Accordius Health at Rose Manor LLC

Inspectors wroteBased on observation, record review, and interviews with residents, staff and Emergency Medical Technician (EMT), the facility failed to provide care in a safe manner when Resident #1 rolled off the bed to the floor while Nurse Aide #1 provided incontinence care for 1 of 3 residents reviewed for accidents (Resident #1).

Inspectors wroteBased on observation and staff interviews, the facility failed to implement a system to air dry all cleaned dishes. The facility also failed to follow the manufacturer's instructions for a minimum temperature of 120 degrees Fahrenheit (F) and the sanitization up to the required level of at least 50 parts per million (ppm) for three of three observations. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, record review, staff and a pest control service technician interviews, the facility failed to maintain an effective pest program that was free of roaches for 3 of 4 observations for pest control.

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of falls, gradual dose reduction (GDR), and diagnoses for 4 of 24 residents (Resident #7, Resident #9, Resident #44, and Resident #57) whose MDS assessments were reviewed. 1. Resident #7 was admitted to the facility on [DATE] with diagnoses that included falls, fracture of left radius, generalized muscle weakness, and abnormalities of gait and mobility. Review of Resident #7's progress notes revealed she sustained a fall with no injury on 10/15/24. Resident #7's care plan dated 10/15/24 revealed a focus for falls. Resident #7's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and was not coded for falls. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to close the doors to dumpsters that contained waste. This was for 2 of 3 dumpsters observed and the deficient practice had the potential to attract pests and rodents.

Inspectors wroteBased on staff and Nurse Practitioner (NP) interviews and record review, the facility failed to ensure a resident's code status information was consistent throughout the medical record for 1 of 2 residents reviewed for advanced directives (Resident #43).

Inspectors wroteBased on record review, and staff and resident interviews, the facility failed to implement their abuse policy in the area of reporting and investigating. When there was an allegation of abuse the Administrator was not immediately notified (Resident #32 and Resident #331) and an investigation was not initiated at the time of the allegation (Resident #331) for 2 of 3 residents reviewed for abuse.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II referral was resubmitted after a resident was given a new mental health diagnosis for 1 of 2 residents (Resident #44) reviewed for PASRR.

Inspectors wroteBased on record review and staff interviews, the facility failed to revise care plans in the areas of antipsychotic use, and a new mental illness diagnosis for 1 of 24 residents (Resident #44) whose comprehensive care plans were reviewed.

Inspectors wroteBased on record review, staff interviews and Nurse Practitioner (NP) interviews, the facility failed to provide supportive documentation of a newly diagnosed mental illness associated with a newly ordered antipsychotic for 1 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to apply a right-hand palm guard for 1 of 1 resident reviewed for a range of motion (Resident #15).

Inspectors wroteBased on observations, record review, Emergency Medical Service (EMS) personnel interview, and staff interview the facility failed to provide supervision to prevent a resident with severe cognitive impairment from exiting the facility unsupervised and without staff's knowledge. On 1/22/24 Resident #83 was found by EMS personnel approximately 1.9 miles from the facility seated on the ground on a sidewalk outside at 3:05 AM with icicles hanging from his nose and beard. He was treated for hypothermia by EMS and was taken to the hospital. This was for 1 of 3 residents reviewed for accidents. Immediate Jeopardy began on 1/22/24 when Resident #83 exited the facility unsupervised and without staff's knowledge. Immediate Jeopardy was removed on 1/23/24 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to provide written documentation in the medical record that advance directives information and/or opportunity to formulate an advance directive was provided or discussed with the resident or resident representative for 4 of 6 residents reviewed for advance directives (Resident #1, #11, #22 and # 49).

Inspectors wroteBased on record reviews, resident representative interview and staff interviews, the facility failed to conduct quarterly care plan meetings with cognitive residents and/or resident representatives (Resident #22 and Resident #59) and failed to revise a resident's care plan requiring 1:1 supervision for behaviors (Resident #70) for 3 of 28 residents reviewed for care planning.

Inspectors wroteBased on record review, observation and staff interviews, the facility failed to complete and document in the electronic medical record weekly assessments and measurements of a resident's pressure ulcers for 1 of 3 residents reviewed for pressure ulcers (Resident #10).

Inspectors wroteBased on record reviews, staff and Pharmacist/Pharmacist Consultant interviews, the facility failed to conduct monthly Medication Regimen Reviews (MRR) (Resident #9) and failed to maintain pharmacy recommendations from the MRR and address the pharmacy recommendations made by the Pharmacist Consultant based on monthly MRR (Resident #1 and Resident #65) for 3 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, and staff interviews the facility failed to avoid duplication of an antipsychotic medication in a resident's orders for 1 of 5 residents reviewed for unnecessary medications (Resident #9).

Inspectors wroteBased on record review and staff and resident interviews the facility failed to obtain approval from a resident group for a greater than 14-hour time span between the evening meal and breakfast the following day. This affected residents on 5 of 5 resident meal carts (Station 1 1st cart, Special Care Unit (SCU) Hall cart, Station 1 2nd cart, Station 2 1st cart, and Station 2 2nd cart).

Inspectors wroteBased on observations, record reviews, interview with Emergency Medical Service personnel, interview with a Resident Representative, interview with the Pharmacist/Pharmacist Consultant, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation survey of 5/11/21, the focused infection control and complaint investigation survey of 3/9/22, and the recertification and complaint investigation survey of 9/16/22. This was for 7 deficiencies that were cited in the areas of: [...]

Inspectors wroteBased on record review, staff and resident interviews, the facility failed to provide the Resident Council with responses regarding grievances reported in the Resident Council meeting for 1 of 3 consecutive months (December 2023).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop and implement individualized person-centered care plans in the areas of anticoagulant use and post-traumatic stress disorder for 2 of 28 residents reviewed for comprehensive care plans (Resident #91 and Resident #58).

Inspectors wroteBased on observations and staff interviews the facility failed to keep medications in a locked treatment cart for 1 of 1 treatment carts observed (Treatment Cart #1).

Inspectors wroteBased on record review and staff interviews the facility failed to provide written notice of discharge that included resident appeal rights and the contact information for the Ombudsman to the resident and/or the resident's representative for 1 of 1 resident who was reviewed for discharge (Resident #6).

Inspectors wroteBased on record review and staff interviews the facility failed to accurately code the discharge destination and tube feeding status of 2 of 28 residents reviewed for Minimum Data Set (MDS) assessments (Resident #87 and Resident #13).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete an accurate medical record related to documentation of the treatment for pressure ulcers for 1 of 3 residents reviewed for pressure ulcers (Resident #10).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to discard expired foods stored for use in 1 of 1 walk-in refrigerator; label, date food items, monitor freezer and refrigerator temperatures, and provide a resident nourishment refrigerator solely for resident's food items brought into the facility; prevent potential cross contamination of food when a staff member (Certified Occupational Therapy Aide #1) placed a leftover food tray into the enclosed meal cart that had meal trays waiting to be served to residents for 1 of 2 meal observations; monitor temperatures on the wash cycle and the temperature during a chemical solution rinse cycle for the dish machine to ensure sanitation of dishes; and ensure 3 of 4 dietary staff (Dietary Aide (DA) #1 and Regional Director of Operations) had their hair covered while observed in the kitchen area. [...]

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to maintain the dish machine in operating condition as evidenced by the temperature gauge not working during the wash and rinse cycles and failed to repair a sink allowing for draining in the kitchen area for 87 of 88 residents.

Inspectors wroteBased on observation, record review and resident and staff interviews, the facility failed to (1) complete smoking assessments on residents observed unsupervised smoking in the facility's designated smoking area (Residents #65, #70, #80, # 81), (2) failed to supervise a resident who required supervision while smoking (Resident #69) and (3) failed to secure smoking materials for a resident (Resident #81) for 5 of 5 residents reviewed for smoking. A review of the facility's provided list of smokers on day one of the survey, 09/12/22, revealed Resident #65, Resident #80, and Resident #81 were not on the list. A revised smoker's list was submitted by the facility on 09/14/2022, day 3 of the survey, which included Resident #65, Resident #80. 1. Resident #65 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure and nicotine dependence. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the 14-day time frame for 2 of 33 residents reviewed for resident assessments (Resident #19, Resident #75). Findings Included: Resident #19 was readmitted to the facility on [DATE]. On 9/12/2022, a SCSA MDS dated [DATE] indicated it was in progress and the care areas and care plan decisions were incomplete. On 9/14/2022 at 9:29 a.m. in an interview with the MDS Corporate Nurse, she stated the facility did not have a MDS nurse, and she filled in at times to complete resident MDS assessments until the facility hired someone to fill the role. She stated she realized MDS assessments were not being completed in the time frames. On 9/16/2022 at 2:28 p.m. [...]

Inspectors wroteBased on record review and staff interview the facility failed to develop and implement an individualized person-centered care plan for 2 of 24 residents reviewed for activities of daily living and indwelling catheter. (Resident #32 and Resident #29).

Inspectors wroteBased on record review, resident interview and staff interviews, the facility failed to conduct a care plan meeting for 1 of 2 residents (Resident # 29) reviewed for care planning meeting and failed to revise the care plan for 1 of 1 resident observed using oxygen by nasal cannual (Resident #137) reviewed for the use of oxygen.

Inspectors wroteBased on observations, record review, staff interviews, the facility failed to obtain a written physician's order for the use of oxygen and display cautionary signage indicating oxygen in use for 1 of 1 resident reviewed for respiratory care. (Resident #137) Findings Included: Resident #137 was admitted to the facility on [DATE], and diagnoses stage 4 chronic kidney disease and anemia. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #137 was cognitively intact and was not experiencing shortness of breath or receiving oxygen. Nursing documentation dated 8/23/2022 revealed when Resident #137 developed shortness of breath, oxygen was applied. Nursing documentation dated 9/11/2022 revealed Resident #137 continued to use oxygen at 2 liters per minute via nasal cannula. [...]

Inspectors wroteBased on record review, staff interviews, and the Pharmacy Consultant interview, the facility failed to respond to a Medication Regimen Review on the length of time for an as needed (PRN) psychotropic medication for 1 of 5 (Resident #58) residents reviewed for unnessary medications.

Inspectors wroteBased on record review, staff interviews, and the Pharmacy Consultant interview, the facility failed to obtain documentation of the rationale to extend PRN (as needed) psychotropic medication beyond 14 days and failed to have an adequate clinical indication for the use of a psychotic medication for 1 of 5 residents (Resident #47) reviewed for unnecessary medications.

Inspectors wroteBased on observations, record review, resident and staff interviews, and physician interviews the facility's Quality Assessment and Assurance Committee failed to maintain and implement procedures and monitor interventions the committee put into place following the recertification and complaint survey on 5/11/21 and the recent recertification and complaint survey on 9/16/22. This was for 1 deficiency that was cited in the area of care plan timing and revision (F657) and recited on the current recertification and complaint survey of 9/16/22. The duplicate citations during 2 federal surveys of record shows a pattern of the facilities inability to sustain an effective QAA program. Findings Included: This tag was cross-referenced to: 1. [...]

Inspectors wroteBased on record review, observation and staff interview, the facility failed to maintain a sanitary environment by having cigarette butts littered throughout the courtyard and smoking area for 1 of 1 outdoor courtyard designated for smoking. Findings Included: An observation of the facility's smoking area on 09/07/22 09:30 AM revealed 2 entrances and 2 exits. Continued observation also revealed 78 cigarette butts littered throughout the facility's courtyard. An interview with the facility's Housekeeping Director on 09/07/22 at 9:31 AM who was in the courtyard of the facility at the time of interview, revealed the housekeeping department was responsible for cleaning the courtyard area including sweeping and removing the cigarette butts and acknowledged the cigarettes butts should not be on the ground and did not have a record of when the courtyard was last cleaned. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to complete accurate Minimum Data Set (MDS) assessments in the areas of mental status and mood assessment (Resident #138), medications (Resident #40), weight (Resident #7), and hospice (Resident #75) for for 4 of 25 residents with MDS assessments reviewed.