Heritage Hall Dillwyn

In the surveyor’s words

From the most serious findings on record at Heritage Hall Dillwyn, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF677Mar 20, 2024

  Based on observations, staff interviews, facility document review, and clinical record review, it was determined the facility staff failed to provide evidence of ADL (activities of daily living) care for one of 28 residents in the survey sample, Resident #46. The findings include: For Resident #46, the facility staff failed to provide evidence of ADL (specifically incontinence care, feeding assistance, and turning/positioning) care. Resident #46 was admitted to the facility on [DATE] with diagnoses that included but were not limited to non-traumatic brain dysfunction, cancer, Alzheimer's Disease and aphasia. […]

• No harm, potential for more than minimal, patternF886Jul 28, 2022

  Based on clinical record review, staff interview and facility document review, it was determined facility staff failed to maintain resident COVID-19 testing results in the medical record for 3 of 3 residents reviewed during the infection control task, Residents #1, #2 and #14. The findings include: 1. The facility staff failed to maintain the results of COVID-19 testing for Resident #1 (R1) in the clinical record. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 4/14/2022, the resident was coded as being moderately impaired for making daily decisions. On 7/26/2022 at 11:15 a.m., an interview was conducted with LPN (licensed practical nurse) #1, the infection preventionist. […]

• No harm, potential for more than minimal, patternF656Mar 31, 2021

  Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop and implement the comprehensive care plan for six of 38 residents in the survey sample, (Residents #11, #43, #2, #21, #5 and #34). The facility staff failed to ensure Resident #11's pommel cushion and Resident #43's wheelchair alarm were implemented to prevent falls per the comprehensive care plan and physician orders. The facility staff failed to develop and implement a care plan for devices to address and prevent the worsening of Resident #2's bilateral hand contractures and failed to develop and implement a comprehensive care plan to address urinary tract infections, the prescribed treatment and care required for Resident #21, #5 and… […]

• No harm, potential for more than minimal, isolatedF558Mar 20, 2024

  Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to maintain the call bell in a position accessible to the resident, for two of 28 residents in the survey sample, Residents #14 and #161. 1. For Resident #14, the facility staff failed to maintain the call light in a position where they could access it. Resident #14 was observed on 3/19/24 at 8:54 AM and 10:18 AM with the call bell clipped to the top of their mattress above their pillow, not in reach of resident. On 3/19/24 at 1:20 PM, Resident #14 was observed in bed with the call bell clipped below the bed on the right side. An interview was conducted on 3/19/24 at 1:20 PM with RN (registered nurse) #1. […]

• No harm, potential for more than minimal, isolatedF600Mar 20, 2024

  Based on resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to protect one of 28 residents in the survey sample from resident to resident abuse, Residents #31. The findings include: The facility failed to protect Resident #31 from physical abuse from another resident, Resident #50 on 12/18/23. A review of a facility synopsis of event with an incident date of 12/18/23 revealed, This evening at approximately 8:00 PM, (Resident #31) was in her room yelling after numerous attempts to redirect her with no success. (Resident #50) comes across the hall and hits (Resident #31) on her left forearm with her Reacher telling her to shut the h**l up, people are trying to sleep. […]