Community First Medical Center

Inspectors wroteBased on observation, interview, and record review the facility failed to follow proper sanitation and food storage practices as evidenced by a.) food not properly labeled, and b.) food not properly stored. These deficient practices have the potential to affect all 20 residents receiving food prepared for the nursing skilled facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) maintain infection control standard precautions by removing an IV (intravenous) access timely after discontinuation of the IV antibiotic for 1 (R64) resident, b.) failed to clean and disinfect equipment between 5 (R59, R60, R61, R62, R66) residents use and c.) failed to maintained infection control for 1 (R60) of resident observed during medication administration. Findings Include: R64 has diagnosis not limited to Physical Deconditioning, Fracture of Proximal end of Humerus, Dizziness, Cerebral Vascular Accident, Essential Hypertension, Low Back Pain, Radiculopathy, Spinal Stenosis Lumbar Region, Disc Displacement Lumbar, Lumbar Radiculopathy, Right Hip Pain, Hypoxia, Fall at Home, Chronic Obstructive Pulmonary Disease, Pulmonary Embolism, Shortness of Breath. Report Viewer document in part: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 (R63, R64) of 4 residents peripheral intravenous (IV needle inserted within the vein) site was labeled with the date and time that it was inserted. This deficient practice has the potential for R63 and R64 to not receive the necessary care to the IV site. Findings Include: R64 has diagnosis not limited to Physical Deconditioning, Fracture of Proximal end of Humerus, Dizziness, Cerebral Vascular Accident, Essential Hypertension, Low Back Pain, Radiculopathy, Spinal Stenosis Lumbar Region, Disc Displacement Lumbar, Lumbar Radiculopathy, Right Hip Pain, Hypoxia, Fall at Home, Chronic Obstructive Pulmonary Disease, Pulmonary Embolism, Shortness of Breath. Report Viewer document in part: Peripheral IV line - Single lumen 07/29/24 0920 cephalic vein (lateral left arm), Left 20 gauge. Placement date/time: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their respiratory infection control practices policy by not storing Continuous positive airway pressure mask in a closable bag for one [163] resident reviewed in a sample of 20. Findings Include: R163's clinical record indicates in part, R163 was admitted with transient cerebral ischemic attack, obstructive sleep apnea, morbid obesity, bradycardia, chronic diastolic heart failure, facial weakness, atrial fibrillation, monoplegia of upper limb affecting left side, hypertensive heart disease, osteoarthritis, mitral insufficiency, and lymphedema. R163's Respiratory Orders: Non-Invasive Ventilation at bedtime [Continuous positive airway pressure-CPAP]. On 08/06/24 10:45 AM, surveyor observed R163's C-PAP mask hanging off the side of the machine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label all insulin vials and eye drops, and failed to Maintain insulin vials used by multiple residents at dedicated clean medication preparation area. These failures can affect all residents in facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food storage practices by not labeling and storing food appropriately. These deficient practices have the potential to affect all 14 residents receiving food prepared in the facility kitchen. Facility census, dated 08/29/2023, documents a total of 14 residents admitted to the extended care unit/ECU of the facility.

Inspectors wroteDeficiencies at this level require 2 Deficient Practice Statements. A. Based on observation, interview, and record review the facility failed to perform apprpriate hand hygiene after touching multiple high-touched areas to prepare and administer medicines for 2 out of 7 residents (R18 and R16) during medication administration. These failures have the potential to place 2 residents (R18 and R16) at risk of infections. B. Based on observation, interview, and record review, the facility failed to conduct an assessment to identify where Legionella (a bacteria that can cause a serious type of pneumonia (lung infection) called Legionnaires' disease) and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter) could grow and spread; and failed to consistently perform and monitor control measures. These failures have the potential to affect all the residents in the facility.

Inspectors wroteBased observation, interview, and record review, the facility failed to provide person-centered care plans for 4 out of 5 residents (R5, R8, R9, and R158) for a total of 14 residents reviewed for plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy on dignity for one (R12) of five residents reviewed in a sample of 14.

Inspectors wroteBased on observation, interview ,and record review, the facility failed to follow their policy to ensure two residents (R11, R15) of five residents reviewed were free of physical restrains in sample of 14 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure by failing to administer/offer the pneumonia vaccine to two (R11, R12) of five residents reviewed in a sample of 14.

Inspectors wroteBased on observation, intervies, and record review, the facility failed to follow policies in ensuring call lights are functioning and can be used for 3 out of 3 residents (R158, R10, and R8) out of a total sample of 14 residents reviewed for access to staff by using call lights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have evidence of rountine testing of the the dish machine sanitizing temperatures and demonstrated the dish machine had proper santizing temperatures, failed to ensure food stored in the dry storage and refrigeration areas were stored in a manner to prevent cross contamination of the food items, failed to ensure an expired food item and each food item was dated while stored in the refrigeration area, failed to ensure can foods have in-out dating tracking, and failed to ensure staff perform hand hygiene when taking food temperatures; These failures have the potential to affect 14 residents in the facility whom recieve an oral diet. Per Facility Census there are 15 total number of residents, with 1 resident on NPO.

Inspectors wroteBased on observation, interview, and record reivew, the facility failed to maintain kitchen equipment in working order. This has the potenital to affect 14 of 15 residents receiving meals from the facility's kitchen.

Inspectors wroteBased on interview and record review, the facility failed to reconcile controlled narcotic medications stored in automated dispensing machines located on the fourth floor of the facility. This failure affected six of six residents (R163, R7, R1, R11, R65, R8) who receive narcotic medications from the 4th floor medication dispensing machine.

Inspectors wroteBased on interview and record review, the facility failed to follow their Pneumonia/Flu Vaccine policy to ensure residents received education regarding the benefits of influenza and/or pneumococcal immunization. This applies to 5 of 15 residents (R113, R62, R8, R63) residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized care plan to address a resident's pain and use of anticoagulation medication. This applies to 2 of 15 (R65 and R66) residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident's pain level every shift, to manage a resident's pain. This applies to one of 15 residents (R66) who was reviewed for pain management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy on labeling and dating opened insulin medication vials for three of three residents (R162, R64, R63) receiving insulin medications and house stock insulin vials located on the 4 west unit of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene for one (R7) resident receiving a wound dressing change, and failed to place a new disinfecting port protector on a needleless intravenous connector for one (R163) resident after accessing the intravenous connector during medication administration. These failures have the potential to affect 2 of 15 (R7, R163) residents residing in the facility.