Ashton Memorial Living Center

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives at the time of the resident's transfer to the hospital. This was true for 1 of 2 residents (Resident #6) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed or room at the facility within a specified time.

Inspectors wroteBased on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 1 of 4 residents (Resident #1) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels.

Inspectors wroteBased on staff interview and review of employee personal files, it was determined the facility failed to ensure each CNA's annual performance review was completed at least once every 12 months for 1 of 1 CNAs (CNA #1) whose personnel records were reviewed for sufficient and competent staffing. This failure created the potential for incompetent CNAs providing care and increased the risk for harm for all residents living in the facility.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure medications available for residents were stored appropriately; this was true for 1 of 18 resident's rooms inspected (Resident #17) and 1 of 1 medication carts audited for labeling and storage of medication. This failure created the potential for adverse effects if residents self-administered medications inappropriately or did not take their medications and created the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff.

Inspectors wroteBased on observation, interview, and review of the Idaho Food Code, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses.

Inspectors wroteBased on observation, document reviews, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.

Inspectors wroteBased on observation, food code review, and staff interview, it was determined the facility failed to ensure the food was stored in a safe and sanitary manner. These deficiencies had the potential to affect all residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on staff interview and review of employee personal files, it was determined the facility failed to provide a minimum of 12 hours of in-service education per year for 3 of 18 CNAs (#4, #5, and #7) whose personnel records were reviewed. Additionally, the facility failed to ensure each CNA's annual performance reviews were completed at least once every 12 months for 3 of 3 CNAs (#2, #4, and #5) whose personnel records were reviewed for sufficient and competent CNA staffing. This failure created the potential for incompetent CNAs providing care and increased the risk for harm for all residents living in the facility.

Inspectors wroteBased on policy review, observation, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not offer or encourage residents hand hygiene prior to meals served in their rooms, and follow appropriate cleaning of medical equipment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to provide the Advance Beneficiary Notice (CMS-10055 form) for 3 of 3 residents (#7, #19, and #25) reviewed for beneficiary protection notification. This deficient practice had the potential to cause financial harm or distress for residents when they were not informed of their potential liability for payment when their Medicare Part A benefits ended.

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure the MDS assessments accurately reflected residents' status. This was true for 3 of 7 residents (#5, #7, and #14) whose MDS, care plan, and nursing assessments were reviewed. This deficient practice had the potential for negative outcomes if residents were not assessed, cared for, or monitored due to inaccurate assessments.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a major mental illness, intellectual disability, or a related condition. This was true for 1 of 3 residents (Resident #27) reviewed for PASARR Level II evaluations. This deficient practice had the potential to cause harm if resident's specialized services for mental health needs were not evaluated by an appropriate state-designated authority.

Inspectors wroteBased on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice for wound care were followed for 1 of 1 resident, (Resident #3), reviewed for wound care. This deficient practice created the potential for resident harm, or adverse outcomes related to infection and skin breakdown.

Inspectors wroteBased on observation, document review, and staff interviews, the facility failed to ensure a completed daily staffing sheet had been posted in the nursing facility. This deficient practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels.

Inspectors wroteBased on observation, record review, and interview, it was determined the facility failed to obtain an order for prescription medicine. This was true for 1 of 1 resident (Resident #3), reviewed for oxygen usage. This deficient practice created the potential for resident harm or adverse outcomes with the use of non-prescribed medical oxygen.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were stored appropriately. This was true for the 1 medication storage room inspected. This failure created the potential for misappropriation of residents' medications.

Inspectors wroteBased on observation, staff interview, and record and policy review, it was determined the facility failed to ensure position change alarms, floor mat alarms, and seat belt alarms were assessed as potential restraints and a consent was obtained from the resident and/or representatives prior to initiation of the alarms. This was true for 4 of 4 residents (#10, #20, #22 and #129) reviewed for potential restraints. This deficient practice had the potential for harm if the position change devices were improperly used and if resident experienced physical deterioration due to lack of movement.

Inspectors wroteBased on observation, policy review, resident and staff interview, it was determined the facility failed to ensure the residents' environment was free from accident hazards when thresholds were too high in 2 of 2 dining rooms. This was true for 5 of 12 residents (#1, #13, #19, #20, and #26) reviewed for accident hazards and 1 of 11 residents (Resident #5) in the group interview. This deficient practice created the potential for harm if residents fell due to trip hazards.

Inspectors wroteBased on observation, staff interview and policy review, it was determined the facility failed to ensure infection control measures were consistently implemented. This was true for 3 of 3 residents (#1, #10 and #25) when staff failed to perform hand hygiene between resident contact. Additionally, it was determined the facility failed to ensure a Sara lift used to safely transfer residents to a standing position was cleaned after each use. These deficient practices created the potential for the spread of infectious organisms from cross-contamination.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' records included clear and accurate information related to Advance Directives. This was true for 2 of 8 residents (#10 and #20) reviewed for Advance Directives. This failure created the potential for harm should residents not have their decisions documented, honored, and respected when they were unable to make or communicate their health care preferences.

Inspectors wroteBased on record review, policy review, and resident and staff interview, the facility failed to ensure written notice was provided to the resident and resident's representative prior to transfer to the hospital. This was true for 1 of 1 resident (Resident #9) reviewed for transfer/discharge to the hospital. This created the potential for harm if residents were not made aware of or able to exercise their rights related to transfers.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure comprehensive resident-centered care plans included the use of tab/chair alarm. This was true for 2 of 12 residents (#20 and #129) whose care plan were reviewed. This failure created the potential for harm should residents receive inappropriate or inadequate care.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure residents were assisted with hand hygiene. This was true for 1 of 12 residents (Resident #10) reviewed for ADL care. This failure created the potential for harm by potentially exposing residents to the risk of infection.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure residents received gradual dose reductions (GDR) of psychotropic medications unless clinically contraindicated. This was true for 1 of 5 residents (Resident #12) reviewed for unnecessary medications. This failure created the potential for harm if residents receive psychotropic medications that were unwarranted, ineffective, and used for excessive duration.