Blue Ridge Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Blue Ridge Rehabilitation and Nursing, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 24, 2022

  Based on observation, staff interview, group interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to provide supervision during meal time for two of 25 residents in the survey sample. Resident #1 assessed as, Total dependence on staff with one person physical assist for eating, was not supervised during lunch on [DATE], he choked on mashed potatoes and subsequently died (HARM). Resident #22 assessed as, Limited assistance with one person physical assist, was observed eating in his room during the lunchtime meal on [DATE] with no staff present. […]

• No harm, potential for more than minimal, widespreadF835Aug 24, 2022

  Based on staff interviews, resident interviews, and in the course of complaint investigation, the facility staff failed to provide effective administration in a manner to maintain and attain the highest practicable well-being of each resident. The facility failed to employ sufficient staff to ensure the administration of medications, treatments, and/or procedures to residents in a timely manner according to physician orders; failed to report an incident of failure to administer medications, treatments, and/or procedures to the State Survey Agency in a timely manner; failed to ensure prompt call bell response to provide for resident needs; and, failed to ensure bathing was provided in a timely and consistent manner. The findings include: 1. […]

• No harm, potential for more than minimal, widespreadF801Dec 9, 2021

  Based on staff interview and facility document review, the facility staff failed to employee a qualified dietary manager. The facility's dietary manager had no certifications or education in food service management or food safety. The findings include: On [DATE] at 2:25 p.m., a follow-up inspection of the kitchen was conducted accompanied by the dietary manager (other staff #1). The dietary manager was interviewed at this time about his qualifications as the food services manager. The dietary manager initially stated he was not certified but had ServSafe training regarding food service/safety. A copy of the certification was requested. The dietary manager then stated that he used to have a food safety certificate but it had expired. […]

• No harm, potential for more than minimal, patternF558Aug 28, 2024

  Based on staff interview and clinical record review, the facility failed to ensure preferences were met for showers/bathing for 3 of 31 residents. Resident #'s 71, 57, and 53 did not receive showers on multiple scheduled shower days. The Findings Include: 1. Resident #71 (R71) received one shower between 7/29/24 through 8/27/24. R71's most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 8/5/24 and assessed R71 with a cognitive score of 15 indicating cognitively intact. On an annual MDS dated [DATE] preferences were assessed and indicated that it was very important to choose between tub bath, shower and bed bath. […]

• No harm, potential for more than minimal, patternF559Aug 28, 2024

  Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide written notice prior to room changes for five of thirty-one residents in the survey sample (Residents #12, #13, #53, #57 and #200). The findings include: 1. No written notice was provided to Resident #53 prior to room changes on 5/10/24 and 7/1/24. Resident #53 (R53) was admitted to the facility with diagnoses that included coronary artery disease, hypertension, diabetes and depression. The minimum data set (MDS) dated [DATE] assessed R53 as cognitively intact. On 8/26/24 at 6:46 p.m., R53 was interviewed about quality of life/care in the facility. R53 stated she had moved rooms twice and had no notice prior to the changes. […]