FORK UNION, VA- OAKHURST HEALTH & REHABILITATION

The Department of Health & Human Services conducted an inspection of the facility. The following  highlighted decencies listed below were found in a public survey.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Based on observation, staff interview, and clinical record review, the facility failed to administer medication according to physician orders for 1 of 22 residents (Resident #27).

Provide safe and appropriate respiratory care for a resident when needed.

Based on observation, staff interview, and clinical record review, the facility failed to ensure parameters were put in place for supplemental oxygen for one of 22 residents. An oxygen order for resident #49 (R49) did not have a rate of delivery.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to respond to pharmacy recommendations for 1 of 22 residents in the survey sample (Resident #9).

Allow residents to easily view the nursing home’s survey results and communicate with advocate agencies.

Based on observation and staff interview the staff failed to ensure the survey results were readily accessible. Findings included:

Survey result book was not in a place that was visible and easily accessible for the resident, staff or family members to be able to view.

On 2/21/24 at 10:00 a.m., a Resident Council meeting was conducted. When the asked if they knew where the survey results were located, the residents voiced uncertainty regarding the location of the survey result book.

On 02/22/24 8:36 a.m., observations were conducted to locate the survey result book but was not found in any of the common areas accessible to residents or the public

Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, resident interview, facility staff interviews, and facility documentation review, the facility staff failed to maintain a safe, comfortable, and homelike environment on 1 of 4 nursing units and in the main dining room.
The findings included:
1. On the 300 unit of the nursing facility, the facility staff failed to ensure a safe and homelike environment, affecting multiple residents.
1a. For resident #58 (R58), the facility failed to maintain the room furnishings of a bedside table that was in good operating condition, which resulted in an environment that was not homelike.
On 2/20/24, in the late morning, it was observed that R58’s bedside table was missing 2 of the 3 drawers. R58 was not in the room at the time of this observation.

On 2/21/24 at 9:28 AM, R58’s bedside table was noted to still have only 1 drawer, the other 2 were missing. When questioned, R58 reported that it had been like that for weeks.

On 02/22/24 at 08:53 a.m., an interview was conducted with CNA #5. CNA #5 confirmed the surveyor’s observation that R58’s bedside table was missing 2 drawers. CNA #5 confirmed that the drawers had been like that for weeks and stated, I think since he was going home, they just decided to not fix it.

Ensure each resident receives an accurate assessment.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) assessment for one of twenty-two residents in the survey sample (Resident #44).

The findings include: Resident #44’s admission MDS (an assessment tool) dated 1/18/24 inaccurately assessed the resident with having no dental problems, when the resident was edentulous (no natural teeth).

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Based on observation, staff interview, and clinical record review, the facility failed to develop a care plan for three of twenty two residents.
1. Resident #49 (R49) was not care planned for the use of a hoyer lift (hydraulic equipment used to safely transfer residents).
2. R21 had an admitting diagnoses of PTSD (Post Traumatic Stress Disorder) and a care plan had not been developed.
3. R44 did not have a care plan for dental issues.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility failed to review and revise the care plan for 2 of 22 residents (Resident #9 and #32) in the survey sample and failed to invite/involve 2 residents (Resident #6 and #25) in their care plan meeting.

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Based on staff interview, and clinical record review, the facility staff failed to ensure one of 22 residents in the survey sample was free of unnecessary medications (Resident #9). The findings included:

The facility staff failed to attempt a gradual dose reduction of Seroquel for Resident #9 (R9).

Ensure services provided by the nursing facility meet professional standards of quality.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of nursing practice for one resident (Resident #22- R22) in a survey sample of 22 residents. The findings included:

For R22, who refused lab work, the facility staff failed to notify the physician that the order was not able to be carried out.

On 2/20/24 and 2/21/24, a clinical record review was conducted of R22’s chart. This review revealed that on 1/26/24, the physician entered an order that read, LAB- Valproic Acid [Valproic acid level], CMP [complete metabolic panel], CBC [complete blood count], LFT [liver function tests] on [DATE] and July 26 every night shift every 6 month(s) starting on the 26th for 1 day(s).
According to the treatment administration record, R22 refused the lab draw on 1/26/24. There was no documentation within the progress notes, nor elsewhere, that indicated the physician was made aware that the order for labs was unable to be carried out.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for two of twenty-two residents in the survey sample (Residents #1 and #3).

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based observation, facility documentation, and staff interview, the facility failed to accurately label open medication to ensure safe administration and storage.

The facility failed to ensure that a multi-dose vial of medication was labeled with a open date.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain an accurate clinical record for one resident (Resident #25- R25) in a survey sample of 22 residents.

For R25, the facility staff failed to maintain a complete and accurate clinical record with regards to
documentation of when showers were provided.

Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren’t provided.

Based on staff interview and clinical record review, the facility staff failed to obtain physician ordered laboratory (Lab) services for one of 22 residents (Resident #38 – R38) in the survey sample; a CBC (Complete Blood Count) and A1C (Glycated Hemoglobin Test) were not collected as ordered for R38.

Provide care or services that was trauma informed and/or culturally competent.

Based on observation, resident interview, staff interview, and clinical record review the facility staff failed to identify the specific trauma or triggers regarding post-traumatic stress disorder (PTSD) for 1 of 22 residents in the survey sample (Resident #21).

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member’s vaccination status.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed t provide education and offer the COVID-19 spike vaccine booster for the 2023-2024 season, to 5 of 5 residents (Resident #6, 31, 3, 55, and 14) and 5 of 5 staff (RN #3, CNA #6, Other Employee #1, Other Employee #5, and Other Employee #7) sampled.