Cavalier Healthcare of England

Inspectors wroteBased on record review and interview, the facility failed to ensure the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment or change in condition for four (Resident #10, #47, #35, and #43) of five sampled residents.

Inspectors wroteBased on observations, interviews, and facility policy review, it was determined that the dietary staff failed to ensure hand hygiene was completed for one of one meal service observed.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident’s family member serving as Power of Attorney was invited to participate in a care plan meeting for one (Resident #13) of three residents reviewed for care plans.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure one (Resident #15) of one resident reviewed had formulated an advanced directive that provided a clear understanding of the resident's wishes. Specifically, documentation regarding Resident #15’s code status containing conflicting information regarding life-sustaining treatments.

Inspectors wroteBased on record review and interview, it was determined the facility failed to complete a significant change Minimum Data Set (MDS) within 14 days after the facility determined there had been a significant change in a resident’s physical or mental condition for one (Resident #35) of one resident.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure an entry Minimum Data Set (MDS) comprehensive assessment was encoded and transmitted in the allotted timeframe for one (Resident #35) of one resident reviewed for MDS requirements.

Inspectors wroteBased on record review, observation, interviews, facility document review, and facility policy review, the facility failed to ensure a resident was checked and changed every two hours for perineal care and repositioned to prevent the risk of infection and skin breakdown for one (Resident #39) of one resident reviewed.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure meals were served in a method that conserved the nutritive value and maintained the appearance of cold and hot products and serving of food items at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed.

Inspectors wroteBased on observation and interview, the facility (1) failed to ensure food items stored in the refrigerator were covered and dated, (2) failed to ensure that the kitchen vents were cleaned to provide a sanitary environment for food preparation, (3) failed to ensure floors, dish washer the door frames, baseboard and ceiling tiles were free of chipped, holes, paint peeling, rust, stains, (4) failed to ensure dietary staff washed their hands when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1 kitchen, dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, and (5) failed to ensure hot food item was maintained at 135 degrees Fahrenheit or above on the steam table while awaiting service to prevent potential food borne [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nails were clean and trimmed for 1 (Resident #2) of 1 sampled resident.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure a safe and hazard-free environment for 2 (Resident #43 and #50) sample mixed residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure the refrigerated narcotic medications in 1 of 1 medication storage room were stored in a permanently affixed compartment to prevent the potential misappropriation of resident property.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure meals were served in a method that maintained the appearance of cold product and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. This failed practice had the potential to affect 16 residents who receive meal trays in their rooms on the A Hall, 15 residents who receive meal trays on the B hall, 24 residents who receive meal trays in their room on the C hall.

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. This failed practice had the potential to affect 6 residents who received pureed diets.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure the biohazard and oxygen rooms remained locked at all times. This failed practice had the potential to affect all 57 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure that the residents had knowledge of the State Inspection Book, and it was made accessible to them if they chose to read it.

Inspectors wroteBased on observation, staff interviews, record review and review of manufacturer's instructions, the facility failed to properly secure the seat belt for 1 Resident #1 of 2 (Resident #1, and #2) case mix residents who were transported in the facility's transport van. This failed practice resulted in a past immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment; the freezer temperature was maintained at 0 degrees Fahrenheit to prevent growth of bacteria; food in the refrigerator was covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; and leftover food items were used properly to maintain food quality for residents who received meal trays from 1 of 1 kitchen. The failed practices had the potential to affect 59 residents who received meals from the kitchen (total census:59 ), as documented on a list provided by Dietary Supervisor on 01/19/2023.

Inspectors wroteBased on observation, interview, and record review the facility failed to review and revise the care plan to include that a resident had a wound on the right hip to ensure appropriate coordination of care for 1 (Resident #35) of 3 (Residents #35, #58 and #62) sampled residents who had wounds, and failed to ensure the care plan documented the correct code status for 1 (Resident #29) of 2 (Residents #29 and #56) sampled residents who had a change in code status in the past 120 days. These failed practices had the potential to affect 7 residents who had wounds according to a list provided by the Administrator on [DATE] at 3:25 PM, and 5 residents who had changed their code status in the past 120 days according to a list provided by the Administrator on [DATE] at 1:45 PM.

Inspectors wroteA. Based on observation, interview, and record review, the facility failed to ensure the resident's environment was free from accident hazards by allowing residents to have over the counter medications in their room and not locked up for 1 (Resident #58) of 8 (Residents #7, #19, #29, #50, #56, #57, #58 and #59) sampled residents who resided on the 200 Hall. The failed practice had the potential to affect 21 residents with cognitive impairments and ambulated by any means and had access to the medications according to a list provided by the Administrator on 01/18/23.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for respiratory complications for 1 (Resident #22) of 4 (Residents #7, #22, #58 and #82) sampled residents who received Oxygen. This failed practice had the potential to affect 5 residents that had physicians' orders for Oxygen as documented on a list provided by the Administrator on 01/18/22 at 3:25 PM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food was prepared by methods that maintained appearance; failed to ensure meals were served at temperatures that were acceptable to the residents to maintain palatability and encourage good nutritional intake for 2 of 2 meals observed on A Hall and C Hall. The failed practice had the potential to affect 4 residents who received pureed diets, 44 residents who received regular diets, 11 residents who received mechanical soft diets, 18 residents who received meal trays in their rooms on A Hall, and 18 residents who received meal trays in their rooms on C Hall as documented on a list provided by the Dietary Supervisor on 01/19/2023 at 10:02 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment was free from accident and hazards for 1 (Resident #58) of 8 (Resident #7, #19, #29, #50, #56, #57, #58 and #59) sampled residents on the 200 Hall, as evidenced by allowing the resident to have over the counter medications in their room and not locked up. This failed practice had the potential to affect 21 residents who were cognitively impaired and ambulated by any means and had access to the medications according to a list provided by the Administrator on 01/18/23.