Ashley Rehabilitation and Health Care Center

Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure that the food preparation equipment and environment were maintained in a clean and sanitary condition to prevent contamination and potential development of foodborne pathogens in one of one kitchen observed.

Inspectors wroteBased on observations, interviews, facility policy, and record reviews, it was determined the facility did not consistently follow the supplied menu for 57 of 57 residents who received meals from the facility.

Inspectors wroteBased on observations, interviews, record review and facility policy review, it was determined that the facility failed to provide wound care in a manner to prevent infection for two (Resident #4 and Resident #5) of five residents reviewed for wound care. Specifically, staff performing wound care did not perform hand hygiene after contaminating their hands and before touching wound care supplies or applying ointments and dressings, and an impervious barrier was not used to prevent the contamination of wound care supplies.

Inspectors wroteNumber of residents sampled:5Number of residents cited:3Based on interviews, facility record and policy reviews the facility failed to ensure consistent behavior monitoring with antipsychotic medications; failed to ensure antipsychotic medications were prescribed for an indicated diagnosis; failed to gradually reduce or eliminate antipsychotic medications with no documented behaviors for 3 (Residents #4, #7 and #41) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews, and facility document review, the facility failed to ensure the privacy and confidentiality of residents' protected health information (PHI) was maintained for 1 (200 hall) of 1 hall of the facility.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure staff performed hand hygiene after care of a resident and before and after medication administration for three (Resident #6, #8, and #9) of three residents observed.

Inspectors wroteBased on interview and record review, the facility failed to ensure required annual in-service trainings were performed to ensure staff received the required information/education needed to care for residents.

Inspectors wroteBased on observations, interviews, record review, document review, and facility policy review, the facility failed to ensure a resident was free from abuse for 1 (Resident #5) of 3 sampled residents reviewed for abuse. Specifically, the facility failed to ensure Resident #5 was free emotional abuse. The Immediate Jeopardy began on 09/02/2024, when CNA #4 made inappropriate statements to Resident #5 when she walked into the shower room while Resident #5 was taking a shower with help of CNA #4. CNA #4 and showed an inappropriate picture to Resident #5. The facility failed to investigate this incident until 09/09/2024. The facility had failed to train staff in abuse and neglect.

Inspectors wroteBased on record review, interview, and facility policy review the facility to administer Cardiopulmonary Resuscitation (CPR) upon discovering 1 (Resident #62) sampled resident pulseless and breathless despite the resident being a full code. The Facility notified of the Immediate Jeopardy on [DATE] at 1:40 PM. The Facility Plan of Removal (POR) noted the facility will continue CPR upon discovering a resident pulseless and breathless when the resident is a full code signed [DATE].

Inspectors wroteBased on interview and record review, the facility failed to ensure there was sufficient nursing staff to meet the residents' needs for 7 shifts reviewed from 09/01/2024 through 09/30/2024. On 10/28/2024 at 3:42 PM, Resident #29 was interviewed and stated the resident believed the daytime [shift] was understaffed because residents do not receive showers as they should. Resident #29 stated the resident's scheduled bath/shower days were Tuesday, Thursday, and Saturday. Resident #29 stated the resident did not receive a shower on Saturday, 10/26/24, due to the facility only had one Certified Nursing Assistant (CNA) working the hall the resident resided. The resident alleged the facility has two CNAs working in the building some nights. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the daily nurse staffing information, to include the facility name, the current date, the number and actual hours worked by staff, and the resident census. The deficient practice had the potential to affect all residents. The total census was 60. A Shift Staffing Schedule, dated 10/28/2024 for the 7:00 AM to 3:00 PM shift, was reviewed and did not have the facility's name, the number and actual hours worked by staff, the resident census or the licensed staff scheduled to work. The shift staffing schedule, dated 10/28/2024 for the 11:00 PM to 7:00 AM shift, was reviewed and only one Certified Nursing Assistant's (CNA's) name was listed on the sheet. On 11/01/2024 at 6:40 PM, the Director of Nursing (DON) was interviewed by another surveyor about the nurse staffing. [...]

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure food items stored in the freezer, refrigerator and dry storage areas were covered or sealed; expired food items were promptly removed/discard by the expiration or use by dates as when it was delivered,; 1 of 1 ice machines was maintained in clean and sanitary condition, staff washed their hands, and dietary staff washed their hands and between clean tasks when contaminated.

Inspectors wroteBased on interview and record review, the facility failed to ensure a policy was developed and implemented pertaining to the governing body and failed to ensure the governing body was active in the development and implementation of the facility assessment.

Inspectors wroteBased on record review and interview, the facility failed to ensure the facility assessment contained pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents. This deficient practice had the potential to affect all residents of the facility. The total census was 60.

Inspectors wroteBased on observations, interviews, record review and facility document review, it was deterred that the facility failed to ensure the Arbitration agreement contained all necessary components including the right to resend the agreement within the first 30 days of admission. The failed practice had the ability to affect all the residents who had signed the arbitration agreement.

Inspectors wroteBased on interview and record review, the facility failed to ensure the arbitration documentation includes the selection of a neutral arbitrator and a location that is convenient for all. The failed practice had the ability to affect all 47 residents who currently reside in the facility.

Inspectors wroteBased on interviews, record review, and facility policy review the facility failed to implement consistent infection surveillance to prevent the spread of possible communicable diseases. The facility also failed to develop and implement a water management plan to prevent the growth and/or spread of waterborne pathogens.

Inspectors wroteBased on interviews, record review, and facility policy review the facility failed ensure there was a consistent antibiotic stewardship to determine if the antibiotic is indicated or adjustments to the therapy should be made.

Inspectors wroteBased on interview and record review, the facility failed to ensure required annual in-service trainings were performed to ensure staff received the required information/education needed to care for residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure required annual in-service trainings were performed to ensure staff received the required information/education needed to care for residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure required annual in-service trainings were performed to ensure staff received the required information/education needed to care for residents.

Inspectors wroteBased on observations and interviews the facility failed to ensure lint traps were free from excessive lint build up.

Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to ensure established abuse policies and procedures were implemented after receiving an allegation of abuse for 1 (Resident #5) of 3 sampled residents for the implementation of abuse prohibition policies and procedures, that resulted in facility and contract staff, involved in allegations of abuse, to remain in the facility and to have continued contact with residents.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure a written discharge summary (dc) included a condensed summary of the stay in the facility and course of treatment, a reconciliation of medications, and resident status at discharge for 1 (Resident #61) sampled resident reviewed for a discharge.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure baths/showers were provided to residents on their scheduled days to promote good personal hygiene and grooming for 1 (Resident #29) sampled resident reviewed for personal hygiene and grooming.

Inspectors wroteBased on observations, interviews, record review, and facility policy review the facility failed to ensure 1 (Resident #57) sampled resident received proper incontinence care and the incontinence care was done in a timely manner.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure bed rails were in use only after an assessment for risk of entrapment was completed for 1 (Resident #57) sample resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication was available during a medication administration observation for 1 (Resident #46) of 11 residents who received medications from 3 Licensed Practical Nurses (LPNs) and 2 Registered Nurses (RNs).

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the medication error rate was less than 5 percent (%) during the medication administration observation of 2 (Residents #7 and #46) of 11 residents who received medications from 2 Registered Nurses (RNs) and 3 Licensed Practical Nurses (LPN). 27 opportunities of medication administration were observed and 2 of the 27 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 7.41%.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure food items were prepared and served according to planned written menu for 1 of 2 meals observed.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep medications secured by leaving it unattended on the resident's over the bed table in the resident's rooms, this failed practice had the potential to 4 of 4 Residents (Resident #4, #5, #6, and #7 case mix residents who had medication left on their over the bed table.