Westport Rehabilitation And Nursing Center

Observation of the call bell revealed it was draped over the left side of the headboard.

After pointing out the location of the call bell to R103, he was asked if he was able to access it.

Observations revealed R103 propelling his wheelchair to the opposite of the bed but unable to mauver the wheelchair alongside the left side of the bed to reach the call bell. R103 stated that he could not reach the call bell. On 12/16/2025 at approximately 10:55 a.m. an observation revealed LPN (licensed practical nurse) #5 enter R103's room, remove the call bell from the head of the bed and clip it to R103's shirt while he was sitting in his wheelchair. On 12/16/2025 at approximately 10:57 a.m. an interview was conducted with LPN # 5.

When asked about the purpose of a call bell for residents she stated that it was used to call for assistance.

She further stated that R103's call bell was not within his reach and should have been where R103 could access it. On 12/17/2025 at approximately 2:00 p.m. ASM (administrative staff member) # 1, administrator, and ASM #2, director of nursing, were made aware of the above findings.

No further information was provided prior to exit.

495227 10/22/2025

Westport Rehabilitation and Nursing Center 7300 Forest Ave Richmond, VA 23226

limited to receiving treatment and supports for daily living safely.

observations and staff interview, facility staff failed to maintain a clean environment for one of 12

[ROOM NUMBER], facility staff failed to maintain the PTAC (packaged terminal air conditioner) unit vents in a clean manner. On 12/16/2025 at approximately 12:45 p.m. an observation of the PTAC in resident room [ROOM NUMBER] revealed the vents to have a black, greasy substance coating them.

On 12/16/2025 at approximately 3:36 p.m. an observation of the PTAC unit in resident room [ROOM NUMBER] and interview with OSM (other staff member) #7 was conducted.

After observing the vents on the PTAC unit he agreed that they were not clean.

When asked about maintaining the vents in a clean manner he stated that PTAC units are checked every two weeks and that this one was overlooked. On 12/17/2025 at approximately 2:00 p.m. ASM (administrative staff member) # 1, administrator, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

495227 10/22/2025

Westport Rehabilitation and Nursing Center 7300 Forest Ave Richmond, VA 23226

Review of the fax transmittal confirmation of the event to the state agency documented the report sent 1/28/2025 at 10:54 AM.The progress notes for R4 documented in part, 01/27/2025 13:12 (1:12 p.m.) Note Text: Resident has been yelling throughout the shift today related to roommates' mats on floor and bedside table.

Writer arranged room to accommodate resident's needs, but resident was still yelling.

Writer went to check resident's BS (blood sugar) and explained to resident that he will be getting 10 units of Humalog (insulin).

Resident started yelling at nurse that he is allergic to Humalog.

Nurse apologized to resident and stated that I did not mean Humalog but Admelog (another brand of insulin).

Resident started cursing and yelling I'm allergic to Humalog.

Writer attempted to show Insulin pen to resident, when writer showed insulin pen to resident, resident attempted to grab pen from writer and then attempted to hit resident (sic).

Writer backed up and walked out of room.

After leaving resident's room he came out of his room and stated that nurse hit me twice.

Writer went to inform ADON (assistant director of nursing) of situation.On 10/21/2025 at 2:24 PM, an interview was conducted with administrative staff member (ASM) #1, the director of nursing, who stated that R4 had alleged that the nurse had hit them.

She stated that the former administrator had taken over the investigation due to her personal relationship with the accused nurse. ASM #1 stated that when there was any allegation of abuse the staff member is suspended, a pain and skin assessment is completed, a trauma screening is completed by social services, and they notified the physician and responsible party.

She stated that abuse allegations were reported within two hours and the event for R4 would qualify as required to report in two hours because it was an allegation of abuse. On 10/22/2025 at 10:09 AM, ASM #1 and ASM #2, the administrator were made aware of the concern.No further information was provided prior to exit.

495227 10/22/2025

Westport Rehabilitation and Nursing Center 7300 Forest Ave Richmond, VA 23226

Review of the fax transmittal confirmation of the event to the state agency documented the report sent 1/28/2025 at 10:54 AM.The progress notes for R4 documented in part, 01/27/2025 13:12 (1:12 p.m.) Note Text: Resident has been yelling throughout the shift today related to roommates' mats on floor and bedside table.

Writer arranged room to accommodate resident's needs, but resident was still yelling.

Writer went to check resident's BS (blood sugar) and explained to resident that he will be getting 10 units of Humalog (insulin).

Resident started yelling at nurse that he is allergic to Humalog.

Nurse apologized to resident and stated that I did not mean Humalog but Admelog (another brand of insulin).

Resident started cursing and yelling I'm allergic to Humalog.

Writer attempted to show Insulin pen to resident, when writer showed insulin pen to resident, resident attempted to grab pen from writer and then attempted to hit resident(sic).

Writer backed up and walked out of room.

After leaving resident's room he came out of his room and stated that nurse hit me twice.

Writer went to inform ADON (assistant director of nursing) of situation.On 10/21/2025 at 2:24 PM, an interview was conducted with administrative staff member (ASM) #1, the director of nursing, who stated that R4 had alleged that the nurse had hit them.

She stated that the former administrator had taken over the investigation due to her personal relationship with the nurse. ASM #1 stated that when there was any allegation of abuse the staff member is suspended, a pain and skin assessment is completed, a trauma screening is completed by social services, and they notified the physician.

She stated that abuse allegations were reported within two hours and the event for R4 would qualify as required to report in two hours because it was an allegation of abuse.

The facility policy Reporting Requirements/Investigations effective 2/5/2023 documented in part, .Immediately upon notification of any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, the Administrator will immediately report to the State Agency, but not later than 2 hours after the allegation is made, if the events that caused the allegation involves abuse or results in serious bodily injury .On 10/22/2025 at 10:09 AM, ASM #1 and ASM #2, the administrator were made aware of the concern.No further information was provided prior to exit.

495227 10/22/2025

Westport Rehabilitation and Nursing Center 7300 Forest Ave Richmond, VA 23226

complete an accurate MDS assessment for one of 17 residents in the survey sample, Resident # 1.

(minimum data set) assessment. R1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to paraplegia, ASCVD (atherosclerosis cardiovascular disease) and neuromuscular dysfunction of bladder.

The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 9/27/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bed mobility, transfer, hygiene and supervision for eating. A review of MDS Section: GG0115.

Functional Limitation in Range of Motion- B.

Lower extremity coded 0 = no impairment. MDS Section: GG0170.

Mobility: I.

Walk 10 feet: coded as 88 = not attempted due to medical condition or safety concerns. A review of the comprehensive care plan dated 1/13/25 and revised 9/27/25 revealed, FOCUS: Resident is at risk for falls related to muscle weakness, related to poor balance, related to psychoactive medications. INTERVENTIONS: ensure the resident wears shoes when ambulating, 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).R1 had been transferred to hospital on [DATE] and was not in facility during the survey. On 10/21/25 at 7:14 AM, an interview was conducted with LPN (licensed practical nurse) #2.

When asked what she remembered about R1, LPN #2 stated he could not walk and used a wheelchair. On 10/21/25 at 7:25 AM, an interview was conducted with LPN #10, the MDS coordinator.

When asked to review R1's, 9/27/25 MDS functional limitations in range of motion and mobility sections and asked if there was an error in what was coded, LPN #10 stated yes, there is.

When asked what standard is followed to complete the MDS, LPN #10 stated the RAI (resident assessment instrument) manual. On 10/22/25 at 10:15 AM, ASM (administrative staff member) #1, the director of nursing, ASM #2, the administrator and RN (registered nurse) #1, the assistant director of nursing, were made aware of the findings.

According to the RAI (resident assessment instrument) MDS Section GG0170: Code based on the resident's performance.No further information was provided prior to exit.

495227 10/22/2025

Westport Rehabilitation and Nursing Center 7300 Forest Ave Richmond, VA 23226

actions that can be measured.

observations, staff interview facility document review and clinical record review, it was determined

sample, Resident #112 (R112).The findings include: The facility staff failed to develop the comprehensive care plan for sexual / inappropriate behavior monitoring for R112.R112 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ischemic cardiomyopathy, CHF (congestive heart failure), atrial fibrillation and LVAD (left ventricular assist device).The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 11/8/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for bathing/transfer/dressing/toileting and independent for eating.A review of the comprehensive care plan dated 10/3/24 revealed, FOCUS: Resident has behaviors refuses cardiac clinic appointments.

Resident refuses daily weights.

Encourage compliance with routine weight monitoring. INTERVENTIONS: assure the resident they are safe if they become distressed.

Contact clinic and see if can do facility visit.During a complaint investigation regarding admission of residents on the VSP (Virginia State Police) Sex Offender Registry, R112 was found to be on the registry.On 12/17/25 at 10:45 AM, an interview was conducted with ASM (administrative staff member) #2, the DON (director of nursing).

Asked if monitoring sexual / inappropriate behaviors should be on the care plan for a resident who is listed on the sex offender registry, ASM #2 stated, It should be on the care plan. I would expect it to be there.On 12/17/25 at 2:00 PM ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, RN (registered nurse) #3, the assistant director of nursing, RN #4, the assistant director of nursing was made aware of the concerns.According to the facility's Care Planning policy, which revealed, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental and psychosocial well-being of the patient.According to the facility's Behavioral Assessment/Behavior Monitoring policy, which revealed, Behaviors will be assessed and monitored.

Factors influencing behaviors, as well as management interventions will be evaluated and care planned.No further information was provided prior to exit.

495227 10/22/2025

Westport Rehabilitation and Nursing Center 7300 Forest Ave Richmond, VA 23226

R1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to

bladder.

The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 9/27/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bed mobility, transfer, hygiene and supervision for eating. A review of MDS Section: GG0115.

Functional Limitation in Range of Motion- B.

Lower extremity coded 0 = no impairment. MDS Section: GG0170.

Mobility: I.

Walk 10 feet: coded as 88 = not attempted due to medical condition or safety concerns.

A review of the comprehensive care plan dated 1/13/25 and revised 9/27/25 revealed, FOCUS: Resident is at risk for falls related to muscle weakness, related to poor balance, related to psychoactive medications. INTERVENTIONS: ensure the resident wears shoes when ambulating, 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).

R1 had been transferred to hospital on [DATE] and was not in facility during the survey.

On 10/20/25 at 2:35 PM, an interview was conducted with LPN (licensed practical nurse) #1.

When asked if she remembered R1, LPN #1 stated, yes, he could not walk and he had a foley. I changed his foley and foley bag when the NP (nurse practitioner asked me to, it was before he went to the hospital.

His sister was visiting that day.

When asked the purpose of the care plan, LPN #1 stated, it is to describe the care each resident needs and what interventions we are to implement to meet those needs.

When asked if the care plan for R1 included an intervention of ensure the resident wears shoes when ambulating was the care plan correct, LPN #1 stated, no, because he did not walk.

When asked if the care plan should be revised, LPN #1 stated, yes.

On 10/21/25 at 7:14 AM, an interview was conducted with LPN #2.

When asked what she remembered about R1, LPN #2 stated he could not walk and used a wheelchair.

On 10/22/25 at 10:15 AM, ASM (administrative staff member) #1, the director of nursing, ASM #2, the administrator and (registered nurse) #1, the assistant director of nursing, were made aware of the findings.

No further information was provided prior to exit.

495227 10/22/2025

Westport Rehabilitation and Nursing Center 7300 Forest Ave Richmond, VA 23226

(ASM) #1, the director of nursing stated that the former unit manager had taken over for the nurse

themselves. On 10/21/2025 at 1:26 PM, an interview was conducted with licensed practical nurse

over for the nurse sent home.

She stated that she was told that R4 had been having behaviors and had gone outside to the edge of the road. LPN #3 stated that when she got out there with R4 she tried to get the resident to return to the building but R4 was upset and confused.

She stated that she had called R4's family member and tried to get R4 to talk with her but they refused.

She stated that R4 used his personal cell phone to call 911 and when the police arrived they tried to get the resident to go back inside but R4 still refused. LPN #3 stated at that time she went back inside but she heard that R4 ended up going to the hospital because he tried going down the street.

She stated that she witnessed R4 being put in the back of the ambulance and the police were there as well.

She stated that the former administrator was outside at the time. LPN #3 stated that there was supposed to be documentation in the medical record and even if the resident called 911 themselves the staff should put in some type of note documenting the incident and notify the physician and the responsible party. [NAME] and Perry's Fundamentals of Nursing, 7th Edition, page 231 documents the following statements: Assessment is the deliberate and systematic collection of data to determine a client's current and past health status .The purpose of the assessment is to establish a database .

Page 243 documents: If you do not record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the client .Observation and recording is a legal and professional responsibility.B) Clarify physician orders for insulin:

Review of the physician orders for R4 documented in part,- Admelog SoloStar 100 UNIT/ML (milliliter) Solution pen-injector, Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units ; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously before meals and at bedtime for Type 1 DM (diabetes mellitus).

Order Date: 01/22/2025.

Start Date: 01/22/2025.- Insulin Lispro 100 UNIT/ML Solution Inject as per sliding scale: if 150 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 Call MD [medical doctor] for BS [blood sugar] >400mg/dl (milligram per deciliter), subcutaneously before meals related to type I Diabetes Mellitus with other specified complication.

Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units Call MD for BS >400mg/dl, subcutaneously three times a day for DM.

Order Date: 06/24/2024.

Start Date: 06/24/2024.

Review of the electronic medication administration record (eMAR) for R4 dated 1/1/2025-1/31/2025 documented R4 receiving the Lispro sliding scale insulin as ordered through 11:30 AM on 1/24/2025.

The eMAR documented the Admelog scheduled to start on 1/22/2025 at 6:30 AM but not administered until 4:30 PM on 1/24/2025.

The eMAR notes for the missed doses 1/22/2025-1/24/2025 of Admelog documented that they were waiting for clarification by the nurse practitioner.On 10/21/2025 at 10:24 AM, an interview was conducted with licensed practical nurse (LPN) #7 who stated that if a medication was not administered they let the physician or nurse practitioner know and if there were questions about a medication they called them to clarify the medication. On 10/22/2025 at 10:09 AM ASM #1 stated that they did not have any evidence that the Admelog order was clarified with the nurse practitioner prior to 1/24/2025. On 10/22/2025 at 10:09 AM, administrative staff member (ASM) #1, the director of nursing and ASM #2, the administrator were made aware of the concern.No further information was provided prior to exit.

495227 10/22/2025

Westport Rehabilitation and Nursing Center 7300 Forest Ave Richmond, VA 23226

the facility staff failed to provide ADL (activities of daily living) care for dependent residents for one

ADL (activities of daily living) specifically turning/repositioning, incontinence care and feeding R104.R104 was admitted to the facility on [DATE] with diagnosis that included but were not limited to quadriplegia, spinal stenosis and TIA (transient ischemic attack).The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/9/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as dependent for bathing/transfer/dressing/toileting and eating; Section H-Bladder and Bowel coded the resident as bowel always incontinent, urinary indwelling catheter. A review of the comprehensive care plan dated 8/1/24 revealed, FOCUS: LONG TERM CARE: the resident requires assistance with ADLS relate to weakness, Quadriplegic and hand contractures. FOLEY CATHETER: resident requires a urinary 18 FR Coude' catheter 10cc balloon related to: obstructive neurogenic bladder. INTERVENTIONS: Assist of one with ADLS, resident dependent with feeding for meals, 2 person assist with bed mobility.

Observe for signs and symptoms of infection such as dark or cloudy urine or blockage and notify md as indicated.

Provide catheter care Q shift.A review of the October, November and December 2025 ADL forms reveal missing documentation on the following dates and shifts:-Turning/repositioning: Day shift: 11/28, 12/3 and Night shift: 10/29, 10/31, 11/25, 11/30 and 12/11.-Incontinence care: Day shift: 11/28, 12/3, 12/4 12/14 and Night shift: 10/26, 10/29, 10/31,11/25, 11/30 and 12/12.-Feeding: Day shift (breakfast/lunch): 11/28, 12/3 and Night shift (supper) 10/29, 10/31, 11/25, 11/30 and 12/12.On 12/15/25 at 2:00 PM an interview was conducted with CNA (certified nursing assistant) #1.

When asked where documentation of specifically turning/repositioning, incontinence care and feeding would be located, CNA #1 stated, we document it in PCC (point click care) on the ADL form.

When asked if the documentation is not present, would there be evidence of the care, CNA #1 stated, no, there would not be any evidence of the care.

They are to document all care given in the ADL form.On 12/17/25 at 2:00 PM ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, RN (registered nurse) #3, the assistant director of nursing, RN #4, the assistant director of nursing was made aware of the concerns.According to the facility's Nursing Care and Services policy, which revealed, The center will utilize Mosby's Textbook for Long-Term Care Assistants by Kostelnick and/or Clinical Nursing Skills & Techniques by [NAME], [NAME] and Ostendorff, as a reference for nursing services and skills not otherwise provided in the Policies and Procedures Manuals.

Turning and repositioning the person- record and document your observations.No further information was provided prior to exit.

495227 10/22/2025

Westport Rehabilitation and Nursing Center 7300 Forest Ave Richmond, VA 23226

staff failed to provide care and services to promote a resident's highest level of wellbeing for one of

inappropriate behaviors for a resident who is listed on the sex offender registry. R112 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ischemic cardiomyopathy, CHF (congestive heart failure), atrial fibrillation and LVAD (left ventricular assist device).The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 11/8/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for bathing/transfer/dressing/toileting and independent for eating.A review of the comprehensive care plan dated 10/3/24 revealed, FOCUS: Resident has behaviors refuses cardiac clinic appointments.

Resident refuses daily weights.

Encourage compliance with routine weight monitoring. INTERVENTIONS: assure the resident they are safe if they become distressed.

Contact clinic and see if can do facility visit.During a complaint investigation regarding admission of residents on the VSP (Virginia State Police) Sex Offender Registry, R112 was found to be on the registry, dated 8/21/24.An interview was conducted on 12/17/25 at 10:45 AM with ASM (administrative staff member) #2, the DON (director of nursing).

When asked the admissions process, ASM #2 stated, they do a sex offender check.

The facility administrators until 4/21/25 allowed sex offenders in the facility.

Asked the process for admitting sex offenders, ASM #2 stated, we find out if the resident is mobile, is the offense recent, nature of offense (virtual or physical).

Asked how staff and residents are protected, ASM #2 stated, we would monitor behavior, and if there is an incident- separation of resident, investigation, if sexual in nature- evaluation in ED (emergency department) and call the police.

When asked where this would be monitored, ASM #2 stated, on the MAR-TAR (medication administration record, treatment administration record).

Asked for evidence of this monitoring for R112, ASM #2 stated, there is no monitoring. On 12/17/25 at 11:50 AM, an interview was conducted with OSM (other staff member) #1, the social worker.

Asked, what is the process for residents on the sex offender registry, OSM #1 stated, We previously had accepted these residents, we do not anymore. I'll pass information along to case worker or parole officer.

Asked if sexual / inappropriate behaviors should be monitored, OSM #1 stated, Yes, his behaviors should be monitored. On 12/17/25 at 2:00 PM ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, RN (registered nurse) #3, the assistant director of nursing, RN #4, the assistant director of nursing, were made aware of the concerns.According to the facility's Behavioral Assessment/Behavior Monitoring policy, which revealed, Behaviors will be assessed and monitored.

Factors influencing behaviors, as well as management interventions will be evaluated and care planned.No further information was provided prior to exit.

495227 10/22/2025

Westport Rehabilitation and Nursing Center 7300 Forest Ave Richmond, VA 23226

They are considered a specific type of basilar skull fracture. mostly occur in the setting of

website: Occipital condyle fracture | Radiology Reference Article | Radiopaedia.org.

• Oxycodone is used to relieve severe pain.

Oxycodone is in a class of medications called opiate (narcotic) analgesics.

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

• Tylenol (acetaminophen) Acetaminophen is used to relieve mild to moderate pain from headaches,

muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, reactions to vaccinations (shots), and to reduce fever.

This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a681004.html

495227 10/22/2025

Westport Rehabilitation and Nursing Center 7300 Forest Ave Richmond, VA 23226

catheter care, and appropriate care to prevent urinary tract infections.

staff/resident interview, facility document review and clinical record review, it was determined that

residents in the survey sample, Resident #104 (R104).The findings include:

The facility failed to evidence treatment and services for Resident 104's (R105's) indwelling catheter.R104 was admitted to the facility on [DATE] with diagnosis that included but were not limited to quadriplegia, spinal stenosis and TIA (transient ischemic attack).The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/9/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as dependent for bathing/transfer/dressing/toileting and eating; Section H-Bladder and Bowel coded the resident as bowel always incontinent, urinary indwelling catheter. A review of the comprehensive care plan dated 8/1/24 revealed, FOCUS: LONG TERM CARE: the resident requires assistance with ADLS relate to weakness, Quadriplegic and hand contractures. FOLEY CATHETER: resident requires a urinary 18 FR Coude' catheter 10cc balloon related to: obstructive neurogenic bladder. INTERVENTIONS: Assist of one with ADLS, resident dependent with feeding for meals, 2 person assist with bed mobility.

Observe for signs and symptoms of infection such as dark or cloudy urine or blockage and notify md as indicated.

Provide catheter care Q shift.A review of the physician orders dated 6/20/25 revealed, FOLEY CATH : Catheter Output every day and night shift for foley monitoring.A review of the physician orders dated 11/6/25 revealed, Foley catheter and Suprapubic catheter: Flush with 60ml of Normal Saline 1x/daily while patient is lying in bed. one time a day for UTI prophylaxis.

Suprapubic catheter: Provide foley catheter care every day and night shift for Obstructive Neurogenic bladder.A review of the physician orders dated 11/10/25 revealed, Suprapubic catheter: Flush with 10cc NS (normal saline) as needed for sluggish urine AND every day and night shift.A review of the October, November and December 2025 MAR-TAR (medication administration record-treatment administration record) revealed missing evidence of treatment provided:-Catheter Output every day and night shift for foley monitoring: Day shift: 10/21, 10/24 and Night shift: 10/24, 10/25, 11/9, 11/19.-Flush with 60ml of Normal Saline 1x/daily: Day shift: 11/11.-Suprapubic catheter: Provide foley catheter care every day and night shift: Day shift: 10/24, 11/24 and Night shift: 10/24, 11/9, 11/24.-Flush with 10cc NS (normal saline) as needed for sluggish urine AND every day and night shift: Day shift: 11/11.On 12/16/25 at 1:05 PM an interview was conducted with LPN (licensed practical nurse) #4, asked where evidence of catheter care would be documented, LPN #4 stated, it would be documented on the MAR-TAR.

When asked if there is no evidence of care being documented- the care been done, LPN #4 stated, no, if it is not documented it was not done. On 12/17/25 at 2:00 PM ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, RN (registered nurse) #3, the assistant director of nursing, RN #4, the assistant director of nursing was made aware of the concerns.According to the facility's Urinary Catheterization policy, which revealed, Licensed nurses will irrigate catheter, if indicated, per provider's order.

Perform catheter care every shift and document in the medical record.No further information was provided prior to exit.

495227 10/22/2025

Westport Rehabilitation and Nursing Center 7300 Forest Ave Richmond, VA 23226

facility staff failed to provide food at a palatable temperature for one of twelve residents, Resident

for R104 during lunch on 12/15/25. R104 was admitted to the facility on [DATE] with diagnosis that included but were not limited to quadriplegia, spinal stenosis and TIA (transient ischemic attack).The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/9/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as dependent for bathing/transfer/dressing/toileting and eating. A review of the comprehensive care plan dated 8/1/24 revealed, FOCUS: LONG TERM CARE: the resident requires assistance with ADLS relate to weakness, Quadriplegic and hand contractures. INTERVENTIONS: Assist of one with ADLS, resident dependent with feeding for meals.A test tray was done on Unit 1 for lunch on 12/15/25. 12:10 PM lunch trays arrived in cart on Unit 1, 12:14 PM, first tray taken off of cart. R104 was in the last room on the right of Unit 1 Hall. R104 received his tray at 12:43 PM.

Temperatures of test tray: fish 118.6 degrees, noodles 122.8 degrees, zucchini and tomatoes 120.0.An interview was conducted on 12/15/25 at 12:52 PM with OSM (other staff member) #3, the dietary manager.

When asked about the temperatures on the lunch test tray, OSM #3 stated, No, the food should be warmer. I get a lot of complaints about food temperatures.

The staff do not deliver them to residents quickly enough. On 12/15/25 at 1:10 PM an interview was conducted with R104, when asked about his lunch food temperatures, R104 stated, it was warm at best, but it was not good to eat at that temperature.On 12/17/25 at 2:00 PM ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, RN (registered nurse) #3, the assistant director of nursing, RN #4, the assistant director of nursing was made aware of the concerns.According to the facility's Timely Meal Service policy, which revealed, Food will be delivered promptly to assure safe, palatable and high-quality food served at the proper temperature.

Food will be served at preferable temperatures as discerned by the patients/residents and customary practice.No further information was provided prior to exit.