Heritage Hall Front Royal

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF622May 15, 2024

  Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide all required documentation to the receiving facility upon a hospital transfer for one of 20 residents in the survey sample; Resident #11. The findings include: A review of the clinical record revealed a nurse's note dated 3/1/24 documented, Resident voiced increased fatigue, started SQ (subcutaneous) normal saline 0.9% fluids 1000ml (1000 milliliters) bag at 80ml/hr (80 milliliters per hour) in RUQ (right upper quadrant) without difficulties Called NP (nurse practitioner) N/O (new order) Send to ED (emergency department) for further evaluation d/t (due to) hyperkalemia. Voicemail left for emergency contact. No return call at this time. […]

• No harm, potential for more than minimal, isolatedF656May 15, 2024

  Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to develop and/or follow the comprehensive care plan for three of 20 residents in the survey sample, Residents #42 (R42), R14 and R7. The findings include: 1. For R42 the facility staff failed to develop the comprehensive care plan for the use of bed rails. R42 was admitted to the facility with diagnosis that included but was not limited to muscle weakness. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/10/2024, the resident scored two out of 15 on the BIMS (brief interview for mental status), indicating R42 was severely impaired of cognition for making daily decisions. […]

• No harm, potential for more than minimal, isolatedF757May 15, 2024

  Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to evidence the monitoring of side effects for the use of an anticoagulant for two of 20 residents in the survey sample, Residents #7 and #14. The findings include: 1. For Resident #7, the facility staff failed to evidence the monitoring of side effects for the use of Xarelto (Rivaroxaban) (1) On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/29/24, the resident scored a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. […]

• No harm, potential for more than minimal, isolatedF641Sep 8, 2022

  Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 26 residents in the survey sample, Resident # 31. The findings include: The facility staff inaccurately coded two MDS assessments that Resident #31 was receiving insulin when in fact the resident was not receiving insulin. On the most recent MDS assessment, an annual assessment, with an ARD (assessment reference date) of 7/6/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status), indicting the resident was not cognitively impaired for making daily decisions. […]

• No harm, potential for more than minimal, isolatedF698Sep 8, 2022

  Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure ongoing communication with the dialysis center for one of 26 residents in the survey sample, Resident #112. The findings include: The facility staff failed to review the dialysis communication book upon return to the facility and failed to ensure the dialysis center documented in the communication book post dialysis for Resident #112. There was no completed MDS (minimum data set) assessment completed for Resident #112 at the time of the survey. The physician orders dated, 9/2/2022, documented in part, Pre dialysis vitals (blood pressure, temperature, pulse and respirations) Q (every) T - Th - Sat (Tuesday, Thursday, Saturday), complete in dialysis book. […]