Ayden Court Nursing and Rehabilitation Center

Inspectors wroteBased on record review and staff interviews, the facility failed to designate a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program. This had the potential to affect all residents in the facility.

Inspectors wroteBased on record review, and interviews with the Resident Representative, staff, Medical Director, and Nurse Practitioner (NP), the facility failed to ensure a resident had an indication and a diagnosis for the use of an antipsychotic medication and failed to administer the antipsychotic medication on an as needed basis as specified in the hospital discharge summary. This was for 1 of 6 residents reviewed for chemical restraints (Resident #32).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code a Minimum Data Set Assessment for Antipsychotic Medication Review for 1 of 21 residents reviewed for unnecessary medications (Resident #32).

Inspectors wroteBased on record review and interviews with facility staff, pharmacy staff, Nurse Practitioner, and Medical Director, the Pharmacy Consultants failed to identify and report medication irregularities related to antipsychotic medication (primarily used to manage symptoms of psychosis, such as hallucinations, delusions, and paranoia) that included a medication transcription error and no adequate indication and diagnosis for use. This deficient practice affected 1 of 6 residents reviewed for unnecessary medications (Resident #32).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to implement infection prevention and control practices when a nurse provided tracheostomy care and did not wear a gown. This deficient practice occurred for 1 of 3 staff observed for infection control practices (Nurse #1).

Inspectors wroteBased on observation, record review, and interviews with facility staff, the Medical Director, the Nurse Consultant, Emergency Medical Services (EMS) paramedic, and the [NAME] President of Clinical Education and Research for the Passy-Muir Valve medical device company, the facility failed to maintain a staff member with the resident who had stopped breathing, immediately initiate a code, and immediately remove the Passy-Muir Valve (one-way speaking valve) to provide effective ventilation through the tracheostomy site (surgical opening made through the front of the neck into the trachea (windpipe)) during cardiopulmonary resuscitation (CPR) for Resident #1 when she was observed to have stopped breathing and had only a faint pulse. [...]

Inspectors wroteBased on observation and interviews with staff and a family member, the facility failed to provide a clean homelike environment for 1 of 5 resident rooms on 1 of 6 halls reviewed for the environment (room [ROOM NUMBER]).

Inspectors wroteBased on observations, record reviews, and staff, Pharmacist, and Pharmacy Consultant interviews, the facility failed to protect the resident's right to be free from misappropriation. This affected 1 of 1 resident reviewed for misappropriation of property (Resident #223).

Inspectors wroteBased on record review and staff interviews, the facility failed to code cognition and mood (Resident #58), and discharge destination (Resident #70) for 2 of 26 residents reviewed for Minimum Data Set (MDS) accuracy.

Inspectors wroteBased on record review, physician, and staff interviews, the facility failed to administer medications to Resident #21 as ordered when Resident #21 received the incorrect dose of Oxycodone Hydrochloride (HCL) on two occasions. This affected 1 of 1 resident reviewed for services provided meet professional standards (Resident #21).

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to apply a left-hand palm guard for 1 of 2 residents reviewed for a range of motion (Resident #30).

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to post cautionary signage outside the resident's room to indicate supplemental oxygen (O2) was in use for 1 of 6 residents reviewed for respiratory care (Resident #174).

Inspectors wroteBased on observations and staff interviews, the facility failed to secure residents' medications in a locked medication cart for 1 of 4 medication carts observed (Station 1 medication cart).

Inspectors wroteBased on record review, staff interviews, the facility failed to ensure the medical record was accurate regarding administration of Oxycodone Hydrochloride (HCL) (an opioid medication which is a controlled substance) for 1 of 1 resident (Resident #21) reviewed for accuracy of medical records.

Inspectors wroteBased on resident and staff interviews and medical record reviews, the facility failed to invite a cognitively intact resident to participate in the planning of the resident's care for 2 of 3 residents (Resident #46 and Resident #125) reviewed for participation in care plans.

Inspectors wroteBased on observations and staff interviews, the facility failed to (1) discard expired medications in 1 of 3 medication storage rooms (Nurse Station #2 medication storage room) and (2) discard expired medications in 2 of 4 medication carts (600-hall medication cart and 300-hall medication cart) observed for storage and labeling.

Inspectors wroteBased on record review, resident interview and staff interviews, the facility failed to ensure a resident's code status was accurately recorded on the electronic and paper medical record for 1 of 18 residents reviewed for advance directives (Resident #125).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to develop a person-centered comprehensive care plan for 1 of 23 residents (Resident #125) reviewed for comprehensive care plans.

Inspectors wroteBased on record review, observations, resident interview and staff interviews, the facility failed to change a dependent resident's incontinent soiled brief due to meal trays being passed on the hall (Resident #30) and to provide mouth care after a resident requested mouth care (Resident #4) for 2 of 8 residents reviewed for activities of daily living.

Inspectors wroteBased on record reviews, observations, and interviews with staff and Physician #1, the facility failed to clarify an order for psychotropic medication for 1 of 5 residents reviewed for unnecessary medications (Resident #55).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to have a medication error rate less than 5% as evidenced by the two medication errors that occurred out of the twenty-seven opportunities when Nurse #1 mixed two crushed medications and administered via gastrotomy tube for 1 of 6 residents observed for medication administration (Resident #125). This resulted in a medication error rate of 7.41% for the facility.

Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification survey of 3/5/21, the recertification and complaint survey of 8/25/22, and the revisit and complaint investigation survey of 10/13/22. This was for 4 deficiencies that were cited in the areas of: Formulate Advance Directives (F578), Accuracy of Assessments (F641), Develop/Implement Comprehensive Care Plan (F656), and Activities of Daily Living (ADL) Care Provided for Dependent Residents (F677). These deficiencies were recited on the current recertification and complaint survey of 11/16/23. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for residents receiving Aspirin (an antiplatelet that prevents blood cells clumping together to form a clot) for 2 of 18 residents reviewed for MDS accuracy (Resident #30 and Resident #68).