SW VA M H Inst Geri TRT CTR

In the surveyor’s words

From the most serious findings on record at SW VA M H Inst Geri TRT CTR, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF578Dec 30, 2025

  Based on staff interview, clinical record review and facility document review the facility staff failed to periodically review with the resident/resident representative advance directives for all residents of the facility. The findings included:The facility staff failed to ensure that advance directives were periodically reviewed with the resident and/or the resident representative.During clinical record review, surveyors could not locate evidence that each residents advance directive had been reviewed with either the resident or the resident's representative. During an end of day meeting on 12/29/25 at 4:15 pm, the issue of advance directives was discussed with the administrator, registered nurse (RN) #1, and social worker/administrator-in-training (SW/AIT). […]

• No harm, potential for more than minimal, widespreadF656Dec 30, 2025

  Based on staff interviews, clinical record review, and facility document review, the facility staff failed to develop comprehensive care plans (CCPs) that included the residents current code status for all residents in the survey sample. The findings included:The facility staff failed to develop CCPs that included the residents current code status. During the clinical record review, the surveyors were unable to locate information on the resident's CCPs that referenced their current code status. On 12/29/2025 at 4:15 p.m., during an end of the day meeting with the Administrator, Registered Nurse (RN) #1, and Social Worker/Administrator in Training the issue with the code status not being on the resident's current CCP's was reviewed. […]

• No harm, potential for more than minimal, widespreadF756Aug 31, 2023

  Based on staff interview, clinical record review and facility document review the facility staff failed to ensure that monthly medication regimen reviews were reviewed by the physician and/or the director of nursing and that pharmacist recommendations were acted upon for all residents of the facility. The findings included: While reviewing the monthly Medication Regimen Review (MRR) forms for five residents selected for review of psychotropic medication use, it was found that the MRR forms were not being reviewed by the physician and/or the director or nursing and that pharmacist recommendations were not being acted upon. Surveyor spoke with the unit manager on 08/30/23 at 11:30 regarding MRR's. […]

• No harm, potential for more than minimal, patternF759Feb 26, 2021

  Based on observations, staff interviews, and clinical document review, it was determined the facility staff failed to ensure a medication error rate of less than 5%. There were six (6) medication errors in 32 opportunities resulting in a medication error rate of 18.75%. (The residents involved in these medication errors were: Resident #14, Resident #4, and Resident #1.) The findings include: Medication errors were observed while completing the Medication Administration Task on the morning of 2/24/21. […]

• No harm, potential for more than minimal, isolatedF758Aug 31, 2023

  Based on staff interview and clinical record review the facility staff failed to ensure one of 16 residents was free from unnecessary psychotropic medications, Resident #17. The findings included: For Resident #17, the facility failed to provide a discontinue date or re-evaluate the resident for continued use for the as needed (prn) medication Zyprexa. Zyprexa is an antipsychotic medication used to treat severe agitation associated with schizophrenia and/or bipolar mania. Resident #17's clinical record listed diagnoses which included but not limited to major neurocognitive disorder due to probable Alzheimer's disease, severe, with other behavioral disturbances, adjustment disorder with anxious mood, and Alzheimer's dementia. […]