Care Manor Nursing and Rehab

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interview it was determined the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for five (Resident #7, Resident #4, Resident #69, Resident # 34, and Resident #58) of 10 residents reviewed for MDS accuracy.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interviews it was determined that the facility failed to address intravenous therapy, primary diagnoses, and antibiotic therapy in the comprehensive care plan for one (Resident #52) of one resident reviewed.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure a written bed hold notification was issued prior to a hospital transfer for 1 (Resident #1) of 1 resident reviewed for transfer process.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the comprehensive care plan was revised or updated for 1 (Resident #47) sampled resident.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure PRN (as needed) orders for psychotropic drugs were limited to 14 days without documentation from the attending physician or prescribing practitioner indicating their rationale in the resident's medical record for 2 (Residents #11 and #42) sampled residents that were selected for medication review.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that narcotic medications were stored in a permanently affixed compartment to prevent the potential of misappropriation of resident property, that multi-use vials were dated when opened, and medications from discharged residents were appropriately accounted for and secured to prevent misappropriation of medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a multi-resident use glucometer was disinfected after use to prevent potential spread of infection for 1 (Resident #45) who had physician orders for capillary blood glucose (CBG) monitoring.

Inspectors wroteBased on record review and interview, the facility failed to ensure that an Infection Preventionist was employed by the facility during the time frame of 01/02/2024 to 02/08/2024 in which a COVID-19 outbreak occurred.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that a residents expressed preference for having their bed made was honored for one (Resident #32) sampled resident.

Inspectors wroteBased on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment; food items stored in the refrigerator /freezer were covered, sealed and dated; expired food items were promptly removed/discarded by the expiration or use by dates; foods were dated when received or opened to assure first in first out usage and hot foods on the steam table were maintained at or above 135 degrees Fahrenheit while awaiting service, to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 44 residents who received meals from the kitchen (total census: 45), as documented on a list provided by the Dietary Supervisor on 03/07/23 and the

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive, person-centered Care Plan was developed to address the necessary care and monitoring related to the administration of antipsychotic, antianxiety, antidepressant, anticoagulant, and diuretic medications, to enable staff to determine the effectiveness of the medication and promptly identify any potential adverse effects for 1 (Resident #26) of 1 sampled resident who received Risperdal, for 1 (Resident #35) of 2 (Resident #35 and #41) sampled residents who received Buspirone; for 1 (Resident #35) of 3 (# 2, #34, and #35) sampled residents who received Trazodone; for 1 (Resident #26) of 2 (#14 and #26) sampled residents who receive Sertraline; for 1 (Resident #26) of 3 (#16, #26, and #43) sampled residents who received Eliquis; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure bathing services were regularly provided to maintain good hygiene for 2 (Residents #31 and #34) of 13 (Residents #2, #3, #5, #10, #14, #15, #16, #17, #21, #28, #31, #34, #41) case mix residents who were dependent on staff for bathing. This failed practice had the potential to affect 14 residents residing on the 300 hall, who were dependent on staff for bathing/showers, according to a list provided by the Administrator on 03/09/23 at 14:16 [2:16] pm.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the oxygen/updraft mouthpiece/mask was stored in a bag or other closed container when not in use to prevent potential contamination for 1 (Resident #304) of 5 (Residents #5, #18, #28, and #34, and #304) sampled residents who had an order for an updraft and for 2 (Residents #18 and #304) of 6 (Residents #2 #5, #18 #31, #34, and #304) sampled residents who had an order for oxygen.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 4 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 03/07/23.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate and complete to facilitate the ability to plan and provide necessary care and services for 1 (Resident #26) of 11 (Resident (#10, #17, #18, #26, #31, #34, #35, #36, #39, #41, and #304) case mix residents selected for MDS accuracy review. This failed practice had the potential to affect all 45 residents who resided in the facility, as documented on a Resident Census and Conditions of Resident dated 03/06/23.