Acadia Center for Nursing and Rehabilitation

Inspectors wroteBased on observations, record review, and interviews, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that included measurable objectives and timeframes to meet each resident's medical and nursing needs. This was identified for two (Resident #94 and Resident #122) of four residents reviewed for Accident Hazards. Specifically, 1) Resident #94 had a physician's order for bilateral floor mats when in bed. On multiple observations Resident #94 was observed in bed without the use of the floor mats. 2) Resident #122 was admitted to the facility on [DATE] with Cholecystostomy tube (a catheter that is placed through the skin directly into the gallbladder to drain trapped fluids), and there was no documented evidence that a care plan was initiated for the use and care of the Cholecystostomy tube.

Inspectors wroteBased on observations, record review, and interviews, during the recertification survey initiated on 9/11/2024 and completed on 9/18/2024, the facility did not ensure that food was stored in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, expired and opened containers of food were observed in the refrigerator; The freezer was observed with frozen food products out of their original packaging with no label or date. Additionally, stored dry goods were unlabeled and undated in the basement dry storage area. The finding is: An undated facility policy titled Food Storage documented foods received shall be properly stored to maintain high quality and sanitary conditions. Items may be utilized until the date of expiration, based on the production date and item shelf life. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 9/11/2024 and completed on 9/18/2024, the facility did not ensure medications were properly stored in medication carts. This was identified for two (Unit A and Unit C) of four units reviewed during the Medication Storage Task. Specifically, loose unidentifiable medications were observed in medication carts in Unit A and Unit C; residents' hearing aids, hearing aid batteries, and nail clippers were stored in medication carts in Unit A and Unit C; and the Unit C Medication Storage Room refrigerator had a dried pink substance spilled on the refrigerator shelf.

Inspectors wroteBased on record review and interview during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that admission and Annual Minimum Data Set (MDS) assessments were completed within 14 calendar days after admission and not less than once every 12 months for 13 (Resident #4, #9, #22, #26, #59, #71, #73, #86, #94, #95, #98, #106, and #107) of 19 residents reviewed for Resident Assessment. Specifically, three (Resident #86, #106 and #107) of 19 Residents did not have an admission MDS completed within 14 calendar days of admission and 10 (Resident #4, #22, #26, #59, #71, #73, #94, #95, and #98) of 19 had an Annual MDS assessment completed less than once every 12 months. [...]

Inspectors wroteBased on record review and interview during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that Quarterly Minimum Data Set (MDS) assessments specified by the state and approved by the Center for Medicare and Medicaid Services (CMS) were completed not less frequently than once every 3 months for 19 (Resident #4, #9, #22, #25, #26, #48, #55, #59, #61, #71 #73, #79, #86, #90, #94, #95, #98, #106, and #107) of 19 residents reviewed for Resident Assessment. Specifically, the facility did not complete Quarterly Minimum Data Set Assessments at least every 92 days following the previous assessment for all 19 Residents sampled for Resident Assessment. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that resident who need respiratory care, is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #224) of two residents reviewed for oxygen. Specifically, Resident #224 had a Physician's order for continuous oxygen at two liters per minute via a nasal cannula (tubing used to deliver supplemental oxygen). On two separate occasions, the resident was observed not receiving oxygen therapy as prescribed by the resident's Physician. The finding is: [...]

Inspectors wroteBased on observation, interviews, and record reviews during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was identified for one (Resident #64) of two residents reviewed for Pain Management. Specifically, during the medication administration observation task on 2/1/2023 for Resident #64, the resident complained of inadequate pain control to Licensed Practical Nurse (LPN) #2 medication nurse; however, there was no documented evidence that this was reported by the nurse to the resident's Physician until the next day (2/2/2023). [...]

Inspectors wroteBased on observations, record review and interviews conducted during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that each resident was free from significant medication errors. This was identified for one (Resident #271) of five residents reviewed for Unnecessary Medication. Specifically, Resident #271 had a Physician's order for Midodrine (medication used to treat low blood pressure) with Blood Pressure (BP) parameters to hold the medication if the systolic BP was greater than 110 Millimeters of Mercury (mmHg). The facility staff administered Midodrine on one occasion to Resident #271 when the medication was supposed to be held and held the medication twice when the medication was supposed to be administered. The finding is: The Policy and Procedure for Medication Administration: [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023 the facility did not ensure that an infection prevention and control program was established to maintain a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #272) of four residents observed for medication administration. Specifically, during the medication pass observation, Licensed Practical Nurse (LPN) #1, the medication nurse, did not wear appropriate Personal Protective Equipment (PPE) while administering medications for Resident #272, who was on contact and droplet precautions for Respiratory Syncytial Virus (RSV), and was observed coughing. [...]

Inspectors wroteBased on observation, record review and staff interviews during the Recertification survey, the facility did not ensure that each resident had a person-centered Comprehensive Care Plan (CCP) developed to address the resident's medical and nursing needs. This was identified for two (Resident #134 and Resident #77) of two residents reviewed for restraints. Specifically,1) Resident #134 did not have a CCP developed for the use of a bed alarm; and 2) Resident # 77 did not have a CCP developed for the use of a chair alarm.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey, the facility did not ensure that residents receive treatment and care in accordance with professional standards and the comprehensive person-centered care plan. This was identified for one (Resident #13) of two residents reviewed for dignity and one (Resident #99) of one resident reviewed for skin condition. Specifically, 1) Resident #13 had an order for Silvadene 1% topical cream which was initiated for a buttocks rash. There was no documented evidence that an assessment of the change in the resident's skin condition was completed by a Registered Nurse (RN) or a Physician and there was no documented evidence that a Comprehensive Care Plan (CCP) was developed for the change in the resident's skin condition; [...]