Castle Manor Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure four of twenty-one sampled residents (12,17, 231, 233) had Advanced Directives or documented discussions with Social Services Director (SSD) about Advance Directives. This failure had the potential to prevent residents from making their own decisions in the case of emergency treatment. Cross Reference:

Inspectors wroteBased on interview and record review the facility's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify and include in the facility's Quality Assurance Performance Improvement plan (QAPI-plan developed by QAA to help improve conditions in the facility), trends found by surveyors during the recertification survey concerning Advance Directives (a legal document that allows you to make decisions about your future medical care). This failure had the potential for the facility to overlook trends in resident care that might have affected residents' dignity and/or health. Cross Reference:

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure confidential information was kept private for one of 4 sampled residents (181) when Licensed Nurse (LN) 11 left Resident 181's bubble wrap medications (unit dose packaging organizing medications into individual doses) unattended. As a result, Resident 181's right to privacy and confidentiality was violated.

Inspectors wroteBased on observation, interview and record review the facility failed to implement an individualized care plan for one of twenty-two sampled residents (Resident 41) with pruritis (itching) and rashes. This failure had the potential for Resident 41 to experience continued discomfort and skin breakdown.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure injuries (skin breakdown caused by pressure) for one of twenty-two sampled residents (Resident 1) by failing to turn/reposition resident and failing to provide pericare (cleaning the private area) for an extended period of time. This failure had the potential to result in the decline of Resident 1's skin integrity.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy on smoking procedures for one of twenty-two residents (Resident 41) reviewed for smoking. As a result, there was potential to jeopardize the health and safety of Resident 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered appropriately for two of twenty-one sampled residents (41, 133). This failure had the potential for medication error resulting in decline in residents' health.

Inspectors wroteBased on observation, interview, and record review the facility failed to demonstrate infection control practices when: 1. A staff member was observed leaving an isolation room wearing full Personal Protective Equipment (PPE-gown, gloves, mask, face shield). and 2. A staff did not perform hand hygiene for one of 4 sampled residents (34) during medication administration. As a result, residents were at risk for exposure to unwanted pathogens (microorganisms that cause disease).

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurse (LN) 1 performed a complete assessment (a process that evaluates a resident's health by gathering and analyzing information) and notified the physician for one of three residents (Resident 1), when Resident 1 experienced a sudden decrease in oxygen level and blood pressure. As a result, Resident 1 was found with cold, pale skin and without pulse approximately four hours after the decreased blood pressure (Measurement of the force exerted by blood against the walls of the arteries as the heart pumps) and oxygen level was first identified. An hour later, Resident 1 was pronounced dead.

Inspectors wroteBased on interview and record review, the facility failed to ensure license nurse (LN) 3 transcribed a medication accurately for one of three residents (Resident 1) reviewed for pharmacy services, when Resident 1 ' s Carvedilol (a medication used to treat heart failure and high blood pressure) 3.125 milligrams (mg) order was incorrectly documented as Carvedilol 25 mg. As a result, Resident 1 was given a higher dose of Carvedilol than what was ordered by the physician which may cause for the resident ' s blood pressure to decrease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide wound care as ordered by the physician for four of six residents, (Residents 2, 13, 26, 226), reviewed for skin integrity. As a results, residents were at risk for wound deterioration and delayed healing.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide showers consistently for two of two sampled residents (Residents 19, 65) reviewed for ADLs (activities related to personal care). As a result, residents' preferences and choices were not honored and respected.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop a care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to dialysis (treatment to remove waste from the body) access care for one of two sampled residents reviewed for dialysis (Resident 19). As a result, there was the potential for undetected complications after dialysis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine nail care to one of two residents (Resident 42), reviewed for Activities of Daily Living (ADL, activities related to personal care) for dependent residents. As a result, Resident 42 was at risk for skin injury and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to set a Low Air Loss (LAL) mattress per the physician's order and according to the resident's weight for one of six residents (Resident 45), reviewed for pressure ulcers (injuries to the skin and underlying tissue). As a result, there was a potential for Resident 45 to develop pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess for a decline in range of motion (ROM, distance and direction a joint can be extended) for one of one resident (Resident 42), reviewed for positioning and limited ROM. As a result, Resident 42 had the potential for contractures (shortening of muscles and tendons, often leading to permanent deformity and stiffening of joints) and a decline in movement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one residents reviewed for dental services received a referral to the dentist (Resident 45). This failure had the potential to lead to decreased food intake and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection control practices when a urinary catheter (a tube inserted into the bladder to aide in urine flow) bag and dignity bag (a bag used to cover and conceal contents inside) was lying on the floor for one of three residents reviewed for urinary catheter care (Resident 276). This failure had the potential for cross contamination (spread of germs and bacteria) and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure practices that mitigated the risk of resident food contamination were followed, when: 1. Prepared tuna sandwiches were not accurately cooled down to ensure food safety. 2. A dishwasher (DW) touched dirty dishes and then handled clean dishes without washing his hands. 3. A ready for use resident ice cart had small black dots resembling mold in it. 4. A nutritional shake stored with ready to use shakes was expired. 5. The dates on loaves of bread were inaccurate. These failures to mitigate potential food contamination may result in food borne illness. The facility census at the time of survey was 89.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dietary staff were competent on the ambient temperature food cool down process and following hand hygiene standards in the kitchen. These failures placed residents at risk of foodborne illness. The facility census was 89.

Inspectors wroteBased on interview and record review, the facility failed to update a care plan for one of 20 (7) residents reviewed for care plans. This failure resulted in Resident 7 receiving less nutrition than ordered following an episode of hypoglycemia (low blood sugar).

Inspectors wroteBased on observation, interview, and record review, the facility failed to change the dressing as ordered for one of one residents (7) reviewed for quality of care. This failure had the potential to cause an infection at Resident 7's GT (a procedure in which a tube is placed in the stomach for nutritional support) site.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of seven residents (7, 52) reviewed for nutrition received tube feeding and hydration as ordered. This failure resulted in Resident 52 not receiving the correct amount of tube feeding and hydration, and Resident 7 requiring treatment in the Emergency Department for hypoglycemia (low blood sugar). Further, the facility did not ensure Resident 7 received tube feedings as ordered in the days following the hypoglycemic episode.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 5 residents (45) reviewed for medications had the root cause of their yelling fully investigated prior to initiating and continuing the resident on an antipsychotic medication (a drug that affects brain activities associated with mental processes and behavior). This failure put Resident 45 at risk for unnecessary medications and had the potential to disrupt the resident's means of communication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately record the intake (amount of food or fluid taken into the body) for two of three residents with GT feedings (7, 3). As a result, the documentation related to nutrition and/or hydration was inaccurate.