Corwin Center at Emerald Heights

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly stored for (Resident 2) and failed to dispose of expired medical supplies for 1 of 1 medication room (Cedar Hallway Medication Room), reviewed for medication storage and labeling. These failures placed the residents at risk of medication errors, receiving compromised medical supplies, possible infections, and adverse consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard expired sanitizing solution test strips for 2 of 2 kitchens (Fire Side Grill Kitchen and Main Kitchen) and failed to ensure food items were stored and handled appropriately in accordance with professional standards of food safety for 1 of 1 dry storage room (Main Kitchen Dry Storage Room) and for 1 of 1 resident refrigerator (Resident Use Only Refrigerator), reviewed for food services. In addition, the facility failed to cover food items during meal tray delivery. These failures placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages) and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident records were complete and accurate for 4 of 6 residents (Residents 42, 36, 53 & 3), reviewed for resident records. The failure to accurately write medications orders, fill out resident forms properly, and complete/check routine bed positioning device placed the residents at risk for unmet care needs, inaccurate monitoring, potential for injury, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately use Personal Protective Equipment (PPE-use of face mask, gown, and gloves) for 1 of 4 staff (Staff T) and failed to perform hand hygiene during meal tray pass for 3 of 8 residents (Residents 52, 39 & 257), reviewed for infection control. In addition, the facility failed to handle a urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) bag appropriately for 1 of 1 resident (Resident 23), reviewed for urinary catheter care. These failures placed the residents, staff, and visitors at an increased risk of infection and related complications.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 3 of 19 residents (Residents 24, 48 & 10), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding weights and constipation (passing fewer than three stools a week or having a difficult time passing stool) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- an assessment used to identify residents referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions are not inappropriately placed in nursing homes for long term care) forms were accurate and/or sent out timely for a Level II PASARR referral for 3 of 6 residents (Residents 10, 53 & 32), reviewed for PASARRs. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident-centered care and treatment were provided in accordance with professional standards of practice when facility staff failed to do skin care evaluations for 1 of 4 residents (Resident 12), reviewed for skin conditions. This failure placed the resident at risk for unmet care needs and a diminished quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor significant weight loss for 1 of 2 residents (Resident 53), reviewed for nutrition/hydration. This failure placed the residents at risks for nutrition-related complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring of adverse side effects and parameters (when to notify the provider or hold the medication) for insulin (medication/hormone that regulates blood sugar levels) were conducted for 1 of 5 residents (Resident 36), reviewed for unnecessary medications. This failure placed the resident at risk for unmet care needs, related complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring was in place for psychotropic (mind altering) medications for 1 of 5 residents (Resident 18), reviewed for unnecessary medications. This failure placed the resident at risk for unnecessary medications, adverse side effects, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received education regarding the potential risks and benefits when offering influenza vaccine (used to prevent influenza [an infection of the nose, throat, and lungs]) for 1 of 5 residents (Resident 10), reviewed for immunizations. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about their influenza immunization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed rails (bed positioning devices) were properly secured and maintained/checked for safety for 1 of 5 residents (Resident 3), reviewed for accident hazards. This failure placed the residents at risk for injury and/or entrapment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 1 resident (Resident 1), and failed to accurately assess, identify and/or monitor residents at risk of elopement for 5 of 6 residents (Residents 1, 5, 2, 3 & 4), reviewed for accident hazards. Resident 1 experienced harm when they exited the facility unsupervised, was subsequently found by a bystander outside the facility lying on the ground and sustained a significant injury requiring a hospital admission. This failed practice placed the residents at risk for elopement, falls, and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and/or develop comprehensive care plans for 5 of 6 residents (Residents 2, 1, 3, 4 & 5), reviewed for care planning. The failure to implement and develop care plans for risk of elopement placed residents at risk for elopement, unmet care needs, and potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 4 residents (Resident 1), reviewed for medication management. The failure to document narcotic (opioid/controlled drugs) medications in accordance with professional standards of practice placed the resident at risk for uncontrolled pain, medication errors, negative outcomes, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were protected from misappropriation of controlled (narcotic or opioid) medication for 1 of 3 residents (Resident 1), reviewed for misappropriation of controlled medications. This failure placed the resident at risk for pain, unmet care needs, ongoing misappropriation of medications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to timely report allegations of misappropriation of controlled (narcotic or opioid) medication to the State Agency within the required timeframe for 1 of 3 residents (Resident 1), reviewed for allegations of misappropriation. This failure placed the resident at risk for potential unidentified abuse and lack of protection from misappropriation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 1 kitchen (Fireside Grill Skilled Kitchen). The failure to perform hand hygiene before and after glove change before and/or after serving food placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to discard expired medication for 1 of 3 medication carts (Cedar Medication Cart) and failed to label/date an open vial of Tubersol (testing solution to diagnose Tuberculosis [infectious bacterial disease that affects the lungs]) for 1 of 1 medication storage room (Cedar Medication Room), reviewed for medication administration and storage. This failure placed the residents at risk to receive expired or compromised medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed during soiled linen collection by 1 of 1 staff (Staff Z) and failed to properly disinfect medical equipment for 3 of 5 staff (Staff AA, Staff J & Staff K). In addition, the facility failed to ensure the facility's water management program included a flow diagram that assessed the potential growth of Legionella (a water-borne bacteria that can cause pneumonia [a lung infection]) or other waterborne pathogens (an organism that can cause disease) reviewed for infection control. These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in a manner that maintained and promoted dignity while assisting with meals for 1 of 6 residents (Resident 16), reviewed for dining observations. This failure placed the resident at risk for a diminished self-worth and over-all well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure missing item was logged and investigated for 1 of 2 residents (Resident 23), reviewed for personal property. This failure placed the resident at risk for decreased sense of security and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from physical abuse for 3 of 4 residents (Residents 37, 33 & 4), reviewed for abuse investigations. This failure placed the residents at risk for further physical abuse, injury, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse was reported to the State Agency as required for 1 of 3 residents (Resident 30), reviewed for abuse allegations. This failure placed the resident at risk for potential unidentified abuse and lack of protection from abuse.

Inspectors wroteBased on interview and record review, the facility failed to transmit resident assessment data to the Centers for Medicare & Medicaid Services (federal agency that provides health coverage) within the required timeframe for 1 of 3 residents (Resident 5), reviewed for timeliness in transmitting discharge Minimum Data Set (MDS-an assessment tool). This failure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 1 of 6 residents (Resident 29), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate medication coding placed the resident at risk for unidentified or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise comprehensive care plans for 3 of 14 residents (Resident 11, 9 & 20), reviewed for care plan revision. The failure to revise care plans for oxygen use and refusal with care placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow insulin (medication to lower blood sugar) orders and clarify medication orders to ensure parameters were in place in accordance with professional standards for 2 of 5 residents (Residents 11 & 1), reviewed for unnecessary medications. This failure placed the residents at risk for medication errors and negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor for signs and symptoms of bruises or bleeding on a resident receiving anticoagulant therapy (medication that decreases blood's ability to clot) for 1 of 2 residents (Resident 41) and failed to follow physician's order related to insulin (medication to lower blood sugar) sliding scale (a method where the insulin dosage is adjusted based on blood sugar level) for 1 of 1 resident (Resident 1), reviewed for quality of care. These failures placed the residents at risk for adverse consequences and other related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain, label/date, and properly store oxygen nasal cannula/tubing (flexible tubing that sits inside the nose and delivers oxygen) for 2 of 2 residents (Residents 11 & 2), reviewed for respiratory care. This failure placed the residents at risk for unmet care needs, respiratory infections, and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure monthly pharmacy recommendations were followed up on by the physician for 1 of 5 residents (Resident 40), reviewed for unnecessary medications. This failure placed the resident at risk of receiving unnecessary medications, medication-related adverse consequences, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain an Antibiotic (medications to treat infection) Stewardship Program when the facility failed to implement antibiotic use protocols for 2 of 2 residents (Residents 43 & 38), and failed to ensure standardized tools and criteria were utilized for Antibiotic Stewardship Program (such as Loeb Minimum Criteria [minimum set of signs/symptoms used to determine whether to treat an infection with antibiotics] and/or SBAR [Situation, Background, Assessment, and Recommendation - a toolkit that helps staff/prescribing clinicians communicate about suspected UTIs [Urinary Tract Infections-bladder infection] and facilitates appropriate antibiotic prescribing) to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use, and decrease the development of adverse side effects and antibiotic resistance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance with hot water for 1 of 3 residents (Resident 2), reviewed for accident hazards. This failure caused harm to Resident 2 who sustained a partial thickness burn (second degree burn, involving the epidermis/part of the dermis [layers of the skin] that forms blisters [small pocket of body fluid], are red and painful) and pain after hot water spilled on Resident 2's left upper arm, left forearm, left abdomen, and left flank (side of the body between ribs and hip).

Inspectors wroteBased on interview and record review, the facility failed to ensure resident screened for rehabilitation services received timely order and initiation of specialized rehabilitation services for 1 of 4 residents (Resident 1), reviewed for therapy services. The facility's delay in coordinating a Physical Therapy (PT) and Occupational Therapy (OT) evaluation and treatment placed the resident at risk for decline in function, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate use of Personal Protective Equipment (PPE - face mask/respirator, face shield, gown, and gloves) were followed when providing care for residents positive for COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) in 2 of 6 rooms (Rooms 315 and room [ROOM NUMBER]), reviewed for infection control. This failure placed the residents at risk for facility acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 4 of 15 residents (Residents 16, 43, 19 & 5) reviewed for Minimum Data Set (MDS) assessments. The failure to ensure accurate assessments regarding wound dressing to the foot, Brief Interview for Mental Status (BIMS - cognitive patterns), mood interview (PHQ9), pressure ulcer wound/injury and wound care dressing placed the residents at risk for unidentified or unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan and/or provide written summary of the baseline care plan to the residents or the resident representatives within 48 hours of admission for 4 of 15 residents (Residents 19, 35, 46, and 8) reviewed for baseline care plans. This failure placed newly admitted residents at risk of not receiving necessary care and services, not being informed of their initial plan for delivery of care and services, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods stored in 2 of 3 refrigerators (kitchen & walk-in refrigerators) were properly labeled/dated when first opened and failed to ensure kitchen thermometer was properly sanitized in between use in 1 of 1 kitchen. In addition, the facility failed to ensure ready to eat food was handled appropriately in accordance with professional standards for food service safety in 1 of 1 dining room. These failures placed the residents at risk for food borne illnesses (an illness caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain infection control practices that provide a safe and sanitary environment to help prevent and contain the transmission of communicable diseases including COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death). The facility failed to ensure contaminated/used N95 respirator/mask were discarded, and face shield/eye protection was changed or disinfected upon exiting residents' rooms on Transmission Based Precautions (TBPs) (Rooms 315 & 317) and failed to perform hand hygiene during wound care dressing change for 1 of 4 residents (Resident 9) reviewed for infection control. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's physician and the resident's representatives when there was a severe weight loss for 1 of 1 resident (Resident 46) reviewed for nutrition. The failure to report significant weight loss to the resident's physician placed Resident 46 at risk for not receiving the needed care and services and for not having their representatives involved in any treatment plan and/or participation in care decisions regarding their weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive assessment was completed timely as required for 1 of 15 residents (Resident 43) reviewed for comprehensive Minimum Data Set (MDS - an assessment tool). This failure placed the resident at risk for delayed or unidentified care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to conduct a timely significant change in status Minimum Data Set (MDS) assessment for 3 of 15 residents (Residents 8, 12, and 16) reviewed for significant change in status assessment. The failure to complete a significant change in status assessment within 14 days placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for 3 of 15 residents (Residents 35, 21 and 27) reviewed for comprehensive care plans. The failure to develop a pressure ulcer/injury (PU) care plan for Resident 35, a wandering/behavior care plan for Resident 21, and to implement the Activities of Daily Living (ADL) care plan for Resident 27 placed these residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the comprehensive care plan for 1 of 15 residents (Resident 46) reviewed for care planning. The failure to review and revise Resident 46's nutrition care plan after the resident had a significant weight loss placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide restorative nursing programs to maintain range of motion (ROM) and mobility for 2 of 4 residents (Residents 1 and 9) and failed to apply an orthotic splint (brace to position the hand) in accordance with physician's order to prevent further decrease in ROM for 1 of 4 residents (Resident 27) reviewed for restorative services. These failures placed the residents at risk for decreased mobility, decreased ROM, pain, and a diminished quality of life.