Nassawadox Rehabilitation and Nursing

In the surveyor’s words

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

• Actual harm, patternF600May 20, 2022

  Based on information gleaned during a complaint investigation, observations, resident interviews, staff interviews, clinical record reviews, and review of facility documents, the facility staff neglected to provide proper care and prompt services to avoid unnecessary suffering, and pain for 5 of 5 residents (Resident #85, 291, 339, 189, 190), in the survey sample of 55, which constituted harm. For Resident #85 the facility staff neglected to provide the necessary care and services to include weekly skin assessments, turning and repositioning and pressure relieving devices to ensure a pressure ulcer was not first identified at a Stage 3, who was assessed as a high risk for developing pressure ulcers which constituted harm. […]

• Actual harm, patternF686May 20, 2022

  Based on a complaint investigations, observations, clinical record review, staff interviews and facility document review the facility staff failed to ensure 3 of 7 residents in the facility with pressure ulcers were provided the necessary treatment and services to ensure that pressure ulcers were not identified at advanced stages for Resident #85, Resident #339 and Resident #291, which constituted harm for all three residents. For Resident #85 the facility staff failed to provide the necessary care and services to include weekly skin assessments, turning and repositioning and pressure relieving devices to ensure a pressure ulcer was not first identified at a Stage 3, who was assessed as a high risk for developing pressure ulcers. […]

• Actual harm, isolatedF580May 20, 2022

  The facility staff failed to notify the physician or the wound Nurse Practitioner of a deteriorating stage II pressure ulcer prior to advancing to an unstageable pressure ulcer for 1 out of 55 residents (Resident #291) in the survey sample. The finding included: Resident #291 was originally admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #291's Admission Assessment (14-day) with an ARD of 03/19/22 coded Resident #291 Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long term memory problems and severe cognitive impairment - never/rarely made decisions. […]

• Actual harm, isolatedF684May 20, 2022

  Based on information gleamed during a complaint investigation, staff interviews, and clinical record review, the facility staff failed to provide the necessary care and services for 3 of 55 residents (Resident #189) in the survey sample. For resident #189, the facility staff failed to recognize, assess and provide the necessary care and services after the resident experienced a significant change in condition presenting as shortness of breath because of low oxygen saturation 87 percent on room air. At the hospital the resident was diagnosed with acute [CONDITION(S)], severe [CONDITION(S)], a urinary tract infection and severe dehydration evidenced by a blood pressure reading of 80/50, only 30 milliliter of dark urine when catheterized and dry tongue and mucous membranes and peeling lips. […]

• Actual harm, isolatedF791May 20, 2022

  Based on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to ensure a resident received emergency dental services promptly after referrals were made adequately while experiencing the acute dental problem for 1 of 1 resident (Resident #190), with dental concerns in the survey sample. The STAT (now) dental appointment ordered 3/1/22, was scheduled on behalf of Resident #190 on 3/10/22, with a local general practice dentistry office for 3/23/22, which was 22 days after the STAT order. […]