The Culpeper

In the surveyor’s words

From the most serious findings on record at The Culpeper, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 18, 2021

  Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the necessary care and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure injury for one of 20 residents in the survey sample, Resident #16. Resident #16 was readmitted to the facility on [DATE], with a stage two pressure injury on the sacrum/buttocks. The facility staff failed to complete ongoing thorough wound assessments including measurements and staging of the pressure injury from 10/30/20 thorough 11/19/20, and from 11/27/20 through 12/10/20, and failed to provide treatment to the pressure injury from 11/7/20 through 11/17/20, with the exception of 11/14/20. […]

• No harm, potential for more than minimal, widespreadF812Apr 7, 2022

  Based on observation, staff interview and facility document review, it was determined the facility staff failed to maintain clean kitchen equipment in one of two kitchens, the main kitchen. The findings include: Observation was made of the main kitchen on 4/5/2022 at 11:28 a.m. The oven racks appeared to be covered in a brown substance. When asked what the cleaning schedule was, OSM (other staff member) #3, the executive chef, stated they should be cleaned on a weekly basis, but may have been missed last week. When asked if they could provide documentation when the ovens were cleaned last, OSM #1, the certified dietary manager, stated it was unlikely that they could provide that. On 4/6/2022 at 10:41 a.m. […]

• No harm, potential for more than minimal, patternF638Oct 18, 2023

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to complete quarterly MDS (minimum data set) assessments in a timely manner for four of 26 residents in the survey sample, Residents #1, #48, #36 and #51. The findings include: 1. For Resident #1 (R1), the facility staff failed to complete the resident's quarterly MDS with an ARD (assessment reference date) of 9/7/23 within 14 days. A review of R1's clinical record revealed a quarterly MDS assessment with an ARD of 9/7/23. Further review of R1's clinical record revealed the MDS was not completed until 9/30/23 (23 days). On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). […]

• No harm, potential for more than minimal, patternF812Oct 18, 2023

  Based on observation, staff interview, and facility documentation review, the facility failed to prepare and store food in a sanitary manner in one of two nourishment refrigerators, the rehab to home unit refrigerator, and in one of two facility kitchens, the main kitchen. The findings include: The facility staff failed to maintain a clean main kitchen, and failed to store food safely in the main kitchen and in the rehab to home unit refrigerator. On 10/16/23 at 10:15 a.m., observation was made of the main facility kitchen. The upper oven contained a large amount of baked-on grease and dark particles on the doors, sides, bottom and back. The areas around the burners on the stove contained cooked-on grease, and a large amount of crumbs and dark black debris. […]

• No harm, potential for more than minimal, patternF697Apr 7, 2022

  Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to have a complete pain management program for one of 21 residents in the survey sample, Resident # 24 (R24). The facility staff failed to clarify the physician orders, document the location of pain and document the level of pain for R24. The findings include: On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 2/24/2022, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. […]