Glenburnie Rehab & Nursing Center

determined the facility staff failed to ensure resident rights by accommodating the needs of one of

failed to ensure accommodation of needs for R104's call bell was implemented. R104 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: diabetes mellitus, pressure injury and embolism.R104's most recent MDS (minimum data set) assessment, a five-day Medicare assessment, with an assessment reference date of 10/31/25, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. MDS Section G- Functional Status: coded the resident as moderate assistance with bed mobility; total dependence for transfers, dressing, hygiene and bathing. A review of MDS Section M-Skin Conditions: coded the resident as two unstageable pressure injury (PI), POA (present on admission).A review of the comprehensive care plan dated 10/29/25 revealed, FOCUS: Resident is at risk for falls related to weakness. INTERVENTIONS: place common items within reach of the resident, remind the resident to use their call light to ask for assistance with ADLS (activities of daily living).On 12/10/25 at 10:20 AM, observed the call bell in Resident 104 (R104)'s room dangling from side rail to the floor.

Resident did not know where the call bell was and could not reach it. An interview was conducted on 12/10/25 at 10:25 AM with LPN (licensed practical nurse) #2, when asked where the call bell was located for R104, LPN #2 stated, it must have fallen off the bed when I was in here earlier. It was on the bed before then.

The ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, and ASM #3, the vice president of operations was made aware of the finding on 12/10/25 at 4:00 PM.A review of the facility's Nurse Call System policy revealed, Inspect push button cords in all patient/public restrooms/shower rooms and verify each cord has a clip and that cord is not in contact with the floor.No further information was provided prior to exit.

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Glenburnie Rehab & Nursing Center 1901 Libbie Ave Richmond, VA 23226

limited to receiving treatment and supports for daily living safely.

observations and staff interview, facility staff failed to maintain a homelike environment for one of 11

[ROOM NUMBER]-B, facility staff failed to maintain a section of wall in good repair. On 12/09/2025 at approximately 1:50 p.m., an observation of resident room [ROOM NUMBER]-A revealed a section of wall behind the head-of-the-bed roughly plastered, measuring approximately 15 inches wide and 36 long.

Further observation revealed white plaster dust coating the top of the headboard of the bed and coating the floor under the head of the bed.

Call bell within reach. On 12/10/2025 at approximately 8:05 a.m., an observation of resident room [ROOM NUMBER]-A revealed a section of wall behind the head-of-the-bed roughly plastered, measuring approximately 15 inches wide and 36 long.

Further observation revealed white plaster dust coating the top of the headboard of the bed and coating the floor under the head of the bed. On 12/10/2025 at approximately 10:20 a.m., an observation of resident room [ROOM NUMBER]-A revealed a section of wall behind the head-of-the-bed roughly plastered, measuring approximately 15 inches wide and 36 long.

Further observation revealed white plaster dust coating the top of the headboard of the bed and coating the floor under the head of the bed. On 12/11/2025 at approximately 1:10 p.m. an observation of R101's room and interview was conducted with OSM (other staff member) #3, maintenance director and OSM # 4, housekeeping director.

When asked about the section of wall behind the head-of-the-bed roughly plastered, measuring approximately 15 inches wide and 36 long OSM #3 stated it needed to be sanded, re-mudded, sanded again and painted.

When asked if it presented a homelike appearance and if the room was in good repair, he stated no.

Regarding the white plaster dust observed coating the top of the headboard of the bed and coating the floor under the head of the bed, OSM #4 stated the room should not be in the condition observed.

She further stated it was not clean or homelike.

The facility's policy Patient Rooms Inspection documented in part, All patient rooms, beds, and bathrooms will be inspected regularly to verify operational safety and environmental safety for patients. PROCEDURE.

Monthly: 2.

Inspect room environment including but not limited to sprinkler heads, lights, globes, privacy curtains and tracks, wallpaper, walls, floor tile, carpet, baseboards, door, door hardware, bumper stops, and frames, ceiling tiles, toilet seats, towel bars, grab bars, furniture, windows, blinds, and all electrical appliances and/or equipment including medical devices to verify items are safe and properly maintained. 11.

Replace cracked or broken wall/floor tile. On 12/10/2025 at approximately 3:55 p.m. ASM (administrative staff member) #1, interim administrator, ASM #2, director of nursing and ASM #4, vice president of operations, were made aware of the above findings. No further information was provided prior to exit.

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Glenburnie Rehab & Nursing Center 1901 Libbie Ave Richmond, VA 23226

being admitted

plan for one of 11 residents in the survey sample, Resident #103.

The finding include:For R103, facility

pressure) machine (1). R103 was admitted to the facility with diagnosis that included but not limited to sleep apnea (2).

The MDS (minimum data set) assessment was not due at the time of the survey.

The facility's admission assessment for R103 dated 12/08/2025 documented in part, Cognitively intact.

Oriented to person.

Oriented to place.

Oriented to situation.On 12/09/2025 at approximately 2:11 p.m. an observation of R103's room revealed a C-PAP machine and mask on R103's over-the-bed table.The facility's nurse's note for R103 dated 12/08/2025 at 8:50 p.m. documented in part, Use of CPAP/BiPAP (bilevel continuous positive airway pressure): Yes.The discharge summary from (Name of Hospital) documented in part, Details of Hospital Stay.

Sleep - CPAP.

Review of the baseline care plan for R103 dated 12/08/2025 failed to evidence documentation for the use of a C-PAP.On 12/10/25 at 1:20 PM, an interview was conducted with LPN (licensed practical nurse) #1.

Asked the purpose of the care plan, LPN #1 stated, the purpose is to make sure everyone is on the same page for the care for that resident.

When asked if C-PAP should be on the care plan, LPN #1 stated, yes, it should. On 12/10/2025 at approximately 3:55 p.m. ASM (administrative staff member) #1, interim administrator, ASM #2, director of nursing and ASM #4, vice president of operations, were made aware of the above findings.No further information was provided prior to exit.References:(1) The forced air delivered by CPAP (continuous positive airway pressure) prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems.

This information was obtained from the website: https://medlineplus.gov/ency/article/001916.htm. (2) Sleep apnea is a common disorder that causes your breathing to stop or get very shallow.

Breathing pauses can last from a few seconds to minutes.

They may occur 30 times or more an hour.

This information was obtained from the website: https://medlineplus.gov/sleepapnea.html.

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Glenburnie Rehab & Nursing Center 1901 Libbie Ave Richmond, VA 23226

necrotic tissue is absorbed into the dressing.

Eschar and debris tissue are taken up by the mesh fiber

website

(4) Deep tissue pressure injury remains one of the most serious forms of pressure injury.

The pressure is exerted at the muscle-bone interface, but due to the resiliency of the skin, the color change is not immediate, in contrast to a bruise.

The process leading to deep tissue pressure injury precedes the visible signs of purple or maroon skin by about 48 hours.

Then about 24 hours later, the epidermis lifts and reveals a dark wound bed.

This phase of deep tissue injury evolution is often confused with skin tears.

Within another week, the wound bed is often necrotic.

The lag between the pressure event and the change in color of the skin makes the root cause analysis complex.

This information is taken from the website https://npiap.com/news/546664/Evolution-of-Deep-Tissue-Pressure-Injury.htm.

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Glenburnie Rehab & Nursing Center 1901 Libbie Ave Richmond, VA 23226

Can be used in combination with other ManukaMed(R) formulations, such as ManukaPli, for optimal

tissue is absorbed into the dressing.

Eschar and debris tissue are taken up by the mesh fiber in the

and reduces or eliminates wound odor.

This information is taken from the manufacturer's website https://shop.manukamed.com/products/manukamedhd-superlite?srsltid=AfmBOooPOny07IGh0wQs2X7RpZL9pJjNvbUTNCH6F7xqbY3fygSVVWL. (4) The wound bed may be covered with necrotic tissue (non-viable tissue due to reduced blood supply), slough (dead tissue, usually cream or yellow in color), or eschar (dry, black, hard necrotic tissue).

Such tissue impedes healing.

This information is taken from the website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360405/

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Glenburnie Rehab & Nursing Center 1901 Libbie Ave Richmond, VA 23226

survey sample, Resident #1.The findings include:For Resident #1 (R1), the facility staff failed to bathe

assessment with an ARD (assessment reference date) of 10/15/25, the resident was coded as being completely dependent on facility staff for bathing/showering.A review of R1's October 2025 point of care records revealed no evidence that he received a shower or a bath on 10/12/25 and 10/13/25.

This review revealed no evidence that the resident refused being bathed on either of these days.On 10/29/25 at 10:07 a.m., CNA (certified nursing assistant) #1 was interviewed.

She stated she bathes every resident assigned to her each and every morning.

She stated this is simply part of her job of taking care of the residents.

She stated she wants to bathe every day and her residents deserve the same care she gives to herself.

She stated she documents the baths she gives in the electronic medical record.On 10/29/25 at 10:16 a.m., CNA #2 was interviewed.

She stated she is a lead CNA and is responsible for checking to make sure all the residents on her unit receive the care they need.

She stated she bathes and dresses all residents assigned to her every day.

She stated she documents the bath/shower in the electronic medical record.

She stated if the bath is not documented in the record, there is no way to verify that the bath actually occurred.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns.A review of the facility policy, Bathing, revealed, in part: Bathing usually occurs after breakfast or the evening meal.

The person's choice of type of bath and time of day is respected when possible.No additional information was provided prior to exit.

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provided prior to exit.REFERENCES(1) A pressure injury (ulcer) is localized damage to the skin and

intense and/orprolonged pressure or pressure in combination with shear.

The tolerance of soft tissue

condition of the soft tissue.

This information is taken from the website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf.(2) Wound dressing with super-absorbent and cross-linked mesh fibers, impregnated with Manuka honey, pH of 3.0-4.5.

Designed for ease of application and DAILY dressing changes for monitoring progress.

Can be used in combination with other ManukaMed(R) formulations, such as ManukaPli, for optimal medical grade honey dosage with every dressing change.

Reduces wound bed pH to optimize wound healing.

Manuka honey released into wound bed with sustained flow, while exudate and necrotic tissue is absorbed into the dressing.

Eschar and debris tissue are taken up by the mesh fiber in the dressing resulting in a clean and viable wound bed.

Creates optimal wound bed healing environment and reduces or eliminates wound odor.

This information is taken from the manufacturer's website https://shop.manukamed.com/products/manukamedhd-superlite?srsltid=AfmBOooPOny07IGh0wQs2X7RpZL9pJjNvbUTNCH6F7xqbY3fygSVVWL. (4) The wound bed may be covered with necrotic tissue (non-viable tissue due to reduced blood supply), slough (dead tissue, usually cream or yellow in color), or eschar (dry, black, hard necrotic tissue).

Such tissue impedes healing.

This information is taken from the website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360405/

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Glenburnie Rehab & Nursing Center 1901 Libbie Ave Richmond, VA 23226

management staff members were informed of the concerns related to the lack of incontinence care for

provided prior to exit.

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Glenburnie Rehab & Nursing Center 1901 Libbie Ave Richmond, VA 23226

respiratory services for one of eight residents in the survey sample, Resident #1.The findings include:

hospital Discharge summary dated [DATE] revealed, in part: Acute.respiratory failure [secondary to] CHF (congestive heart failure).OSA (obstructive sleep apnea).CPAP at night.A review of R1's clinical record revealed the following progress note: 10/14/2025 11:20 Health Status Note.Note Text: Writer spoke with NP (nurse practitioner) in regards to Bipap (3) placement d/t (due to) rsd (resident) was on Cpap during stay in the hospital. NP.stated she will place and order for Bipap.

Writer notified.respiratory therapist.he stated he will come to the facility and set up the machine.Further review of R1's clinical record failed to reveal any evidence that a CPAP was ever initiated for R1 during his stay at the facility.On 10/29/25 at 10:30 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed.

She stated that if a resident needs a CPAP on admission, this information is usually in the hospital discharge summary.

She stated the admitting nurse should verify the order with the physician and the physician should be informed that the facility does not have CPAP machines in stock. At that time, the physician might want to put some other type of order in place until the CPAP can be obtained by the central supply clerk and provided to the resident.

She stated most residents who need a CPAP have a device at home that they bring to the facility.

She explained that even if the resident has a CPAP at home, it is still the facility's responsibility to provide one at the facility if the resident is unable to bring the device from their home.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A CPAP policy was requested.No additional information was provided prior to exit.REFERENCES(1) CPAP (Continuous Positive Airway Pressure) is a treatment that uses mild air pressure to keep your breathing airways open .It involves using a CPAP machine that includes a mask or other device that fits over your nose or your nose and mouth, straps to position the mask, a tube that connects the mask to the machine's motor, and a motor that blows air into the tube. CPAP is used to treat sleep-related breathing disorders including sleep apnea.

This information is taken from the website https://www.nhlbi.nih.gov/health-topics/cpap.(2) Obstructive sleep apnea, also called OSA, happens when your upper airway becomes blocked many times while you sleep.

The blockage can reduce or completely stop airflow.

This is the most common type of sleep apnea.

This information is taken from the website https://www.nhlbi.nih.gov/health/sleep-apnea.(3) Biphasic Positive Airway Pressure (BIPAP) can be described as pressure controlled ventilation in a system allowing unrestricted spontaneous breathing at any moment of the ventilatory cycle. It can also be described as a Continuous Positive Airway Pressure (CPAP) system with a time-cycled change of the applied CPAP level.

This information is taken from the website https://pubmed.ncbi.nlm.nih.gov/8143712/.

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Glenburnie Rehab & Nursing Center 1901 Libbie Ave Richmond, VA 23226

staff failed to implement a complete pain program for one of eight residents in the survey sample,

report of severe pain on [DATE].R2 was admitted to the facility on [DATE] with a history of fractures in the left hip, and right leg. On admission the resident was documented to have recent surgical wounds on both knees.On the following dates and times, R2 was observed in her room and was both alert and conversant: [DATE] at 1:54 p.m. and 4:19 p.m.; [DATE] a.m. at 9:03 a.m.; and [DATE] at 8:15 a.m. At each observation, the resident reported pain in her knees.

She stated the staff usually treated her pain effectively, but that she had experienced severe pain once or twice that the medication did not help.A review of R2's progress notes revealed the following note dated [DATE] at 11:57 p.m.: Patient c/o (complained of) 10/10 (ten out of ten) bilat (bilateral - both left and right) knee pain and requesting prn (as needed) Oxycodone (1).

This writer explained that it was no longer on her current medication list.

Patient requesting MD (medical doctor) review meds and add it back if appropriate. MD Communication Book updated for this request.

The nurse who wrote this note was not interviewed during the survey.Further review of R2's progress notes failed to reveal any immediate intervention by the facility staff to address R2's severe pain in both knees.A review of R2's medication orders revealed that an as needed order for Oxycodone was added to R2's medication regimen at 6:45 p.m. on [DATE].

Further review of R2's progress notes revealed no evidence that either ASM (administrative staff member) #5, the attending nurse practitioner or ASM #6, the attending physician ever was made aware of or addressed R2's specific report of severe pain on [DATE]. On [DATE] at 10:30 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed.

After reviewing R2's progress note, she stated that it was almost midnight, and the physician/NP (nurse practitioner) coming to the facility until the next morning, at the earliest.

She explained that if the resident was reporting 10/10 pain, the nurse should have called the on-call physician and obtained an order for a pain medication that could be administered immediately.

She stated the resident should not have been left without any medication until the resident could be seen by the physician or NP.

She added: At 10/10, we need to get the on-call doctor on the phone.

She could not explain why the physician/NP never addressed the 10/10 pain.

She stated that even if the report of pain had been listed in the physician's book of concerns to be addressed at the next visit, this concern should have been passed along in the shift to shift nursing report.On [DATE] at 10:51 a.m., ASM #5 was interviewed.

After reviewing R2's progress note, she stated she assumed the Oxycodone fell off the resident's medication list because the order expired as an as needed medication.

She stated she did not remember anything being written in the physician concern book about R2 having 10/10 knee pain.

She stated she would hope that the nurse would have called the physician on call to get an order for a pain medication that could be administered immediately. On [DATE] at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns.A review of the facility policy, Pain Management Assessments, revealed, in part: Initiate a pain assessment any time.a patient experiences pain that is not usual for the patient.No additional information was provided prior to exit.REFERENCES(1) Oxycodone is used to relieve moderate to severe pain .

Oxycodone is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain.

This information is taken from the website https://medlineplus.gov/druginfo/meds/a682132.html.

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#3.The findings include:For Resident #3 (R3), the facility staff failed to provide on-call physician

review of R3's clinical record revealed the following progress note dated 10/21/25 at 1:10 a.m Critical lab called in from lab.

Potassium 2.9 (1).

Contacted on call physician to make aware. No call returned. 0145AM (1:45 a.m.) Contacted on call physician again, no returned call. 0658 (6:58 a.m.), no call returned, will have nurse follow-up with physician.On 10/29/25 at 7:54 a.m., ASM (administrative staff member) #4, the regional director of clinical operations, was interviewed.

She stated the facility nurses should always be able to reach an on-call physician.

She explained that if the nurses cannot reach an on-call physician in a reasonable amount of time, the medical director should be contacted.On 10/29/25 at 11:53 a.m., ASM #6, the attending physician, was interviewed.

After reviewing R3's progress note, he stated that in this context, there is always a back up for the provider who is on call. He explained that the on call service has the contact information for the back up provider in case the person on call is unable to respond right away. He stated the nurse is responsible for asking the telephone on-call personnel to notify the back up person. He stated he was never aware that the resident's potassium level was 2.9. He stated the risks of low potassium include heart rhythm dysfunction and neurological fogginess. He stated he would have ordered an immediate oral supplement to be given.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A policy regarding 24 hour physician coverage was requested.No additional information was provided prior to exit.REFERENCE(1) This [laboratory] test measures the amount of potassium in the fluid portion (serum) of the blood.

Potassium (K+) helps nerves and muscles communicate. It also helps move nutrients into cells and waste products out of cells.The normal range is 3.7 to 5.2 milliequivalents per liter (mEq/L) 3.70 to 5.20 millimoles per liter (millimol/L).

This information is taken from the website https://medlineplus.gov/ency/article/003484.htm.

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Glenburnie Rehab & Nursing Center 1901 Libbie Ave Richmond, VA 23226

decisions.

The physician's order for R109 documented in part, Oxycodone HCl (hydrochloride) Oral

August 2025 documented the physician's order as stated above.

Further review of the eMAR revealed

Controlled Drug Administration Record for R109 documented the physician's order for Oxycodone as stated above.

Further review of the record failed to document the administration of Oxycodone on 08/06/2025 at 9:00 a.m. and 5:00 p.m. On 12/11/2025 at approximately 2:00 p.m. an interview was conducted with ASM (administrative staff member) #2, director of nursing, regarding the controlled drug administration record and eMAR for R109.

After reviewing the eMAR and controlled drug administration record for the dates and times stated above ASM #2 stated that the nurse forgot to accurately document controlled drug administration record indicating that R109 received the physician ordered Oxycodone on 12/06/2025 at 9:00 a.m. and 5:00 p.m.

She further stated that the nurse should immediately document the controlled drug administration record when the medication is removed for administration. On 12/11/2025 at approximately 2:05 p.m. ASM #1, interim administrator, ASM #2, director of nursing and ASM #4, vice president of operations, were made aware of the above findings.

No further information was provided prior to exit.

Reference:(1) Used to relieve moderate to severe pain.

This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html.

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Glenburnie Rehab & Nursing Center 1901 Libbie Ave Richmond, VA 23226

failed to implement infection control procedures for one of eight residents in the survey sample,

barrier precautions (1) to protect residents from infection.On 10/28/25 at 9:03 a.m., LPN (licensed practical nurse) #2, the facility wound nurse, was observed preparing to provide wound care to R2. As LPN #2 prepared to enter R2's room, no signage or personal protective equipment related to any sort of isolation precautions was observed in plain view. LPN #2 did not don any PPE prior to entering R2's room or providing wound care.

Further review of R2's clinical record revealed the resident had chronic wounds and a Foley catheter (2).

This review revealed no orders for or evidence of enhanced barrier precautions being implemented since the resident was admitted to the facility on [DATE] (a total of 47 days).On 10/29/25 at 7:54 a.m., ASM (administrative staff member) #2, the director of nursing, and ASM #4, the regional director of clinical operations, were interviewed. ASM #2 stated enhanced barrier precautions are implemented to prevent the spread of harmful bacteria from resident to resident. ASM #4 stated enhanced barrier precautions are implemented when any resident has any kind of chronic wound and/or invasive medical device such as a Foley catheter.On 10/29/25 at 12:20 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns.A review of the facility policy, Enhanced Barrier Precautions, revealed, in part: Employees providing high-contact patient care activities will follow Enhanced Barrier Precautions for patients who meet the criteria.May be indicated for patients.with chronic wounds.with indwelling medical devices.[Enhanced Barrier Precautions] require the use of gown and gloves by staff during high-contact patient care activities.[including] wound care for chronic wounds.No additional information was provided prior to exit.REFERENCES(1) Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes.

Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).

This information is taken from the website https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html.(2) Foley catheters are small flexible tubes inserted into the urethra to drain urine from the bladder.

This information is taken from the website https://www.ncbi.nlm.nih.gov/books/NBK564404/