To ensure the public remains fully informed, the Centers for Medicare and Medicaid Services (CMS) and the state of Virginia conduct routine surveys and investigations of every nursing facility statewide. The inspectors’ efforts help to identify serious deficiencies, violations and health issues at the nursing home. When problems are identified, regulators provide the facility numerous opportunities to correct serious health-related issues to protect the health and well-being of every resident.
Some deficiencies are so egregious that the nursing facility will be designated a Special Focus Facility (SFF). This undesirable designation includes being added to the federal Medicare deficiency watch list. These convalescence centers tend to remain on the watch list for many years until surveyors and inspectors are assured that any improvements made by the staff, employees, and administration are permanent.
In 2017, regulators designated Fredericksburg Health and Rehab Center (Golden Living Center) as a Special Focus Facility. Some of the serious problems, deficiencies, and violations involving this Home are detailed below.
This facility is a 177-certified bed ‘for profit’ Long-Term Care Home providing services and cares to residents of Fredericksburg and Stafford County and Spotsylvania County, Virginia. The Center is located at:
3900 Plank Road
Fredericksburg, VA 22407
(540) 786-8351
Inspectors working for the state of Arizona are legally authorized to impose monetary penalties against any nursing facility identify with serious deficiencies and violations. Publicly identifying these facilities help to keep the public informed and notified the facility that substandard care is never allowed.
Over the last thirty-six months, Fredericksburg Health And Rehab Center (Golden Living Center) received one monetary penalty of $63,291 on April 28, 2017. During this time, regulators received 20 formally filed complaints that after investigations all resulted in citations.
The state and federal governments regularly update their long-term care home database system with complete details of all dangerous hazards, filed complaints, safety concerns, health violations, opened investigations, and incident inquiries. The search results can be viewed at numerous online sites including Medicare.gov.
Currently, Fredericksburg Health And Rehabilitation Center maintains an overall one out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, two out of five stars for staffing issues, and three out of five stars for quality measures. Some serious concerns, health violations and deficiencies involving this facility include:
In a summary statement of deficiencies dated June 12, 2015, the state surveyor noted that the facility “failed to notify [the resident’s] responsible party or physician of changes in condition…” This deficiency included a failure “to notify and consult with the physician when [the resident] was inconsolable with signs of pain, after a fall.”
The surveyor noted additional failures at the facility including:
- The facility staff failed to notify “the Medical Doctor of elevated blood sugar levels for [one resident].”
- The facility “staff failed to notify [the resident’s] responsible party when the resident was moved from one room to another in the facility.”
- The facility “staff failed to notify the responsible party the physician when [another resident] experienced a significant weight loss and the thirty-day period between April 23, 2015, and May 24, 2015.”
In a summary statement of deficiencies dated June 12, 2015, the state investigator documented that the facility “failed to review and revise the Comprehensive Care Plan for [three residents].” It was documented that the facility also “failed to review and revise [one resident’s] Comprehensive Care Plan following a fall on March 11, 2015” and another resident’s Plan “following a fall on October 22, 2014.”
In a summary statement of deficiencies dated June 12, 2015, the state investigator documented that the facility “failed to follow professional standards of practice for [six residents].” The facility “failed to ensure staff was adequately trained in cardiopulmonary resuscitation (CPR) to provide initial emergency care to [a resident] during a medical emergency.” Surveyors documented that the facility “failed to ensure that CPR included usage of a backboard or firm surface to ensure effective chest compressions.”
Documentation revealed that the Licensed Practical Nurse “provided CPR to a resident in the bed [on a soft surface] without using a backboard and was not certified with the required Health Care Provider CPR Certification.” The surveyor stated that the “facility failed to ensure an emergency equipment backboard, oxygen, oxygen tubing and AED (automated external defibrillator) was stocked and available to nursing staff for use when [the resident was involved in a medical emergency with no pulse or respirations.” The deficient practice by the nursing staff resulted in the resident dying.
In a summary statement of deficiencies dated June 12, 2015, the state investigator documented that the facility staff “failed to ensure licensed nurses working and employed at the facility have the required CPR (cardiopulmonary resuscitation) certification for health care providers.” The investigator stated that “the facility did not have any documentation of CPR certification for [four] licensed nurses. [And] of the 29 licensed nurses with CPR certification; 7 nurses did not have the required health care providers certification.”
In a separate summary statement of deficiencies dated June 21, 2016, the state surveyor noted that the facility staff “failed to preserve a resident’s right to execute an Advance Directive regarding steps to be followed in the event he became without a heartbeat and not breathing in the facility.” The surveyor documented that the facility staff “failed to honor the resident’s advance directive instructing the facility staff to administer CPR (cardiopulmonary resuscitation) to the resident when he was found to be without a heartbeat and not breathing.”
In this incident, the resident had previously signed a document “stating he wanted CPR to be administered in the event he was found to be without a heartbeat and not breathing. He had a physician’s order for CPR to be administered. He was pronounced dead by outside EMS (emergency medical services) personnel after they arrived at the facility and unsuccessfully attempted to resuscitate him.”
In a summary statement of deficiencies dated June 12, 2015, the state investigator in the course of a complaint investigation identified specific deficiencies. These deficiencies included a failure “to provide care and services to obtain/maintain the highest practicable physical, mental, and psychosocial well-being of [four residents].” Additional deficiencies included a failure:
- To monitor a resident’s AV (arterial-venous) fistula.
- To maintain communication with a resident’s medical treatment center.
- To “administer medications according to the physician’s orders.”
- To consistently apply two layers of Ace wraps to the resident’s bilateral lower extremities as ordered by the physician…”
- To obtain an “administer an antibiotic for a resident ordered by the hospital discharge in physician to be initiated upon admission to the facility.”
- To provide a resident Tubi Grips (wraps to protect the lower legs) as ordered by the resident’s physician.
- To “obtain daily weights on the resident as ordered by the physician” during two different time frames.
In a separate summary statement of deficiencies dated April 20, 2017, the state investigator documented during a complaint investigation listing numerous deficiencies. The deficiencies included the facility’s failure:
In a summary statement of deficiencies dated June 12, 2015, the state investigator documented that the facility had failed “to ensure the medication regimen for [one resident] was free from unnecessary medications.” This incident involved a review of a resident’s blood pressure medication [when the resident’s] blood pressure was below the physician order parameter on multiple occasions in May and June 2015.”
In a summary statement of deficiencies dated June 12, 2015, the state investigator documented that the facility staff had “failed to maintain a complete and accurate infection control program as evidenced by incomplete Monthly Infection Control Logs from December 2014 through May 2015.” The investigator also documented the facility’s failure “to follow infection control practices during the medication administration observation for [one resident].” And additional deficiency included the facility’s failure “to administer eyedrops in a sanitary manner.”
In a summary statement of deficiencies dated June 21, 2016, the state investigator documented that the facility staff “failed to report and investigate allegations of abuse for [nine residents at the facility].” In one incident, “the facility staff failed to report to the State Agency an allegation of abuse when [the resident] struck [another resident] on December 29, 2015, causing swelling and bruising to [the abused resident’s] right chest, right arm, and right hand.”
In a separate incident, involving a different resident, the facility “staff failed to report to the State Agency an allegation of resident-to-resident abuse when [this resident] entered another resident’s room and was kicked on the shin by [a fourth resident], causing an injury. The facility did not report this to the required State Agency” as required by nursing home regulations.
In a third incident, involving different residents, “the facility staff failed to report an allegation of misappropriation of resident property [the resident was allegedly missing $43.00 on February 4, 2016].” The surveyor noted that the “facility did not report this to the required State Agency” according to state law.
The facility also “failed to [complete a] follow-up report to the State Agency in the required five days, evidencing thorough investigation was completed after a reported allegation of abuse for [a different resident].” In a separate incident involving another resident, “the facility staff failed to complete an investigation and report to the State Agency for an allegation of abuse [involving resident to resident assault].”
In a summary statement of deficiencies dated June 21, 2016, the state investigator documented that the facility “failed to implement the facility abuse policy for reporting resident allegations of the State agency” involving multiple resident-to-resident assaults.
In a summary statement of deficiencies dated June 21, 2016, the state investigator following the course of a complaint investigation identified certain deficiencies. The surveyor “determine the facility staff failed to implement the Plan of Care for [a resident] …to do weekly skin assessments.” The surveyor noted that “there was no documentation that the skin assessments were completed.”
The lack of care was confirmed by the Administrative Staff Member and the Director of Nursing who “was asked for any skin assessments completed [for the resident].” The Administrative Staff Member stated, “I have no skin assessments for the resident.”
In a separate summary statement of deficiencies dated April 28, 2017, the state investigator during a complaint investigation identified deficiencies. These deficiencies included a facility staff failure “to follow professional standards of practice for [seven residents].” The list of deficiencies included a staff failure “to clarify physician’s orders, transcribe physician’s orders, transcribe a physician’s recommendations into orders, and clarify the parameters for administration of ‘as needed’ pain medication.” Also, there was a failure “to obtain a physician’s orders” to treat a sacral wound.
In a summary statement of deficiencies dated June 21, 2016, the state surveyor following up on a complaint investigation identified specific failures. This deficiency included the facility staff’s failure “to provide care and services to treat and prevent pressure ulcers” for one resident. The surveyor documented that the resident had been admitted to the facility “with an area on his sacrum/coccyx [tailbone].
No treatment orders were put in place for the wound, and on December 1, 2015, it was identified and documented as having declined to an unstageable wound with yellow slough. On December 8, 2015, the Wound Care Specialist identified the resident as having developed an unstageable deep tissue injury of the left heel.” Two days later the resident “was identified as having developed an unstageable wound with tunneling where the scrotal sack attaches to the perineal area before the anus.”
The surveyor documented that “there were no documented skin assessments for [the resident], and no interim Care Plan to address his needs [before] the comprehensive assessment. There were no documents, other than the wound specialist notes, regarding the assessment, measurement or treatments of the wounds for [the resident].”
If you believe your loved one suffered harm at the hands of visitors, caregivers, employees or other residents while a patient at Fredericksburg Health And Rehab, contacting a personal injury lawyer can help you receive financial compensation for damages. An attorney working on your behalf can file your claim, gather evidence, build your case, and litigate your lawsuit in front of a judge and jury or negotiate an out of court settlement.
No upfront payments are required because personal injury attorneys accept every wrongful death lawsuit, nursing home abuse case and medical malpractice claim for compensation with contingency agreements. This arrangement means that payment of your fees are postponed until after the case is resolved successfully and you have obtained monetary recovery for your damages.
Sources:
Chicago Nursing Home Injury Lawyer Nursing Home Law Center LLC Home