Fredericksburg Health and Rehab

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 26, 2023

  Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide the required assistance while providing ADL (activities of daily living) care which resulted in an injury for one of 11 residents in the survey sample, Resident #11. The resident sustained a laceration to the forehead requiring transport to the emergency room and sutures which constituted harm cited at past non-compliance. The findings include: For Resident #11 (R11), the facility staff failed to implement the plan of care while providing ADL care which resulted in the resident sustaining a laceration to the forehead requiring sutures at the emergency room . […]

• No harm, potential for more than minimal, patternF755Jan 17, 2024

  Based on observation, staff interview, and facility document review, it was determined the facility staff failed to store medications in a secure location. The findings include: On [DATE] at approximately 3:00 p.m., an observation was made of a bathroom in the conference room where the surveyor was stationed. The door had a slide lock on the top of the door. Inside the bathroom were many binder books with documents, boxes of papers and a box, measuring 14 inches wide by 17 ,d+[DATE] inches deep by 14 ,d+[DATE] inches tall. The box contained the following: 174 medication cards with pill/capsules remaining in the card. Two insulin pen dispensers with insulin remaining in them. Eight Scopolamine Transdermal Patch - expired ,d+[DATE]. One bottle of Nystop Nystatin. […]

• No harm, potential for more than minimal, patternF656Oct 26, 2023

  Based on observations, staff /resident interviews and facility document review, it was determined the facility staff failed to develop/implement the care plan for four of 39 residents in the survey sample, Resident #130, Resident #6, Resident #79 and Resident #61. The findings include: 1. The facility staff failed to develop the comprehensive care plan for trauma informed care for Resident #130. Resident #130 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: PTSD (post-traumatic stress disorder) and epilepsy. […]

• No harm, potential for more than minimal, patternF741Oct 26, 2023

  Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide trauma informed care education for five of five staff reviewed. The findings include: During the course of an investigation of Resident #130's PTSD (post-traumatic stress disorder) / trauma informed care, five staff who were caring for Resident #130 were chosen to have their education files reviewed; RN (registered nurse) #1, LPN (licensed practical nurse) #5, LPN #11, CNA (certified nursing assistant) #5 and CNA #15. An interview was conducted on 10/25/23 at 3:00 PM with LPN #5. […]

• No harm, potential for more than minimal, patternF812Oct 26, 2023

  Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store and serve food in a sanitary manner in one of one kitchen. The findings include: The facility staff failed to accurately label prepared food not stored in the original container, discard expired produce, store dry good scoops and thickener in a sanitary manner in the facility kitchen. On [DATE] at 8:30 a.m., an observation was conducted of the kitchen of the facility with OSM (other staff member) #4, dietary manager. Observation of the walk-in refrigerator revealed a four-shelf wire cart with a 5.2-quart plastic container with a white plastic lid on the third shelf labeled Ranch dressing with a prepared date of [DATE] and a use by date of [DATE]. […]