Bridges to Home

Inspectors wroteBased on interview and record review, the facility failed to inform a resident and/or their representative of their health status in a timely manner for 1 of 3 residents (Resident 2), reviewed for resident rights. This failure placed the resident and/or their representative at risk of not being fully informed of changes in condition, making informed decisions, and ensuring that treatment aligns with the resident's goals and preferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse and/or neglect was reported to the State Agency within the required timeframe for 1 of 3 residents (Resident 1), reviewed for abuse reporting. This failure placed a resident at risk for potential unidentified abuse and/or neglect and lack of protection from abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegation of abuse and/or neglect was investigated timely and thoroughly for 1 of 3 residents (Resident 1), reviewed for abuse investigation. This failure placed the resident at risk for repeated incidents, unidentified abuse, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement care plan for 1 of 3 residents (Resident 1), reviewed for comprehensive care plan. The failure to implement care plan for droplet precaution (an infection control measure used to prevent the spread of germs [tiny organisms]) placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient dietary support personnel were available for 2 of 8 residents (Residents 1 & 3), reviewed for food and nutrition services. This failure to provide the kitchen with adequate dietary staff left residents at risk for less than palatable meals, improperly prepared meals, foodborne illness, late food service, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 2 residents (Resident 4) was free from a significant medication error. Resident 4 experienced harm when they were hospitalized for a benzodiazepine (medication to treat seizures [a temporary, uncontrolled burst of electrical activity in the brain that can cause temporary changes in behavior, movements, sensations, or awareness]) overdose (excessive/dangerous dose of a drug). This failure placed the residents at risk for serious medication errors, complications, and adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement care plans for 4 of 7 residents (Residents 7, 1, 6 & 4), reviewed for comprehensive care plans. The failure to implement care plans for use of benzodiazepine (a medication for seizures/epilepsy [a temporary, uncontrolled burst of electrical activity in the brain that can cause temporary changes in behavior, movements, sensations, or awareness]), diuretic (medications that help move extra fluid out of the body), and antibiotic (medications to treat infections) placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nurse staffing information postings were posted at the beginning of each shift for 3 of 4 days and failed to ensure the nurse staffing information posting was in a prominent location readily accessible to residents/representatives and visitors, reviewed for Nurse Staffing Information. These failures placed the residents/representatives and visitors at risk for not being fully informed of current nurse staffing levels and resident census information.

Inspectors wroteBased on interview and record review, the facility failed to ensure Medication Regimen Review (MRR- a comprehensive assessment of resident's medications, performed by a pharmacist [a qualified professional to provide expert advice on medication management, safety, and regulatory compliance] to identify and address potential problems) was completed for 1 of 5 residents (Resident 6), reviewed for unnecessary medications. This failure placed the resident at risk of receiving unnecessary medications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain proper temperature for 1 of 1 refrigerator (Medication Room Refrigerator), reviewed for medication storage. This failure placed the residents at risk of receiving compromised and ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP-precaution to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) practices were followed for 1 of 7 residents (Resident 2), reviewed for infection control. In addition, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed during garbage disposal and resident care for 4 of 8 staff (Staff M, Staff G, Staff R & Staff C). These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff followed and implemented abuse and neglect policies and procedures for the protection of residents during a medication error investigation for 1 of 2 residents (Resident 4), reviewed for allegations of potential neglect. This failure placed the residents at risk for abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman (an advocate for residents of nursing homes who protect and promote resident rights under federal and state law and regulations) of discharges and/or transfers, as required for 1 of 1 resident (Resident 11), reviewed for discharge process. This failure placed the residents at risk for lack of advocacy and possible unidentified or unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff document medications and/or enter physician orders before administration of medication in accordance with professional standards for 2 of 4 residents (Residents 5 & 6), reviewed for medication administration. These failures placed the residents at risk for medication errors and negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's representative was provided information about COVID-19 (an infectious disease-causing respiratory illness) vaccinations, including risks, benefits, potential side effects, documented if the vaccine was accepted and/or refused in the medical record for 1 of 5 residents (Resident 5), reviewed for COVID-19 immunizations. This failure placed the resident at risk for COVID-19 infection and denied their representative of the right to make informed decisions.