Wythe Cnty Community Hosp Ecu

Based on staff interview and clinical record review, the facility staff failed to ensure the correct code status was in place for 1 of 6 residents, Resident #1.The findings included:Resident #1's diagnoses included but were not limited to congestive heart failure, hypertension, myocardial infarction, and hyponatremia. Resident #1's ECU [extended care unit] admission History dated 11/20/25 indicated the resident had no advanced directive but code status was DNR (do not resuscitate). A review of Resident #1's clinical record on 11/24/25 revealed a current order dated 11/20/25 for full code resuscitation status. On 11/24/25 at 2:45 PM, during an interview with Registered Nurse (RN) #1, the documentation discrepancy regarding Resident #1's code status was discussed. RN #1 stated she would clarify this with the resident. RN #1 returned and stated the resident's code status was correct on the admission history and should be DNR. Resident #1's code status order was changed to DNR on 11/24/25 at 3:30 PM. On 11/25/25 at 1:15 PM, RN #1 stated the physician entered the code status order and she did not know what happened to cause the error. On 11/25/25 at 1:40 PM, the survey team met with the administrative team and discussed the concern regarding Resident #1's code status.No further information regarding this concern was presented to the survey team prior to the exit conference on 11/25/25.

Based on staff interview and clinical record review, the facility staff failed to provide residents and/or resident representatives with a copy of the baseline care plan.The findings included: A review of residents' clinical records failed to reveal evidence of the facility providing a copy of the baseline care plan to the resident and/or resident representative. On 11/25/25 at 12:24 PM, the Director of Clinical Effectiveness Quality and Risk Management stated they were unaware of the need to provide residents with a copy of the baseline care plan, and this was not a facility practice. The facility policy titled Interim Care/Interdisciplinary Care Plans did not address providing the resident and their representative with a summary of the baseline care plan.No further information regarding this concern was presented to the survey team prior to the exit conference on 11/25/25.

Based on staff interview and clinical record review, the facility staff failed to offer a pneumococcal vaccine in accordance with nationally recognized standards for 1 of 5 sampled residents, Resident #1. The findings included:Resident #1's diagnoses included but were not limited to congestive heart failure, hypertension, myocardial infarction, and hyponatremia.Resident #1's ECU [extended care unit] admission History dated 11/20/25 indicated the resident had received a pneumococcal vaccine after the age of 65. However, the date and type of pneumococcal vaccine was not documented in Resident #1's clinical record.Registered Nurse (RN) #1 was interviewed on 11/25/25 at approximately 11:45 AM. RN #1 verified Resident #1's admission history form only indicated he had received a pneumococcal vaccine after the age of 65 but did not include the type of pneumococcal vaccine or date received. The facility Infection Preventionist (IP) provided Resident #1's Official Immunization Record from the Virginia Immunization Information System (VIIS) which indicated the resident had not received a pneumococcal vaccine in the past. The facility was unable to provide evidence of Resident #1 being offered a pneumococcal vaccine following admission. On 11/25/25 at 12:15 PM, the survey team met with the administrative team and discussed the concern of staff failing to offer Resident #1 a pneumococcal vaccine.No further information regarding this concern was presented to the survey team prior to the exit conference on 11/25/25.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate MDS (minimum data set) assessment for 1 of 7 records, Resident # 7.
The findings included:
The discharge MDS was coded that Resident #7 was discharged to an acute care hospital when the resident was actually discharged home with home health services.
Resident #7's closed electronic clinical record was reviewed on 02/06/2020. The physician's discharge summary listed the resident's diagnoses that included, but not limited to, physical therapy and occupational therapy strengthening status post hospitalization, atrial fibrillation, and chronic kidney disease stage 3 to 4.
The discharge MDS with an ARD (assessment reference date) of 11/20/19 noted in Section C (Cognitive Patterns) that Resident #7 had a BIMS (brief interview for mental status) score of 6 out of 15. In Section A (Type of Assessment) the resident's discharge was described as planned and return was not anticipated. Also in Section A (Identification Information), the MDS noted Resident #7 was discharged to an Acute Hospital.
The clinical record included a nurse's note dated 11/20/19 that indicated Resident #7, with their medical power of attorney, were given discharge instructions, education and prescriptions before being escorted by staff via wheelchair to the facility's front entrance for discharge. The clinical record also included a discharge summary that read within the Hospital Course that Resident #7 would be discharged home with home health. The discharge summary was written and electronically signed by a nurse practitioner and also electronically signed by the attending physician.
The facility's administrator was interviewed on 2/06/2020 at 10:40 a.m. regarding the inaccurate MDS concern. The administrator stated that none of the facility's MDS coordinators were available at the time to be interviewed; the MDS coordinator who filled out Resident #7's discharge MDS was out sick. The administrator recalled Resident #7 and remembered the resident leaving the facility with family after being discharged home with home health services. After viewing the MDS, the administrator acknowledged the MDS read that Resident #7 was discharged to an acute hospital.
No further information regarding this issue was provided to the survey team prior to exit.

Based on staff interview and clinical record review the facility staff failed to ensure that residents receive treatment and care by following physician's orders for medication administration for 1 of 7 residents (Resident #107).
The findings included:
The facility staff failed to wait 6 hrs between two doses of Ultram which was ordered every 6 hrs prn (as needed) and failed to administer Lipitor in the evening as ordered for Resident #107.
Resident #107's electronic clinical record was reviewed on 02/05/2020. Diagnoses noted within physician documentation included but were not limited to cerebrovascular accident (CVA - stroke), neurosarcoidosis (long-term inflammatory disease affecting the nervous system), left side weakness, and severe right lower weakness.
Resident #107 was a new admission and therefore no MDS (minimum data set) was reviewed. The resident was alert and oriented on 02/05/2020.
Physician orders included but were not limited to:
1. Tramadol Tab (Ultram Tab) 50mg by mouth every 6 hours as needed for pain (pain scale 4-10).
2. Atorvastatin Tab (Lipitor Tab) 80mg by mouth every night at bedtime.
The electronic Medication Administration Record (eMAR) provided documentation that Resident #107 received Ultram 50mg by mouth on 02/04/2020 three times. The first time at 7:15 a.m. for a pain scale of 4, the second time at 11:36 a.m. for a pain scale of 6, and the third time at 9:20 p.m. for a pain scale of 4. There was 4 hours and 21 minutes between the first and second dose instead of 6 hours that was ordered. The eMAR provided documentation that Resident #107 received Lipitor 40mg by mouth on 01/26/2020 at 9:02 a.m. even though the medication was ordered to be given at bedtime.
The facility's administrator was informed of these medication administration concerns on 02/05/2020 at approximately 4:30 p.m. The administrator acknowledged the eMAR showed there was less than 6 hrs between the first two doses of Ultram on 02/04/2020 and Lipitor was given in the morning of 01/26/2020 (9:02 a.m.) instead of the ordered bedtime (scheduled for 9:00 p.m.).
The facility's administrator was interviewed on 02/06/2020 at 11:53 a.m. regarding the medication administration time concerns. The administrator had spoken with the nurse who had administered the medications and there was no more information provided.
No further information regarding the medication administration times was provided to the survey team prior to exit.

Based on observation and staff interview, the facility staff failed to store food and items used to prepare food in a manner to prevent the outbreak of foodborne illness. As evidenced by outdated items in the kitchen area and nesting of wet pans.
The findings included:
The facility kitchen included 7 containers of out of date water chestnuts, 18-gallon jugs of out of date water, and nesting of wet pans.
Two surveyors entered the facility kitchen (dietary department) on 02/05/2020 at approximately 11:00 a.m. The registered dietician (RD) accompanied the surveyors on this observation.
Surveyor #1 identified the following issues. Eighteen-gallon jugs of water with a best buy date of 12/27/2019. The RD verbalized to the surveyor that the jugs of water were not for oral consumption, they knew they were out of date, and they were going to discard them. However, the jugs of water were stored with items that were currently being used in the facility kitchen.
This surveyor also observed metal baking pans turned upside down and stacked on top of each other. The surveyor visualized water droplets on the outside of one of these pans. When brought to the attention of the RD, the RD stated they should have been placed on a drying rack and they would have them redone.
Surveyor #2 identified 7 cans of water chestnuts labeled best before 12/2019. After reviewing the date on the container dietary staff person #1 stated these were expired.
When asked who was responsible for discarding expired items the RD verbalized to the surveyors that it was everyone responsibility to identify out of date products and they used the process First in first out.
On 02/06/2020 at 9:53 a.m., surveyor #1 made a second observation of the dietary department. The 18-gallon jugs of water remained on the same shelf in the dietary department.
On 02/06/2020 at 12:08 p.m., Registered nurse #1 was made aware of the issues in the kitchen area.
No further information regarding these issues were provided to the survey team prior to the exit conference on 02/06/2020.