Champion Rehabilitation and Nursing Center

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure it provided an environment free of potential safety hazards for seven Residents (#27, #55, #81, #8, #30, #98, and #15), out of a total sample of 26 residents. Specifically, the facility failed:1. For Residents #27, #55, and #81, to ensure safe smoking practices were implemented; 2. For Resident #8, to complete a smoking evaluation prior to him/her smoking on facility property; and 3. For Residents #30, #98, and #15, to ensure falls were investigated thoroughly and interventions were developed and implemented to prevent future falls and/or mitigate risk of injury.

Inspectors wroteBased on interview and record review, the facility failed for one Resident (#13), out of a total sample size of 24 residents, to collaborate with the dialysis center on the Resident's care and services. Specifically, the facility failed to ensure the facility's Dietitian monitored Resident #13's Dialysis lab communication report cards and addressed abnormal laboratory results.

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal immunizations for three eligible Residents (#7, #15, and #30), out of a total sample of five residents.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the physician and/or registered dietitian of a significant weight loss for one Resident (#98), out of a total sample of 24 residents, to determine if a change in treatment was necessary.

Inspectors wroteBased on observations, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#98) with an unplanned significant weight loss, out of a total sample of 24 residents. Specifically, the facility failed to assess and evaluate after a severe weight loss (11.62% weight loss in one month and 13.61% in six months) had been identified for two weeks resulting in no interventions being implemented and he/she continued to lose weight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan for three Residents (#43, #2, and #36), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #43, to develop and implement a care plan for the Resident's smoking needs; 2. For Resident #2, to develop and implement a care plan for epilepsy (seizure disorder); and 3. For Resident #36, to develop and implement a care plan for the Resident's suicidal ideation.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three Residents (#36, #51, and #89), out of a total sample of 18 residents, received culturally competent, trauma-informed care in accordance with professional standards of practice. Specifically, the facility failed to assess and identify triggers of trauma to prevent potential re-traumatization.

Inspectors wroteBased on observations, interview, and policy review, the facility failed to store, prepare, and serve food in accordance with professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to perform hand hygiene during meal service on two of three units observed.

Inspectors wroteBased on record review and interview, the facility failed to ensure for one Resident (#2), out of a total sample of 18 residents, recommended specialist appointments were scheduled. Specifically, the facility failed to ensure Inpatient Epilepsy (seizure disorder)and Neurology appointments were scheduled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one Resident (#53), out of a total sample of 18 residents, received care and treatment to promote healing of a pressure ulcer. Specifically, the facility failed for Resident #53, to implement treatments as ordered for an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (necrotic (dead) tissue that is green, yellow, tan, or brown and may be moist, loose, or stringy) or eschar (dry, thick, leathery tissue)) on the sacrum (lower spine area).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the environment was free from accident hazards for one Resident (#51), out of a total sample of 18 residents. Specifically, the facility failed to implement interventions on the comprehensive care plan to ensure safety precautions were taken for resident safety related to smoking, and to complete quarterly smoking evaluations.

Inspectors wroteBased on record review and interview, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care and management consistent with professional standards for one Resident (#2), out of a total sample of 18 residents. Specifically, the facility failed to ensure the Foley catheter was assessed for removal as soon as possible after returning from the hospital and failed to ensure he/she followed up with Urology as recommended.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to monitor the nutritional status for one Resident (#18) with an unplanned gradual weight loss, in a total sample of 18 residents. Specifically, the facility failed for Resident #18, to obtain weekly weights as ordered and to monitor the gradual weight loss of 9.68% over six months.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure for one Resident (#42), out of a total sample of 18 residents, that the Resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to ensure Azithromycin (antibiotic) was not administered without an adequate indication for use for an excessive duration of time (one year).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the physician ordered therapeutic diet was followed for one Resident (#29), in a total sample of 18 residents.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure for one Resident (#53), out of a total sample of 18 residents, infection prevention and control measures were implemented to prevent the potential transmission of infections. Specifically, the facility failed to ensure staff followed basic infection control practices, including hand hygiene, resulting in potential cross contamination (transfer of pathogens from one surface to another).

Inspectors wroteBased on a resident group meeting, interview, policy review, and document review, the facility failed to ensure grievances and concerns brought forward by the Resident Council were addressed and/or responded to.

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident environment was clean, comfortable, and homelike for the residents residing on two of three units. Specifically, 1. For the Astoria Unit (2nd floor), multiple areas in the environment were found to be dirty and/or in disrepair; and 2. For the [NAME] Unit (4th floor), multiple concerns were identified with regard to the cleanliness of resident rooms and equipment.

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to ensure an individualized plan of care was developed and implemented for three Residents (#66, #28, and #77), in a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #66, a. to develop a care plan for an indwelling urinary catheter, an intravenous (IV) catheter, and an active infection, and b. to ensure the air mattress settings were implemented per the plan of care; 2. For Resident #28, to develop a care plan for edema; and 3. For Resident #77, to ensure the air mattress settings were implemented per the plan of care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure one Resident (#16) with a pressure ulcer received treatment and services to promote wound healing, in a sample of five residents with pressure ulcers. Specifically, the facility failed to ensure for Resident #16, a. wound treatment recommendations were implemented, and b. the pressure-relieving air mattress was utilized following professional standards.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's drug regimen was free from unnecessary drugs without adequate monitoring for signs/symptoms of adverse consequences (i.e., side effects) to ensure the safe administration of medications for four Residents (#19, #42, #40, and #28), in a total sample of 19 residents. Specifically, the facility failed to ensure Residents #19, #42, #40 and #28 were monitored for signs/symptoms of adverse complications/side effects (signs and symptoms of hypo/hyperglycemia) and effectiveness related to the administration of antidiabetic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of changes in condition, to re-evaluate the potential need to alter the treatment plan for two Residents (#16 and #19), from a total sample of 19 residents. Specifically, the facility failed to notify the primary physician when: 1. Resident #16 developed an open area on the sacrum (lower back near the pelvis) and a new dressing was applied; and 2. Resident #19 had recommendations from the consultant Ophthalmologist.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed for one Resident (#85), out of five residents observed during medication administration, to verify the prescribed dose of medication prior to administering the medication to the Resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities of daily living, including getting out of bed to a wheelchair and receiving a shower, for one Resident (#16) who was dependent for care, in a total sample of 19 residents.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure one Resident (#59) received his/her hearing aids daily, to maintain hearing ability, out of a total sample of 19 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure compartments containing drugs and biologicals were locked when not in use for 2 of 6 medication carts in use by the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of discharge prior to transferring one Resident (#6) to the hospital on two occasions, out of 19 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed-hold notice upon transfer to the hospital on two occasions for one Resident (#6), out of 19 sampled residents.