Inspection Reports for Virginia Highlands Health and Rehabilitation Center

The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, notification procedures, PASARR screening, and food safety practices at the nursing home.

The facility was found deficient in obtaining protective placement for a resident beyond 60 days, notifying the Ombudsman of hospital transfers for certain residents, completing PASARR Level II screening for a resident, and ensuring safe food cooling and storage practices. These deficiencies posed minimal harm or potential for actual harm to residents.

The inspection was conducted to assess the facility's compliance with pharmaceutical services requirements, specifically regarding the accurate administration of drugs and biologicals to residents.

The facility failed to ensure accurate medication administration for 5 of 20 sampled residents, who had medications at their bedsides without proper self-administration assessments, physician orders, or care plans authorizing self-administration.

The inspection was conducted due to complaints regarding the facility's failure to timely report suspected abuse, neglect, or theft and to properly investigate allegations of abuse and misappropriation involving three residents (R3, R4, and R9).

The facility failed to report allegations of abuse and misappropriation to the State Agency or local law enforcement and did not thoroughly investigate these allegations for the three residents. Specifically, a resident-to-resident altercation resulting in injury was not reported, and a missing wallet incident was not properly investigated.

The complaint investigation involved three residents (R3, R4, and R9). R3 sustained injuries from a resident-to-resident altercation with R4 on 6/17/24, which was not reported to the State Agency or law enforcement. R9 reported a missing wallet containing a debit card and cash approximately six to seven months prior, but the facility did not conduct a proper investigation or report the incident. The facility's Director of Nursing and Nursing Home Administrator acknowledged these failures.

The inspection was conducted due to allegations of abuse and neglect involving two residents, including an allegation of sexual abuse and an injury of unknown origin resulting in a fracture.

The facility failed to timely report suspected abuse and injury of unknown origin to the appropriate authorities for two residents. Additionally, the facility did not remove the accused staff member from resident care pending investigation, and improper transfer techniques led to a resident's fracture. The abuse allegation was ultimately not substantiated.

The complaint involved allegations that a male nurse tried to sexually abuse resident R2 and that resident R1 suffered a fracture of unknown origin due to improper transfer. The allegation of sexual abuse was investigated and found not substantiated. The facility delayed reporting both incidents to the appropriate authorities.

The inspection was conducted due to complaints filed by or on behalf of three residents regarding missing personal items, grievances not being addressed, and concerns about staff behavior and response times.

The facility failed to make prompt efforts to resolve grievances for three residents, including missing wallet and phone, missing clothing, and issues with call light wait times and rude staff. Follow-up on grievances was inadequate or absent, and documentation of corrective actions was incomplete.

The complaint investigation involved grievances from residents R32, R20, and R212. R32's wallet and phone were missing with no follow-up; R20's family filed a grievance about missing clothing with no follow-up; R212's family filed a grievance about call light wait times, rude staff, and inadequate care, which was not fully addressed. The facility acknowledged the grievances but failed to complete proper follow-up or documentation.

The inspection was conducted due to complaints regarding unresolved grievances by residents and their representatives, inadequate provision of scheduled showers, and improper use and assessment of bed rails.

The facility failed to promptly resolve grievances for 3 residents, did not ensure scheduled showers were consistently provided for 5 residents, and did not properly assess or obtain consent for the use of bed rails for 1 resident. Follow-up and documentation were incomplete or missing in these areas.

The complaint investigation found grievances filed by residents or their representatives regarding missing personal belongings, call light response delays, and rude staff were not properly addressed or followed up. Additionally, scheduled showers were not consistently provided to several residents, and one resident was not properly assessed for bed rail use.

The inspection was conducted based on complaints regarding the facility's failure to thoroughly investigate and resolve a resident grievance related to hygiene, and failure to review and revise a resident's care plan as required.

The facility failed to properly investigate and follow up on a hygiene-related grievance filed on behalf of one resident, and did not update the care plan for another resident to include a new intervention for active assistive range of motion as indicated by physical therapy notes.

The grievance, dated 10/24/23, was filed on behalf of Resident 2 related to hygiene. The facility did not thoroughly investigate or provide follow-up and resolution. The investigation lacked resident or staff interviews and follow-up with the complainant. The grievance was forwarded to the Social Worker and Assistant Director of Nursing, but follow-up was not completed.

The inspection was conducted to investigate complaints regarding failure to notify a provider of elevated blood sugar, failure to record and resolve grievances, failure to implement abuse prevention policies, and inadequate investigation and prevention of falls.

The facility failed to notify a provider of a resident's elevated blood sugar level, did not properly record or investigate grievances for a resident, failed to complete required background checks for staff, and did not thoroughly investigate a resident's fall or provide staff education to prevent future falls.

The complaint investigation included issues related to failure to notify a provider of a resident's elevated blood sugar (Resident R9), failure to record and resolve grievances related to missing dentures, care concerns, and injury during transfer (Resident R10), failure to complete required background checks for staff (CNA-F and CNA-G), and failure to investigate a fall with injury and provide staff education (Resident R4).

The inspection was conducted to assess compliance with Medicare and Medicaid regulations, including resident rights, discharge planning, fall prevention, nutrition, medication administration, respiratory care, infection control, and equipment safety.

The facility was found deficient in multiple areas including failure to provide proper notice of Medicare non-coverage, inadequate discharge planning, insufficient assistance with activities of daily living, incomplete fall investigations and interventions, significant unaddressed weight loss in residents, medication errors, lack of physician orders for CPAP use, improper infection control practices by unvaccinated staff, and unsafe maintenance of laundry equipment.