Pulaski Hlth & Rehab Cntr

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 REDACTED] was reviewed. The only devices listed as currently in use were side rails. The Device assessment dated [DATE REDACTED] 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.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pulaski Hlth & Rehab Cntr

2401 Lee Highway Pulaski, VA 24301

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 REDACTED] 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 REDACTED] 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.

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