Daleville Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Daleville Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Apr 10, 2024

  Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility kitchen and 2 of 2 nourishment rooms. The findings included: 1. In the facility kitchen, staff failed to maintain the correct concentration of sanitizing solution in the low temperature sanitizing dish machine and stacked (nested) wet pans together. On [DATE] at 12:40 PM, during the initial kitchen tour, surveyor observed dietary staff washing pans in the dish machine. The Dietary Manager (DM) stated the dish machine was a low temperature machine using a chemical sanitizer. […]

• No harm, potential for more than minimal, patternF812Feb 16, 2023

  Based on observation, staff interview, and facility document review, the facility staff failed to distribute and serve food in accordance with professional standards for food service safety as evidenced by a final rinse temperature below 180 degrees Fahrenheit (F) for a high temperature (heat sanitization) dishwasher in the facility kitchen. The findings included: The facility staff failed to consistently maintain a final rinse temperature at the manufacturer recommended minimum temperature of 180 degrees F for the facility high temperature dishwasher. On 2/13/23 at 2:10 pm, the surveyor observed the facility dishwasher in use. The dietary manager (DM) stated the machine was a high temperature dishwasher. […]

• No harm, potential for more than minimal, patternF842Feb 16, 2023

  Based on interviews and document reviews, the facility staff failed to maintain complete and accurate clinical records for five (5) of 24 residents, Resident #50, Resident #68, Resident #70, Resident #125, and Resident #176. The findings include: 1. Resident #50's Medication Regimen Review (MRR) dated 12/30/22 failed to include documentation of the medical provider's reason for not attempting a Gradual Dose Reduction (GDR). Resident #50's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/9/23, was signed as completed on 2/3/23. Resident #50 was assessed as able to make self understood and able to understand others. Resident #50's Brief Interview for Mental Status summary score was documented as an 8 out of 15; this indicated moderate cognitive impairment. […]

• No harm, potential for more than minimal, patternF677May 27, 2021

  Based on resident interview, staff interview, and clinical record review, the facility staff failed to ensure that residents who were unable to carry out activities of daily living received the necessary care and services to maintain personal hygiene for 7 of 22 residents, Residents #12, 19, 32, 45, 62, 64 and 11. The findings included: 1. For Resident #12, the facility failed to complete nail care. Resident #12's toenails were observed to be long and jagged. Resident #12's face sheet included the diagnosis, [CONDITION(S)], malignant neoplasm of colon, and [CONDITION(S)]. […]

• No harm, potential for more than minimal, isolatedF578Apr 10, 2024

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the correct code status was in place for 1 of 19 residents in the survey sample, Resident #46. The findings included: For Resident #46, the current code status order was full code, however the comprehensive person-centered care plan and the clinical record Advanced Directive information tab documented the resident as having a DNR (do not resuscitate) decision in place. The resident's clinical record also included a completed Durable Do Not Resuscitate [DDNR] Order. […]