Club Healthcare and Rehabilitation Center at the V

In the surveyor’s words

From the most serious findings on record at Club Healthcare and Rehabilitation Center at the V, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Jan 30, 2025

  Based on record review and interview, the facility failed to submit accurate direct care staffing information to CMS for the fourth quarter of 2024. Findings include: Review of the Payroll Based Journal (PBJ) for the fourth quarter of 2024 (July 1 - September 30) showed low weekend registered nurse (RN) staffing for Saturday and Sunday on September 7-8, 2024. During an interview on 1/28/2025 at 2:00 PM, the Administrator stated, The PBJ staffing trigger of low weekend staffing for nurses was because an RN who was covering for the RN Supervisor on the weekend of September 7th and 8th, while the weekend supervisor was on vacation was coded for another sister facility and not here at this facility. […]

• No harm, potential for more than minimal, widespreadF761Apr 27, 2022

  Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with current professional standards in 3 of 3 medication carts and 1 of 2 medication rooms reviewed for medication labeling and storage. Findings: During an observation on [DATE] at 9:34 AM of medication cart #1 with Staff B, Licensed Practical Nurse (LPN) it showed there was one opened bottle of [MEDICATION(S)] without an open date or expiration date, one opened [MEDICATION(S)] pen without an open or expiration date, and 10 (ten) [MEDICATION(S)] [MEDICATION(S)] 0.,d+[DATE]mg (milligrams)/3ml (milliliter) without a resident identifier or original pharmacy packaging. […]

• No harm, potential for more than minimal, widespreadF812Apr 27, 2022

  Based on observation, interview, and record review, the facility failed to ensure food is safely stored, covered, labeled, and/or discarded in the areas of the kitchen coolers, dry storage areas, and including emergency supply. Findings: During an observation on [DATE] beginning at 8:26 AM with Staff E, Dietary Aide it showed in the walk-in cooler a partially opened box located on the bottom shelf labeled breast raw chicken. The open container of raw chicken did not have a catch tray or an under liner pan on the shelving. A red watery liquid is observed dripping and pooling on the floor under the open box of chicken. A box labeled boneless pork loin raw is located on the shelf to the right of the raw chicken. […]

• No harm, potential for more than minimal, widespreadF867Apr 27, 2022

  Based on record review and interview the facility quality assurance and performance improvement committee failed to implement a performance improvement plan related to pressure wounds when identified as a negative and problematic indicator of quality deficiencies. Findings: Review of the medical record for Resident #197 documented the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . May change dressing PRN (as needed) every day shift for wound care. During an interview on 4/25/22 at 10:53 AM Resident #197 was resting quietly, when asked if he had a wound he stated, On my butt and on my heel. My dressing has not been changed since last Thursday. […]

• No harm, potential for more than minimal, widespreadF880Apr 27, 2022

  Based on observation, interview, and record review, the facility failed to ensure proper infection control standards were maintained for central line dressings for 3 of 3 residents reviewed for central line catheters, Resident #149, #7, and #27, and failed to perform hand hygiene during medication administration for 2 of 6 observations. Findings: 1) Review of the medical record for Resident #149 documented the resident was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/24/2022 at 10:49 AM Resident #149 was observed with a right upper arm midline catheter which had a date of 4/20/22 on the clear occlusive dressing. […]