Amelia Rehabilitation and Healthcare Center

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to protect the resident's right to be free from financial exploitation for one resident (Resident #2) in a survey sample of fourteen residents.

Inspectors wroteBased on staff interviews and clinical record review, the facility staff failed to ensure that basic life support, including cardio-pulmonary resuscitation (CPR), was initiated to a resident. This resulted in a failure to adhere to the resident's specific advance directive and code status for one of 14 residents in the survey sample, Resident #1 (R1).

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to ensure all staff received mandatory training on effective communication for six of six employees reviewed for training (RN #1, LPN #6, CNA #5, 6, 7, and 8).

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to ensure part of the facility's Quality Assurance and Performance Improvement (QAPI) program included training to facility staff on the program elements and goals for six of six employees reviewed (licensed practical nurse #6- LPN 6, registered nurse #1-RN 1, and certified nursing assistants #5, 6, 7, and 8).

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to take measures to protect the resident from an alleged perpertrator who financially abused the resident while an investigation was being conducted for one resident (Resident #2-R2) in a survey sample of 14 residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and implement a comprehensive resident centered care plan for two of fourteen residents (Resident #1-R1 and Resident #11-R11).

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to review and revise the care plan for one resident (Resident #8-R8) in a survey sample of 14 residents.

Inspectors wroteBased on staff interviews and facility document review, the facility failed to ensure RN (registered nurse) coverage included 8 (eight) consecutive hours for 2 (two) days of the past 30 (thirty) days on 2 (two) of 2 (two) units, (4/24/26, 4/30/26).

Inspectors wroteBased on staff interview and staff record review, the facility staff failed to ensure two of six employees had trianing on infection control (certified nursing assistants #6 and #8).

Inspectors wroteBased on staff interview and staff record reviews, the facility staff failed to ensure that staff were trained in compliance and ethics for two of six staff sampled (Certified nursing assistant #7- CNA 7 and certified nursing assistant #8- CNA 8).

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide written notice, including the reason for the change, prior to a room transfer for three of five residents reviewed, Resident #1, Resident #3 and Resident #4.

Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to develop a policy for monthly medication regimen reviews with times frames for the different steps in the process, including identifying the time frame in which the physician/nurse practitioner should respond to the recommendations from the consulting pharmacist for five of five residents included in the unnecessary medication reviews, Residents #71, #17, #22, #32, and #5.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician of a potential need to alter treatment for one of 42 residents in the survey sample, Resident #20.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for eight of 42 residents in the survey sample; Residents #12, #78, #90, #17, #73, #20, #5, and #62.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to monitor residents weights per physician's orders for six of 42 residents in the survey sample; Residents #12, #78, #90, #17, #73, and #5.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to evidence communication with the dialysis center for one of one residents receiving dialysis services, Resident #82.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for one of 42 residents in the survey sample, Resident #20.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in one of one facility kitchens.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide complete and accurate documentation for two of 42 residents in the survey sample, Resident #301 and Resident #45.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide a dignified dining experience for one of 42 residents in the survey sample, Resident #16.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to evidence the required clinical documents were sent to the hospital for a facility-initiated transfer for three of 42 residents in the survey sample, Residents #82, #32, and #5.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to notify the State Long-Term Care Ombudsman of a facility initiated transfer for one of 42 residents in the survey sample, Resident #82.

Inspectors wroteBased on staff interview and clinical record review it was determined that the facility staff failed to ensure an accurate MDS (minimum data set) assessment for one of 42 residents in the survey sample, Resident #98.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide adequate respiratory care and services for three of 42 residents in the survey sample, Residents #77, #71, and #62.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from unnecessary psychotropic medications for one of 42 residents in the survey sample, Resident #71.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow infection control procedures during medication administration for two of four residents in the survey sample, Residents #60 and #88.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to conduct regular bed inspections for two of 42 residents in the survey sample, Residents #16 and #32.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for one of five residents in the survey sample, Resident #1.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to monitor a resident's urine output as ordered by the physician for one of five residents in the survey sample, Resident #1.

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to evidence written documentation to the Resident or RP (responsible party) upon transfer for six out of 36 residents in the survey sample who were transferred to the hospital; Residents #18, #71, #69, #81, #17 and #36.

Inspectors wroteBased on clinical record review and staff interview, the facility staff failed to evidence completion of a level 1 PASRR (preadmission screening and resident review) for 5 of 36 residents in the survey sample, Residents #11, #90, #81, #20, and #64.

Inspectors wroteBased on resident interview, resident representative interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to provide adequate bathing for 2 of 36 residents in the survey sample, Residents #57 and #29.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide care and service for a complete dialysis program for one of 36 residents in the survey sample, Resident # 59 (R59). The facility staff failed to provide dialysis communication forms for R59 and the dialysis center on 03/02/2022, 03/04/2022, 03/07/2022, 03/09/2022, 03/11/2022, 03/14/2022, 03/16/2022, 03/18/2022 and on 03/21/2022.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to store and prepare food in a sanitary manner in one of one facility kitchens, and on one nursing unit.

Inspectors wroteBased on observation, resident interview and staff interview, the facility staff failed to provide a homelike environment for one of 36 residents in the survey sample, Resident # 64. The facility staff failed to clean a black substance on the floor around the base of the sink and the wall behind and to the right of the sink and failed to repair a hole in the wall behind R64's head-of the-bed.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services for 1 of 36 residents in the survey sample, Resident #191. The facility staff failed to administer oxygen to Resident #191 (R191) per the physician prescribed rate of two liters per minute.

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to post daily staffing for one of three days reviewed.

Inspectors wrote2. While using a Hoyer lift (1) to transfer Resident # 17, the facility staff failed to follow the recommended procedures, Resident # 17 fell from the lift and sustaining a head injury, and was sent to a local hospital. Resident # 17 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia (2), diabetes mellitus (3), and cerebral infarction (4). Resident # 17's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/07/18, coded Resident # 17 as scoring a 11 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15 - being moderately impaired of cognition for making daily decisions. Resident # 17 was coded as requiring extensive assistance of one staff member for activities of daily living and independent with eating, totally dependent of two staff members for transfers. [...]

Inspectors wroteBased on observation, staff interview, and facility documentation review, it was determined that the facility staff failed to serve food in a dignified manner in two of one facility dining rooms, (main dinning room); and for three of 45 sampled residents, (Resident #501, #39 and #50). 1. During a meal observation in the main facility dining room on 4/2/19 residents were observed being served and eating the lunch meal on trays cafeteria style and not in a homelike dining manner. 2. The facility staff failed to ensure a dignified dining experience during the lunch meal on 4/2/19. Resident #501 was observed seated at a table waiting approximately eleven minutes for her lunch meal to be served, while her tablemate's and other residents were eating their lunch meal. 3. [...]

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to implement the abuse policies for reporting allegations of abuse for four of 47 residents in the survey sample, Residents #63, #146, #53 and #16. 1. The facility staff failed to implement their policies for reporting Resident #63's allegation of abuse within 2 hours to the state agency and other required agencies. On 12/28/18, Resident #63 informed the facility staff of the allegation of abuse, and the facility staff failed to report the allegation to the state agency until 1/2/19. 2. The facility staff failed to implement their abuse policies and procedures for a resident-to-resident incident between Resident #146 and Resident #53. [...]

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to report allegations of abuse immediately, but not later than 2 hours and/or failed to report to the state agency the final findings of an investigation for four residents in the survey sample, Residents #63, #146, #16, #53 and #2. 1. The facility staff failed to immediately (or within 2 hours) report, Resident #63's allegation of abuse to the state agency and to other officials in accordance with State law through established procedures. On 12/28/18, Resident #63 informed the facility staff of the allegation of abuse, and the facility staff failed to report the allegation to the state agency until 1/2/19. 2. [...]

Inspectors wrote6. The facility staff failed to evidence that Resident # 36's comprehensive care plan goals were sent with the resident to the hospital for the transfer dated 12/31/18. Resident # 36 was admitted to the facility on [DATE] with the most recent readmission date of 01/03/19. His diagnoses included but were not limited to acute bronchitis (1), hypertension (2), and umbilical (belly button area) hernia (3). Resident # 36's most recent Minimum Data Set (MDS) assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 02/01/19. The Brief Interview for Mental Status (BIMS) coded Resident # 36 as scoring a 11 on BIMS of a score of 0 - 15, 11 - indicating moderately impaired for making daily decisions. A review of Resident # 36's clinical record was conducted on 04/04/19. [...]

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to ensure expired medications were not available for use in two of two medication carts, (South Back Unit medication cart and the facility's North Front Unit medication cart). The facility staff failed to ensure four expired inhalers, three Advairs (1) and one Flovent (2) were not available for use on two of two medication carts.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to store and serve food in a sanitary manner in one of one facility kitchen. 1. An unopened three pound bag of an unlabeled item reported to be 'ginger liver' by OSM (other staff member) #1 was observed stored in the freezer without manufacturer expiration date, or use-by-date and no labeling of the contents on the bag. 2. The facility staff failed to maintain the food mixer in a sanitary manner in the facility kitchen.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure accommodation of resident needs and preferences for one of 47 residents in the survey sample, Resident #64. The air mattress box located on the footboard of Resident #64's prevented Resident #64 from independently accessing her nightstand and bathroom.

Inspectors wroteBased on resident interview, staff interview and facility document review it was determined that the facility staff failed to provide prompt delivery of the resident's postal mail and the facility staff failed to protect the resident's private information for two of six residents in the medication observation, Resident #73 and Resident #23. 1. The facility staff failed to maintain postal mail delivery for the residents on Saturdays. During the Group Resident meeting, residents stated they did not receive mail on Saturdays. 2. The facility staff failed to protect Resident #73's private information during medication administration. LPN (licensed practical nurse) #1 left a box of medication on the top of the medication cart unattended with Resident #73's name on the label, visible to anyone who may have passed by the medication cart. 3. [...]

Inspectors wroteBased on staff interview, facility document review ad clinical record review, it was determined the facility staff failed investigate an allegation of abuse and failed to protect residents during an investigation for three of 47 residents in the survey sample, Residents #63, #146 and #53. 1. The facility staff failed to ensure Resident #63 and other residents were protected during the investigation of Resident #63's allegation of abuse. The employee, LPN (licensed practical nurse) #11 named in the allegation was not suspend, and worked on 12/31/18, during the investigation. 2. The facility staff failed to investigate an allegation of abuse between Resident #146 and Resident #53.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide written notification to the ombudsman of a facility initiated transfer for one of 47 residents in the survey sample, Residents # 3. The facility staff failed to notify the ombudsman when Resident # 3 was transferred to the hospital on [DATE].

Inspectors wroteBased on staff interview, facility document review and clinical record, it was determined that the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 47 residents in the survey sample, Resident # 34. The facility staff failed to accurately code Resident # 34's 14-Day MDS (minimum data set), assessment with an ARD (assessment reference date) of 03/23/19, for a pressure ulcer.

Inspectors wroteBased on observation, staff interview, and facility record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for three of 47 residents in the survey sample, Residents #2, #60, #45, and #83. 1. The facility staff failed to implement the comprehensive care plan for a physician ordered treatment for Resident #60. 2. The facility staff failed to implement the care plan for when a resident has behaviors for Resident #45. On 12/8/18 the facility staff only attempted the intervention of redirection and failed to implement other intervention identified on the care plan for her behaviors 3. The facility staff failed to implement Resident # 83's comprehensive care plan for the administration of oxygen to the resident as ordered.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that facility staff failed to review or revise the care plan for one of 47 residents in the survey sample, Resident # 3. The facility staff failed to update Resident # 3's comprehensive care plan concerning a fall on 03/08/19.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one resident (Resident #60) of 47 sampled residents, received the care and services in accordance with professional standards and the comprehensive care plan. The facility staff failed to administer a treatment to Resident #60 per the physician orders.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review it was determined that the facility staff failed to provide the necessary treatment and services, consistent with professional standards of practice, to promote the healing pressure ulcers for one of 47 residents in the survey sample, Resident #83. The facility staff failed to ensure weekly measurements were completed to assess and monitor the healing of Resident #83's multiple pressure ulcers.

Inspectors wroteBased on observation, staff interview, facility policies review, and clinical record review, it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice, and the comprehensive person-centered care plan for one of 47 residents in the survey sample, Resident # 83. The facility staff failed to administer Resident # 83's oxygen according to the physician's orders.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one resident (Resident #45) of 47 sampled residents were free of unnecessary psychotropic medications. The facility staff restarted an antipsychotic medication without proper indications for Resident #45.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow infection control practices for one of 47 residents in the survey sample and for one of six residents in the medication administration observation, (Resident #23), and in one of one facility dining rooms, (main dining room). 1. The facility staff failed to follow infection control practices during a wound are observation for Resident # 34. 2. The facility staff popped Resident #23's pills into a gloved hand that had just touched the medication cart and then administered the medication to Resident #23. 3. The facility staff failed to serve food to the residents in a sanitary manner during a dining room observation. Staff were observed touching the food surface of plates that were then served to residents.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to maintain the dumpster area in a sanitary manner.