Achieve Rehabilitation and Nursing Center

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Baseline Care Plan included required information related to the resident's tracheostomy status for 1 of 1 residents,(R)1 reviewed for baseline care planning. In addition, the facility did not have a policy or procedure addressing the development of baseline care plans. This failure had the potential to result in unmet care needs.

Inspectors wroteBased on review of facility policy, observation, record review and interview, the facility failed to ensure Resident (R)1 was free from misappropriation of a narcotic medication for 1 of 4 residents reviewed for misappropriation.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to accurately document Resident (R)110's wishes to be a full code; and failed to periodically review code statuses for R110, for 1 of 36 sampled residents reviewed for code status. This failure placed the resident at risk of not receiving life saving measures. On [DATE] at 8:56 PM, the Administrator was notified that the failure to accurately reflect a residents code status in the medical record, in accordance with the resident's wishes, constituted Immediate Jeopardy at F578. On [DATE] at 8:56 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.10 - Resident Rights. On [DATE] at 6:39 PM, the facility provided an acceptable plan for removal of the IJ. [...]

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure sanitizer was at a strength to sanitize the counters; ensure pans, utensils, equipment, and food preparation counters were clean and sanitized; ensure food was labeled and dated and disposed of by the use by date; ensure food was refrigerated after opening in accordance with the manufacturer's instructions; ensure hand washing between touching soiled objects and returning to serving; and ensure the outside of food and spice containers were clean with the potential to affect 151 of 157 census residents consuming food out of 1 of 1 kitchen. Failure to store, prepare, and distribute under sanitary conditions had the potential to result in cross contamination of food and food borne illness.

Inspectors wroteBased on observation and interview, the facility failed to ensure the laundry room equipment was clean, which included two large washing machines, six dryers, one fan, the windowsill, items lying directly on the floor or in a plastic bag on the floor, and a dusty laundry chute for 1 of 1 laundry room.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure a clean, comfortable, homelike environment related to the rooms and common areas not being maintained in clean conditions for 3 of 4 units (100 unit, 200 unit, and 300 unit). Failure to maintain a clean homelike environment has the potential to result in resident dissatisfaction with their living conditions and increased depression.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure the menu was followed for 2 of 2 residents, who wish to remain anonymous, of 36 sample residents. Failure to follow the menu had the potential to result in weight loss, resident dissatisfaction, and resident hunger with the potential to affect 151 of 157 residents consuming food in the facility.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to maintain all electrical outlets in safe operating conditions for 4 of 4 resident rooms and 7 of 7 residents (Resident (R)68, R39, R54, R15, R82, R11, and R7) reviewed of 36 sample residents. Failure to ensure residents had functioning outlets in their rooms resulted in the residents not being able to watch their televisions, charge their devices, or run their refrigerators. Failure to ensure the outlet covers are not in disrepair exposing the wires had the potential to result in shock of a resident or employee.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to provide care and services in a manner that maintained and promoted dignity which included ensuring the privacy curtain was pulled closed, for 1 of 1 resident, (Resident (R)123), reviewed for resident rights. This failure placed residents at risk for diminished self-worth, self-esteem, and feelings of embarrassment.

Inspectors wroteBased on record review and interview, the facility failed to provide the Advanced Beneficiary Notice of Non-Coverage (ABN) and the Notice of Medicare Non-Coverage (NOMNC) to 1 of 2 residents (Resident (R)136) reviewed for Beneficiary Notification of 36 sample residents. This failure had the possibility to negatively impact residents due to them not being aware that they no longer had coverage for their stay under Medicare Part A.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to provide appropriate Activities of Daily Living (ADLs) for residents to maintain adequate personnel hygiene for 2 of 2 residents (Resident (R)145 and R115) reviewed for ADLs of 36 sample residents.

Inspectors wroteBased on facility policy review, observations, interviews, and record review, the facility failed to provide a consistent activities program for residents on the secure/dementia care unit for 1 of 4 residents (Resident (R)116) and failed to provide activities of choice for 1 of 1 resident (R75) reviewed for activities of 36 sample residents. The failure to provide an activities program in a behavioral health unit can exacerbate behaviors due to boredom and negatively impact their psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow physician's orders for compression wrap for 1 of 1 resident (Resident (R)33) reviewed for edema of 36 sample residents. This failure had the potential to negatively affect R33's diagnosed undated circulatory deficits.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that residents who were dependent on staff for restorative nursing received range of motion, a carrot to the left hand, and/or a wedge to the leg for positioning, as ordered by the Physician for 2 of 3 residents (Resident (R)115 and R71) reviewed for restorative services of 36 sample residents. This failure has the potential for other residents to be at risk for decreased range of motion, worsening of their contracture, and/or increased edema.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain acceptable nutritional parameters by not monitoring weights, implementing interventions, and monitoring meal intake for 1 of 2 residents (Residents (R)123) reviewed for nutrition of 36 sample residents. This had the potential to cause further weight loss without a root cause analysis and/or additional interventions put in place.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure residents received oxygen via nasal cannula, according to the physician's order, and that oxygen supplies were stored appropriately when not in use for 2 of 2 residents (Resident (R)400 and R87) reviewed for oxygen administration of 36 sample residents. Additionally, the facility failed to ensure 1 of 1 resident (R71) had physician orders for oxygen administration of 36 sample residents. This failure had the potential for the residents to receive increased oxygen causing hyperoxia (cells, tissues and organs are exposed to an excess supply of oxygen).

Inspectors wroteBased on record review and interviews, the facility failed to ensure the medical record accurately and completely reflected the physician's orders for 1 resident (Resident (R) 44) reviewed for medical records of 36 sample residents. Failure to accurately and completely document physician's orders had the potential in this resident not receiving needed care.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure staff conducted and maintained documentation of a thorough investigation of a staff-to-resident abuse allegation for 1 (Resident #3) of 7 residents reviewed for abuse.

Inspectors wroteBased on the review of the facility policy, observations, and interview, the facility failed to ensure that Resident (R)1 was free from elopement from the facility on February 27th, 2024, at approximately 5 PM. On 03/06/2024 at 4:11 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 03/06/2024 at 4:11 PM, the survey team provided the Administrator and Interim Director of Nursing with a copy of the CMS Immediate Jeopardy (IJ) Template at F689 related to 42 CFR 483.25 - Quality of Care, Informing the facility IJ existed as of 02/27/2024 for failure to ensure that Resident (R)1 was free from elopement from the facility on February 27th, 2024, at approximately 5 PM. [...]

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility failed to administer medications according to medication practices for 1 of 1 Resident, Resident (R)2. R2 was given his medications whole versus crushed and the nurse did not observe the resident while administering the medications. On 03/06/2024 at 4:11 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. [...]

Inspectors wroteBased on record review, interview and facility policy, the facility failed to review and revise the comprehensive care plan for 2 of 11 residents reviewed, Resident (R)2 and R10.

Inspectors wroteBased on record review and interview, the facility failed to follow physicians orders related to Ileostomy care for 1 of 1 resident reviewed, Resident (R)10.

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility failed to record narcotic medication on the Medication Administration Record (MAR) as given for 1 of 11 records reviewed. Resident (R) 11 had inaccuracies on their MAR.

Inspectors wroteBased on observation and interview, the facility failed to secure a medication cart for 1 of 4 units.

Inspectors wroteBased on review of facility policy, interview and record review, the facility failed to provide adequate supervision to prevent an elopement. Specifically, on 12/12/23 at approximately 8:30 AM, Resident (R)1 was found by police at a gas station approximately 3.7 miles from the facility. This failure placed R1 at risk for severe harm and/or death due to cold exposure, dehydration and/or other medical complications, or being struck by a motor vehicle. On 12/14/23 at 3:15 PM, the Administrator and the Director of Nursing were notified that the failure to prevent the elopement of Resident (R)1 constituted Immediate Jeopardy (IJ) at F689. On 12/14/23 at approximately 3:15 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 12/12/23. [...]

Inspectors wroteBased on review of the facility policy titled, Medication Storage, observations, and interviews, the facility failed to ensure expired medications were removed from storage with resident medications that were in use in 3 of 4 treatment carts. The facility further failed to ensure a red, sticky, dried substance and a cookie were not in the locked refrigerator in 1 of 3 medication rooms reviewed.

Inspectors wroteBased on record reviews, interviews, and review of the facility policy titled, Resident Assessment - Coordination with PASARR Program, the facility failed to ensure Resident (R)10 with a new diagnoses of Schizophrenia was screened for specialized services in a timely manner for 1 of 2 residents identified with a new diagnosis of a mental illness.

Inspectors wroteBased on observation, interviews and review of the facility policy titled, Flushing a Feeding Tube, the facility failed to ensure placement and residual was verified prior to administering a water flush and a bolus feeding for Resident (R)47, for 1 of 1 residents reviewed for tube feeding.

Inspectors wroteBased on observations, interviews, record review and review of the facility policy titled, Insulin Pen, the facility failed to ensure a medication error rate of less than 5 percent (%) during medication administration. The medication error rate was 12% during medication administration, for 3 of 25 opportunities for error. The residents observed were Resident (R)57, R50 and R87.

Inspectors wroteBased on observations, interviews, record review and review of the facility policy titled, Insulin Pen, the facility failed to ensure 3 residents (R) 57, R50 and R87 were free from significant medications errors as evidenced by incorrect administration of an Insulin Pen during the observations of medication pass. Cross F759. Findings Include: Review of the facility policy titled, Insulin Pen, revised January 2023, states, It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. The Policy Explanation and Compliance Guidelines states under number 6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. Number 11, Procedure, Attach pen needle: [...]

Inspectors wroteBased on a random observation and interviews, the facility failed to ensure Licensed Practical Nurse (LPN)2 followed a procedure during wound care to prevent infection and to provide privacy to 1 of 1 residents observed receiving wound care in the hallway at the nurses' desk on Unit 400.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain a comfortable, homelike environment for Residents #60 and #26, 1 of 1 sampled residents reviewed with a urinary catheter and 1 of 32 Initial Pool residents reviewed for environmental concerns. Resident #60 had a leaking urinary catheter and their room had a strong urine odor. Resident #26's bed was in disrepair.

Inspectors wroteBased on observation, record review and interview, the facility failed to review and revise Resident #60's care plan due to a leaking urinary catheter, 1 of 1 sampled residents reviewed with a urinary catheter. Record review and interview revealed the catheter had been leaking for several months and had not been addressed on the care plan.