Deep Creek Health & Rehabilitation

During an interview on 09/17/2025 at 9:55 AM, CNA #3 said she answered the call light for Resident #12 that morning (09/17/2025) about 7:15 AM. CNA #3 said the resident said they needed incontinence care. CNA #3 said she told the resident that breakfast trays were about to come out, and she would tell CNA #6, the assigned CNA, that the resident needed incontinence care. CNA #3 further stated that there was a lot going on that morning (09/17/2025), and she forgot to tell CNA #6 that Resident #12 needed incontinence care.

During a follow-up interview on 09/17/2025 at 10:30 AM, CNA #6 revealed she provided incontinence care to Resident #12 about 15 minutes prior at approximately 10:15 AM. CNA #6 clarified that she did not tell LPN #5 that she would be right there, but that she told the nurse to notify therapy staff that another resident was ready for therapy. CNA #6 said she was talking about a different resident who was waiting for her to complete morning care to attend therapy and CNA #6 stated she was not aware that Resident #12 was waiting for incontinence care.

During an interview on 09/17/2025 at 10:26 AM, the Director of Nursing (DON) revealed she expected CNA #3 or LPN #5 to provide incontinence care when they answered the call light or to notify CNA #6, the assigned CNA, so that the care could be provided promptly.

The DON stated residents should not be left in soiled briefs, and passing meal trays was not a reason to delay care.

The DON further stated that she expected incontinence care to be provided while other staff assisted with meals.

During an interview on 09/17/2025 at 4:05 PM, the Administrator (ADM) revealed he expected staff to provide the necessary care immediately. He further stated that if the assigned CNA was providing care to another resident, the staff member who answered the call light should get another CNA, or the nurse to provide incontinence care, if a CNA was unavailable.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Deep Creek Health & Rehabilitation

1017 George Washington Highway North Chesapeake, VA 23323

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 09/19/2025 at 4:44 PM, Administrator (ADM) #2 stated that the previous administration eliminated or loosened some of the restrictions and monitoring of individuals who smoked to honor the rights for those residents who were more independent with smoking. He stated the reason smoking assessments were overlooked was because of repeated changes in administration, and the current administration being unaware they were not completed. He stated he expected smoking assessments to be completed on admission, quarterly, and with all changes in the residents' condition.

During an interview on 09/19/2025 at 5:01 PM, the Director of Nursing (DON) stated she was unaware of concerns that the facility was not completing required smoking assessments.

The DON stated she expected smoking assessments to be completed on admission, quarterly, and as needed.

During the survey, no concerns were identified with unsafe handling of lit cigarettes/lighters or residents smoking outside the designated smoking area.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Deep Creek Health & Rehabilitation

1017 George Washington Highway North Chesapeake, VA 23323

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 09/19/2025 at 5:01 PM, the Director of Nursing (DON) stated she was unaware of concerns that the facility was not completing required smoking assessments.

The DON stated she expected smoking assessments to be completed on admission, quarterly, and as needed. 3. An admission Record revealed the facility admitted Resident #72 on 03/05/2024. Resident #72's medical record contained no evidence that a smoking safety assessment had been conducted.

During an interview on 09/19/2025 at 10:14 AM, Licensed Practical Nurse (LPN) #8 stated Resident #72 was an independent smoker and kept their smoking supplies with them.

During an interview on 09/19/2025 at 4:44 PM, the former Administrator (ADM) #2 stated with the repeated changes in administration, smoking assessments were overlooked, and the facility's current administration was unaware they were not completed. He stated he expected smoking assessments to be completed on admission, quarterly, and with all changes in the residents' condition.

During an interview on 09/19/2025 at 5:01 PM, Director of Nursing (DON) stated she was unaware of concerns that the facility was not completing required smoking assessments.

The DON stated she expected smoking assessments to be completed on admission, quarterly, and as needed.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Deep Creek Health & Rehabilitation

1017 George Washington Highway North Chesapeake, VA 23323

SUMMARY STATEMENT OF DEFICIENCIES

Based on interview and facility policy review, the facility failed to ensure an effective water management program was developed and implemented to prevent the growth of opportunistic waterborne pathogens, including Legionella, which had the potential to affect all residents residing in the facility.

According to the Midnight Census report, dated 09/15/2025, the facility census was 89.

Findings included:A facility policy titled, Legionella Water Management Program, revised 07/2017, revealed Our facility is committed to the prevention, detection, and control of water-borne contaminates, including Legionella.

The policy also revealed a section titled, Policy Interpretation and Implementation that specified, 1. As part of the infection prevention and control program, our facility has a water management program which is overseen by the water management team. 3.

The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 5.

The water management program includes the following elements: a. An interdisciplinary water management team; b. A detailed description and diagram of the water system in the facility, including the following: 1) receiving; 2) cold water distribution; 3) heating; 4) hot water distribution; and 5) waste; c.

The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: 1) Storage tanks; 2) Water heaters; 3) Filters; 4) Aerators; 5) Showerheads and hoses; 6) Misters, atomizers, air washers, and humidifiers; 7) Hot tubs; 8) Fountains; and 9) Medical devices such as CPAP machines, hydrotherapy equipment, etc. d.

The identification of situations that can lead to Legionella growth, such as 1) Construction; 2) Water main breaks; 3) Changes in municipal water quality; 4) The presence of biofilm scale or sediment; 5) Water temperature fluctuations; 6) Water pressure changes; 7) Water stagnation and 8) Inadequate disinfection. G. A diagram of where control measures are applied, and j.

Documentation of the program.

During an interview on 09/19/2025 at 2:52 PM, the Maintenance Director stated the facility had a water management plan prior to his employment as the Maintenance Director approximately two years prior and no current testing was being performed to monitor areas for potential sources of Legionella.

The Maintenance Director stated he performed checks of the water temperatures and monitored the ice machine, but he did not document that.

The Maintenance Director also acknowledged he did not have a diagram or list of any areas that could be potentially at risk of being a source of waterborne bacteria and stated, This is an old building, and I don't have a clue about the plumbing.

During an interview on 09/19/2025 at 4:53 PM, the Director of Nursing (DON) stated she felt that the water management plan was overseen by administration.

She stated she expected the facility to develop and implement a water management plan as part of the infection control program.

During an interview on 09/19/2025 at 1:57 PM, Administrator (ADM) #1 stated they no longer had a water management program after the previous administrator shut that down when the facility turned off the water fountain in the front of the building.

During an interview on 09/19/2025 at 4:36 PM, the previous interim Administrator (ADM) #2 stated the facility should have an implemented water management program. He stated the facility previously had one in place until they removed all the fountains that should have extended through the entire inside and outside of the facility and included anywhere water could become stagnant in order to prevent the spread of waterborne bacteria.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Deep Creek Health & Rehabilitation

1017 George Washington Highway North Chesapeake, VA 23323

SUMMARY STATEMENT OF DEFICIENCIES

During a follow-up interview on 09/17/2025 at 3:56 PM, ADM #1 stated that if residents observed pest activity in the facility, he expected them to notify staff, so the pest activity was addressed by the Maintenance Director with appropriate pest control products. He stated that if that did not resolve the pest problem, then a pest service provider would be contacted.

The ADM stated if staff witnessed pest activity, he expected staff to report to their supervisor and have it discussed in morning meeting and resolved that day by the Maintenance Director. ADM #1 stated that he expected the Maintenance Director to resolve the pest issue and to contact the pest control vendor if he could not resolve the pest issue.

The Administrator said he expected pest control services to be provided to maintain an effective pest control program.

During an interview on 09/17/202 at 2:53 PM, the Director of Nursing (DON) stated she expected staff to record in the maintenance logbooks at each nursing station any pest activity observed or to report pest activity directly to the Maintenance Director.

The DON stated that she expected the Maintenance Director to review the maintenance logbooks daily, address any concerns, and report on the follow-up during the morning meetings.

The DON stated that if the Maintenance Director could not resolve the pest activity, then he should coordinate with management and contact the pest control vendor for the pest activity to be addressed.

The DON stated that she was aware of the facility's current pest activity, described as “gnats,” from discussions during the facility's morning meetings.

The DON said she expected the facility to provide and maintain a pest control program that minimized pest activity.

During an interview on 09/17/2025 at 3:16 PM, the former Interim Administrator (ADM #2) stated that he was the Administrator for the facility from July 2025 until Friday, 09/12/2025, and that he was aware of residents who had voiced concerns in August 2025 regarding flies in the facility. He stated the flies were coming from the door to the smoking patio. He stated that residents propped the smoking patio door open, which allowed pests to enter the facility. He stated staff were educated to monitor the door to the smoking patio to ensure the doors were closed and not held open for extended periods of time. He stated he was not aware that the pest control contract was terminated. He stated the facility received an email from the pest control provider for the account to be paid in full, and payment was made. He said after he observed pest activity in the facility in the last month, he spoke to the Maintenance Director about pest services and was told that pest services from the vendor were on hold due to lack of payment. ADM #2 stated he contacted the corporate payable clerk and verified that the facility's bill was paid, so he expected the pest control vendor to resume services, but he did not contact the pest control vendor to verify the status of current services for the facility.

• During a tour of the kitchen on 09/17/2025 at 11:15 AM, a fly was observed flying around in the kitchen.

During an interview on 09/17/2025 at 11:15 AM, the Certified Dietary Manager (CDM) stated that there were flies in the kitchen periodically.

The CDM stated the occasional observations of pests in the kitchen were no comparison to the seriousness of pests observed in the rest of the building. He stated that to minimize the flies in the kitchen, staff were to ensure the double entry doors that led to the exterior of the building near the back parking area were kept closed and staff used rolled up parchment paper to swat the flies.

Facility ID: