Amelia Manor Nursing Home

Inspectors wroteBased on record review and interview, the facility failed to ensure the State Ombudsman Office was notified of a resident discharge for 1 (#87) out of 1 discharge record reviewed.

Inspectors wroteBased on record review, observations and interview, the facility failed to ensure that a resident's enteral feeding was properly labeled for 1 (#2) out of 1 (#2) sampled residents reviewed for tube feeding.

Inspectors wroteBased on observation, interview and record and policy review, the facility failed to provide respiratory care consistent with professional standards of practice, by failing to label a nebulizer tubing and mask with a date, and store the mask in a bag when not in use for 1(#5) of 1 residents investigated for respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nurse maintained infection control practices while administering wound care treatments for 1 resident (#40) out of 2 residents reviewed for wound care in a sample of 32 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure a resident's plan of care was implemented for 1 (Resident #51) out of 32 sampled residents. The facility failed to ensure Resident #51's splint was applied on her left hand.

Inspectors wroteBased on record review, interviews, and review of the facility's policy and procedure, the facility failed to ensure all allegations of injuries of unknown source with serious bodily injury was reported immediately, or within 2 hours of the allegation to the state survey agency for 1 (#1) of 4 (#1, #2, #3 and #R1) residents sampled with facility reported incidents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment accurately reflected the status of 1 (Resident #2) out of 3 (Resident #1, #2, and #3) sampled residents by failing to ensure that Resident #2 was coded correctly for the use of a wander guard.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infections as evidence by S3CNA failing to: 1. utilize the proper PPE (Personal Protective Equipment) while providing care to Resident #2 who was on Contact Precautions. 2. perform hand hygiene before entering and exiting Resident #2's room. 3. disinfect the vital sign machine and blood pressure cuff after use. The facility had a census of 88.

Inspectors wroteBased on observations, review of policy and procedure and interviews, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety by failing to follow appropriate food handling practices as evidenced by: 1. One opened package of bread on the counter not labeled with the date. 2. Food residue noted on the deep fryer and layer of oil and debris noted on the floor underneath the deep fryer. 3. Food storage: A. Walk-in cooler: 1. A container of onion mix not labeled with the date it had been prepared. 2. Two bags of ham opened and placed in a zip log bag not labeled with the date. 3. One bag of lettuce opened and not labeled with the date. 4. Four cucumbers with texture changes indicated the items were spoiled. 4. Failure to distribute food under sanitary conditions for Resident #61. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive patient-centered care plan for 2 residents (Resident # 6 and Resident # 84) out of a total sample of 30 residents.

Inspectors wroteBased on observation, interview, and policy and procedures review, the facility failed to ensure menus met the nutritional needs of the residents and were followed as evidenced by: 1. No menu posted in resident areas, in a position and in print large enough for resident to read them. 2. The kitchen staff failing to have knowledge of recipes to be followed when preparing pureed foods. This deficient practice had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs and weight loss for the 14 residents who consumed pureed diets.

Inspectors wroteBased on observation, policy review and interview, the facility failed to complete an accurate facility-wide assessment that reflected the resident population. This was evidenced by failure to address or include Mexican ethnic or cultural factors for 1(#48) out of a total sample of 30 residents. The facility's census was 92 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure consent was obtained from the Resident's Representative prior to purchasing a burial policy for a resident who did not have the mental capacity to consent for 1 (#51) out of 1 sampled residents in a final sample of 30 residents.

Inspectors wroteBased on observations and interview, the facility failed to properly label respiratory equipment for 1 resident (#6) out of 1 (#6) resident investigated for respiratory care.

Inspectors wroteBased on record review and interview the facility failed to ensure appropriate care and services had been provided for 1 (Resident #21) of 1 resident investigated for dialysis. The facility failed to ensure Resident #21 was accurately assessed and monitored for the care of his dialysis access site following dialysis.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored according to professional standards of practice as evidenced by loose pills found in the bottom of medication cart drawers for 1 (Cart B) of 2 medication carts (Cart B, Cart C ) reviewed.

Inspectors wroteBased on record review, and interview the facility failed to provide quarterly statements for resident personal funds for 1 (#1) resident out of 1 resident (#1) reviewed for personal funds.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that charges were not imposed against the personal funds of a resident for personal liability for 1 (#1) out of 5 sampled residents.

Inspectors wroteBased on record review and interview, the facility's staff failed to notify the resident's representative and/or the resident's physician of a change in the resident's condition for 1 (#1) of 5 (#1 - #5) sampled residents.

Inspectors wroteBased on record review, and interview, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 2 (#2, #4) of 5 (#1- #5) residents reviewed for ADLs. The facility failed to provide baths/showers for Resident #2, and #4.

Inspectors wroteBased on record review and interview, the facility failed to ensure appropriate nursing competencies to assure resident safety and maintain the highest practicable physical well-being for one (#1) of 5 (#1- #5) sampled residents.