Bath Manor Special Care Centre

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate and timely incontinence care was provided. This affected one resident (#53) of three observed for incontinence care. The facility census was 111.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to maintain acceptable infection control practices during medication administration to prevent the spread of infection. This affected one resident (#16) and had the potential to affect eight (8) residents (#19, #23, #25, #35, #77, #100, and #118) residing on 100 hall and 300 hall who were identified by the facility to require blood glucose monitoring. The facility census was 113.

Inspectors wroteBased on kitchen observation, staff interview, and facility policy review, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all residents receiving meals from the kitchen. The facility identified six Residents (#30, #57, #60, #75, #119, and #269) as receiving nothing by mouth (NPO). The facility census was 112.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented as required. This had the potential to affect all residents residing in the facility. Facility census was 112.

Inspectors wroteBased on observation and interview, the facility failed to ensure clean linen rooms and common shower rooms were maintained in a clean and sanitary manner. This affected 25 (#43, #33, #220, #24, #15, #48, #400, #219, #45, #78, #51, #97, #220, #225, #107, #44, #79, #221, #112, #113, #80, #269, #270, #114, and #63) of 112 facility residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was provided with a dignified dining experience. This affected one (#220) resident of one resident reviewed for dignity. The facility census was 112.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure quarterly statements for resident funds accounts were mailed to the individuals who were identified as the guardian or primary financial contact for residents. This affected three residents (#33, #71,#93) out of six residents reviewed for resident funds. The facility identified 50 residents (#1 to #3 , #5, #6, #9, #11, #15 to #19, #21, #24, #26 to #28, #30 to #33, #35, #37, #39, #40, #42, #46, #47, #49 to #55, #61, #62, #64, #68, #69, #71, #72, #81, #82, #86, #89, #93, #94 , and #121) as having a personal funds account. The facility census was 112.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to provide notice to Resident #94 when his resident funds account reached $200 less than the Supplemental Security Income (SSI) resource limit for one person and failed to ensure Resident #226's account funds were dispersed timely after expiration. This affected two residents (#94 and #226) of six residents reviewed for resident funds. The facility census was 112 residents.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to develop a person- centered care plan related to the consumption of alcohol. This affected one (#44) of one resident reviewed for alcohol consumption. The facility census was 112.

Inspectors wroteBased on observation, resident record review, resident interview, staff interview, and facility policy review, the facility failed to ensure oxygen tubing was changed and an order was in place for administering oxygen. This affected one (#221) of one resident for respiratory care. The facility census was 112.

Inspectors wroteBased on observation, resident record review, resident interview, staff interview, and facility policy review, the facility failed to ensure all drugs and biologicals were properly secured and permit only authorized personnel to have access. This affected one (#221) of one resident reviewed for self-administration of medications. The facility census was 112.

Inspectors wroteBased on record review, interview, review of the Emergency Medical Services (EMS) Prehospital Care Report and review of the facility policy, the facility failed to timely notify the Guardian of Resident #18 when a significant change in condition occurred. This affected one resident (#18) of three residents reviewed for notification of changes. The facility census was 109.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to provide A.M. care to include washing face and hands and oral care for Residents #76 and #106. This affected two residents (#76 and #106) of three residents reviewed for activities of daily living (ADL). The facility census was 109.

Inspectors wroteBased on observation, interview, record review and review of the Emergency Medical Service (EMS) Prehospital Care Report, the facility failed to provide appropriate care and services to Resident #18, who had a significant change in condition with an altered mental status, difficult to arouse, and periods of unconsciousness. Resident #18 was administered by mouth routine medications to include psychotropic medications while being difficult to arouse and prior to notifying the physician of the change in condition. Once contacted, the physician requested Resident #18 to be transported to the emergency room. Resident #18 was not transported to the hospital emergency room per direction of the physician, Resident #18 was administered Narcan for a potential drug overdose then resided at the facility. [...]

Inspectors wroteBased on interview, record review and review of the Emergency Medical Services (EMS) Prehospital Care Report, the facility failed to involve pharmacy services related to a possible overdose involving Resident #18 who was administered Narcan. This affected one resident (#18) of three residents reviewed for a potential overdose. The facility census was 109.

Inspectors wroteBased on record review, observation, interview and review of the facility policy, the facility failed to ensure blood sugars were assessed prior to meal for Residents #82 and #112 as ordered by the physician to ensure accurate dosage of the sliding scale insulin and failed to ensure Resident #18's medication was administered correctly, (not to be crushed). This affected three residents (#82, #112, and #18) of four residents reviewed for medication administration. The facility census was 109.

Inspectors wroteBased on observation, interview, record review, review of the label directions on the cleaning wipes and review of the facility policy, the facility failed to ensure infection control practices were maintained while assessing Residents #82 and #112's blood glucose levels via fingerstick. This affected two residents (#82 and #112) and had the potential to affect an additional 19 residents (#1, #7, #13, #14, #17, #21, #31, #49, #50, #53, #63, #65, #66, #69, #74, #80, #91, #94, and #97) identified by the facility as receiving blood glucose levels via fingerstick. The facility census was 109.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, review of a facility Self-Reported Incident (SRI) and investigation, review of a police report and medical examiner information, personnel file review, review of narcotic/controlled drug sheets, review of Medscape drug reference information, facility policy review and interviews, the facility failed to ensure Resident #117 was free from a significant medication error and failed to ensure the error was reported immediately so that timely and appropriate medical intervention could be provided. This resulted in Immediate Jeopardy and actual harm/death of Resident #117 when on [DATE] at approximately 6:56 A.M. [...]

Inspectors wroteBased on record review, interview, observation of photographic evidence, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure communication and coordination of services with the dialysis center regarding the care of Resident #119's dialysis catheter. This affected one resident (#119) of four residents reviewed and observed for dialysis catheter care. The facility census was 112.

Inspectors wroteBased on medical record review, interview, and review of the facility policy, the facility failed to ensure timely notification of death of the legal guardian for Resident #119. This affected one resident (#119) of three residents who were reviewed for notification of significant incidents or changes in condition. The facility census was 118.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, interview, review of drug information on triamcinolone 0.1% cream (a topical corticosteroid) on Drugs.com, and review of the facility policy the facility failed to ensure ongoing care and services remained appropriate and failed to address repeated concerns voiced by state tested nurse aides (STNAs) regarding a black discoloration in Resident #82's percutaneous endoscopic gastrostomy (PEG) tube (a surgically placed feeding tube into the stomach) resulting in the resident being transferred to the hospital related to a clogged PEG tube with maggots noted in the tube. [...]

Inspectors wroteBased on observation, interview, record review, facility Self-Reported Incident review, hospital record review, and review of the facility policy the facility failed to ensure a comprehensive fall risk assessment with individualized interventions was in place for Resident #83 and failed to timely assess and properly treat the resident after a fall. Actual harm occurred on 04/29/24 when Resident #83, who was at risk for falls did not have individualized interventions in place to address the risk, fell in her room and was not thoroughly assessed before being returned to bed. This resulted in the resident experiencing severe pain to her leg and a delay in immediate treatment. The resident was subsequently transferred to the emergency room for treatment of a femur fracture requiring surgical repair. This affected one resident (#83) of three residents reviewed for falls. [...]

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure and allegation of verbal abuse towards Resident #23 was thoroughly investigated. This affected one resident (Resident #23) out of three residents reviewed for abuse. The facility census was 122.

Inspectors wroteBased on interview, record review and review of the facility policy the facility failed to ensure Resident #125's physician was provided accurate information regarding a discharge Against Medical Advice to ensure the safest discharge possible. This affected one resident (Resident #125) out of three residents reviewed for a safe discharge. The facility census was 122.

Inspectors wroteBased on record review and interview, the facility failed to timely ensure a comprehensive treatment plan was in place to properly drain, monitor, and dress Resident #125's chest tube. This affected one resident (Resident #125) of three residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #121's incontinence care was completed timely. This affected one resident (Resident #121) out of three residents reviewed for incontinence care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean and sanitary kitchen area. This had the potential to affect all residents who received meals from the kitchen. The facility identified 12 residents (#2, #13, #15, #41, #62, #77, #80, #88, #94, #96, #420, and #670) that had a nothing by mouth (NPO) diet. The facility census was 123.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dumpster area was maintained in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 123.

Inspectors wroteBased on record review and interview, the facility failed to ensure assessments were accurately completed. This affected four (Residents #4, #52, #93 and #112) of four residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 123.

Inspectors wroteBased on observation and interview, the facility failed to ensure space heaters were not used by residents in the facility. This affected one resident (Resident #116) and had the potential to affect an additional 28 residents (Residents #1, #10, #17, #25, #26, #39, #50, #54, #58, #63, #66, #67, #82, #84, #85, #101, #107, #110, #120, #470, #471, #472, #473, #474, #475, #476, #477 and #670) residing on the 300 hall. The census was 123.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #470's call light was available and accessible for the resident's use. This affected one (Resident #470) of 18 residents (Residents #4, #10, #11, #48, #50, #52, #53, #54, #63, #85, #107, #112, #118, #470, #471, #472, #475 and #570) who were observed for call lights within reach. The facility census was 123.

Inspectors wroteBased on observation and interview, the facility failed to ensure Residents #82's and #470's bathrooms were maintained at a comfortable ambient temperature. This affected two (Residents #82 and #470) of nine residents (Residents #10, #54, #55, #78, #82, #116, #470, #471 and #473) whose bathroom temperatures were checked. The census was 123.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely incontinence care for residents. This affected one (Resident #4) of one resident reviewed for incontinence care. The facility census was 123.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #107's tube feeding was infused per the physician's orders. This affected one resident (Resident #107) of one resident reviewed for tube feedings. The facility census was 123.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were obtained timely from the pharmacy and were administered as ordered. This affected one (Resident #48) of three residents reviewed for pain medications being administered as ordered. The facility census was 123.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of medications when they expired. This affected two (Residents #30 and #69) of four residents reviewed for medication storage. The facility census was 123.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #10's medical record was complete and accurate. This affected one resident (#10) of two residents reviewed for antibiotic use. The facility census was 123.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain adequate infection control practices during administration of medications to residents. This affected one (Resident #6) of six residents observed during medication administration. The facility census was 123.

Inspectors wroteBased on record review, observation and interview the facility failed to store and prepare foods under sanitary conditions. This had the potential to affect all residents receiving meals from the kitchen except eight residents (#9, #25, #26, #35, #38, #45, #105 and #109) who did not receive food/nutrition by mouth. The facility census was 109.

Inspectors wroteBased on record review, observation and interview the facility did not ensure menus were posted in a highly visible area and/or ensure residents received a copy of the menu to support individual food choices each day. This affected four residents (#19, #52, #68, and #95) of 24 residents who were reviewed for choices. The facility census was 109.

Inspectors wroteBased on record review, observation and interview the facility failed to serve meals in a timely manner. This affected 21 residents (#2, #3, #5, #11, #16, #19, #23, #28, #31, #46, #52, #59, #65, #68, #76, #86, #88, #89, #99, #100 and #114) residing on the 200 unit and had the potential to affect all residents in the facility except eight residents (#9, #25, #26, #35, #38, #45, #105 and #109) who did not receive food/nutrition by mouth. The facility census was 109.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure the call light was in reach at all times for Resident #89 who had limited mobility. This affected one of 24 residents reviewed for accommodation of needs. The facility census was 109.

Inspectors wroteBased on record review, observation, interview, and policy review the facility failed to conduct predialysis and postdialysis blood pressure checks and assessments for Resident #2 and Resident #56. This affected two of nine residents reviewed for dialysis. The facility census was 109.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to ensure narcotics were reconciled every shift. The facility also failed to ensure accurate accounting of narcotics were maintained in one of four medication carts reviewed. This affected one (Resident #55) of eight (Residents #32, #53, #55, #70, #73, #74, #91 and #117) residents who had narcotics in the 100 hall medication cart. The facility census was 109.

Inspectors wroteBased on record review, observation and interview the facility failed to provide a therapeutic diet as ordered for Resident #2 who was receiving hemodialysis treatments. This affected one of 23 residents reviewed for therapeutic diets. The facility census was 109.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure administered medications were consistently documented on the Medication Administration Record (MAR). This affected one (Resident #55) of 13 (Residents #21, #25, #27, #30, #36, #51, #52, #55, #102, #106, #112, #120 and #320) residents whose MARs were reviewed. The facility census was 109.