Parham Health Care & Rehab Center

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

inch of water in the basin. On 8/29/25 at approximately 9:45 AM a bath basin was observed under the sink with approximately one (1) inch of water in the basin. Resident #103 was admitted to the facility on [DATE REDACTED] with diagnosis including but not limited to human immunodeficiency virus, hypertension, seizures, chronic obstructive pulmonary disease, Adrenocortical insufficiency, pancreatitis, fibromyalgia, psychoactive substance abuse and major depressive disorder. Resident #103's most recent Minimum Data Set (MDS) assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 6/18/2025.

Resident #3 was coded in Section C. Cognitive Summary with a Brief Interview of Mental Status score of 15 out of 15 which means the resident has been cognitively intact with daily decision making. On 8/27/25 at 2:35 PM an interview was conducted with Resident #103 regarding had she had issues with her sink leaking and she replied yes, I thought they had fixed it. On 8/28/25 at 9:35 AM, a further interview with Resident #103 on had anyone come in to check on the leaking sink and she said they had emptied the pan.

On 8/29/25, when interviewing Resident #103 about her sink she stated, they haven't fixed that thing yet?

On 8/28/25 at approximately 10:15 AM, observed a footboard leaning against the wall in room [ROOM NUMBER]D. Resident #109 was admitted to the facility on [DATE REDACTED] with diagnosis including but not limited to

the following human immunodeficiency virus, hypertension, anxiety, traumatic subdural hemorrhage without loss of consciousness, Type 2 diabetes mellitus, long term use of insulin, alcohol abuse, psychosis, major depressive disorder cerebral infarction, vascular dementia, neurocognitive disorder with [NAME] Bodies and obstructive pulmonary disorder.Resident #109's most recent Minimum Data Set (MDS) assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 7/7/2025. Resident #109 was coded in Section C. Cognitive Summary with a Brief Interview of Mental Status score of 11 out of 15 which means the resident has moderate cognitive impairment in daily decision making.On 8/28/25 at approximately 10:15 AM, an interview was conducted with Resident # 109 who stated it belonged to his roommate. The roommate's bed was observed without a footboard attached. Resident #128 could not recall how long it had been there.On 8/29/25 at 12:28 PM during end of day debriefing these findings were reviewed with the Administrator, Director of Nursing, Regional Director Clinical Services and Divisional Regional Director of Clinical Services. No further information was provided.

Event ID:

Facility ID:

If continuation sheet

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

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Parham Health Care & Rehab Center

2400 E Parham Road Richmond, VA 23228

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 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide Activity of Daily Living (ADL) care to a dependent Resident (Resident #123) in

a survey sample of 28 Residents. The findings included: For Resident #123, the Resident, and Resident's bed, were soaked in a brown halo of partially dried old urine from 10:00 A.M. until 1:40 PM. Resident #123 was admitted to the facility on [DATE REDACTED] with diagnoses including: Parkinson's disease, muscle atrophy, diabetes type 2 hypertension, and anemia. The Resident was her own responsible party and by facility agreement cognitively intact and able to make her own decisions. Her MDS (an assessment) recorded a Brief Interview for Mental Status (BIMS) score of 15 of a possible 15 points, indicating no cognitive impairment. During an initial interview on 8-29-25, at 10:00 A.M., and again at 1:40 PM, Resident #123 was found to be alert and oriented to person, place, time, and situation. During the 1:40 PM interview, Resident #123 verbalized that she was uncomfortable and need to have her brief changed as she was Wet head to toe. The Resident was noted to have her body and bed smell strongly of urine, and in fact the entire room had a pervasive odor of urine, feces, and body odor. The Resident wore socks which were meant to be white, however, had brown stains on them which were dried on. The Resident stated that there just were not enough staff to take care of Residents, and this situation happened to her often. The Resident's bed had a brown halo of partially dried strong-smelling urine around her body from her knees to her mid back.

Her mattress was soaked as well with a permanent divot in the area directly under her bottom that did not spring back into place when she rolled off of it onto her side. A pervasive smell of urine and feces permeated the room and the entire unit. ADL care records were reviewed for Resident #123 and revealed that the Resident was totally dependent on one staff member. The document indicated that a bath was given every morning, however, the Resident was observed on 8-29-25 during survey and found to be soiled from 10:00 A.M. until 1:40 PM. in a soiled bed with soiled linens. The Resident was never seen out of bed

during daytime hours for the entire survey. On 8-29-25 during an end of day meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns. Furthermore they were made aware that Residents were not being bathed and given hygiene timely, nor as often as needed, as this was the observation on days during the survey with Residents being soiled with dirty linens and clothing. On 9-3-25, prior to the survey exit the Director of Nursing informed surveyors that Resident #123 was now receiving needed care every 2 hours, and stated

they had nothing further to provide.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Parham Health Care & Rehab Center

2400 E Parham Road Richmond, VA 23228

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide timely medication administration to one Resident (Resident #123) in a survey sample of 28 Residents. The findings included: For Resident #123, the Resident received her medications

in March, April, and May 2025 Late, and in some cases hours after they were scheduled to be given.

Resident #123 was admitted to the facility on [DATE REDACTED] with diagnoses including: Parkinson's disease, muscle atrophy, diabetes type 2 hypertension, and anemia. The Resident was her own responsible party and by facility agreement cognitively intact and able to make her own decisions. Her MDS (an assessment) recorded a Brief Interview for Mental Status (BIMS) score of 15 of a possible 15 points, indicating no cognitive impairment. During an initial interview on 8-29-25, at 10:00 A.M., and again at 1:40 PM, Resident #123 was found to be alert and oriented to person, place, time, and situation. During the 1:40 PM interview, Resident #123 verbalized that she received her medications late on occasion, and sometimes hours later than they were scheduled to be given. The Resident was laying in bed and noted to have her body and bed smell strongly of urine, and in fact the entire room had a pervasive odor of urine, feces, and body odor. The Resident wore socks which were meant to be white, however, had brown stains on them which were dried on. The Resident stated that there just were not enough staff to take care of Residents, and this situation happened to her often. ADL care records were reviewed for Resident #123 and revealed that the Resident was totally dependent on one staff member. The document indicated that a bath was given every morning, however, the Resident was observed on 8-29-25 during survey and found to be soiled from 10:00 A.M. until 1:40 PM. in a soiled bed with soiled linens. The Resident was never seen out of bed during daytime hours for the entire survey. The Resident's Medication administration record was reviewed with time stamps for

the time medications were administered for 3 months, in March. April, and May of 2025. The records revealed that medications were being administered later than they were ordered to be administered. The examples follow below. March 2025 - 3-25-25, Carbidopa/levodopa ordered for 1:00 P.m., given at 2:31 P.m.

April 2025 - 4-25-25, Carboxymethylcellulose-glycerin eye drops, multivitamin, docusate sodium, Carbidopa/levodopa, Meloxicam, amlodipine, Sitagliptin phosphate, house supplement drink, ordered for 9:00 A.m., given at 11:00 A.m. May 2025 - 5-25-25, Carbidopa/levodopa ordered for 5:00P.m., given at 7:42 P.m., Ascorbic acid, ferrous sulfate, Carboxymethylcellulose-glycerin eye drops, melatonin, tizanidine, Carbidopa/levodopa, doxepin, atorvastatin, oxycodone, mirtazapine, and gabapentin all ordered for 9:00 P.m., and not given until the next morning on 5-26-25 at 8:15 A.m., (11 hours late). Review of the Facility Medication Administration policy indicated medication administration would be completed according to the doctor's orders. The Resident's care plan was reviewed and indicated medications would be administered according to the doctor's orders. On 8-29-25 during an end of day meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns. On 9-3-25, prior to the survey exit, the Director of Nursing informed surveyors that Resident #123 was now receiving needed care every 2 hours, and medications timely. They further stated they had nothing further to provide.

Event ID:

Facility ID:

If continuation sheet

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

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Parham Health Care & Rehab Center

2400 E Parham Road Richmond, VA 23228

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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

building. Closet replacements and repairs in other Resident rooms were also ongoing during the survey as other units were in need of replacement. The facility knew or should have known that the closets were a hazard, and did not act quickly enough to mitigate the hazard resulting in a minor injury requiring only first aid to Resident #124. Teams were then dispatched to identify any other doors that could fall for immediate repair or removal. The housekeeping and maintenance directors notified the pest control contractor who responded immediately to treat the cockroach infestation in Resident #124's room. On 8-29-25 at the end of day debrief, the Administrator, Corporate RN, and DON were notified of the above findings. They stated there was no further evidence to present.

Event ID:

Facility ID:

If continuation sheet

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

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Parham Health Care & Rehab Center

2400 E Parham Road Richmond, VA 23228

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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

I thought they had fixed it. On 8/28/25 at 9:35 AM, a further interview with Resident #103 on had anyone come in to check on the leaking sink and she said they had emptied the pan. On 8/29/25, when interviewing Resident #103 about her sink she stated, they haven't fixed that thing yet? 7. On 8/28/25 at approximately 10:15 AM, observed a footboard leaning against the wall in room [ROOM NUMBER]D.

Resident #109 was admitted to the facility on [DATE REDACTED] with diagnosis including but not limited to the following human immunodeficiency virus, hypertension, anxiety, traumatic subdural hemorrhage without loss of consciousness, Type 2 diabetes mellitus, long term use of insulin, alcohol abuse, psychosis, major depressive disorder cerebral infarction, vascular dementia, neurocognitive disorder with [NAME] Bodies and obstructive pulmonary disorder.Resident #109 ‘s most recent Minimum Data Set (MDS) assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 7/7/2025. Resident #109 was coded in Section C. Cognitive Summary with a Brief Interview of Mental Status score of 11 out of 15 which means the resident has moderate cognitive impairment in daily decision making.On 8/28/25 at approximately 10:15 AM, an interview was conducted with Resident 109 who stated it belonged to his roommate. The roommate's bed was observed without a footboard attached. Resident #128 could not recall how long it had been there.On 8/29/25 at 12:28 PM during end of day debriefing these findings were reviewed with the Administrator, Director of Nursing, Regional Director Clinical Services and Divisional Regional Director of Clinical Services. No further information was provided.

Event ID:

Facility ID:

If continuation sheet