Dinwiddie Health and Rehab Center

In the surveyor’s words

From the most serious findings on record at Dinwiddie Health and Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 3, 2025

  Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide a safe transfer using a mechanical lift resulting in a fall with fractures for one of eight residents in the survey sample (Resident #1).The findings include:Facility staff failed to attach a mechanical lift sling according to facility and manufacturer's recommendations during a transfer of Resident #1 from the bed to a wheelchair. Resident #1 slid out of the sling during the transfer causing fracture of the resident's shoulder (proximal left humerus) and left wrist (harm).Resident #1 (R1) was admitted to the facility with diagnoses that included cerebrovascular accident (stroke), left side hemiplegia, hypothyroidism, chronic pain, mood disorder, major depressive… […]

• No harm, potential for more than minimal, patternF582Feb 7, 2024

  Based on staff interview, clinical record review and facility documentation review, the facility staff failed to submit a demand bill, as requested on the SNF ABN notice (Skilled Nursing Facility Advance Beneficiary Notice) issued to 2 Residents (Resident #4- R4 and Resident #36- R36) in a survey sample of 3 Residents, reviewed for such notices. The findings included: For R4 and R36, the facility staff failed to continue skilled therapy services and submit a claim to Medicare for a coverage decision, as the resident and/or their representatives requested on the SNF ABN form. On 2/5/24, the facility administration was asked to provide the NOMNC (notice of Medicare non-coverage) and SNF ABN forms provided to R4 and R36. These notices were received and reviewed. […]

• No harm, potential for more than minimal, patternF607Feb 7, 2024

  Based on staff interviews, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policy for 3 Residents (Resident #18- R18, Resident #210-R210, and Resident #211-R211) in a survey sample of 37 Residents and for 2 employees in a sample of 25 staff records reviewed. The findings included: 1. For R18, R210, and R211, all who reported allegations of abuse, the facility staff failed to report the allegations of abuse to the required agencies, failed to have evidence of an investigation being conducted and for R210 and R211, failed to take measures to protect the residents while an investigation is being conducted. On 2/6/24 and 2/7/24, a review was conducted of facility documents to include allegations of abuse. […]

• No harm, potential for more than minimal, patternF684Feb 7, 2024

  Based on staff interview and clinical record review, the facility staff failed to change insulin administration times as ordered by physician for one of thirty-seven residents in the survey sample (Resident #33). A provider approved pharmacy recommendation to change Resident #33's Humulin insulin administration times was not implemented for over three months. The findings include: Resident #33 (R33) was admitted to the facility with diagnoses that included cerebral infarction, diabetes, congestive heart failure, gastroesophageal reflux disease, chronic kidney disease and atrial fibrillation. […]

• No harm, potential for more than minimal, patternF684Jun 23, 2022

  Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #10 had elastic tubular bandages in use for over two weeks without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: 1. Resident #10 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #10 as cognitively intact. On 6/21/22 at 2:35 p.m., Resident #10 was observed seated in a wheelchair in his room. The resident's lower legs were wrapped with elastic gauze dressings. There were red/brownish stains scattered near the bottom of the wraps. […]