Ashton Place Health and Rehab, LLC

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure manufacturer specifications were followed to maintain food quality; dietary staff washed their hands and changed their gloves before handling food items; hot food items were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service and cold food items were maintained at or below 41 degrees Fahrenheit for 1 of 1 meal observed.

Inspectors wroteBased on observation, interviews, facility policy review, and facility document review, it was determined the facility failed to ensure staff performed hand hygiene while passing ice to residents to prevent the spread of infection and cross contamination. This failed practice had the potential spread of infection to all residents on the 400 Hall who received ice. The facility also failed to ensure residents were free from the risk of infection by providing a safe, sanitary environment related to flushing a feeding tube by not following enhanced barrier precautions, specifically ensuring the nurse wore a gown during 1 of 1 observation of flushing the feeding tube of 1 sampled (Resident #103) resident.

Inspectors wroteBased on observations, record review, interview and facility policy review, the facility failed to ensure a client with a right hand contracture was receiving right hand splint treatments in line with Resident #103's physician orders and goals as outlined in the comprehensive care plan during 4 of 4 observations of 1 (Resident #103) of 1 sampled resident to prevent the risk of further reduction in range of motion.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure information regarding resident care was posted in a manner that protected the privacy of one 1 Resident (Resident #24) of 1 sampled resident who resided on 200 Hall.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that lotions, perfumes, and powder containers were not allowed in the facility for 5 Residents (R#4, #38, #46, #54, and #91) final sample residents. This failed practice had the potential to affect all residents in 100 and 200 hall.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure physician's orders and the manufacturer's guidelines were followed to prevent a significant medication error, which could result in complications for 1 (Resident #104) of 1 sampled resident who had physician orders for NovoLog insulin.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were stored in accordance with state laws and accepted standards of pharmacy practice for 1 (Resident #85) of 1 sampled residents, to prevent the possible ingestion and or injury.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure foods in the dry pantry were properly sealed, dated and stored in 1 of 1 facility kitchens. This failed practice had the potential to affect 112 (total 114 in facility) residents who received their meals from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control precautions were implemented and followed, as evidenced by failure to implement universal source control by wearing face shields/goggles and failed to ensure staff implemented hand hygiene before entering a COVID-19 positive resident room, for 1 (Resident #56) of 1 sampled resident, to prevent the transmission of COVID-19 and or other respiratory diseases. This failed practice had the potential to affect 114 residents. , according to the Roster Matrix provided by the Administrator on 1/2/2024 at 12:15 p.m.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents and staff. This failed practice had the potential to affect 3 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident received care/urinalysis with culture ordered by the physician for 1 (Resident #1) of the 3 sample residents (Resident #1, Resident #2, and Resident #3).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods stored in the freezer, refrigerator, dry storage area, and nutrition rooms were dated, failed to discard spoiled fresh fruits and vegetables, failed to ensure nutrition room refrigerators and freezers had thermometers, and failed to ensure dietary employees wore masks over both mouth and nose while preparing foods to minimize the potential for food borne illness and the spread of COVID-19 for residents who received meals from 1 of 1 kitchen and failed to ensure 1 of 2 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals and beverages from 1 of 1 kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure residents' fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 1 (Residents #43) of 18 (#43, 27, 39, 197, 18, 24, 7, 81, 83, 68, 52, 86, 93, 45, 40, 54, 8, and 58) sampled residents who were dependent on staff for nail care as documented on a list provided by the Director of Nursing (DON) on 9/15/22 at 8:47 AM.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure foley catheter drainage bags were secured to prevent the catheter bag from touching the floor to prevent the potential for infection for two (Resident #52, Resident #83) of nine (Resident #21, #39, #42, #52, #83, #85, #87, #93, and #199) sample selected residents reviewed who required indwelling Foley catheters according to a list provided the DON on 09/14/22 at 4:35 pm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required a pureed diet for 1 of 1 meal observed. The failed practice had the potential to affect 3 residents who received pureed diets as documented on list provided by Director of Nursing on 09/14/22.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the opening between the clean and dirty side of the laundry room had negative air pressure from the clean side to the dirty side to help prevent the potential from cross contamination for 94 residents who had their linens laundered by the facility per resident census received from Director of Nursing (DON) 09/12/22 and 91 residents who had their personal belongings laundered by the facility per list received from DON on 09/15/22.

Inspectors wroteBased on record review and interviews the facility failed to employ a qualified social worker with a minimum of a bachelor's degree to meet the needs of the residents. This failed practice had the potential to affect all 94 residents who resided in the facility per resident Census provided by the Director of Nursing on 09/12/22.