Pulaski Hlth & Rehab Cntr
PULASKI HLTH & REHAB CNTR in PULASKI, VA — inspection on November 6, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
as applicable.
Under the heading, Fall Occurrence item #3 read, A licensed nurse will review, revise, and implement interventions to the care plan based on: Post Fall Investigation findings, Review of Device Assessment, Review of Fall Risk Scoring Tool.The most recent Device assessment dated [DATE] was reviewed.
The only devices listed as currently in use were side rails.
The Device assessment dated [DATE] was reviewed.
Devices listed as current included bilateral fall mats, chair/bed alarm, side rails, and a specialty bed/mattress. On 11/6/25 at 10:30 AM this surveyor met with the Director of Nursing, (DON) and Regional Director of Clinical Services (RDCS) to discuss this concern.
The DON reported that the certified nursing assistant assigned to resident #4 had gotten the resident up to the toilet after breakfast and forgot to put the mat back in place.
The survey team met with the Administrator, the DON and the RDCS at 12:22 PM and this concern was reviewed with them at that time. No further information was provided to the survey team prior to the exit conference.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Pulaski Hlth & Rehab Cntr
2401 Lee Highway Pulaski, VA 24301
SUMMARY STATEMENT OF DEFICIENCIES
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review, and facility document review, the facility staff failed to maintain a complete and/or accurate clinical record for (1) one of (2) two closed record reviews, Resident #1.
The findings included:For Resident #1 the facility staff failed to accurately document a skin assessment and/or nursing progress note on 6/20/25 after an allegation of staff to resident abuse was reported and a nurse performed a skin assessment of the resident. Resident #1's diagnosis list indicated diagnoses that included, but were not limited to, Congestive Heart Failure, Altered Mental Status, Aphasia, Cerebral Infarction, and Cognitive Communication Deficit.
The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/30/25, assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A Skin assessment dated [DATE] read in part, .Large areas of bruising noted to bilateral buttocks/hip areas d/t (due to) medication injections.
Generalized bruising noted to bilateral upper extremities from blood draws .No other skin impairments noted at this time. An Encounter Note dated 6/20/25, read in part, .Periods of agitation reported.has had increase in behaviors, has accused the staff of dragging her across floor to cause bruising, bruising is actually from IM (intramuscular) injections. A review of a facility synopsis of events included an investigative reporting statement from registered nurse #2 (RN#2) dated 6/20/25 which read in part, .Skin assessment completed, no new areas were observed. A Skin assessment dated [DATE] read in part, .Bruising noted to bilateral buttocks. no change from previous assessment completed on 6/17/2025. On 11/6/25 at 9:13 AM, surveyor interviewed RN#2 and she informed this surveyor she did a skin assessment on Resident #1 after learning of an abuse allegation.
This surveyor inquired about the protocol when conducting a skin assessment after an allegation of abuse and RN#2 stated she did not document it because she did not find anything new, if she had found something new, she would have documented a skin assessment. On 11/6/25 at 9:44 AM, this surveyor interviewed the director of nursing (DON) and she informed this surveyor her expectation when there is an allegation of abuse is a head-to-toe skin assessment to be documented in the clinical record under the assessments tab or in a nursing progress note.
This concern was discussed at the pre-exit meeting on 11/6/25 at 12:25 PM with the administrator, director of nursing, and regional director of clinical services.
This surveyor requested but did not receive a facility policy regarding accuracy of documentation in the clinical record.
This surveyor did receive a facility policy titled Nursing Care & Services which read in part, .Nursing staff will provide nursing care and services following current standards of practice. No further information was provided to the survey team prior to exit on 11/6/25.
Facility ID: