Ashland Place Health and Rehabilitation, LLC

Inspectors wroteBased on observation and interview the facility failed to ensure 21 cups of expired yogurt were not left in the cooler. This had the potential to affect 21 of 21 residents to receive the yogurt. Findings Include: On 1/21/20 at 1:37 PM, during the initial tour of the kitchen the surveyor observed in the walk in cooler 21 cups of yogurt which had expired on [DATE]. On 1/23/20 at 8:36 AM, an interview was conducted with Employer Identifier (EI) #5 Dietary Manager. EI #5, was asked, what did they see on 1/21/20 that had expired. EI #5 replied, the yogurt was expired. EI #5 was asked, how often were the dates checked on foods items. EI #5 replied, daily in the am and pm. EI #5 was asked, was the date on the yogurt expired, EI #5 replied, yes. EI #5 was asked, what was the facility policy on expired foods. EI #5 replied, report it to dietary manger and throw it away immediately. [...]

Inspectors wroteBased on observation, interviews, and a review of the facility's Resident Rights, the facility failed to ensure staff did not stand to feed Resident Identifier (RI) #77 the supper meal on 1/21/20. This affected one of three residents observed being fed by staff. Findings Include: A review of the facility's Resident Rights revealed . Resident Rights (a) Resident Rights. The resident has the right to a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility. (e) Respect and dignity. The resident has a right to be treated with respect and dignity, . RI #77 admitted to facility on 12/2/19 with a diagnosis to include Dementia with behavioral disturbance. [...]

Inspectors wroteBased on observations, interviews, and a review of the facility's policies titled, Food Receipt and Storage and Hand-washing Guidelines, the facility failed to ensure honey thickened milks were discarded before the expiration date. The facility also failed to ensure (Employee Identifier) EI #4, a Dietary Aide, washed her hands to prevent cross contamination after putting her hands in her pocket, touching her jacket and picking up a dirty dish off the floor prior to handling the clean dishes. This deficient practice had the potential to affect 122 of 122 residents who received meals from the kitchen. Findings Include: A review of a facility policy titled, Food Receipt and Storage with an effective date of August 23, 2017, revealed: .PURPOSE: Foods should be received and stored properly to prevent food borne illnesses .PROCESS .II. Storage of Foods .e. [...]

Inspectors wroteBased on observation, group interview, staff interview and a review of the Resident Handbook, the facility failed to ensure residents in the group meeting held on 11/28/18 were aware of the survey results and where they were located in the facility. The facility further failed to ensure there were signs posted in the facility indicating the location of the survey results. This deficient practice affected all 10 residents in the group meeting and had the potential to affect all 134 residents who resided in the facility. Findings Include: A review of the Resident Handbook, pages 8-11 documented: .Resident Rights .(g)(1) Information and communication .(g)(10) The resident has a right to .Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; . [...]

Inspectors wroteBased on observations, interviews and a review of a facility policy titled, Federal Rights of Resident/Guest(s) and a form titled, .JOB DESCRIPTION, the facility failed to ensure residents' rooms and common areas were maintained to provide a safe, clean, comfortable homelike environment. The deficient practice affected Room Locator (RL) #'s 1-24, on three of four units and two resident common areas in the facility and had the potential to affect all 134 residents residing in the facility. Findings Include: A review of a facility policy titled, Federal Rights of Resident/Guest(s), with an effective date of November 28, 2016, revealed: .PURPOSE: All resident/guest(s) in long term care facilities have rights guaranteed to them under Federal and State law. STANDARD: .(i) Safe environment. The resident/guest has a right to a safe, clean, comfortable and Homelike environment, . [...]

Inspectors wroteBased on interview and a review of a facility document titled, Facility Assessment, the facility failed to evaluate and identify areas of the environment needing to be maintained. This deficient practice had the potential to affect all 134 residents residing in the facility. Findings Include: Cross Reference F584. A review of a document titled, Facility Assessment, dated 11/19/18, revealed the following: .The following criteria were examined and evaluated by our team . Physical environment .considerations necessary for resident population. Equipment necessary for resident population . During the recertification the survey team identified multiple environmental concerns including: missing floors tiles, rusted doorframes, rusted bathroom sinks, broken bathroom fixtures, peeling paint, dirty and wax build up on floors, broken closet doors, broken furniture and other environmental concerns. [...]

Inspectors wroteBased on interviews, record reviews, and a review of a facility policy titled, Federal Rights of Resident/Guest(s), the facility failed to ensure privacy was provided while a resident used the phone. This affected RI (Resident Identifier) #1, one of five residents that were individually interviewed. Findings Include: A review of the Facility's Policy & Procedure titled Federal Rights of Resident/Guest(s) with an effective date of November 28, 2016 revealed: .PURPOSE: . (g)(1) Information and communication . All resident/guest(s) in long term care facilities have rights guaranteed to them under Federal and State law. (g)(6) The resident/guest has the right to have reasonable access to the use of a telephone ., and a place in the facility where calls can be made without being overheard. This includes the right to retain and use a cellular phone at the resident/guest(s) own expense. [...]

Inspectors wroteBased on observations, interviews, record review, and a review of a facility policy titled, Privacy Upon Entering Resident's Room, the facility failed to ensure staff knocked on residents' door prior to entering the room. This affected RI (Resident Identifier) #s 3, 17, and 19, three of 127 residents residing in the facility. Findings Include: A review of the facility's Policy and Procedure titled Privacy Upon Entering Resident's Room with an effective date of November 6, 2014 revealed: . PURPOSE: The resident has the right to privacy and confidentiality. STANDARD: Resident right to privacy will be honored. PROCESS: 1. Prior to entering Resident's room, knock on door and ask permission to enter. 2. If resident able to respond, await permission to enter. 3. If resident unable to respond, announce entrance. [...]

Inspectors wroteBased on an observation, interviews, record reviews, and a review of the facility policy titled, Diet Orders, the facility failed to ensure the Physician's diet order was followed. No meat was served at a breakfast meal for RI (Resident Identifier) #2. This affected RI #2, one of twelve residents whose meals were observed. Findings Include: A review of the facility's Policy and Procedure titled, Diet Orders, with an effective date of August 23, 2017, revealed: . PURPOSE: To provide a standardized method for the preparation of foods to resident/guests, consistent with the resident/guests' individual needs and recommended dietary allowances (RDA). STANDARD: The physician's order should specify the appropriate diet for each resident/guest to assure that the resident/guest receives and consumes foods in the appropriate form and/or the appropriate nutrition content. [...]

Inspectors wroteBased on observations, interviews, record reviews, and a review of [NAME] and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure the plan of care was followed regarding meals served with items missing for RI (Resident Identifier) #1 and RI #2. This affected RI #1 and RI #2, two of fourteen residents whose care plans were reviewed. Findings Include: A review of [NAME] and Perry's Fundamentals of Nursing, Ninth Edition, with a Copyright date of 2017, Chapter 18 titled, Planning Nursing Care, page 248 revealed: . In any health care setting a nurse is responsible for providing a nursing plan of care for all patients. A nursing care plan includes diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluations findings so any nurse is able to quickly identify a patient's clinical needs and situation. [...]

Inspectors wroteBased on observations, interviews, and record review, including [NAME] and Perry's Fundamentals of Nursing, the facility failed to ensure staff provided incontinence care to RI (Resident Identifier) #3 in a manner to prevent cross-contamination on a resident with a pressure ulcer. This affected RI #3, one of five residents observed for incontinence care. Findings Include: A review of [NAME] and Perry's Fundamentals of Nursing, Ninth Edition, with a Copyright date of 2017, Chapter 40 titled Hygiene, page 858 and 859, SKILL 40-1 BATHING AND PERINEAL CARE . revealed: . r. Wash back. (This follows both female and male perineal care.) . (3) Next move from back to buttocks and anus. Have patient remain in prone or side-lying position and keep covered to avoid chilling. Clean anus and buttocks area. [...]