Cherrydale Health And Rehabilitation Center

F-F804)

3. The facility failed to ensure the facility maintained and practiced food service by offering each resident drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration. (Refer to

F-F807)

4. The facility failed to date, label, and/or cover bread products stored in the kitchen, which had the potential to create an environment for food-borne illnesses. (Refer to

F-F812)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 32 495121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495121 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center 3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 20413 potential for actual harm Based on observation and interview, the facility failed to ensure food was served at proper and appetizing Residents Affected - Some temperatures for seven (Resident (R) 32, Resident R35, Resident R49, Resident R66, Resident R86, Resident R89 and Resident R154) out of 46 sampled residents, increasing the risk for altered nutritional status.

Findings include:

During the resident council meeting on 04/23/25 at 1:30PM, Resident R32, Resident R35, Resident R49, Resident R66, Resident R86, Resident R89 and Resident R154 complained that the food they receive at their meals was served cold.

On 04/21/25 at 3:35PM, a policy for food palatability was requested from the Registered Dietician (RD), who was from the sister facility. The RD stated that there was no policy regarding palatability. The RD explained that there were some issues from different residents about the food not being served hot. When questioned,

the RD stated that she had not done a test tray at this facility to determine whether the food that was served to the residents was served hot. When questioned further, the RD stated that she had not implemented any interventions to address the complaints about the food being cold.

On 04/23/25 from 12:30 PM to 12:35 PM, food temperatures were taken of food on the steam tablet in the presence of two Corporate Registered Dietitians,0S4 and OS5. Test trays were taken from second floor satellite kitchen, and temperatures were recorded as follows:

Regular turkey meatloaf - 150 degrees Fahrenheit (F)

Mashed Potatoes - 145 degrees F

[NAME] Gravy - 146 degrees F

Corn - 158 degrees F

On 04/23/25 at. 2:05 PM, the test tray arrived at the unit and when it was the last tray remaining, temperatures were taken by OS4 and recorded as follows:

Regular turkey meatloaf - 104 degrees F

Mashed Potatoes - 104 degrees F

[NAME] Gravy - 104 degrees F

Corn - 103 degrees F

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 32 495121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495121 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center 3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 From the test tray, the meatloaf, mashed potatoes with gravy and corn with butter were tasted and found to be cold. Both OS4 and OS5 agreed that the meatloaf, mashed potatoes with gravy and corn with butter Level of Harm - Minimal harm or tasted cold. OS4 stated that it was too long of a period of time between when food was being served to the potential for actual harm residents. Neither the OS4 or the OS5 offered any explanation as to why the food had taken so long to arrive

on the unit. Residents Affected - Some No additional information was provided prior to survey exit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 32 495121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495121 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center 3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0807 Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Level of Harm - Minimal harm or potential for actual harm 20413

Residents Affected - Some Based on observations, interviews, and facility documentation, the facility failed to provide drinks at meals that were consistent with the residents' preferences and meal slips for 12 of 46 residents.

Findings include:

On 04/22/25 at 12:35PM, the lunch meal was observed in the main dining room on Unit 2. It was observed that twelve residents did not receive their milk with their lunch. Review of all 12 residents' meal slips showed that milk should have been included with their meals. A review of the lunch menu noted that milk was to be served for all diets.

Upon interview on 04/22/25 at 12:40PM, Resident (R) 89, Resident R66, and Resident R86, all stated that milk had not been provided or offered to them. Resident R89, Resident R66 and Resident R86 stated that meals had been served in the past that did not include milk. Review of the meal slips for Resident R89, Resident R66 and Resident R86 showed that six ounces of milk should have been provided.

During the lunch observation on Unit 2 on 04/23/25 about 12:30PM, it was again observed that there were 12 residents who were served their lunch meal without milk, which was confirmed by a corporate registered dietician (OS4), who also was present. OS4 directed the Head Cook, who was serving food, to make sure that the 12 residents received their milk, as noted on their meal slips. OS4 also directed that the residents who were eating in their rooms be served milk with their lunch meal.

During an interview on O4/23/2025 at 1:30PM, OS4 stated that she did not realize that 12 residents on Unit 2 were not receiving milk with their meals, along with residents who were served their meals in their rooms. OS4 stated that there was no reason the residents were not served their milk, as it was available, and listed

on both the lunch menu and the residents' meal slips.

No additional information was provided prior to survey exit.

28106

Based on observation, resident interview, and staff interview, the facility staff failed to provide drink preferences for one of 46 residents. Resident # 80 (Resident R80) was not provided milk as indicated on the meal ticket.

The findings include:

According to the clinical record, diagnoses for Resident R80 included difficulty walking, dialysis, diabetes, chronic kidney failure, and peripheral vascular disease. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/29/2025, which assessed Resident R80 with a cognitive score of 15 out of 15, indicating cognitively intact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 32 495121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495121 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center 3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0807 During an interview conducted on 4/21/25 at 3:53 p.m., Resident R80 verbalized concerns regarding food preferences, that what shows on the meal ticket is not always what is on the tray, and some things are missing. Level of Harm - Minimal harm or potential for actual harm On 4/21/25 at 5:45 p.m., Resident R80's meal tray was observed and was compared with the meal ticket. The meal ticket indicated 2% milk to be an item on the meal tray but was missing from the meal. When asked about Residents Affected - Some the milk, Resident R80 verbalized he didn't drink milk all the time, but would like to have the option, as it is listed on

the meal ticket.

The meal serving line was observed at this time and evidenced milk was available for distribution.

On 4/22/25 at 1:16 p.m., the lunch meal for Resident R80 was observed and again did not have 2% milk on the tray, as listed on the meal ticket. At this time, license practical nurse (LPN #4) was asked to verify Resident R80's meal with

the meal ticket. LPN reviewed the ticket and verbalized that Resident R80 should have received milk on the tray. LPN #4 then went to the dining room and retrieved a milk for Resident R80.

On 4/23/25 at 4:47 p.m., the above findings were presented to the administrator and director of nursing.

No other information was presented prior to exit conference on 4/24/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 32 495121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495121 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center 3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20413

Residents Affected - Many Based on observation, interview, and facility policy review, the facility failed to date, label, and/or store food products safely to decrease the risk of food borne illness, potentially affecting 185 of 189 residents who consume food prepared from the facility's kitchen.

Findings include:

Review of the facility's policy titled, Storage Areas dated [DATE REDACTED] indicated, It is the intent of this center to store food in a manner that maintains quality and safety. First in first out should be followed with Refrigerator Food codes and internal tools may be used as a reference for proper dating.

Observation on [DATE REDACTED] from 02:30 PM to 03:15 PM, during the initial kitchen inspection with the Registered Dietitian (RD), from a sister facility, revealed dinner rolls and crescent rolls being stored in the main refrigerator. The kitchen's bread storage racks revealed dinner rolls in an open plastic bag inside a cardboard box, exposed to air, unlabeled, and undated. The crescent rolls were wrapped in plastic wrap but were undated and unlabeled. In the kitchen's dry goods storage room, it was observed that Perfect rice was

in a large open bag with no date; Arborio rice was in a large, open paper bag with no date, and extra-long rice was in a large, open paper bag with no date.

During an interview on [DATE REDACTED] at 4:15 PM, the RD confirmed the concerns and stated that bread products should be in closed packaging and dated by staff when taken out of the main refrigerator. The RD confirmed that the rice products should be stored in closed containers and dated by staff after it was opened. The RD also stated that there was no schedule for food being checked for dates or expired food.

No additional information was provided prior to survey exit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 32 495121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495121 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center 3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25232 jeopardy to resident health or safety Based on observations, interviews, record review and policy review, the facility failed to ensure that staff followed the Infection Control and Prevention Program standards, policies, and procedures affecting five Residents Affected - Few residents (Resident (R) 346, Resident R56, Resident R3, Resident R145, and Resident R178) of 46 sampled residents.

Immediate Jeopardy (IJ) was determined related to the failure to disinfect multi-use glucometers with a manufacturer approved disinfectant when performing fingerstick blood glucose testing between residents, with the IJ start date identified as 4/22/25 at 8:14 AM. Following the facility's provision of an acceptable Immediate Jeopardy Removal Plan, the survey team verified full implementation of the removal plan, and the Immediate Jeopardy was subsequently removed on 04/23/25 at 11:20 AM. After the removal of the Immediate Jeopardy, the remaining noncompliance was determined to be at the scope and severity of Level Two - Pattern, with potential for more than minimal harm.

Findings include:

1. For Resident (R) 346, Resident R56, Resident R3, and Resident R145, the facility failed to ensure that multi-use glucometers were properly disinfected with an approved environmental protection agency (EPA) disinfectant when performing fingerstick blood glucose testing between residents.

During medication administration on 04/22/25 at 8:14 AM, Registered Nurse (RN) 1 obtained Resident R346's blood sugar (BS) and did not disinfect the glucometer prior to placing it back into the caddy. At 8:17 AM, RN1 obtained Resident R56's BS with the same glucometer without it being disinfected prior to use. At 8:28 AM, RN1 finished and cleaned the glucometer with a germicidal wipe; however, RN1 did not allow it to dry before placing it back into the caddy.

Review of Resident R346's Admission Record under the tab Profile located in the Electronic Medical Record (EMR) indicated Resident R346 was admitted to the facility on [DATE REDACTED] with a diagnosis of type two diabetes mellitus.

Review of Resident R346's Order Summary under the tab Orders located in the EMR, dated 04/12/25 indicated, Fingerstick BS every six hours.

Review of Resident R56's Admission Record under the tab Profile located in the EMR indicated Resident R56 was readmitted to

the facility on [DATE REDACTED] with a diagnosis of type two diabetes mellitus.

Review of Resident R56's Order Summary under the tab Orders located in the EMR dated 09/15/24 indicated, AccuCheck's before meals and at bedtime.

Interview on 04/22/25 at 1:00 PM, RN1 confirmed that she did not disinfect the glucometer between residents and indicated that she should have. RN1 verbalized that the glucometer can be disinfected with either the germicidal wipes or with alcohol wipes if the germicidal wipes are not available.

During another medication observation on 04/22/25 at 11:00 AM, LPN2 wiped the glucometer with alcohol wipes before and after use to obtain the BS results for Resident R3. LPN2 verbalized that this was the process that the facility uses to clean the glucometer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 32 495121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495121 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center 3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a third medication observation on 04/22/25 at 12:15 PM, Licensed Practical Nurse (LPN) 1 verbalized that the glucometers are cleaned with alcohol pads. LPN1 was observed completing Resident R145's BS check and Level of Harm - Immediate then afterwards, LPN1 cleaned the glucometer with alcohol pads and allowed the glucometer to dry. jeopardy to resident health or safety Review of Resident R145's Admission Record under the tab Profile located in the EMR indicated, Resident R145 was readmitted to the facility on [DATE REDACTED] with a diagnosis of type two diabetes mellitus. Residents Affected - Few

During an interview on 04/22/25 at 2:20 PM, the DON stated that the glucometers should be sanitized with a germicidal wipe, left wet to dry one to five minutes, then put up, and this was to be done between residents.

He stated that it depended on the type of wipes they get from the manufacturer. The DON explained that white bottom container of wipes with red top are five minutes and the white bottom container of wipes with purple top is one minute. The DON confirmed that alcohol wipes should not be used.

Review of facility's policy titled, Patient Care Equipment dated 04/06/23 indicated, It is the center's policy to maintain an environment that reduces the risk of transmitting and acquiring infections, therefore all clinical equipment shall be handled in such a manner as to eliminate, reduce or minimize the spread of disease. Procedure .13. Glucometers: a. Clean the outside of the meter using a lint-free cloth. Clean in accordance with the manufacturer's recommendation.

Review of the facility provided User's Guide for the Meter Memory glucometers, which were used to obtain

the blood sugars, revealed that the glucometers should be cleaned and disinfected between each patient and requires a germicidal wipe disinfectant, which alcohol is not.

The survey team discussed the potential for this facility's failure to disinfect multi-glucometers with an appropriate disinfectant increases the likelihood of transmission of bloodborne pathogens among all residents requiring this point-of-care testing. It was determined that immediate action was needed to prevent

the likelihood of transmission of bloodborne pathogens between residents. Following consultation with the SA to confirm that immediate Jeopardy (IJ) exists, the facility's Administrator, Administrator in Training (AIT), Director of Nursing (DON), Regional Director of Clinical Services, and [NAME] President of Operations were informed on 04/22/25 at 3:44 PM that the facility was in IJ.

The facility provided the following Immediate Jeopardy Removal Plan, that was accepted on 04/22/25 at 5:22 PM.

Plan Corrective Action for those residents found to be affected by the deficient practice:

A. Resident R346, Resident R56, and Resident R145 had no negative outcomes related to the deficient practice.

Corrective Actions taken for residents with potential to be affected by deficient practice:

A. Residents who require blood sugar monitoring will have their glucometers cleaned after each use with the appropriate disinfectant that will kill bloodborne pathogens and kept out until the dry time has completed. Two glucometers will be placed in each nurses cart to allow for time in-between use to allow for proper disinfection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 32 495121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495121 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center 3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Systemic Changes put into place to ensure the deficient practice does not recur:

Level of Harm - Immediate A. The Interdisciplinary Team (Administrator, Director of Nursing, Assistant Director of Nursing, Director of jeopardy to resident health or Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Maintenance, safety Director of Housekeeping and Laundry, Human Resources, and Unit Managers) will be educated by the Regional Director of Clinical Services on the facility policy for using glucometers to maintain infection control Residents Affected - Few standards. This education will cover how to disinfect the glucometer after use on each patient and the required dry time to prevent the spread of bloodborne infections. All licensed nursing staff will be educated by the DON or designee on the glucometer cleaning policy per manufacturer guidelines to include the steps to take to use and disinfect after each patient. This education will be provided to agency nurses prior to starting with the facility. Any nurse who hasn't completed will be educated before the start of their next shift.

The Administrator to conduct an ADHOC Quality Assurance Performance Improvement Meeting on 4/22/25 including the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Housekeeping and Laundry, and Unit Managers to review the policy for the use of glucometers.

Monitoring of corrective action to ensure the deficient practice does not recur.

A. DON or designee will monitor the procedure for disinfecting the glucometer between residents by random

observations of glucometer usage/use five times per week for four weeks and weekly for four weeks.

Completion of removal plan 4/22/25 at 9:00pm.

The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone on 4/22/25 at 4:14pm

The survey team reviewed the in-service training documentation/signature sheets for nursing staff and verified procedures were in place to educate the remaining staff prior to the start of their next shift. All staff educated had a competency checklist completed, that included indications of return demonstration of proper disinfecting procedure. No concerns were noted.

The survey team reviewed education of interdisciplinary team regarding disinfection procedure of glucometers, reviewed documentation of ad hoc QAPI meeting held by administrator on 4/22/25 regarding

F-F880 IJ, interviewed all nurses providing direct care and medication administration on units 2, 3, 4, and 5, with all able to describe/verbalize steps for proper disinfection of glucometers using germicidal wipes. The survey team also verified that two glucometers and supply of germicidal wipes were available on all medication carts in use in the facility. No concerns were noted.

The survey team reviewed the form that had been developed for monitoring the disinfecting procedure for glucometers in coming weeks, as listed in removal plan. No concerns were noted.

After consulting with the SA, the survey team determined that the removal plan was fully implemented and that the likelihood of serious injury, serious harm, serious impairment, or death no longer existed, the facility was notified that the Immediate Jeopardy had been removed on 04/23/25 at 11:20 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 32 495121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495121 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center 3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2. For Resident R178, who was on Enhanced Barrier Precautions (EBP), facility staff failed to wear personal protective equipment (PPE) during catheter care. Level of Harm - Immediate jeopardy to resident health or Review of facility policy titled, EBP dated 03/26/24 indicated, Employees providing high-contact patient care safety activities will follow EBP for patients who meet the criteria. Procedure: 1. May be indicated for patients .with indwelling medical devices ( .urinary catheter) .3. EBP require the use of gown and gloves by staff during Residents Affected - Few high contact patient care activities as defined below .g. device care or use ( .urinary catheter)

Review of facility policy titled, Personal Protective Equipment, dated 05/27/21, indicated, PPE is provided to employees at no cost to them. Procedure .2. Gloves .Disposable gloves are to be replaced if contaminated, if torn or punctured, or if the gloves' ability to function as a barrier is compromised.

Review of Resident R178's Admission Record under the tab Profile located in the EMR indicated Resident R178 was admitted to the facility on [DATE REDACTED] with a diagnosis of obstructive and reflux uropathy.

Review of Resident R178's Order Summary under the tab Orders located in the EMR dated 03/27/25 indicated, EBP related to Foley and trach, every shift for precaution.

3. For Resident R178, facility staff failed to ensure that soap was used during catheter care, and failed to ensure that gloves were changed before going from a dirty area to a clean area, along with appropriate hand hygiene.

During catheter care observation on 04/23/25 at 11:07 AM, Certified Nursing Assistant (CNA) 2 was observed gathering two washcloths, and one towel which he brought into Resident R178's room without putting on any PPE prior to entering room. After putting on gloves, one washcloth dropped on the floor. CNA2 picked the washcloth up off the floor with a gloved hand and placed it on the overbed table. With the same gloves, CNA2 went through Resident R178's dresser drawers and found a gray wash basin. CNA2 added a small amount of water in the basin without soap and placed the basin on the overbed table. At this time, CNA2 removed his gloves and emptied Resident R178's Foley catheter. CNA2 applied gloves again, wiped the catheter tubing with the wet washcloth, in a downward motion, changed the direction of the washcloth, and dried the tubing while wearing the same gloves. CNA2 refastened the incontinent brief on Resident R178.

During an interview on 04/23/25 at 11:15 AM, CNA2 stated that PPE (gown, gloves, and mask) should have been worn because he is on EBP related to catheter care. He confirmed that he did not wear the appropriate PPE. CNA2 stated that gloves should be changed when going from a dirty area to a clean area. CNA2 said that he did not change his gloves when going from a dirty area to a clean area. CNA2 explained that he did not put soap into the water because he thought it was just a demonstration, so he .just left it out.

During an interview on 04/23/25 at 2:00 PM, RN3 indicated that PPE (gown, gloves, mask) should have been worn due to Resident R178 being on EBP. RN3 indicated that CNA2 should have used soap in the water and should have changed gloves when going from dirty area to clean area.

During an interview on 04/23/25 at 3:00 PM, the DON stated that he expected that CNA2 to wear appropriate PPE (gown, gloves, mask) due to Resident R178 being on EBP. The DON stated that he expected CNA2 to add soap to the water and change his gloves when going from a dirty area to a clean area.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 32 495121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495121 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center 3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 No additional information was provided prior to survey exit.

Level of Harm - Immediate 21875 jeopardy to resident health or safety 4. For Resident #56, staff failed to follow infection control practices for proper positioning of a urinary catheter bag. Residents Affected - Few Resident R56's clinical record documented that Resident #56 (Resident R56) was admitted to the facility with diagnoses that included cerebral infarction with hemiplegia, diabetes, hypertension, anemia, obstructive uropathy, and cognitive communication deficit. The minimum data set (MDS) dated [DATE REDACTED] assessed Resident R56 with moderately impaired cognitive skills. The record also included a physician's order dated 9/17/24 for a Foley urinary catheter for management of urinary retention due to obstructive uropathy.

On 4/21/25 at 2:53 p.m., Resident R56 was observed in bed. The urine collection bag for Resident R56's catheter was positioned with the bottom part of the bag resting on the floor. The bag was strapped to the bed frame but was not positioned or strapped to ensure the bag was off the floor.

On 4/22/25 at 7:51 a.m., Resident R56 was observed in bed. The urinary catheter bag was observed positioned with

the bottom part of the bag resting on the floor.

On 4/23/25 at 8:52 a.m., the registered nurse (RN #1) caring for Resident R56 was interviewed about the catheter bag seen resting on the floor. RN #1 stated the catheter bag was not supposed to be on the floor but was supposed to be attached to the bed frame so that the bag remained off the floor.

On 4/23/25 at 9:02 a.m., the unit manager (RN #3) was interviewed about Resident R56's catheter bag observed on

the floor. RN #3 stated catheter bags should be positioned below the bladder and without contact with the floor for infection prevention.

The facility's policy titled Urinary Catheterizations (effective 1/29/24) documented under procedures for management of urinary catheters, .Maintain drainage bags below the level of the bladder .Ensure drainage bags are not touching the floor .

This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 4/23/25 at 4:45 p.m., with no further information provided prior to the end of the survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 32 495121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495121 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center 3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 52322 potential for actual harm Based on facility policy review, record review, and interviews, the facility failed to provide the required Residents Affected - Some documentation and/or refusals related to administration of vaccinations for influenza, pneumococcal, and COVID-19 for four of five Residents (R)(13, 57, 56, 157) which increased the risk of acquiring, transmitting, and/or experiencing complications of respiratory infections.

Findings include:

Review of the facility's policy titled, COVID-19 Vaccinations dated 03/11/24 revealed .Prior to administering any COVID-19 Vaccine (and for each dose) complete the following for patients: Screen for eligibility (contradictions, precautions, previous doses, etc.) If contraindicated or refused, document in patient's medical record .

Review of the facility's policy titled, Influenza Vaccination dated 05/01/23 revealed .Influenza vaccine should be offered annually. During flu season refer to the CDC influenza website for additional information. The optimal time to administer influenza vaccine is in late September or early October of each year. The flu shot can be given after the flu season ends .

Review of the facility's policy titled, Pneumococcal Vaccinations dated 08/04/2023 revealed .Prior to administering a pneumococcal vaccination to patients, complete the following: 1. Screen for eligibility (contradictions, previous doses, etc.) 2. Allow the resident and/or RP (responsible party) to accept or refuse vaccine .

1. Review of the Face Sheet found under the profile tab in the electronic medical record (EMR) revealed Resident R13 was admitted to the facility on [DATE REDACTED] with a diagnosis of type two diabetes.

Review of Resident R13'sImmunization record revealed no documentation of administration of influenza and pneumococcal vaccines or refusals from the resident or responsible party.

2. Review of the Face Sheet found under the profile tab in the EMR revealed Resident R57 was admitted to the facility

on [DATE REDACTED] with a diagnosis of type two diabetes.

Review of Resident R57's Immunization record revealed no documentation of administration of influenza and pneumococcal vaccines or refusals from the resident or responsible party.

3. Review of the Face Sheet found under the profile tab in the EMR revealed Resident R56 was admitted to the facility

on [DATE REDACTED] with a diagnosis of type two diabetes.

Review of Resident R56's Immunization record revealed no documentation of administration of influenza, COVID-19, and pneumococcal vaccines or refusals from the resident or responsible party.

4. Review of the Face Sheet found under the profile tab in the EMR revealed Resident R157 was admitted to the facility on [DATE REDACTED] with a diagnosis of type two diabetes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 32 495121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495121 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center 3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Review of Resident R157's Immunization record revealed no documentation of administration of COVID-19 and pneumococcal vaccines or refusals from the resident or responsible party. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/23/25 at 5:27 PM, the Infection Preventionist (IP) stated, We do not have any documented refusals or administrations for these resident. The IP stated that it was her process to look up Residents Affected - Some the Virginia Data for vaccination history.

No other information was provided prior to survey exit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 32 495121 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495121 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center 3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28106

Residents Affected - Few Based on observation, resident interview, and staff interview, the facility staff failed to maintain safe and functioning equipment. Resident #80's (Resident R80) hand assist bar in the bathroom was not securely anchored to

the wall.

The findings include:

Clinical record documented that diagnoses for Resident R80 included difficulty walking, dialysis, diabetes, chronic kidney failure, and peripheral vascular disease. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/29/2025, which assessed Resident R80 with a cognitive score of 15 out of 15, indicating cognitively intact.

During an interview conducted on 4/21/25 at 3:53 p.m., Resident R80 verbalized concerns regarding the hand assist bar in the bathroom. Resident R80 reported that it is not secured to the wall and is worried about it being pulled off the wall when trying to get off the toilet. Resident R80 said the concern has been reported but no one has repaired it. At

this time, the hand rail was observed loosely anchored to the wall and when pulled on, the bar would move approximately 2 inches, scraping the wall.

04/23/25 at 11:59 AM, the maintenance director (other staff, OS #9) was interviewed. OS #9 said that the facility has a leadership team that are assigned to rooms, who are supposed to look at rooms each day, Monday through Friday, and report or log a work order if there is a repair is needed. OS #9 then reviewed the work orders for Resident R80's room (room [ROOM NUMBER]), verbalized that there were no work orders pending, and indicated the last repair in the room was to change out a light.

At this time, the OS #9 and the administrator (along with the surveyor) observed Resident R80's bathroom. After observing the poorly secured grab bar, OS #9 verbalized that there should have been a work order placed and indicated that the bar was not safe to be used.

On 4/23/25 at 4:47 p.m., the above findings were presented to the administrator and director of nursing.

No other information was presented prior to exit conference on 4/24/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 32 495121