Avalon Health & Rehabilitation Center - Pasco

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) remained free from significant medication errors. The facility failed to accurately transcribe Resident 1's admission medication orders onto the Medication Administration Record (MAR), which resulted in the entry of an incorrect medication suboxone (a medication used to help people recover from addiction to pain medication) rather than the ordered pain medication buprenorphine (a medication used to treat chronic pain) transdermal patch (an adhesive patch designed to deliver a specific dose of medication through the skin and into the blood stream) , and failed to remove a previously applied transdermal patch prior to administering a new one, leaving the resident with two active medication patches simultaneously. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement safety interventions to prevent an avoidable fall for 1 of 3 residents (Resident 1) reviewed for accidents. This failure placed the residents at risk for additional falls and substantial injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure the designated Infection Preventionist (IP) met the qualifications for experience, education, and training or certification for the role to assume responsibility for the facility's Infection Prevention Control Program (IPCP). This failure placed residents, family members, and staff at risk of contracting communicable diseases.

Inspectors wroteBased on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Review ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) were done prior to admission and were corrected on admission, had the required level two referral sent if residents had a positive level one PASARR, as needed for 2 of 5 residents (Resident 65, and 2) reviewed for unnecessary medications. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform timely and thorough assessments and monitoring of 1 of 3 residents (Resident 56), reviewed for a change in condition. Additionally, the facility failed to identify and provide needed care and services for 1 of 3 residents (Resident 70) reviewed for wheelchair positioning. This failure placed the residents at risk for delayed care, health complications, skin breakdown, and poor clinical outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided for 2 of 4 residents (Resident 4 and 31) reviewed for restorative nursing for Range of Motion (ROM) services to prevent decrease in range of motion and mobility. This failure placed the residents at risk for a decrease in mobility, and inability to maintain their current level of functioning.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were trauma survivors received trauma-informed care (an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma), in accordance with professional standards of practice, for 2 of 3 residents (Resident 7 and 65), reviewed for trauma-informed care. This failure placed the residents at risk for unidentified triggers and re-traumatization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the Centers for Disease Control [(CDC) a public agency that protects the public's health and well-being] guidance for temperature monitoring of vaccines and medications in 1 of 2 medication storage refrigerators (Refrigerator 1) reviewed for medication storage. This failure placed the residents at risk of receiving compromised or ineffective vaccines and/or medications.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate facility assessment [(FA) an evaluation that determines the resources required to meet each resident's care and services needs]. The assessment contained inaccuracies regarding resident demographics, the involvement of a qualified Infection Preventionist, and lacked active involvement of the Medical Director and Director of Nursing. This failure placed the residents at risk for inadequate care, potential infections, and poor health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge that included necessary medications, durable medical equipment [(DME) reusable, medically necessary equipment prescribed by a doctor for use in the home to treat an illness or injury, such as a wheelchair, mechanical lift, or hospital bed], and home health services prior to discharge for 1 of 3 residents (Resident 1) reviewed for inappropriate discharges. This failure placed the resident at risk for medical complications and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication administration services provided met professional standards of practice for 3 of 5 nurses (Staff C, D, and E) reviewed for medication administration. This failure placed the residents at risk for medication errors, unmet medication needs and adverse health consequences.

Inspectors wroteBased on interview and record review, the facility failed to address and provide feedback related to identified concerns brought forth by the Resident Council [(RC) a group of residents that meet regularly to improve the quality of life and care in the nursing home] representatives for 4 of 4 residents (Resident 1, 2, 3, and 4) reviewed for grievances. This failure prevented the residents from reporting concerns that placed them at risk for abuse/neglect, frustration, and diminished self-worth.

Inspectors wroteBased on interview and record review, the facility failed to identify an incident of verbal abuse in a timely manner, failed to protect the resident's right to be free from verbal abuse, and take timely action to prevent further abuse for 1 of 5 residents (Resident 5) reviewed for abuse. This failure placed the residents at risk of continued verbal abuse, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse prevention policy in the areas of identification, investigation, protection, and reporting for 1 of 5 residents (Resident 5) reviewed for abuse. This failure placed the residents at risk for unidentified abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of verbal abuse was reported to the State Agency as required for 1 of 5 residents (Resident 5) reviewed for abuse. This failure placed the residents at risk for additional/continued abuse.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 1 of 5 residents (Resident 5) reviewed for abuse. This failure placed the residents at risk for further unidentified and/or further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an elopement for 1 of 3 residents (Resident 6) reviewed for accidents. This failure placed the residents at risk for serious injury and/or exposure to the elements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control interventions were implemented during a medication pass for 1 of 3 staff (Staff G) reviewed for infection control. This failure placed the residents at risk for infection, illness, and cross contamination.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures related to screening potential staff to ensure the protection of residents against abuse, neglect, misappropriation, and exploitation, as shown by review of Notification of Background Check (BGC) Result forms for 5 of 6 contracted (agency) nursing staff (Staff C, D, E, F, and G) reviewed for criminal background checks. This failure allowed staff unsupervised access to residents without a valid criminal background check, placing the residents at risk for abuse, neglect, misappropriation, and exploitation.

Inspectors wroteBased on interview and record review, the facility failed to monitor bowel movements and assess for and provide treatment for constipation (a condition where stool becomes hardened and difficult to pass) in accordance with professional standards of practice for 2 of 3 residents (Resident 1 and 2) reviewed for quality of care. This failure placed the residents at risk for discomfort and medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision, monitor, and develop care plans with effective fall prevention interventions, and ensure that planned interventions were consistently implemented to prevent avoidable falls for 2 of 5 residents (Residents 1 and 2) reviewed for accidents. In addition, the facility failed to conduct an investigation following a fall for 1 of 5 residents (Resident 1) reviewed for falls. This failed practice placed residents at risk for serious injury.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of room changes that included the reason for the room change for 3 of 3 residents (Resident 1, 2, and 3) reviewed for notification of room changes. This failure prevented the residents from having the necessary information needed to make an informed decision regarding their living situation, placing them at risk for frustration, dissatisfaction, and psychosocial decline.

Inspectors wroteBased on interview and record review, the facility failed to inform residents of their rights and responsibilities and facility rules and regulations both orally and in writing upon admission and during their stay for 4 of 4 residents (Residents 2, 6, 7, and 13) reviewed for communication of resident's rights and responsibilities. This failure placed the residents at risk for the inability to execute their rights and make informed decisions about their care and services while living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the required written notices and contact information for advocacy groups and how to file a complaint with the State Agency for 4 of 4 residents (Resident 2, 6, 7, and 13) reviewed for required notices and contact information. This failure placed the residents at risk for abuse, neglect, and not having rightful resources available to them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that allowed for safe care and services, adequate lighting, and use of personal items for 2 of 2 residents (Resident 4 and 13) reviewed for environment. This failure placed the residents at risk for compromised dignity, low self-esteem, and dissatisfaction with their living environment.

Inspectors wroteBased on interview and record review, the facility failed to address and provide feedback related to identified concerns brought forth by the Resident Council [(RC) a group of residents that meet regularly to improve the quality of life and care in the nursing home] group for 3 of 4 residents (Resident 6, 2, and 7) reviewed for grievances. Additionally, the facility failed to ensure residents were not in fear of retaliation for reporting identified concerns for 3 of 5 residents (Resident 3, 13, and 2) reviewed for the grievance process. This failure prevented the residents from reporting concerns that placed them at risk for abuse/neglect, frustration, and diminished self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure Level II Preadmission Screening and Resident Review [(PASARR) a federal requirement to ensure individuals were not inappropriately placed in nursing homes for long term care] evaluations were not completed prior to admission for 3 of 5 residents (Resident 3, 42, and 10) reviewed for PASARR. This failure placed the residents at risk for inappropriate long term care placement and not receiving necessary mental health care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of meaningful activities for 6 of 6 residents (Resident 2, 6, 7, 13, 19, and 34) reviewed for activities. This failure placed the residents at risk for dissatisfaction with their activity choices, poor psychosocial well-being, and boredom.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide meals that were palatable and at an appetizing temperature for 7 of 11 residents (Resident 19, 10, 36, 2, 3, 33 and 27) reviewed for food. These failures resulted in residents experiencing dissatisfaction with the food and placed residents at risk for inadequate nutritional intake and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration agreement (a legal document that required the use of a third party to resolve a dispute) in its entirety, including the right to rescind (cancel) the agreement within 30 calendar days, in a manner and language that the resident understood for 4 of 4 residents (Resident 2, 6, 7, and 13) reviewed for binding arbitration. This failure placed the residents at risk for losing legal protection, lack of understanding of the legal document, and the right to a jury or court hearing.

Inspectors wroteBased on interview and record review the facility failed to provide care in a manner that maintained and promoted dignity and respect for 2 of 2 residents (Resident 19 and 33) when staff spoke Spanish to each other when providing cares. This failure placed residents at risk for diminished self-worth, frustration and embarrassment.

Inspectors wroteAMENDED Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice [(ABN) a written notification upon a change in coverage that provides an estimated cost of services that may no longer be covered by Medicare Part A] upon a change in coverage for 1 of 3 residents (Resident 157) reviewed for liability notification requirements. This failure placed the residents at risk for the inability to make informed financial and healthcare decisions related to their stay in the facility.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and take preventative action following an avoidable accident for 1 of 2 residents (Resident 3) reviewed for falls. This failure placed the resident at risk for additional falls, serious injury, and death.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold at the time of transfer to the hospital for 2 of 2 residents (Resident 50 and 27) reviewed for hospitalization. This failure placed the residents at risk of not having the necessary information to make an informed decision regarding their ability to return to the facility

Inspectors wroteBased on record review and interview, the facility failed to ensure services provided met professional standards of practice for 1 of 5 residents (Resident 13) reviewed for physician orders. This failure placed the resident at risk for medication errors and adverse outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 3 residents (Resident 4 and 46) reviewed for quality of care. 1.) Resident 4 was not assessed and evaluated for their mobility needs to ensure an appropriate wheelchair was provided for safety and comfort. 2.) Resident 46 was not provided their long-term use medications upon admission for chronic pain and depression. These failures placed the residents at risk for pain, isolation, and worsening of their medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to implement safety interventions, including staff training, to prevent an avoidable fall for 1 of 2 residents (Resident 3) reviewed for accidents. This failure placed the residents at risk for additional falls and substantial injuries.

Inspectors wroteThe facility failed to develop and implement a scheduled toileting program (a process of taking a person to the bathroom at pre-determined intervals to facilitate bowel and bladder emptying) for 1 of 3 residents (Resident 4) reviewed for bowel and bladder incontinence. This failure placed the resident at risk for skin break down, feelings of frustration and embarrassment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure vaccines were discarded when expired for 1 of 2 medication storage refrigerators (East/West Medication Storage room). The facility also failed to follow Centers for Disease Control (CDC) guidance for temperature monitor of vaccines in 1 of 1 medication storage refrigerator located in the medication storage room. This failures placed the residents at risk for receiving compromised or ineffective medications and vaccines and negative health outcomes. Findings inlcuded . Review of the policy titled Pharmacy Services, Labeling and Storage of Drugs and Biologicals, dated 11/2017, showed the facility would store drugs and biologicals under proper temperature controls. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dental services were provided in a timely manner to 1 of 2 residents (Resident 13) reviewed for dental care. This failure placed the resident at risk for nutritional decline, embarrassment, and unmet dental needs.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place that ensured effective consistent communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 1 of 2 residents (Resident 209) reviewed for hospice services. This failure placed residents at risk for not receiving necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to implement written abuse policies and procedures for identification of and protection of further abuse for 1 of 1 resident (Resident 1) reviewed for abuse. This failure placed residents at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported to the State Agency as required for 1 of 1 resident (Resident 1) reviewed for abuse. The failure to report an allegation of abuse placed the residents at risk for additional abuse.

Inspectors wroteBased on interview and record review, the facility failed to obtain registry verification to ensure staff met competency evaluation requirements while allowing them to serve as a nursing assistant for 1 of 5 staff (Staff F), reviewed for staff qualifications. This failure placed the residents at risk for abuse/neglect and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention and control precautions were implemented for 3 of 3 staff (Staff C, D, and E) reviewed for hand hygiene [(HH) handwashing with soap and water or use of an alcohol-based foam or gel hand sanitizer]. This failure placed the residents at risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases.

Inspectors wroteBased on interviews and record review the facility failed to notify administrative staff and law enforcement in a timely manner when 1 of 1 resident (Resident 1) did not return to the facility. This failed practice placed Resident 1 at risk for serious injury and/or exposure to the elements.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide the necessary care and services to maintain the resident's highest practicable level of well-being for 1 of 1 resident (Resident 1) reviewed for seizure activity. The failure to initiate Vagus Nerve Stimulation (VNS) therapy (a treatment for epilepsy, a chronic brain disorder that causes seizures, that involved a stimulator which was connected inside the body to the left vagus nerve in the neck, it sends regular, mild electrical stimulations through the nerve to help calm down the irregular electrical brain activity that leads to seizures therapy. [...]

Inspectors wroteBased on interviews and record review, the facility failed to identify, assess for changes, report and implement interventions to prevent the development of pressure injuries (PI, injury to the skin and underlying tissue due to prolonged pressure) for 1 of 2 residents (Resident 2) reviewed for PIs. This failed practice placed residents at risk for PIs, decreased mobility and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of hospital transfer for 3 of 3 residents (Resident 1, 2, 3) reviewed for hospital transfers. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital and the cost of holding the bed.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rooms were repaired and maintained for 6 of 10 resident rooms (rooms 43, 44, 45, 47, 48, and 51) reviewed for a homelike environment. This failure placed the residents at risk for injury, compromised dignity, and dissatisfaction with their living environment.

Inspectors wroteBased on interview and record review the facility failed to develop a baseline care plan (BCP) within 48 hours of admission that included resident specific initial goals and treatment plans for 6 of 6 newly admitted residents (Residents 59, 165, 167, 47, 2 and 56) reviewed for baseline care plans. This failure placed the residents at risk for lack of continuity of care and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure interdisciplinary team [(IDT) a group of healthcare providers from different fields who work together for the best outcome for residents] care conferences were completed for 5 of 5 residents (Residents 4, 6, 8, 15, and 22) reviewed for comprehensive care planning. Additionally, the facility failed to ensure the IDT care conference meetings included the required team members for 5 of 5 residents (Residents 4, 6, 8, 15, and 22) reviewed for comprehensive care planning. These failures disallowed the resident and/or their representative involvement in planning resident care and placed the residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses had the specific competencies and skill sets which included documented demonstration necessary to safely and efficiently perform care for residents' needs in the area of Central Vascular Access Devices (CVAD - a thin flexible tube that is inserted into a vein with the tip close to the heart) used to instill medications, fluids, flushes, draw blood, and complete sterile dressing changes) for 2 of 2 nursing staff (Staff Y and W) reviewed for staff competencies. This failure placed residents at risk for adverse outcomes related to CVAD's and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Three medication errors were identified for 2 of 8 residents (Residents 22 and 319) observed during 25 medication administration opportunities that resulted in an error rate of 12 percent. This failure placed the residents at risk of not receiving the full therapeutic effect of the medication and potential adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program that identified high-risk (refers to care and services associated with significant risk to the health and safety of residents), high-volume (refers to care and service areas preformed frequently or with a large population of residents, thus increasing the scope of the problem), problem-prone areas and/or implementation of corrective action for identified deficiencies related to nursing staff competencies, medication administration errors, infection prevention and control measures, resident immunizations, antibiotic stewardship program, or resident's homelike environment. Additionally, the facility failed to make a good faith attempt at correcting the identified quality deficiency with residents' baseline care plans. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain components of an infection prevention control program to prevent the development and transmission of communicable (capable of being transmitted from person to person) infections by ensuring, A) the required procedure was followed for hand hygiene/glove change with resident (Resident 36 and 46) cares for 5 of 10 staff (Staff O, P, Q, H and V ) reviewed for hand hygiene, B) enhanced barrier precautions (EBP, indicated with high contact resident care activities with an infection, long term wound, indwelling medical device or colonization [the presence of a bacteria that has not yet started its infection process] of an multi drug resistant organism) and staff use of Personal Protective Equipment (PPE) were implemented during resident wound cares for 1 of 3 residents (Resident 22) reviewed for PPE with EBP, C) [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received pneumococcal immunization (a vaccine that protects against pneumococcal infections that can lead to serious infections such as pneumonia and blood infections) and influenza immunization (a vaccine that protects against a viral infection that attacks the lungs, nose, and throat) education regarding the potential risk versus benefits when offered the immunizations for 5 of 5 residents (Resident 56, 118, 41, 2 and 31) residents reviewed for immunizations and infection control. This failure placed residents at risk of exposure to contagious diseases without the knowledge of the risks and/or benefits of the immunization in order to make an informed decision.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were offered and educated on the COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) vaccination for 5 of 5 sampled residents (Resident 56, 118, 41, 2 and 31) reviewed for immunization status. This failure placed the residents at risk of an uninformed decision and contracting the COVID-19 virus.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform 2 of 2 residents (Resident 22 and 4) reviewed for resident rights, of their physician ordered daily fluid intake restriction. Additionally, the facility failed to provide Residents 22 and 4 with the risks/benefit education of fluid restrictions. These failures placed the residents at risk for the inability to make informed decisions regarding their health care, alternative treatments, and the right to refuse care.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 1 sampled resident (Resident 268), reviewed for choices, was afforded the right to choose their preferred attending physician. This failure caused the resident to question staff about which practitioner ordered their care and potentially impeded their care choices.

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice [(ABN) a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare; beneficiaries may choose to continue services but may be financially liable] as required for 2 of 3 residents (Residents 316 and 317) reviewed for beneficiary notification. Residents 316 and 317 were not issued the required ABN when they remained in the facility after their Medicare Part A skilled nursing and rehabilitation services (nursing services such as intravenous fluids or medications or therapy services) ended. This failure placed the residents at risk for the inability to make informed financial and care decisions related to their continued stay.

Inspectors wroteBased on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility) at the time of hospital transfer for 1 of 2 residents (Resident 15) reviewed for hospital transfers. This failure placed the resident at risk for lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on observation, interview, and record review the facility failed to make an admission comprehensive assessment of each resident's pressure injury for 1 of 3 residents (Resident 268) reviewed for comprehensive assessment and timing. This failure placed the facilty residents at risk of not having comprehensive care, not having appropriate services, and their needs/preferences not being identified or care planned.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) Level II evaluation treatment recommendations were incorporated into a resident's care plan for 1 of 1 residents (Resident 55) who were reviewed for Level II PASARRs. This failure placed the resident at risk for unmet mental health and psychosocial needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) was accurate for 1 of 5 sampled residents (Resident 56) reviewed for the coordination/assessment of the PASARR. This failure placed the resident at risk for not receiving specialized mental health services, and unmet mental health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement measures to prevent skin breakdown for 1 of 3 residents (Resident 268), reviewed for pressure injuries. The facility failed to implement care interventions for Resident 268, who was identified at increased risk for skin breakdown. This failure placed the resident at risk for worsening of their pressure injury and unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide necessary care and services for urinary retention catheters (a flexible tube inserted into the bladder to drain urine) for 1 of 1 resident (Resident 46) reviewed for urinary catheter care. This failure placed Resident 46 at risk for a urinary tract infection (UTI)and a decline in health status. According to Mosbys Text for Nursing Assistants (standard guideline for the instruction of basic nursing care), copyright 2022, eighth edition Caring for Persons with Indwelling Catheters page 393 stated .keep the drainage tube below the bladder this prevents urine from flowing backward into the bladder . [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate treatment and services related to tube feedings [(TF) the delivery of nutrients through a tube directly into the stomach to provide nutrition for those who cannot obtain nutrition by mouth, are unable to safely swallow, or need nutritional supplementation] for 1 of 1 resident (Resident 8) reviewed for TF. The failure check for tube placement and label the tube feeding administration set with the date and time the feeding was initiated, placed the resident at risk for receiving expired and/or inaccurate enteral nutrition, adverse consequences, and complications of tube feeding.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis services met professional standards of care for 1 of 1 resident (Resident 167) reviewed for dialysis care. The facility did not have a coordinated process for communication with the outside dialysis center and for monitoring the resident after dialysis treatments. This failure placed residents receiving dialysis at risk for complications and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 1 resident (Resident 4) reviewed for pharmacy services. Resident 4 expressed a need for an as needed (PRN) pain medication at bedtime and did not receive it. This failed practice placed the resident at risk for ongoing, uncontrolled pain, and emotional distress.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper storage and labeling of medications for 1 of 2 medication carts (North Cart) reviewed for medication storage and labeling. Additionally, the facility failed to ensure 1 of 2 medication carts (North Cart) was locked when unattended. These failures placed the residents at risk for receiving compromised medications and access to potentially harmful medications resulting in negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and sanitary surface of the kitchen stove hood. This included maintenance on a non-operational fan in the hood that vented out and removed grease, smells of food cooking, and hot vapors from the stove during the cooking of foods. Grease accumulated around the hood's large stove pipe from the stove hood, up to the area where the stove pipe reached up towards the ceiling, was bolted through the roof of the building, for 1 of 1 facility kitchen. This failure placed residents at risk of recieving food prepared from a kitchen with less than sanitary conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective coordination of care between the facility and hospice staff, for 1 of 2 residents (Resident 48) reviewed for hospice services. Additionally, the facility failed to communicate and update the resident's care plan, which identified which entity was responsible for resident care. These failures prevented a system by which consistent communication between the facility and hospice staff occurred and placed the residents at risk for not for receiving necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the infection prevention and control antibiotic stewardship program (ASP) implemented measures for a system-wide monitoring/tracking of antibiotic to ensure appropriate use of antibiotics for 2 of 3 sampled residents (Resident 47 and 2) reviewed for antibiotic stewardship. This failure increased all residents' risk for development of multidrug-resistant organisms (MDRO/a bacteria that are resistant to many antibiotics), and unidentified nursing care trends related to infection prevention.

Inspectors wroteBased on observation and interview the facility failed to provide a safe, clean, and comfortable homelike environment for residents and staff for 1 of 1 laundry rooms (LR 1), and 1 of 3 Hallways (North Hallway) reviewed for a homelike environment. This failure placed residents and staff at an increased risk for not feeling safe and secure with their environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of nursing practice were provided when nursing staff failed to accurately transcribe and follow physician orders for 3 of 4 residents (Residents 1, 2 and 3) reviewed for nursing care and services. This failure placed the residents at risk for worsened infections, delay of healing and adverse outcomes.

Inspectors wroteBased on interviews and record review the facility failed to ensure the medical records were accurate for 1 of 10 residents (Resident 2) reviewed for complete medical records. This failure placed Resident 2 at risk for not having accurate information in the medical record and possible harm if inaccurate information was used to make medical decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 4 residents (Resident 1) received treatment and care in accordance with professional standards of practice after the resident was found with medications in their bed and when a change of condition was not identified timely. Resident 1 experienced harm when their change of condition was not promptly identified, monitored by staff, and not reported timely to the medical provider for evaluation which delayed interventions and the resident being emergently transferred to the hospital. This failure placed Resident 1 and other residents at risk for unidentified care needs and poor clinical outcomes.

Inspectors wroteBased on interviews and record review the facility failed to ensure an incident of potential neglect was reported immediately, but not later than 24 hours, to the State Agency for 1 of 3 residents (Resident 1) reviewed for reporting of alleged violations. This failure placed residents at risk for additional incidents of neglect and a decreased quality of life.

Inspectors wroteBased on interviews and record review the facility failed to conduct a thorough investigation of a neglect incident and take appropriate correction action involving 1 of 3 residents (Resident 1) reviewed for neglect incidents. Failure of staff to recognize an incident as neglect prevented the facility from taking the necessary corrective action to prevent further incidents of neglect.

Inspectors wroteBased on interviews and record review, the facility failed to provide timely pain management to 1 of 3 residents (Resident 1) on comfort measures. This failed practice resulted in harm to Resident 1 when they experienced unrelieved pain when waiting a prolonged period of time for pain medication while on comfort measures during their active dying process. This failure placed other residents at risk for unrelieved pain and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review at least once every 12 months as required, for 6 of 6 nursing assistants (NAs) (Staff D, E, F, G, H, and I) reviewed for performance reviews. The failure to complete annual performance reviews placed residents at risk for unmet care needs from potentially unqualified staff.

Inspectors wroteBased on interview and record review, the facility failed to implement their respiratory protection program for fit testing procedures (a medical evaluation, fit testing, training on the use and wearing of a respiratory mask) of the N95 respirator mask (N95 - a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) for staff. Sixty nine of the 108 staff had either not been fit tested annually or were initially assigned duties necessitating an N95 without first being fit tested. [...]

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a person-centered comprehensive care plan that addressed comfort care (includes physical, emotional, social and spiritual support for residents and their families, the goal for comfort care was to control pain and other symptoms so the resident could be as comfortable as possible) for 1 of 3 residents (Resident 1) reviewed for comfort care. This failure placed Resident 1 at risk for not receiving care and services to meet their individualized needs.

Inspectors wroteBased on interviews and record review the facility failed to notify the resident's representatives of changes in condition for 1 of 3 residents (Resident 1) reviewed for notification of changes. The failure to notify the representatives placed the resident at risk of not having their representatives involved in the health care decision making process for timely care and services.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's representative for one of one resident (Resident 1), reviewed for notification of change. Failure to notify the representative of an acute change in the resident's condition and discharge to the hospital emergency room placed the resident at risk of not having a representative involved in the health care decision making for timely care and services.