Avamere Rehabilitation at Park West

Inspectors wroteBased on interview and record review the facility failed to develop and implement an effective system of communication and provision of the medical records upon transfer (expected to return) or discharge (not expected to return) of a resident to the hospital for emergency care for 2 of 2 residents (Resident 1 & 2) reviewed for hospitalization. The failure to provide required information to the receiving provider, the resident, and/or the resident representative and document the required elements in the resident's record placed residents at risk for complications in continued care, unidentified medical needs, violation of resident rights, and diminished quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer and/or discharge, or as soon as practicable, for 4 of 4 residents (Residents 71, 102, 6, & 12), offer a bed hold for 1 of 4 residents (Resident 6), and call report to receiving facility for 1 of 4 residents (Resident 6) reviewed for hospitalization and discharge. Failure to provide residents with a written notification and offer a bed hold placed them at risk of being uninformed about their rights and a discharge that was not in alignment with the resident's stated goals for care and preferences. Failure to call report to the receiving facility, at the time of transfer, placed residents at risk of a break in continuity of care and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were completed as required for 4 (Residents 26, 7, 5, & 9) of 6 residents reviewed for PASRR screening. Facility staff failed to ensure Level 1 PASRR screenings were accurate and/or obtained prior to a resident's admission to the facility, and/or failed to ensure Level 2 PASRR evaluations were obtained on admission or after identification that a level 2 was required. These failures placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to assist residents with Activities of Daily Living (ADLs - personal hygiene, grooming, bathing, eating etc.) for 6 residents (Resident 77, 31, 99, 79, 8, & 28) of 8 dependent residents reviewed for ADLs. The failure to provide ADL assistance to dependent residents as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide Restorative Nursing Programs (RNP) as residents were assessed to require for 6 of 8 residents (Resident 8, 11, 1, 6, 7, & 31) reviewed for position and mobility. This failure placed residents at risk for decline in mobility and Range of Motion (ROM), functional status, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to: ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 2 residents (Resident 71 & 77) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms); ensure staff used appropriate Hand Hygiene (HH) during resident care for 4 residents (Resident 31, 7, 28, & 79) who were observed for care; ensure staff followed Transmission Based Precautions (TBP - a set of infection control practices used to prevent the spread of infectious agents, in addition to standard precautions) for 1 resident (Resident 79) of 1 reviewed for TBP; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a comfortable, appropriately sized bed for 2 of 2 residents (Resident 71 & 77) reviewed for accommodation of needs. This failed practice placed residents at risk for discomfort and skin issues.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure walls and blinds in resident rooms were maintained in a homelike condition for 6 of 19 sample resident rooms (Rooms 211-1, 214-1, 220, 201, 106 & 118) and failed to ensure resident's personal property was kept safe for 1 of 2 residents (Resident 8) reviewed for personal property. These failures left residents at risk for a less than homelike environment, loss of personal property and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to initiate, investigate, and resolve grievances for 2 of 2 residents (Resident 1 & 8) reviewed for missing personal property. This failure placed residents at risk for emotional distress and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed ensure residents were free from physical restraints for 1 of 1 residents (Resident 99) reviewed for physical restraints, and 1 supplemental resident (Resident 7). The failure to obtain a physician's order prior to use of a physical restraint, and evaluate to ensure least restrictive measures were in place placed the resident at risk for entrapment, injury, decreased range of motion and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 (Resident 12) of 5 residents and 1 supplemental resident (Resident 31) whose medication regimens were reviewed, were free of unnecessary psychotropic medications. This failure left residents at risk for unnecessary medications, adverse side effects and other negative health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assessments accurately reflected residents' health status and/or care needs for 1 (Resident 26) of 19 reviewed for assessments. The failure to accurately assess residents' cognitive patterns placed residents at risk for unidentified and unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide baseline Care Plans (CP) to 2 (Residents 5, & 79) of 8 residents reviewed for care planning and 1 supplemental resident (Resident 99). The failure to provide residents and/or their representatives with a summary of their baseline CP placed residents and/or their representatives at risk for not being informed of their initial plan for the delivery of care and services, and placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and/or implement comprehensive Care Plans (CPs) for 4 of 19 sample residents reviewed (Residents 99, 26, 77 & 1). This failure placed residents at risk of unmet care needs, frustration, and diminished quality of life.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure resident Care Plans (CPs) were updated as needed for 2 (Residents 11 & 28) of 19 sample residents, and failed to ensure the Interdisciplinary Team (IDT) attended resident care conferences to ensure residents could express their preferences and goals for 2 of 8 residents (Resident 39, & 5) reviewed for care conferences. These failures placed residents at risk for unmet care needs, and frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: nurses only signed for tasks completed for 1 of 19 sample residents (Resident 2), physician's orders were clarified as needed for 4 (Residents 7, 1, 12, & 5) of 19 sample residents, and failed to follow physician's orders for 1 of 19 sample residents (Resident 5). These failures placed residents at risk for medication errors, delayed treatment, receiving unnecessary medications, and adverse outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were assessed, monitored, refusals were documented, the provider was notified of changes, and they received the treatment they were assessed to require for 2 of 3 (Residents 28 & 1) who were reviewed for edema (swelling) management. The failure to monitor, document, implement interventions, and to follow the physician orders for edema management, placed residents at risk for decline in medical status, decreased quality of life, and unmet care needs and discomfort.

Inspectors wroteBased on observation, interview, and record review facility failed to maintain an environment that was free from accident hazards. The failure to secure chemicals in 1 of 3 soiled utility rooms and 1 of 2 storage rooms placed residents at risk for accident hazards, and diminished safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor and report on nutritional care, provide weight monitoring, and obtain supplements as ordered for 3 (Resident 79, 26, & 1) of 11 residents reviewed for nutrition. The failure to offer meal replacements and monitor residents who consumed less than 50% of their meals and collect timely and accurate weights as ordered and per facility policy, placed residents at risk for nutrition-related complications, unplanned weight fluctuations, inaccurate assessments and delayed interventions of nutritional status, fluid overload, and other negative health outcomes.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were discarded when expired, and/or returned to the pharmacy upon a resident's discharge for 1 of 3 medication rooms (First Floor Unit) observed. The facility failed to ensure resident rooms were free of unsecured medication for 1 of 19 sample residents (Resident 31) observed. The failure to ensure unneeded medications were returned to the pharmacy, discarded when expired, and were stored securely, placed residents at risk for receiving unauthorized, compromised, and/or ineffective medications.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Antibiotic (ABO) Stewardship Program to promote appropriate use of ABO's, reduce the risk of unnecessary ABO use, and decrease the development of an ABO resistance for 2 of 3 residents (Resident 9 & 53) reviewed for ABO Stewardship.<Policy>According to the facility policy titled, ABO Stewardship, dated December 2016, ABOs would be prescribed and administered to residents under the guidance of the facility's ABO Stewardship Program. The policy showed when an ABO was prescribed to a resident the primary care practitioner would assess the resident within 72 hours. The policy showed diagnostic results would be communicated with the resident's primary care provider to determine if ABO therapy should be continued, modified, or discontinued.

Inspectors wroteBased on interview and record review the facility failed to implement interventions to protect resident's skin from injury, accurately identify, assess, document, and report changes in skin integrity for 1 of 3 residents (Resident 1) reviewed for Pressure Ulcer/Pressure Injury (PU/PI). Resident 1 experienced harm when they developed five new PU/PIs and pain. This failed practice placed residents at risk for skin injuries, PUs/PIs, and diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents where provided with a home like environment for 2 of 3 floors (the 200 Floor and 300 Floor) and 1 of 2 elevators. The failure to ensure resident rooms were free of walls with gouges/missing paint and stained ceiling tiles and the elevator was free of broken trim left residents at risk for a less-than-homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to transmit the required Minimum Data Set (MDS - an assessment tool) data to the Center for Medicare and Medicaid Services (CMS) within the required time frames for 6 (Resident 33, 69, 57, 17, 73, & 51) of 20 sample residents reviewed for resident assessments. This failure placed residents at risk for delays in care planning, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a mental health screening required before transfer to a nursing home) assessments were revised to reflect mental health changes for 3 of 6 residents (Residents 37, 30, & 13) reviewed for PASRRs and one supplemental resident (Resident 69). This failure left residents at risk for risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: Physician's Orders (POs) were clarified as needed for 6 (Residents 17, 33, 13, 57, 9, & 83) of 20 sample residents; followed for 2 (Residents 69 & 57) of 20 sample residents; nurses did not sign for incomplete tasks for 1 (Resident 69) of 20 sample residents reviewed; and orthostatic blood pressure (a process where a resident's blood pressure is taken while lying down, then sitting, then standing as practical to assess for changes in blood pressure caused by changes in elevation for safety) was monitored as required for 1 (Resident 2) of 5 residents reviewed for psychotropic medications. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs - i.e. grooming, bathing, eating, etc.) received the assistance they required for 4 of 9 sample residents (Residents 61, 51, 58, & 73) and 1 supplemental resident (Resident 55). The failure to provide nailcare, bathing, and eating assistance left residents at risk for embarrassment, poor personal hygiene, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 3 (Residents 57, 69, & 51) of 6 residents reviewed for Restorative Nursing Program (RNP) services received the care and services they were assessed to require. These failures placed residents at risk for a decline in Range of Motion (ROM), increased dependence on staff, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility was free of accident hazards. The failure to: ensure appropriate supervision and storage of smoking materials for 1 of 1 (Resident 83) sample residents who smoked; ensure 1 of 1 Central Supply rooms was secured; and 2 of 3 soiled utility rooms were secured, placed residents at risk for smoking accidents, accident hazards, and diminished safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nursing staff had the appropriate competencies and skill sets to provide nursing care and related services that assured resident safety and attained or maintained resident's highest practicable physical, mental, and psychosocial well-being as identified by resident assessments and according to individual plans of care, in consideration of the number, acuity and diagnoses of the facility's resident population, and in accordance with the facility assessment and facility policies. The facility failed to verify skills competency for 5 of 5 Certified Nursing Assistants (CNA) (Staff AA, BB, CC, DD, EE, & FF) whose training documents were reviewed, 5 of 5 CNAs (Staff GG, FF, HH, II, and W) and 1 of 1 Registered Nurses (Staff O) interviewed for special focused training for tracheostomy and stoma care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement an effective Infection Prevention and Control Program. The failure to develop and implement a water management program, ensure resident equipment and the facility environment was free of uncleanable surfaces, urinary catheter (tubing to facilitate urinary drainage) bags were secured, and Hand Hygiene (HH) was performed before, during, and after resident care left residents at risk for waterborne illness, exposure to communicable diseases, sickness, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to revise infection prevention and control policies and develop and implement an updated Antibiotic (ABO) Stewardship program to comply with the 10/24/2023 federal requirements. The facility failed to; implement protocols and a system to monitor, document, and analyze the appropriate use of ABOs; failed to include leadership support and accountability for 3 of 3 months (January, February, & March 2024) reviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in a manner that maintained and promoted resident rights and dignity for 4 (Residents 37, 3, 76, & 69) of 20 sample residents. The failure to obtain consent prior to psychotropic medication treatment (Resident 37) and the failure to provide adequate privacy during the provision of care (Residents 3, 76, & 69) placed residents at risk for unwanted psychotropic medications, a diminished sense of self-worth, and wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable, for 3 of 4 residents (Residents 30, 66, & 97) reviewed for hospitalization. Failure to ensure a written notification was provided to the resident and/or representative of the reasons for the discharge and in a language and manner the resident and/or representative understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed hold (a process allowing residents who transfer from a facility temporarily to return to the same bed) policy, at the time of transfer or within 24 hours, for 2 of 4 sample residents (Resident 66 & 97) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized that was necessary for decision-making.

Inspectors wrote<Resident 81> According to the 03/21/2024 admission MDS Resident 81 was assessed with intact memory and was able to understand and be understood in conversation. The MDS showed Resident 81 showed no rejection of care during the assessment's seven-day lookback period. The section of this MDS addressing Resident 81's mood included instructions for staff to conduct a mood interview with the resident unless the resident was rarely or never understood in conversation. Instead, staff completed a staff assessment of Resident 81's mood. The section of this MDS addressing pain included instructions for staff to conduct a pain interview with Resident 81 unless the resident was rarely or never understood in conversation. [...]

Inspectors wroteBased on observation, interview, and record review the failed to ensure a person-centered comprehensive Care Plan (CP) was developed and implemented for 4 of 20 sample residents (Resident's 37, 73, 66, & 91) whose CPs were reviewed. Failure to address the individualized care needs for each resident placed residents at risk for inconsistent and/or inadequate care, and a decreased quality of life. <Facility Policy> According to the facility's [DATE] Comprehensive Person-Centered CP policy, the facility would develop a comprehensive, person-centered CP for each resident. The CP would be consistent with each resident's assessed needs, and should include objective, measurable goals. [...]

Inspectors wrote<Care Plan Revision> <Resident 83> According to the 03/20/2024 Quarterly MDS Resident 83 had diagnoses including coronary artery disease and heart failure. The MDS showed Resident 83 did not receive an anticoagulant medication. The MDS showed Resident 83 had an above knee left leg amputation. Review of Resident 83's Physician's Orders (POs) showed no orders for an anticoagulant medication. The 09/16/2023 Deep Vein Thrombosis (DVT - a condition where blood clots form in veins located deep inside the body, often the legs) CP included an intervention for nursing staff to monitor laboratory values to monitor/document effect of anticoagulant therapy [ .] report values outside desired range. In an interview on 04/22/2024 at 2:23 PM Staff I (Resident Care Manager - RCM) stated Resident 83 did not receive an anticoagulant medication. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement care for 1 (Resident 69) of 1 resident reviewed for Tube Feeding (TF - nutrition delivered into the stomach by tube) management including: failure to provide a consistent formula or rate of administration; failure to document the total intake provided over 24 hours; failure to clarify and administer the amount of water flushing required by the resident; and failure to label and date the TF formula. These failures placed Resident 69 at risk for TF complications, inadequate or excessive calorie or protein intake and/or hydration.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff timely acted on irregularities identified by the consultant pharmacist for 1 of 5 residents (Resident 33) reviewed for medications. The failure to act on medication-related irregularities identified by the consultant pharmacist placed the residents at risk for medication-related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 1 sample residents (Resident 58) was reviewed for Antibiotic (ABO) use. Failure to follow provider's recommendations and to schedule appointments to adjust medications placed residents at risk for inadequate treatment of medical conditions and the potential for adverse side effects of unnecessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free of unnecessary medications for 1 of 5 (Residents 37) sample residents. The failure to ensure residents had an appropriate diagnosis in place prior to administration left residents at risk for adverse side effects, unnecessary psychotropic medications, and other negative health outcomes.

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs and biologicals were secured and expired medications and biologicals were disposed of timely in accordance with professional standards in 1 of 2 medication rooms and 2 of 4 medication carts reviewed. This failure placed residents at risk for receiving expired medications and at risk for medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prompt dental services were provided for 1 (Resident 57) of 4 sample residents reviewed for dental services. This failure placed the residents at risk for unmet dental needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently implement Infection Control (IC) and Infection Prevention (IP) practices and initiate outbreak management interventions to prevent transmission of COVID-19 (a highly contagious infectious disease, causing respiratory illness with symptoms including cough, fever, 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) for 29 of 39 current sampled residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, & 29) who tested positive for COVID-19 and some who had respiratory symptoms including cough, sore throat, headache, weakness, diarrhea, vomiting, and shortness of breath; [...]

Inspectors wroteBased on interview and record review the facility failed to implement their policy and procedures for accurate billing practices and imposed charges for services covered under Medicare for 1 of 3 residents (Resident 1) reviewed for billing accuracy. The failure to follow insurance verification for out-of-pocket (OOP) requirements, ensure accuracy of resident billing statements, failure to correctly bill insurance copays, and failure to follow established processes for collections of past due balances placed residents at risk for undue stress and worry of their personal financial obligations, overpayment for insurance covered services, and potential diminished quality of life.

Inspectors wroteBased on interview and record review the facility administration failed to implement and monitor billing office staff and billing practices. The failure to identify billing office failures through ongoing monitoring of resident accounts placed residents at risk of overpayment for insurance covered services and Medicare billing fraud.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADL) care for dependent residents with for 3 (Residents 88, 31 & 41) of 5 dependent residents reviewed for ADLs. Facility failure to provide ADL assistance placed residents at risk for poor hygiene, embarrassment, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their non-smoking policy for 2 (Residents 86 & 9) 2 of sample residents and 1 supplemental resident (Resident 34) reviewed for smoking. Facility failure to effectively implement their policy left residents at risk of frustration, burns, other smoking injuries, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an Antibiotic Stewardship Program (ASP) to promote the safe usage of antibiotics and collect outcome data. Facility failure to develop and implement an ASP placed all residents prescribed antibiotics at risk for antibiotic resistance and poor health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to provide residents and/or their representative with written notification of a facility-initiated transfer for 1 (Resident 62) of 1 residents reviewed for hospitalization, and failed to provide notification of transfer to the Ombudsman. These failures placed residents and/or their representatives at risk of not being informed of their condition, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or representative information regarding a Bed Hold for 1 (Resident 62) of 1 sampled residents reviewed for hospitalization. Facility failure to provide information regarding bed holds left residents at risk for lack of knowledge regarding their right to hold their bed while out of the facility

Inspectors wroteBased on interview and record review, the facility failed to ensure Level 2 Preadmission Screening and Resident Review (PASARR) recommendations were followed for 2 Residents (Residents 79 & 3) of 7 residents reviewed for PASSAR. Facility failure to implement mental health services recommended the Level 2 PASARRs left residents at risk for unmet mental health needs and a diminsihed quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure routine dental services were provided for 1 (Resident 31) of 1 resident reviewed for dental services. Facility failure to provide routine dental services left residents at risk for poor dental health and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to: maintain infection control during personal care provided to 1 resident of 1 samle residents (Resident 38) observed during personal care and failed to ensure staff wore appropriate personal protective equipment (PPE) while administering an inhaled medication on the COVID-19 unit for 1 of 7 sample residents (Resident 80) observed during medication pass. These failures placed residents at risk for the development and transmission of communicable disease and infection.