Rappahannock Westminster Canterbury

In the surveyor’s words

From the most serious findings on record at Rappahannock Westminster Canterbury, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jan 13, 2022

  Based on staff interview, facility documentation and clinical record review, the facility staff failed to provide consistent basic life support, including CPR for 1 Resident (Resident #35) in a survey sample of 27 Residents. This resulted in Immediate Jeopardy at Level 4 isolated on [DATE]. After reviewing the facility documentation, Immediate Jeopardy was determined to be removed at past non-compliance on [DATE]. The findings included: 1. For Resident #35, the facility staff failed to continue cardiopulmonary resuscitation (CPR) on [DATE]. Also, the facility staff failed to activate Emergency Medical Services (EMS) when CPR was initiated. Resident #35 was a full code. Resident # 35 was admitted to the facility on [DATE] and expired on [DATE]. […]

• No harm, potential for more than minimal, patternF812Aug 10, 2023

  Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 2 kitchens/food preparation/service areas inspected. The findings included: 1. The facility staff failed to store food in a manner consistent with professional standards for food service safety with regard to, labeling and protection from contaminates. On 8/8/23 at 12:45 PM, observations were made in the facility's main kitchen. The facility's dietary manager was present and accompanied Surveyor C. In the storage bin for the dry goods, a foreign object was observed in the seafood breading. […]

• No harm, potential for more than minimal, patternF925Aug 10, 2023

  Based on observation, staff interviews, and facility documentation review, the facility staff failed to maintain an effective pest control program ensure the facility is free of pests in the main kitchen, which has the ability to affect multiple Residents within the facility. The findings included: On 8/8/23 at 12:45 PM, a preliminary inspection was conducted in the main kitchen. Observations were made with the dietary manager present. The following observations were noted: Throughout the entire kitchen an abundance of flies was noted in all food preparation areas. Flies were noted to be on the food prep tables, in the dry storage room and in the dish machine area. In the bin where the seafood breaded was stored, something was noted to be in the breaded. […]

• No harm, potential for more than minimal, patternF812Jan 13, 2022

  Based on observation, staff interview and facility documentation review, the facility staff failed to store food in a manner to identify the food item and the date opened or to be used by, in 2 of 4 food storage areas inspected. The findings included: On 1/11/22 at 2:59 PM, observations were made in the facility kitchen. Surveyor C was accompanied by Employee F, the dietary manager. In the walk-in freezer, two bags of mixed vegetables and a bag of green peas were open to air, not secured in a manner to protect from environmental contaminates, and had no date. A bag of green beans were observed to be wrapped in saran wrap and had no date. Observations of the walk-in freezer labeled as #4 contained an item in a zip lock bag that Surveyor C was not able to identify. […]

• No harm, potential for more than minimal, isolatedF580Aug 10, 2023

  Based on observation, interview, clinical record review and facility documentation the facility staff failed to immediately inform the Resident's physician, and Resident representative of change in condition for 1 Residents (#14) in a survey sample of 19 Residents. The findings included: For Resident #14, who had a decline in condition, the facility staff failed to notify the physician of the Resident's inability to accept administered medications on several occasions. On 8/8/23-8/9/23, a record review was conducted. This review revealed: A progress note dated 08/04/2023 at 11:17 PM, read, Resident received in bed this evening. Has been resting, refused HS meds and fluids offered, nurse attempted to moisten mouth and resident closed and pursed lips. […]