Aftenro Home

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the narcotic emergency kit was tracked to prevent potential theft and diversion of medications. This had the potential to affect all residents residing on the nursing unit.

Inspectors wroteBased on interview and document review, in the absence of a full-time registered dietician the facility failed to designate a qualified person to serve as the director of food and nutrition services. This deficient practice had the potential to affect any resident in the facility.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a reliable system for identifying ingredients containing food allergens, and to ensure residents were not served items they were allergic to. In addition, the facility failed to have pre-planned menus for therapeutic diet types for 2 of 2 residents (R5, R35) reviewed for nutrition and food concerns.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure no more than 14 hours between the dinner and breakfast meals without offering a substantial snack.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure potentially hazardous food (PHF) was dated when opened and held at safe temperatures when served to residents. In addition, the facility failed to ensure expired PHF was removed from circulation, that temperature logs were complete, and that medical equipment wasn't stored with resident food. These deficient practices had the potential to affect anyone consuming food and beverages at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper measures were in place for the handling of resident and facility laundry. In addition, the facility failed to ensure residents were offered an opportunity to clean their hands prior to meals and that staff properly sanitized hands during dining services. These deficient practices had the potential to impact all residents who resided at the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide timely follow up to resident suggestions from the resident council. This deficient practice had the potential to affect any resident whose requests were brought forth at resident council.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for skin and wound care interventions for a resident at risk for and having actual pressure ulcers for 1 of 6 (R8) reviewed for pressure ulcers. The facility also failed to include interventions related to high-risk medication use for 2 of 5 residents (R4, R12) reviewed for unnecessary medications. In addition, the facility to ensure care conferences were scheduled quarterly and/or for significant changes for 1 of 1 resident (R6) reviewed for care planning.

Inspectors wroteBased on interview and record review, the facility failed to ensure all sections of the minimum data set (MDS) were completed for 2 of 4 residents (R5, R8) reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan for a resident's sensory losses and devices, including the potential for skin impairment related to devices for 1 of 3 residents (R8) reviewed for pressure ulcers. In addition the facility failed to update and incorporate significant change Minimum Data Set (MDS) triggered care areas into the comprehensive care plan for 1 of 3 residents (R6) reviewed for comprehensive care planning.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a safe smoking area, safe extinguishing of cigarettes in designated container, and monitoring of designated smoking area for 1 of 3 residents (R46) reviewed for smoking.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident maintained acceptable nutritional status when they experienced significant unplanned weight loss, despite known dissatisfaction with meals, dietary restrictions, and repeated complaints impacting intake. The facility failed to implement and revise interventions to address their nutritional needs resulting in continued weight loss and psychosocial distress for 1 of 3 residents (R5) reviewed for nutrition.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident rights provided to residents on admission and posted in the facility were up to date. In addition, the facility failed to ensure residents were provided with resident rights during their stay. This deficient practice had the potential to affect any resident in the facility.

Inspectors wroteBased on interview and document review the facility failed to have the appropriate funds available for Medicare/Medicaid residents on the evening shift and weekends for 7 of 8 residents (R42, R24, R36, R1, R21, R46, R13) reviewed for personal funds. This had the potential to affect 39 residents who had funds held by the facility in a trust account.

Inspectors wroteBased on interview and record review the facility failed to develop an infection prevention control program with an annual review that included written standards, policies and procedures that included when and to whom possible incidents of communicable disease or infections should be reported, when and how transmission-based precautions (TBP) and enhanced barrier precautions (EBP) should be implemented to prevent infections, and hand hygiene procedures to be followed by staff involved in direct resident care. This had the potential to affect all 54 residents who reside in the facility.

Inspectors wroteBased on interview and document review, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment. This deficient practice had the potential to affect all residents in the facility who used a bed.

Inspectors wroteBased on interview and document review, the facility failed to ensure a comprehensive, person-centered care plan was developed, accurate, and revised to assure assessed care needs were implemented for 2 of 2 residents (R32, R17) reviewed for care planning.

Inspectors wroteBased on interview and document review, the facility failed to comprehensively reassess and develop interventions to reduce/prevent continued weight loss for 1 of 3 residents (R19) reviewed for nutrition and weight loss.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 6.7 percent with 2 errors out of 30 opportunities for error involving 2 of 5 residents (R50, R22) who were observed during the medication passes.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure therapeutic diets per physician's orders were followed for 2 of 2 residents (R1, R32) reviewed for therapeutic diets.

Inspectors wroteBased on interview and document review the facility failed to submit complete and accurate direct care staffing information, including information for agency and contract staff, during 1 of 1 quarters (Quarter 3: April 1 - June 30, 2023), reviewed for payroll based journal (PBJ).

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store a portable oxygen tank for 1 of 1 resident (R9) who utilized oxygen. R9's significant change Minimum Data Set (MDS) dated [DATE] indicated that R9 had moderately impaired cognition. R9's diagnoses included chronic obstructive pulmonary disease, shortness of breath and chronic systolic (congestive) heart failure. On 10/23/23 at 3:08 p.m., a portable oxygen tank, with regulator attached, was freestanding next to the heating vent near the window in R9's room. Portable oxygen tank was not stored in a secure cart. On 10/24/23 at 11:30 a.m. and 2:29 p.m., portable oxygen tank remained in same location, freestanding and not secured. On 10/24/23 at 11:55 a.m., nursing assistant (NA)-A stated portable oxygen tanks should be stored in the oxygen room. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure pharmacist consultant monitored facility's ongoing psychotropic side effect monitoring for 3 of 5 residents (R26, R9, R42) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents were routinely assessed for tardive dyskinesia were collected to allow adequate monitoring of potential side effects for physician ordered antipsychotic medications for 3 of 5 residents (R26, R9, R42) reviewed for unnecessary medication use.