Circle of Care

Inspectors wroteBased on review of the medical record, interview, review of the facility policy and review of the Nursing Home Residents' [NAME] of Rights, the facility failed to ensure residents representatives were notified of significant changes. This affected two (Resident #7 and #35) of three residents who were reviewed for changes in condition. The facility census was 36.

Inspectors wroteBased on observation, medical record review, review of the facility water management plan and maintenance logs, review of legionella water test results, review of the Centers for Disease Control and Prevention (CDC) guidance related to legionella, review of infection control tracking, and interviews with staff and representative from the Local Health Department (LHD), the facility failed to develop, implement and follow a comprehensive and effective infection control program/water management plan to prevent the continued presence of legionella bacteria in their water supply. Upon identification of elevated legionella levels, the facility failed to re-evaluate or update their water management risk assessment and water management plan or provide effective intervention to mitigate the risk of legionella growth. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to renew their food service operation license in a timely manner. This affected all 35 residents who received food from the kitchen (except Residents #14, #37, #41, #94, and #96 who had orders for nothing by mouth). The facility census was 40.

Inspectors wroteBased on review of the facility Quality Assurance and Performance Improvement Program (QAPI) and Quality Assurance (QA) sign-in sheets and meeting minutes, policy review and interview, the facility failed to ensure the QA committee consisted of the minimum required members. This had the potential to affect all 40 residents residing in the facility.

Inspectors wroteBased on review of training certificates, personnel files, and interview, the facility failed to ensure staff responsible for overseeing the infection prevention and control program (IPCP) completed specialized training in infection prevention and control. This had the potential to affect all 40 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide evidence that the physician conducted in-person examinations of all residents. This affected four residents (#3, #94, #145, and #146) of four reviewed for new admissions. The facility census was 40.

Inspectors wroteBased on record review and interview, the facility failed to provide evidence that the physician did not delegate tasks to non-physician providers that were specified to be completed by the physician personally. This affected four residents (#3, #94, #145, and #146) of four reviewed for new admissions. The facility census was 40.

Inspectors wroteBased on record review and interview, the facility failed to provide spend-down notices to Residents #9 and #10. This affected two residents (#9 and #10) of five reviewed for resident funds. The facility census was 40.

Inspectors wroteBased on record review and interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASRR) level two evaluation for Resident #29 after a new diagnosis of Schizoaffective disorder. This affected one resident (#29) of one reviewed for PASRR. The facility census was 40.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to provide evidence that Resident #145's baseline care plan was developed in a timely manner. This affected one resident (#145) of one reviewed for dialysis. The facility census was 40.

Inspectors wroteBased on review of medical records, interviews, and review of facility policy, the facility failed to initiate and implement person-centered comprehensive care plans that addressed their identified needs for two residents (#11 and #20) of 19 residents whose care plans were reviewed during the annual survey. The facility census was 40.

Inspectors wroteBased on record review, review of fall investigations, interview, and review of facility policy, the facility failed to re-evaluate care planned fall interventions for effectiveness and update the care plan with new interventions after multiple falls for Resident #10. This affected one resident (#10) of three reviewed for falls. The facility census was 40.

Inspectors wroteBased on observation, interviews, and review of facility policy, the facility failed to ensure smoking materials were stored in a safe and secure location. This affected two residents (#17 and #20) of four residents reviewed for accidents. Residents #17 and #20 were also two of the six residents identified by the facility as smokers. The facility census was 40.

Inspectors wroteBased on observation, interview, review of the medical record, and review of facility policy, the facility failed to ensure appropriate and timely services related to an intravenous (IV) midline catheter. This affected one of one resident (#28) reviewed who had an IV. The facility census was 40.

Inspectors wroteBased on medical record reviews, review of pharmacy consultation reports, and interview, the facility failed to ensure the pharmacist recommendations for Resident #11 were reviewed and addressed by the physician. This affected one resident (#11) of five residents who were reviewed for unnecessary medications. The facility census was 40.

Inspectors wroteBased on record review and interview, the facility failed to limit as needed (PRN) psychotropic and antipsychotic medications to 14 days. This affected one resident (#3) of five reviewed for unnecessary medications. The facility census was 40.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain Resident #34's record in a complete and accurate manner. This affected one resident (#34) of nineteen records reviewed. The facility census was 40.

Inspectors wrote2. Review of the medical record for Resident #43 revealed an admission date of 11/23/24 and a discharge date of 12/21/24. Diagnoses included acute respiratory failure with hypoxia, pulmonary hypertension, chronic systolic and diastolic congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), atrial fibrillation, dependence on machines and other devices, diabetes mellitus, and chronic kidney disease. Review of the admission Minimum Data Set (MDS) 3.0 completed on 11/29/24 revealed Resident #43 had intact cognition and medically complex conditions. Review of the orders revealed a physician order dated 12/20/24 to send Resident #43 to the emergency room (ER) for further evaluation and treatment. Review of the progress note dated 12/20/24 at 11:32 A.M revealed Resident #43 was transferred out of the facility by ambulance on 12/20/24 at 11:20 A.M. [...]

Inspectors wroteBased on medical record review, interview, and review of facility policy, the facility failed to ensure all residents transferred out of the facility received information on the facility's bed hold policy. This affected one resident (#43) of two residents who were reviewed for hospitalization. The facility census was 40.

Inspectors wroteBased on review of the medical record and interview with the staff the facility failed to ensure inventions were attempted prior to the use of an as-needed antianxiety medication, and failed to ensure an as- needed lorazepam was not administered more than 14 days without a stop date. This affected one resident (Resident #22) of three residents revealed for behaviors. The facility census was 35.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to prevent the development of an avoidable pressure ulcer and failed to promptly identify, monitor/assess and implement effective treatment for Resident #4 following the development of an in-house pressure ulcer to the resident's left buttock to prevent the deterioration of the ulcer and promote optimal healing. This affected one resident (#4) of two residents reviewed for pressure ulcers. [...]

Inspectors wroteBased on review of personnel files, facility policy and procedure review and interview the facility failed to ensure all staff were checked against the Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This had the potential to affect all 33 residents residing in the facility.

Inspectors wroteBased on observation, facility policy and procedure review and interview the facility failed to ensure food items were stored appropriately in refrigerators on the nursing units to prevent contamination and/or spoilage. This affected one resident (#24) and had the potential to affect 28 of 28 residents who received oral intake. The facility identified five residents (#2, #4, #18, #20 and #30) who had orders for nothing by mouth.

Inspectors wroteBased on record review and staff interview the facility failed to complete a Legionella risk assessment and ensure control measures were in place to decrease the risk of Legionella in the facility. This had the potential to affect all 33 residents residing in the facility.

Inspectors wroteBased on record review and staff interview the facility failed to maintain a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. This affected 17 residents (#6, #7, #8, #10, #12, #13, #14, #15, #16, #17, #19, #21, #23, #25, #27, #31 and #32) of 21 residents identified to have personal fund accounts managed by the facility. The facility census was 33.

Inspectors wroteBased on review of COVID-19 tracking information documents, facility policy and procedure review, review of the Center for Medicare and Medicaid (CMS) Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes (QSO-20-29-NH) and interview the facility failed to notify residents and their representatives of positive staff and resident COVID-19 cases in the facility as required. This had the potential to affect all residents residing in the facility beginning on 01/14/22. The facility census was 33.

Inspectors wroteBased on review of advance beneficiary notices, facility policy and procedure review and staff interview the facility failed to ensure residents and/or their responsible parties received the appropriate advance beneficiary notices when discharged /cut from Medicare (MCR) Part A services. This affected two residents (#11 and #183) of three residents reviewed for liability/beneficiary protection notification.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure Resident #10, Resident #13, Resident #27 and Resident #32 were free from potential incidents of misappropriation when receipts for monies removed from their personal funds account were not completed/maintained. This affected four residents (#10, #13 #27 and #32) of five residents whose personal funds were reviewed.

Inspectors wroteBased on record review and interview the facility failed to ensure the Ombudsman was notified of transfer/discharges for Resident #24, Resident #30 and Resident #33 as required. This affected three residents (#24, #30 and #33) of 16 sampled residents reviewed for hospitalization.

Inspectors wroteBased on record review and interview the facility failed to ensure a comprehensive plan of care was developed and implemented for Resident #24 related to falls/fall risk. This affected one resident (#24) of sixteen residents whose care plans were reviewed.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #4's gastrostomy tube was checked for proper placement prior to the administration of medications to prevent complications and to ensure medications were administered as ordered. This affected one resident (#4) of five residents observed for medication administration.

Inspectors wroteBased on record review and interview the facility failed to ensure a physician attended Quality Assurance committee meetings. This had the potential to affect all 42 residents.

Inspectors wroteBased on record review and interview the facility failed to implement a comprehensive and effective Legionella prevention program including water testing per the facility's plan. This had the potential to affect all 42 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to accurately reflect residents' status on required Minimum Data Set (MDS) 3.0 assessments. This affected four residents (Resident #4, #10, #22, and #30) of 20 residents whose MDS 3.0 assessments were reviewed.

Inspectors wroteBased on observation, record review and interview the facility failed to complete a comprehensive assessment related to activity preferences for Resident #8. This affected one resident (Resident #8) of two residents reviewed for activities.

Inspectors wroteBased on observation, record review and interview the facility failed to revise the care plan for range of motion for Resident #8. This affected one resident (Resident #8) of two residents reviewed for range of motion.

Inspectors wroteBased on record review and interview the facility failed to provide a restorative ambulation program in accordance with Resident #12's restorative plan. This affected one resident (Resident #12) of ten residents interviewed regarding activities of daily living.

Inspectors wroteBased on observation, record review and interview the facility failed to provide range of motion services in a timely manner for Resident #29. This affected one resident (Resident #29) of two residents reviewed for range of motion.

Inspectors wroteBased on observation, record review and interview the facility failed to check placement of a gastrostomy tube prior to the administration of medication for Resident #22. This affected one resident (Resident #22) of one resident observed for the administration of medications per gastrostomy tube of six residents observed during the medication administration.

Inspectors wroteBased on observation, record review, policy review and interview the facility failed to administer oxygen in accordance with physician orders for Resident #10. This affected one resident (Resident #10) of 15 residents screened for oxygen use. The facility identified 15 residents with oxygen orders.

Inspectors wroteBased on record review and interview the facility failed to monitor laboratory tests in accordance with physician orders to ensure the adequate use of medications at the prescribed dose for Resident #4. This affected one resident (Resident #4) of five residents reviewed for medication use.