Autumn Care of Norfolk

Inspectors wroteBased on resident interview, staff interviews, and clinical record review, the facility staff failed to notify the resident, the Physician and/or Practitioner that the scheduled medications were not administered as ordered for one of 43 residents (Resident #149) in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to conduct a comprehensive Minimum Data Set (MDS) assessment within 14 calendar days after admission, for three of 43 residents (Resident #152, #153, and #200), in the survey sample.

Inspectors wroteBased on observations, clinical record review, staff and resident interviews and facility document review, the facility staff failed to provide pharmaceutical services that assured medications were acquired timely to meet the needs of one of 43 residents in the survey sample, Resident #149.

Inspectors wroteBased on observations, staff interview, and clinical record reviews, the facility staff failed to ensure the physician was informed of the pharmacist Monthly Regimen Review (MMR) recommendation for medication changes for three out of 43 residents (Resident #66, #81, and #2) in the survey sample.

Inspectors wroteBased on observation during medication pass and pour, resident interviews, staff interviews, and clinical record review, the facility staff failed to assure residents were free of significant medication errors for one of 43 residents (Resident #149), in the survey sample.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility staff failed to ensure two of three residents (Resident (R) 24 and R74) reviewed for Activities of Daily Living (ADL), out of a sample of 34 residents, received nail care.

Inspectors wroteBased on observation, resident and staff interviews, and clinical record review, the facility staff failed to ensure one of 40 residents (Resident #7) in the survey sample who were unable to carry out activities of daily living received the necessary services to maintain adequate toenail care.

Inspectors wroteBased on resident record review, staff interviews and facility document review, the facility staff failed to ensure residents on hemodialysis had orders for the treatment as well as transportation to the dialysis center for one of 43 residents in the survey sample, Resident #249.

Inspectors wroteBased on observation of medication pass and pour, staff interviews, clinical record review, and facility documentation, the facility staff failed to ensure they were free of medication error rate of 5 percent (%) or greater. During the medication observation, there were twenty-seven (27) opportunities for error, two (2) medication errors were observed which resulted in a medication error rate of 7.41%. The resident involved in the medication error rate was Resident #66.

Inspectors wroteBased on resident and staff interview, clinical record review, and facility documentation, the facility staff failed to ensure one (1) resident (Resident #200) in the survey sample of 43, received rehab services as recommended by the physician.

Inspectors wroteBased on staff interview and review of facility documents, the facility staff failed to inform residents, their representatives, and families of those residing in the facility by 5 p.m., the next calendar day following the occurrence of confirmed infection of COVID-19 or include cumulative updates for residents, their representatives, and families at least weekly with mitigating actions implemented to prevent or reduce the risk of transmission.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide the required documentation at the time of a transfer to the hospital for three of 44 residents in the survey sample, Residents #13, #33, and #108.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to provide activities to support the physical, mental, and psychosocial well-being of two of 44 residents in the survey sample, Resident #96 and #31. The findings Include: 1. Resident #96 was admitted to the facility on [DATE] with diagnoses that included but were not limited to anoxic brain damage, gastronomy status (feeding tube), and post stroke. Resident #96's most recent comprehensive MDS (minimum data set) assessment with an admission assessment with an ARD (assessment reference date) of 5/22/19. Resident #96 was coded in Section B (Hearing, Speech , Vision) as being in a persistent vegetative state. Section F (Preferences for Customary Routine and Services) could not be filled out or completed due to the his vegetative state. [...]

Inspectors wroteBased on resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to failed to provide evidence a care plan meeting was held and/or invite 1 of 44 residents to attend their person centered care plan meeting (Resident #264) in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interview and facility documentation review, the facility staff failed to ensure resident rights were maintained for a facility initiated room change for 1 of 44 residents (Resident #264) in the survey sample.

Inspectors wroteBased on observation and staff interviews the facility staff failed to ensure 1 of 44 residents (Resident #74) mobility wheelchair was in good repair. Resident #74's wheelchair had a worn, torn and cracked left armrest pad.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide written bed hold notification at the time of a facility-initiated transfer for one of 44 residents in the survey sample, Resident #33.

Inspectors wroteBased on observations, staff interview and clinical record review the facility staff failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected 2 residents (Resident #84, #116) of 44 residents in the survey sample.

Inspectors wroteFacility staff failed to ensure the baseline care plan for one of 44 residents in the survey sample, Resident #214, included care for her fractured right shoulder and right femur.

Inspectors wroteBased on observation, family interview, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to develop an activity care plan for one of 44 residents in the survey sample, Resident #96.

Inspectors wroteBased on staff interviews, clinical record review and facility documentation review, the facility staff failed to revise the comprehensive person centered care plan for 2 of 44 residents in the survey sample, Resident #68 and #13.

Inspectors wroteBased on observation, resident interview, staff interview and facility documentation review, the facility staff failed to follow physician orders for 1 of 44 residents (Resident #65) in the survey sample. The facility staff failed to follow physician orders for the application and removal of Icy Hot Patches to bilateral knees.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide treatments per physician's order to promote the healing of a pressure ulcer for one of 44 residents in the survey sample, Resident #108.

Inspectors wroteBased on observations, staff interviews, facility document review and closed record review, it was determined that facility staff failed to prevent elopement of a known resident who wanders for one of 44 residents in the survey sample, Resident #114.

Inspectors wroteBased on observations, staff interview and clinical record review it was determined that facility staff failed to obtain an order for a indwelling catheter for one of 44 residents in the survey sample, Resident # 108.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to act upon pharmacy recommendations for one of 44 residents in the survey sample, Resident #17; and failed to include a timeframe in their policies and procedures for the monthly drug regimen review processes.

Inspectors wroteBased on observation, resident interview, staff interview and facility documentation review, the facility staff failed to ensure a complete and accurate clinical record for 1 of 44 residents (Resident #65) in the survey sample.

Inspectors wroteBased on staff interviews, clinical record review and facility document review, the facility staff failed to provide the resident or residents representative education regarding the benefits and potential side effects of influenza immunization for 2 of 44 residents in the survey sample, Residents #54, #84.

Inspectors wroteBased on observations, and staff interviews, the facility staff failed to maintain the residents environment in a clean, safe and comfortable manner. During the environment inspection on 2/6/18 through 2/14/18 the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly and comfortable environment.

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation review, the facility failed to revise comprehensive person centered care plans for 3 of 56 residents (Residents #87, #88 and #51 in the survey sample). 1. The facility staff failed to revise Resident #87's person centered care plan to include resident options with rehab services. 2. The facility staff failed to revise Resident #88's person centered care plan to include hospice services. 3. The facility staff failed to revise the care plan for Resident #51 to include the need for a CPAP unit.

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure adequate respiratory care for 3 of 56 residents in the survey sample (Residents #51, #7, and #84). 1. The facility staff failed to ensure a Continuous Positive Air Pressure (CPAP) device was on Resident #51 per Physician Orders, and failed to ensure Resident #51 had a filter in her nebulizer. 2. The facility staff failed to ensure a CPAP device was on Resident #7, failed to ensure the CPAP unit was cleaned per facility Policy and Procedure, and failed to ensure Resident's nebulizer filter was changed. 3. The facility staff failed to ensure CPAP device was on Resident #84.

Inspectors wroteBased on observation, staff interview, and facility documentation review, in the facility staff failed to ensure foods were stored and prepared in a sanitary manner.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to maintain an infection prevention and control program to provide safe and sanitary environment and to help prevent the development and transmission of communicable disease and infection for 3 of 56 residents in the survey sample (Residents #7, #105, and #365), and in the facility Dining Room. The facility also failed to maintain an effective infection control system to prevent nosocomial infections. 1. The facility staff failed to ensure infection control measures were implemented in Continuous Positive Airway Pressure (CPAP) care for Resident #7. 2. The facility staff failed to ensure infection control measures were implemented between feeding of Residents in the Dining Room. 3. [...]

Inspectors wroteBased on clinical record review, staff interviews, and facility document review, the facility staff failed to assess a resident for self-administration of medications for 1 of 56 residents (Resident #42) in the survey sample. The facility staff failed to assess Resident #42 for self-administration of Saline Nasal Spray Solution.

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 1 of 56 residents (Residents #22) in the survey sample.

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation, the facility staff failed to assure that 1 of 56 residents (Resident #105) in the survey sample received a complete and accurate assessment.

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure the baseline care plan summary was provided for 2 residents of 56 in the survey sample (Resident #313 and Resident #365).

Inspectors wroteBased on observation, clinical record review, staff interviews, and review of the facility's documentation, the facility staff failed to ensure the necessary treatment was provided to prevent infection and promote healing for 1 of 56 residents (Resident #365) in the survey sample. The facility staff failed to ensure during wound care a standard to promote healing and prevent the spread of infection.

Inspectors wroteBased on observations, staff interviews, and facility documentation review, the facility staff failed ensure appropriate care of a catheter for 1 of 56 residents (Resident #25) in the survey sample. Resident #25's suprapubic catheter bag was observed on the floor inside its protective cover.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to ensure 1 Resident (Resident #313) of 56 in the survey sample was assessed and given measures for pain control during the 4.25 hours she remained sitting in her wheel chair.

Inspectors wroteBased on observation, staff interviews, and facility documentation review, the facility staff failed to ensure one medication cart for 1 of 2 units (Unit 1) was stored in a secured location, accessible to designated staff only. The facility staff failed to ensure medication cart containing medication in the hallway was locked when not in direct sight of the nurse.

Inspectors wroteBased on clinical record review and staff interview, the facility staff failed to ensure complete documentation for Medication Administration Records for 3 Residents out of 56 in the survey sample (Resident #58, Resident #67, and Resident #8).

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to ensure the Medical Director attended and signed the quarterly Quality Assurance (QA) meetings. The findngs included: On 02/13/18 1:39 PM an interview was conducted with the Administrator regarding the facility's Quality Assessment and Assurance (QAA) program. The quarterly sign in sheets acknowledging committee members attendance were reviewed for 3/19/17, 5/11/17, 8/25/17, and 10/27/17. On the 10/27/17 QAA sign in sheet, it was identified that the Medical Director's signature was not present. There was no other staff identifed as a designee for the Medical Director on the sign in sheet. The facility policy titled, QAPI (Quality Assurance and Performance Improvement) effective 11/28/17 documented in part, as follows: 4). The facility will maintain a QAPI committee consisting at a minimum of: [...]