Atlee Hill Health and Rehab Center

Inspectors wroteBased on review of the facility's abuse policy and interview it was determine that the facility failed to ensure the abuse policy addressed all the required components. This was found to be evident for the one abuse policy and has the potential to affect all the residents.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to store food in accordance with professional standards. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on interviews, record reviews and observations, it was determined that the facility failed to 1) have a water management system in place to identify Legionella and other harmful waterborne germs in the building and 2) ensure that wall-mounted Hand sanitizing dispensers in resident and staff areas were maintained within their expiration dates. This was evident during the recertification survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to report allegations of abuse in a timely manner. This was evident for 5 (#80, #81, #77, #10, and #71) of 15 residents reviewed for abuse allegations.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to develop comprehensive person-centered care plans for residents. This was found to be evident for 3 ( #48, #83, #76) out of 43 residents reviewed during the survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to accurately document care in the resident's medical record. This was evident for one (Resident #36) out of two residents reviewed for urinary catheter care.

Inspectors wroteBased on a review of employee education files and staff interviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to employees. This was evident in five out of five employee records reviewed for the staffing task.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to notify an attending physician when there were documented changes in a Resident's condition. This was evident for 1 (#69) out of 15 Residents reviewed for Abuse.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to 1) ensure appropriate information was communicated to the receiving health care institution to ensure an effective transition of care and 2) provide a written transfer notice and a written bed hold policy to a Resident's representative upon transfer to an acute care facility. This was evident for one (#83) out of three residents reviewed for discharge and for one (#4) out of two residents reviewed for hospitalization.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded. This was evident for 3 (#54, #3, #2) of 43 residents reviewed during the survey.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to provide residents/representatives with a copy of their baseline care plan, which included a summary of the Resident's medication. This was evident for 2 (#14, #83) of 43 residents reviewed during the recertification survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to provide evidence to support a diagnosis of schizoaffective disorder. This was evident for 1 (Resident #2) of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to ensure that a resident who required assistance with Activities of Daily Living (ADL) was provided with showers. This was evident for 1 (#48) of 3 Residents reviewed for ADLs.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to ensure that care was provided in accordance with professional standards and physician orders. This was evident for 3 (#75, #76, and #79) of 5 residents reviewed in relation to complaint investigations.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to provide necessary treatment and services to promote the healing of pressure ulcers. This was evident for 1 (#14) out of 3 residents reviewed for pressure ulcers during the survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure a resident received their medication according to the attending physician's order. This was evident for one out of 5 complaints reviewed during the survey.

Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to maintain a medication error rate of less than 5%. This was found to be evident for one (Resident #37) out of the four residents observed for mediation administration as evidenced by two errors out of 25 opportunities for error.

Inspectors wroteBased on record review, observations, and interviews, it was determined that the facility failed to ensure that residents were served meals according to a predetermined menu that incorporated their preferences. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to provide evidence of educating, offering, and/or providing the pneumonia vaccine to residents. This was evident for one (Resident #9) out of five residents reviewed during the infection control task.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure residents did not receive medications ordered for another resident. This deficient practice resulted in actual harm to Resident #5 who experienced critically low heart rate and blood pressure and required hospitalization. This was evident for 1 (Resident #5) resident out of 39 residents reviewed during the annual survey.

Inspectors wroteBased on observation and interview with staff, it was determined that the facility failed to store food and equipment in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen.

Inspectors wroteBased on observation and interviews with staff, it was determined that the facility failed to properly contain and cover waste in dumpsters. This was evident for 2 of 3 dumpsters in the outdoor garbage storage area observed during the annual survey.

Inspectors wroteBased on medical record review and interview with staff it was determined the facility staff failed to develop and implement a baseline care plan to provide resident centered care for each newly admitted resident, based on the resident's minimum healthcare information. This was evident for 4 (#52, 118, #46, and #64) of 41 residents reviewed during the recertification survey.

Inspectors wroteBased on medical record review and interview with staff it was determined the facility staff failed to develop plans of care that included measurable objectives and timeframes to meet the resident's needs and the services to be furnished to assist the resident to attain or maintain his/her highest practicable well-being. This was evident for 4 (#118, #46, #76 and #80) of 41 care plans reviewed during the annual survey.

Inspectors wroteBased on observations, record review and interviews with staff it was determined the facility staff: 1) failed to implement a system for management of resident care equipment, 2) failed to establish and implement consistent infection control measures, 3) staff did not practice hand hygiene and, 4) staff did not follow transmission-based precautions; to prevent transmission of infection. This was evident for 3 (#118, #46 and #119) of 6 residents, and 5 (GNA # 18, 19, 20, 30, & RN #11) out of 7 staff observed for infection control during an annual survey.

Inspectors wroteBased on medical record review and interview with staff it was determined the facility staff failed to inform and provide written information to all residents concerning the right to formulate at the resident's option, an Advance Directive. This was evident for 2 (#54 and #46) of 5 residents reviewed for Advance Directives.

Inspectors wroteBased on medical record review related to a complaint and interviews with the facility staff and family, it was determined that the facility failed to report an unobserved fall with injury to the Office of Health Care Quality (OHCQ). This was evident during the review of 1 of 3 (#80) falls reviewed.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to have a process in place to ensure that the resident and/or the resident representative (RP) were provided with a notice of transfer in writing. This was evident for 3 (#80, #61 and #29) of 3 residents reviewed during an annual survey with complaints.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to notify the resident or the resident representative in writing of bed hold policy in writing. This was found to be evident for 2 (Resident #61 and Resident #29) of 3 residents reviewed for hospitalizations during the investigative portion of the annual survey.

Inspectors wroteBased on interview, record review and observation, it was determined that the facility failed to ensure residents care plans were reviewed and revised as required. This was evident for 2 (Resident #20 and #29) of 41 residents reviewed for careplans during the annual survey.

Inspectors wroteBased on observation, record review and staff interview it was determined the facility staff failed to ensure the resident's environment was as free of accident hazards as possible. This was evident for 1 (#52) of 5 residents reviewed for Accidents.

Inspectors wroteBased on observation, review of the medical record and interview with staff it was determined the facility staff failed to provide appropriate and sufficient services, treatment, and care for a resident with an indwelling urinary catheter. This was evident for 1 (#118) of 2 residents reviewed for Urinary Catheter.

Inspectors wroteBased on medical record review and interview with facility staff and resident representatives, it was determined that the facility failed to have a process in place to implement and determine the competency of staff after a new protocol is put in place. This was evident related to a complaint regarding the implementation of care for a 'PleurX' catheter. A PleurX catheter is a small flexible tube that is surgically placed in the peritoneal space of your abdomen, used to remove excess peritoneal fluid (ascites).

Inspectors wroteBased on review of the facility's Controlled Drug Count Verification sheets and interview with staff it was determined that the facility failed to ensure that an account of all controlled drugs were completed and accurate. This was found to be evident for 1 out of the 2 narcotic lock boxes located in the nursing medication cart.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to 1) have a system in place to ensure that the attending physician documented and signed in the medical record to show they have reviewed an irregularity or recommendation identified by the pharmacist, what, if any action was taken, and his or her rationale of why the recommendation had been rejected in the resident's medical record and 2) have a policy/procedure for the monthly medication regimen review time frames for the different steps the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident, and integrate pharmacy consultant recommendations into the medical record as required. This was evident for 2 (#29 and #46) of 5 residents investigated for Unnecessary Meds during the annual survey.

Inspectors wroteBased on medical record review it was determined the facility failed to ensure adequate indication for use, identify resident specific behaviors, implement non-pharmacological behavioral interventions, and monitor for clinically significant side effects and responses, for use of an antipsychotic medication. This was evident for 1 (#118) of 5 residents reviewed for Unnecessary Meds, Psychotropic Meds and Med Regimen Review.

Inspectors wroteBased on medical record review, interview and observations completed during medication pass, the calculated medication error rate during the annual survey for medication pass was determined to be 7.4%.

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to maintain a safe and effective system for securing medications in designated carts on the nursing unit. This was found to be evident for 2 out of 2 medication carts observed during a tour of the facility.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure that Geriatric Nursing Assistants (GNA) received the required Dementia training. This was found to be evident for 5 (GNA # 10, 23, 26, 27, & 28) out of 5 GNA training records reviewed during the annual survey.

Inspectors wroteBased on surveyor observation and interview it was determined the facility failed to post the results of the most recent surveys in a place readily accessible to residents, families, and visitors. This was evident during entrance and initial observations of the survey.

Inspectors wroteBased on review of the medical record, it was determined the facility failed to perform appropriate revisions to the care plan goals and interventions as resident care needs became apparent or changed over time. This was evident for 6 of 34 (Resident #16, #44, #22, #5, #38 and #12) residents reviewed during the survey process.

Inspectors wroteBased on surveyor observation, interviews with staff and review of resident and facility records, it was determined that the facility failed to have an effective quality assessment and assurance program by failing to implement plans of action to correct quality deficiencies identified during the prior annual quality indicator survey.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined that the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for: 1) 1 of 1 (Resident #12) resident reviewed for communication/sensory deficit and 2) 1 of 5 (Resident #16) residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and resident and staff interview, it was determined that the facility 1) failed to develop a base line care plan within 48 hours of a resident's admission, and 2) failed to provide a resident and/or a resident's representative with a summary of the baseline care plan that included a summary of the resident's medications. This was evident for 1 of 5 (Resident #247) residents reviewed for hospitalization.

Inspectors wroteBased on medical record review and resident/staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan. This was evident for 1) 1 of 1 (Resident #36) resident reviewed for Infections (not UTI or Respiratory); 2) 1 of 1 (Resident #44) residents reviewed for Hospice; 3) 1 of 2 (Resident #22) residents reviewed for dementia care; 4) 1 of 1 (Resident #27)residents reviewed for Constipation and for 5) 1of 2 (Resident #35) residents reviewed for accidents.

Inspectors wroteBased on interview with staff and review of the medical record, it was determined the facility staff failed to provide care to assist residents in maintaining their highest possible level well-being by 1) failing to follow infection control standards of practice. This was evident for 1(#36) resident observed during an initial tour of the facility, 2) failing to provide dental services for a resident who had dental issues and pain, 3) failing to monitor the skin condition for a resident at risk for skin breakdown, weekly, as per the physicians orders. This was evident for 1 (#44) of 1 resident reviewed for Hospice and End of Life, 4) failed to assess residents for weekly skin assessments and document per the physician order for 2 (#37 and #36) of 3 residents assessed for weekly skin assessments.

Inspectors wroteBased on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews and review with the GNAs at least every 12 months this was evident for 4 out of 4 personnel files reviewed. Additionally, the facility failed to conduct at least 12 hours of in-service education for 3 of 4 personnel files reviewed.

Inspectors wroteBased on observations, medical record review and staff interview, it was determined that the facility failed to assess a resident's blood pressure as prescribed prior to the administration of an oral antihypertensive medication. This was identified for 1 (#29) of 6 residents observed for medication administration.

Inspectors wroteReview of the medication administration records for residents #14, #29, #38, and #46 for reconciliation of medications administered on 4/19/19 revealed that medications prescribed for each resident for 6 AM and/or 7 AM administration were not signed off as given. The director of nursing was notified of the concern that night shift did not sign off medications as given by 10 AM on 4/19/19, with report that she would follow-up. Resident #38 was interviewed at 11:26 AM on 4/19/19. The resident acknowledged receiving the medications as he/she would know as he/she did not experience pain. Resident #38 is prescribed to receive a pain medication at 6 AM. Residents #14, #29, and #46 were each interviewed but unable to accurately remember if night shift had administered medications. [...]

Inspectors wroteBased on observation, record review, staff and resident interview, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to properly put on and remove personal protective equipment (PPE), to ensure roommate's area was not contaminated, follow isolation precautions, to properly decontaminate a resident's room following isolation, and have accessible information for Housekeeping staff guiding them on what products to use to decontaminate isolation rooms. This was evident for 1 (#36) out of 1 resident reviewed for Infection (not UTI or Respiratory).

Inspectors wroteBased on observation, it was determined that the facility staff failed to treat each resident in a dignified manner by failing to knock on a resident's door to request permission before entering. This was evident for 1 of 9 (Resident #46) residents reviewed on Short Hall 1.

Inspectors wroteBased on review of the medical record and interview with facility staff it was determined that the facility staff failed to notify the Physician and Resident Representative when the resident experienced a significant weight loss. This was evident for: 1) 1 of 1 (Resident #5) resident's reviewed for Nutrition and 2) the facility failed to document and assess a resident's wound, located over pressure points in a manner that ensured the resident's attending physician remained informed as the wound progressed in size and severity. This was evident for 1 of 1 (Resident #37) resident reviewed for pressure ulcers.

Inspectors wroteBased on observations, medical record review and staff interview, it was determined the facility failed to implement an ongoing resident centered activities program designed to meet the interests and support the physical, mental and psychosocial well-being of each resident for 1 (#1) of 2 residents reviewed for activities.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to ensure that a resident receiving oxygen therapy had orders that did not conflict and that were being followed. This was evident for 1 (Resident #5) of 1 resident reviewed for respiratory care.

Inspectors wroteBased on medical record review and staff interview, the facility staff failed to document a review of the care, the resident's current condition, progress and problems in maintaining or improving their physical, mental and psychosocial well-being and decisions about the continued appropriateness of the resident's current medical regimen. The finding was evident for 1 (#37) of 1 resident reviewed for physician visits.

Inspectors wroteBased on review of the medical record and interview with facility staff, it was determined the facility staff failed to ensure irregularities reported to the attending physician by the pharmacist were acted upon for 2 (#22 and #16) of 5 residents reviewed for Unnecessary Meds, Psychotropic Meds, and Med Regimen Review and for 1 (#35) of 2 residents reviewed for accidents.

Inspectors wroteBased on medical record review, It was determined that the facility failed to ensure that a resident's medication regimen was free from an unnecessary psychotropic medication by 1) failing to ensure that a psychotropic medication prescribed to be administered as needed was limited to 14 days and 2) failing to provide ongoing evaluation for the risks, benefits and continued need for psychotropic medications. This was evident for 2 (#46 and #22) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on medication administration observation, medical record review and staff interview, it was determined the facility staff failed to ensure a medication error rate of less than 5 percent for 2 (#29, #38) of 6 residents observed with 2 errors out of 26 medication administration opportunities which resulted in an error rate of 7.69 by 2 certified medicine aides out of 4 total staff observed.

Inspectors wroteBased on surveyor observation and interview with facility staff, it was determined that the facility staff 1) failed to ensure that inhalation medication and prescribed topical creams were secured in a locked storage area accessible to authorized personnel only, in 1 of 9 room observations on Short Hall 1 and 2) failed to ensure that a respiratory inhaler was labeled to reflect when it was opened in 1 of 2 medication carts observed out of 4 medication carts in the facility.

Inspectors wroteBased on observation, resident and staff interviews, and medical record review, it was determined that the facility failed to provide dental services within a reasonable time frame following a complaint of broken teeth and mouth pain. This was evident for 1 (#36) out of 3 residents reviewed for Dental services.

Inspectors wroteBased on observation, it was determined that the facility failed to ensure that food was stored in a sanitary way. This was evident for 1 of 2 kitchen observations performed during the survey.

Inspectors wroteBased on record review and staff interview, the facility failed to 1) document in the medical record that the Flu and Pneumonia vaccine was offered and administered to 1 (resident #36) of 5 residents and 2) failed to document that the Pneumonia vaccine was administered for 1 (#26) of 5 residents surveyed for immunizations.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to provide residents or resident representatives with the Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) and have them complete this form when it was determined they did not qualify for skilled services. This was evident for 2 (#197 and #198) of 3 residents reviewed for SNF Beneficiary Protection Notification.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 2 of 5 (Resident #103 and #38) residents reviewed for hospitalization.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to document what preparation and orientation was given to a resident to ensure an orderly transfer to an acute care facility. This was evident for 4 of 5 (Resident #46, #38, #247 and #103) residents reviewed for hospitalization.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed-hold policy upon transfer of a resident to an acute care facility. This was evident for 2 of 5 (Resident #103 and #46) residents reviewed for hospitalization.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain the daily past nurse staffing data for a minimum of 18 months.