Auburn Ravine Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to protect one out of seven sampled residents' (Resident 1) right to be free from physical abuse by a resident (Resident 2) when Resident 2 placed her hand over Resident 1's mouth and grabbed and squeezed Resident 1's wrist. This failure resulted in Resident 1 getting hurt and had the potential for Resident 1 and all residents in the facility to experience physical and/or psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for one out of seven sampled residents (Resident 6) when,1. Two facility staff did not wear required personal protective equipment (PPE) when performing wound care on Resident 6 who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use), and,2. for a facility census of 55, facility staff (Facility Hairdresser [FHD]) did not receive ongoing infection prevention and control training from the facility. [...]

Inspectors wroteBased on observation and interview, the facility failed to store and prepare food in accordance with professional standards of food safety for a census of 54 when several food items were not labeled and several food items were not disposed of once past their use-by date. These failures present a potential risk of foodborne illnesses for residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label medications for a census of 54 when four eye drops were not labeled with resident names. This failure increased the potential for residents to receive medication that did not belong to them and for cross-contamination and infection.

Inspectors wroteBased on observations and interviews, the facility failed to follow proper infection control practices for three of 14 sampled residents (Resident 9, Resident 11, and Resident 43) when:1. Resident 9's oxygen tubing and humidifier container (a small container of water connected to oxygen tubing used to moisten the air) were not changed after seven days,2. Resident 11's oxygen tubing and humidifier container were not labeled with a date, and3. A staff member did not put on a gown while providing care to Resident 43 who was on Enhanced Barrier Precautions (EBP, precautions taken to prevent the spread of disease and require the use of a gown and gloves). These failures had the potential to increase the spread of infection.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to develop and implement person-centered comprehensive care plans for four (4) residents (Resident 2, Resident 36, Resident 10, and Resident 56,) of 15 sampled residents when: 1. Resident 2 and Resident 36 did not have a care plan for the use of psychotropic (medication that affects the brain associated with mental processes and behavior) medications; 2. Resident 10 did not have a care plan for the use of a Wander/Elopement Alarm (WEA, a wearable device that alerts when the wearer wanders or elopes out of the building); 3. Nursing staff did not implement Resident 56's care plan when there was no WEA on him. These failures decreased the facility's potential to provide appropriate interventions and person-centered care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide care and services in accordance with acceptable professional standards of quality for seven residents (Residents 2, 36, 19, 10, 34, 56, and 110) out of 15 sampled residents when: 1. Psychotropic medications (medication that affects the brain associated with mental processes and behavior) were prescribed for Resident 2 and 36 without appropriate indications, manifestations or monitoring of behaviors. 2. Resident 19, 14 and 110 nasal cannulas (a plastic tube that delivers extra oxygen into your nose) and humidifiers (devices used to humidify supplemental oxygen) were not labeled or dated, and oxygen was not provided per the physician order. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Dietary Supervisor (DS) met the state's education qualification requirements, as required per federal regulation, to be the DS to carry out the functions of the food and nutrition services. In addition, the facility failed to ensure the Registered Dietitian (RD) provided frequently scheduled consultations with the DS to include overseeing food safety and sanitation, food preparation, meal service and food storage. As a result, there were lapses in the delivery of food and nutrition services associated with meal distribution accuracy (cross reference F803), modified food texture accuracy (cross reference F805), and safe food handling and sanitation (cross reference F812), which lacked the benefit of a qualified DS responsible for the day-to-day food service operation for the skilled nursing facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1) Cool down process was not performed for meat leftovers (any food that was prepared for service but was not served), 2) Procedure for cooling down method for ambient (room temperature) food was not being followed, 3) Metal serving pans had brown and white substances on the inside surface; serving pans were found stacked wet, 4) Expired bread had not been discarded, 5) Microwave had food debris on upper interior surface, 6) Several cutting boards had gouges, black smudges, and rancid odor, 7) Employees' beverage containers were stored in residents' food and drink preparation area, and 8) Ice machines in kitchen and nourishment rooms were not clean. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a clean environment for the residents and visitors when one of one garbage dumpster, located outside the facility, was not closed securely due to deformed dumpster lids. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Certified Nursing Assistant (CNA), CNA 2, of five sampled CNAs had a valid CNA license. This failure had the potential to result in all 55 residents in the facility to receive care from an unqualified person.

Inspectors wroteBased on interview, and record review the facility failed to maintain an infection control program for a census of 55 residents when: 1. Facility staff were observed not performing hand sanitation when entering and exiting resident's rooms; 2. Soiled linens were processed without adequate use of Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses); and, 3. The washing machine's water temperature was not monitored. These failures decreased the facility's potential to prevent the spread of disease and infections among residents.

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and monitor an infection control program with the use of antibiotics when: 1. The Infection Prevention and Control Program (IPCP) failed to monitor the laboratory indications on the use of antibiotics. 2. There were inadequate tracking tools in use for tracking of residents on antibiotics and the indications for the use of antibiotics 3. There were inadequate infection control inservices for the facility staff on handwashing. These failures had the potential for residents to be exposed and acquire infectious diseases causing illness.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the required in-service trainings for three of four sampled Contracted Certified Nursing Assistants (CCNA 1, CCNA 2, and CCNA3) and three of five sampled facility employed Certified Nursing Assistants (CNA 2, CNA 3, and CNA 4), when the facility was unable to provide documentation to demonstrate the CCNAs and CNAs had no less than 12 hours per year of continuing competencies including dementia (a loss of memory and problem-solving abilities which interfere with daily life) management and abuse prevention. These failures had the potential to result in CCNAs and CNAs not identifying and reporting abuse nor being able to effectively care for residents with dementia.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure baseline care plans (instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) were developed, implemented, and signed by the resident or responsible party within 48 hours of admission for two out of 15 sampled residents (Residents 260 and 261). This failure had the potential to cause residents and staff to be unaware of the residents' plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for four residents (Residents 1, 18, 28, and 29) of 15 sampled residents when: 1. Resident 1 was administered morphine ER (extended release, narcotic pain medication) 15 mg (milligram, a unit of measurement) and pramipexole (medication used to treat restless leg syndrome) 0.125 mg at 11:13 a.m. when it was scheduled at 8 a.m.; 2. Resident 18 was administered omeprazole (used to treat heartburn) 20 mg and gemfibrozil (medication to help lower high cholesterol and triglyceride levels in the blood) 600 mg at 8:16 a.m. instead of 30 minutes prior to the breakfast meal.; 3. Resident 28 was administered gabapentin (used to treat nerve pain) 300 mg at 10:17 a.m. when it was scheduled at 8 a.m., and a lidocaine patch 5% (pain relieving patch) at 10:17 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diets (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) during the lunch meal on 7/17/2024 when: 1. 44 out of 44 residents with regular portion size received two scoops (eight ounces (oz.) instead of three scoops (12 oz.) of pasta entrée, 2. Five residents (Resident 6, 9, 14, 33, and 49) with pureed texture diets (diet with modified food texture that is smooth and lump-free for people with swallowing and/or chewing difficulties) received pureed garlic bread sticks instead of soaked white dinner rolls, 3. [...]

Inspectors wroteThe facility failed to ensure the appropriate food texture for five residents (Resident 6, 9, 14, 33, and 49) who were on a puree texture diet and received pureed ziti with cheese with chunks of pasta and tomato. The total census was 55. This deficient practice had the potential to increase risk to the residents with swallowing and/or chewing difficulties to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway).

Inspectors wroteBased on interview and record review the facility failed to ensure one resident (Resident 10) out of 15 sampled residents was free from unnecessary psychotropic medications when Resident 10 was prescribed an order for lorazepam (a psychotropic medication that affects the brain associated with mental processes and behavior) as needed (PRN) indefinitely. This failure had the potential to cause medication interactions, confusion, and falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe food handling and storage for food brought in by family for one resident (Resident 2) out of 15 sampled residents. This failure had the potential for Resident 2 to experience foodborne dangers, such as, nausea, vomiting and diarrhea by consuming moldy food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal the need for help) was accessible for one of 15 sampled residents (Resident 11). This failure had the potential to result in unmet resident needs and delayed staff response.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. The Dietary Manager (DM) met the state's education qualification requirements, as required per federal regulation, to be the DM to carry out the functions of the food and nutrition services; and, 2. The Registered Dietitian (RD) provided frequently scheduled consultation to the DM to include overseeing food safety and sanitation, food preparation, meal service and food storage. These failures resulted in lapses in the delivery of food and nutrition services associated with meal distribution, safe food handling, sanitation, and insufficient oversight of food service operations for a census of 29 residents who received meals from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one dietary personnel was competent to carry out the functions of the food and nutrition service when the [NAME] 1 (CK 1) was unable to verbalize the process of properly cooling down cooked food and was unable to practice safe food handling while preparing food for a census of 29 residents who received food from the facility kitchen. These failures had the potential to cause food borne illness in a potentially compromised population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person. It could be part of a treatment or medical condition and is normally prescribed by a physician.) during the lunch meal on 9/6/23 when: 1. Six residents (Residents: 4, 6, 11, 23, 27, and 29) with small portion and/or consistent carbohydrate (CCHO, a diet to help keep blood sugar levels stable) received half of a white roll instead of a whole white roll; 2. Nine residents (Residents: 3, 5, 9, 11, 15, 20, 21, 25, and 29) with mechanical soft texture diets (chopped or ground food prescribed to those who have trouble chewing and swallowing) received whole spears of asparagus and sweet potato with the peel instead of diced asparagus and sweet potato without the peel; 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service safety when: 1. Food items were found with missing or incorrect labels and dates; 2. Food items found expired and available for use; 3. A food item was found opened and uncovered to prevent cross contamination (the unintentional transfer of bacteria and substances from one food to another); 4. Trays of prepared food were found uncovered, unlabeled and/or undated; 5. Drawers which stored clean ready-to-use utensils were dirty and one was broken; 6. Ice machines in the kitchen and in the nourishment room were not clean; 7. A juice dispenser was not cleaned per the manufacturer's instruction; 8. One Dishwasher did not perform the sanitizer concentration recording appropriately; and, 9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean environment for the residents and visitors when one of one garbage dumpsters, located outside the facility, were not secure with the dumpster lids closed. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing requirements were met when the facility did not employ a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time (40 hours per week) basis. This failure resulted in a lack of administrative oversight and supervision and has the potential to affect the quality of care delivered to all residents by nursing staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: -Opened multi-dose inhalers and biologicals were dated with an open and discard date to ensure they were not used beyond the discard date; and -Expired medications were not available for resident use. The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their discard date.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) of 13 sampled residents was free of a significant medication error when she received insulin glargine (a long-acting insulin, medication to lower blood sugar level) 10 times (doses) past the expiration date. This deficient practice had the potential for ineffective use of the insulin, resulting in uncontrolled high blood sugar for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program for one of 13 sampled residents (Resident 1) when hand hygiene was not performed during medication administration and an eye drop was not handled with infection control precautions. These failures had the potential to result in transmission of infection in the facility for all 29 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition and good repair when one reach-in freezer had a torn gasket and ice buildup. This failure had the potential to result in the freezer not holding proper temperatures for frozen foods stored inside.