shower rooms had missing tiles creating accident hazards.
Resident #23's tube feeding was set at an incorrect rate contrary to provider orders.
Failed to ensure availability of physician ordered medications for 5 residents including antibiotics, psychiatric medications, and others.
Medication error rate exceeded 5%, with 6 errors in 34 opportunities affecting Residents #30, #32, and #33.
Failed to document blood sugar results as ordered for Resident #21.
Documented medication administration for Resident #20 when resident was not present.
Failed to don proper personal protective equipment (PPE) upon entering Resident #12's room who was on droplet precautions.
Failed to properly label and store insulin pens/vials and failed to discard after 28 days of opening.
Failed to label aspirin medication with correct dosage for Resident #30.
Report Facts
Residents affected: 3
Residents affected: 33
Medication error rate: 17.6
Medication errors: 6
Medication opportunities: 34
Tube feeding rate: 65
Tube feeding rate ordered: 50
Insulin dose: 5
Insulin dose: 45
Insulin dose changed to: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in medication error finding for Resident #30 |
| RN #2 | Registered Nurse | Named in medication error finding for Resident #33 |
| LPN #5 | Licensed Practical Nurse | Named in medication error finding for Resident #30 and Resident #32 |
| LPN #1 | Licensed Practical Nurse | Named in medication error finding for Resident #31 |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding insulin administration and documentation |
| LPN #8 | Licensed Practical Nurse | Documented medication unavailable for Resident #21 |
| RN #1 | Registered Nurse | Observed medication error for Resident #33 |
| RN #4 | Registered Nurse | Observed medication error for Resident #30 |
| RN #2 | Registered Nurse | Observed medication error for Resident #33 and PPE issue for Resident #12 |
| Other Employee #8 | Named in foot care deficiency for Resident #23 | |
| Regional Nurse Consultant | Participated in multiple meetings reviewing deficiencies | |
| Administrator | Participated in multiple meetings reviewing deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 16, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to report incidents, failure to follow physician's orders, and failure to provide adequate supervision to residents.
Complaint Details
The complaint investigation found substantiated concerns that the facility failed to report an incident of neglect, failed to follow physician's orders for vital sign monitoring, and failed to provide adequate supervision during a heat advisory, resulting in Resident #1 suffering heat stroke and hospitalization.
Findings
The facility failed to timely report an incident of neglect involving Resident #1, failed to follow physician's orders for monitoring vital signs for Resident #3, and failed to provide adequate supervision to Resident #1 resulting in heat stroke and hospital admission.
Deficiencies (3)
Facility staff failed to timely report an incident of neglect for Resident #1.
Facility staff failed to follow physician's orders for monitoring vital signs, specifically blood pressure, for Resident #3.
Facility staff failed to provide adequate supervision to Resident #1, resulting in heat stroke and hospital admission.
Report Facts
Residents affected: 6
Temperature: 109
Blood pressure: 95
Blood pressure: 55
Vital signs monitoring frequency: 3
Medication dosage: 25
Medication administration frequency: 8
Duration outside: 45
Number of nurses assisting: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Provided a signed statement describing the heat stroke incident involving Resident #1 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding failure to report incident and failure to monitor vital signs |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 23, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on allegations regarding the facility's management of resident funds and the implementation of the scheduled/controlled medication monitoring system.
Complaint Details
This is a complaint deficiency involving failure to ensure timely availability of resident funds and failure to properly document controlled medication counts during a complaint investigation.
Findings
The facility failed to ensure that resident funds were available within 3 business days for one resident and failed to properly implement the controlled medication monitoring system, with incomplete narcotic reconciliation records and missing signatures on medication counts across all four medication carts.
Deficiencies (2)
Failed to ensure resident funds were available within 3 business days as required by regulation for 1 of 11 residents.
Failed to ensure staff correctly implemented the facility's scheduled/controlled medication monitoring system for four medication carts, including incomplete narcotic reconciliation records and missing signatures.
Report Facts
Residents in survey sample: 11
Withdrawal amount: 3061.22
Receipt amount: 2447.08
Medication carts affected: 4
Inspection Report
Routine
Deficiencies: 15
Date: Jul 19, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements, including medication administration, resident care, reporting, and documentation.
Findings
The facility was found deficient in multiple areas including inconsistent documentation of residents' code status, failure to report investigation results of neglect, failure to provide bed hold policy information, inaccurate assessments, failure to conduct required PASARR screening, medication administration errors, failure to obtain ordered weights and consults, failure to provide ordered treatments, unsafe medication storage, and incomplete medical record documentation.
Deficiencies (15)
Failure to ensure accurate and consistent documentation of Resident #39's code status.
Failure to timely report investigation results of alleged neglect involving Resident #59 to appropriate agencies.
Failure to provide bed hold policy information to Resident #13 or representative after hospital transfer.
Failure to ensure accuracy of MDS assessments for Resident #42, specifically incomplete BIMS scoring.
Failure to conduct required level 1 PASARR screening for Resident #55.
Failure to follow professional standards for medication documentation; Resident #47's nebulizer treatment was documented as given when not administered.
Failure to obtain weight ordered by dietician for Resident #164.
Failure to provide ordered dermatology, gastroenterology consults, chest CT, and upper GI x-ray for Resident #39.
Failure to provide supervision to Resident #5 while smoking as required by care plan.
Failure to store medications securely; unlocked medication cart with unsecured Tylenol and unlocked mini-refrigerator containing liquid oxycodone.
Failure to ensure medications were available for administration for Residents #25 (Azelastine eye drops), #32 (Fentanyl and Pantoprazole), and #3 (Clonazepam on seven occasions).
Failure to ensure Resident #3 received ordered tube feeding and water on 7/18/22.
Failure to maintain respiratory equipment properly for Resident #47; nebulizer mask was uncovered.
Failure to ensure medical regimen review (MRR) recommendations were addressed by medical provider for Residents #1, #31, and #59.
Failure to maintain complete and accurate clinical records for Residents #32, #42, and #59, including documentation of medication administration and MRR results.
Report Facts
Residents sampled: 19
Medication administration failures: 7
Weight loss percentage: 41.28
Medication quantities: 195
Medication quantities: 240
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Discussed discrepancies in Resident #39's code status with survey team | |
| Assistant Director of Nursing | Discussed discrepancies in Resident #39's code status with survey team | |
| Regional Director of Clinical Services | Discussed failure to report neglect investigation results and other deficiencies | |
| Regional Director of Operations | Reported inability to find evidence of reporting neglect investigation results | |
| Nurse Educator | Discussed medication administration and documentation issues | |
| Unit Manager | Discussed discrepancies in Resident #39's code status and other deficiencies | |
| Medical Records Director | Discussed missing dermatology appointment documentation and medication regimen reviews | |
| Licensed Practical Nurse #3 | Discussed Resident #47's Pulmicort administration | |
| Clinical Nurse Educator | Discussed medication administration standards and missing documentation |
Inspection Report
Complaint Investigation
Deficiencies: 19
Date: Aug 5, 2021
Visit Reason
The inspection was conducted based on complaint investigations regarding multiple concerns including failure to implement abuse and neglect policies, failure to report and investigate injuries of unknown source, failure to document hospital transfers, inaccurate assessments, failure to complete PASARR evaluations, incomplete or inaccurate care plans, failure to provide ordered treatments and medications, inadequate catheter care, malfunctioning call systems, and other regulatory compliance issues.
Complaint Details
The inspection was complaint-driven and included investigation of multiple allegations related to abuse, neglect, failure to provide care, medication errors, and facility maintenance issues.
Findings
The facility was found deficient in multiple areas including failure to implement abuse and neglect policies for new hires, failure to report and investigate injuries, failure to document hospital transfers, inaccurate MDS assessments, failure to complete PASARR evaluations, failure to develop and implement comprehensive care plans, failure to provide ordered treatments and medications, failure to maintain respiratory equipment, failure to provide catheter care, failure to maintain accurate medication records, failure to complete dialysis communication forms, failure to maintain call light systems, and failure to offer flu and pneumonia vaccines.
Deficiencies (19)
Failure to implement facility abuse and neglect policy for 4 of 25 new hire employees.
Failure to timely report suspected abuse, neglect, or theft and report investigation results for 1 of 30 residents.
Failure to investigate injury of unknown source for 1 of 30 residents.
Failure to document basis for transfer in clinical record for 1 of 30 residents.
Failure to ensure accuracy of MDS assessments for 1 of 30 residents.
Failure to refer resident for Level II PASARR evaluation and determination for 1 of 30 residents.
Failure to develop and implement comprehensive care plans for 4 of 30 residents.
Failure to review and revise comprehensive care plans for 4 of 30 residents.
Failure to provide care and assistance to perform activities of daily living for 10 of 30 residents.
Failure to provide appropriate treatment and care according to orders for 10 of 30 residents.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for 1 of 30 residents.
Failure to provide appropriate catheter care and prevent urinary tract infections for 3 of 30 residents.
Failure to provide enough food/fluids to maintain a resident's health for 1 of 30 residents.
Failure to ensure that feeding tubes are not used unless medically necessary and provide appropriate care for 2 of 30 residents.
Failure to provide safe and appropriate respiratory care for 1 of 30 residents.
Failure to ensure a licensed pharmacist perform monthly drug regimen review and report irregularities for 1 of 30 residents.
Failure to maintain complete and accurate clinical records for 3 of 30 residents.
Failure to offer flu and pneumonia vaccinations to 1 of 30 residents.
Failure to ensure a properly working call system for parts of two open units.
Report Facts
New hire employees reviewed: 25
Residents in survey sample: 30
Deficiency counts: 19
Weight measurements: 113
Weight measurements: 106.4
Medication doses missed: 6
Medication doses missed: 3
Medication doses missed: 3
Medication doses missed: 3
Medication doses missed: 6
Medication doses administered: 14
Medication doses administered: 37
Medication doses administered: 3
Missing narcotic monitoring sheets: 3
Dialysis communication forms incomplete: 44
Dialysis communication forms incomplete: 9
Viewing
Loading inspection reports...
