Lake Taylor Hosp

Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 09/17/25 and located in the MDS tab of the electronic medication record (EMR) revealed an admission date 07/09/18 and a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R9 was cognitively intact.

The MDS indicated that R9 required supervision or touching assistance with eating, had two unstageable pressure ulcers and diagnoses of quadriplegia, multiple sclerosis, and dysphagia.Review of R9's diet order dated 10/17/24, provided by the facility revealed a Thin Liquids, consistency: Regular, Comments: Ensure daily with meal-staff to assist with set-up PRN [as needed] indications: dysphagia resolved.Review of R9's care plan provided by the facility did not include a care plan for activities of daily living and eating ability.On 09/23/25 at 12:02 PM, R9 was served her lunch in bed on an overbed table, and her room door closed. R9's lunch includes beef/macaroni casserole, green beans, gelatin, a side of macaroni, coffee, a supplement, and ice cream.On 09/23/25 at 12:19 PM and 12:36 PM, R9 was in bed with her meal and her door closed. No assistance was observed with her meal.On 09/23/25 at 1:16 PM, R9 was in bed with her lunch tray, and her consumption was poor.

R9's door remained closed, and no assistance was provided. R9 was asked if she received assistance with her meal and R9 stated, No.Review of R9's Meal Acceptance History provided by the facility revealed 09/23/25 for lunch was documented as 25%.On 09/23/25 at 4:51 PM and 5:00 PM, R9 was served her dinner in bed, and her tray was covered. R9's door remained closed, and no assistance was provided.On 09/23/25 at 5:21 PM, R9 was asleep in bed with her dinner tray unconsumed and sitting at her bedside.Review of R9's Meal Acceptance History provided by the facility revealed 09/23/25 for dinner was documented as refused.

During an interview on 09/25/25 at 12:33 PM, LPN5 was asked why R9 hadn't received feeding assistance for two meals on 09/23/25. LPN5 stated R9 could feed herself.During an interview on 09/25/25 at 2:01 PM, CNA3 confirmed that she was assigned to R9.CNA3 was asked how she would know who needed assistance with eating. CNA3 stated they get information from the family or the previous nursing home on meal intake, and they also follow a feeding list at the nurse's station. CNA3 provided the list which indicated that R9 was to receive queueing/supervision. CNA3 confirmed R9 was to receive queueing/supervision.

During an interview on 09/25/25 at 2:08 PM, the Nurse Manager (NM)3 was asked about the feeding list and R9 listed as queueing/supervision which was different from her diet order instructions. UM3 stated it was the same as queuing/supervision.

During an interview on 09/25/25 at 2:14 PM, the Speech Therapist (ST) was asked about R9's diet order.

The ST stated, Someone should be with R9 to cue/supervise. ST stated R9 would accept someone feeding her. ST confirmed R9 had poor meal consumption and had a pressure sore.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Lake Taylor Hosp

1309 Kempsville Rd Norfolk, VA 23502

SUMMARY STATEMENT OF DEFICIENCIES