Danville Post-Acute Rehab

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1)'s safety, when Resident1's Family Representative (FR) 1 slapped Resident 1 on the face while attempting to feed Resident 1. This failure to protect Resident 1 from abuse violated Resident 1's right to a safe environment and resulted in redness on the left cheek.

Inspectors wroteBased on interview and record review, the facility failed to ensure copies of all medical records were provided to one of three sampled resident's (Resident 1) designated legal representative. As a result, Resident 1's rights were not honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess two of 14 sampled residents (Resident 18 and Resident 7) in the quarterly Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) assessments. 1. Resident 18's quarterly MDS assessment was inaccurately coded Yes for diagnosis of pneumonia (an infection of one or both lungs caused by bacteria, viruses or fungi causing difficulty in breathing, cough, fever, and chills) when Resident 18 did not have active pneumonia. 2. Resident 7's quarterly MDS was inaccurately coded 0 for verbal behavioral symptoms when Resident 7 had multiple episodes of verbal hostility during the look back period (a time period over which the resident's condition or status is captured in the MDS assessment and ends at 11:59 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care and hygiene to one of two sampled residents (Resident 11). Resident 11 had long toenails on both feet. This failure placed Resident 11 at risk for poor hygiene, pain/discomfort from long nails, scratching themselves and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate use of lidocaine patches (to treat pain) and the accountability of controlled medications (those with high potential for abuse and addiction) when: 1. The nursing staff failed to remove lidocaine patches after 12 hours as ordered by the prescriber and per manufacturer recommendations for two out of eight residents (Residents 27 and 194). This failure had the potential for residents to receive an excessive dose of lidocaine which could result in side effects, including swelling and skin irritation; and 2. The Controlled Drug Records (CDR, accountability records, an inventory sheet that keeps records of the usage of controlled medications) for four out of four sampled residents (Residents 2, 10, 240, and 241) did not reconcile with the Medication Administration Records (MAR). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately monitor, document, and intervene for potential side effects of haloperidol (an antipsychotic medication, used to treat symptoms of psychosis, such as perception of something that is not real and suspiciousness, etc.) for one of five sampled residents (Resident 11) when Resident 11 exhibited abnormal, consistent, involuntary lateral movements of the jaw while talking. This failure resulted in inaccurate reflection of Resident 11's clinical status and placed her at risk for experiencing further increased side effects of haloperidol.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 6.67% when two medication errors occurred out of 30 opportunities during medication administration for two out of eight residents (Residents 27 and 33). This failure resulted in medications not given according to the physician's orders and had the potential for residents to not receive the full therapeutic effects of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications according to the facility policy and procedures (P&P) and/or manufacturer's specifications when an opened eye drop bottle was not properly labeled in one of one sampled medication carts. This failure had the potential for medication error due to medication not being labeled and being used for multiple residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards of practice for food service safety when: 1. Perishable food items in the kitchen were stored after the labeled used-by date; and, 2. The floor below Refrigerator 2 in the kitchen storage room was not clean. These failures had the potential to result in food borne illnesses (sickness caused by consuming contaminated food or beverages) for 38 residents who ate food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medication administration records (MARs) for controlled substances (those with high potential for abuse and addiction) in accordance with facility policy and professional standards of practice when the electronic MAR for three out of four residents (Residents 10, 240, and 241) reviewed was altered during the survey. This failure had the potential to result in inaccurate documentation of the resident's medical history and response to care and had the potential for abuse and diversion of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain privacy and confidentiality for one of six sampled residents' (Resident 31) when diet and aspiration precautions (to prevent food or liquid going into the lungs instead of the stomach) information was left uncovered, posted on the wall by Resident 31's head of the bed while Resident 31 shared a room with two other residents. This failure resulted in Resident 31's care instructions being visible to staff not engaged in her care and visitors for other residents sharing the room with her.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, evaluate, treat, and care for edema (swelling) in both feet of one of six sampled residents (Resident 5) for at least 24 hours. This failure resulted in Resident 5 experiencing discomfort, pain, and limited range of motion in both feet, and placed her at risk of untreated edema, causing further pain, skin breakdown and fluid overload.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the appropriate indwelling catheter (a flexible tube used to empty the bladder and collect urine) care and services for two of two sampled residents (Resident 242 and Resident 4) when Resident 242 and Resident 4's indwelling urinary catheter bags and tubes were touching the floor. This failure had the potential for Resident 242 and Resident 4 to develop urinary tract infection (UTI, an infection in any part of the kidneys, bladder, or urethra [the tube which empties urine from the bladder])

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 240), with a peripherally inserted central catheter (PICC, a long, thin, flexible tube that is placed into a small vein in the upper arm and moved forward until it is in a larger vein near the heart) received appropriate care and services when: 1. Resident 240 did not receive his intravenous (IV, a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) antibiotic (medication used to treat infection) on time per physician's order. 2. The facility did not obtain Resident 240's arm circumference measurement during PICC line dressing change on 10/2/24. [...]

Inspectors wroteBased on observation and interview, the facility failed to implement infection control practices when: 1. One out of three licensed nurses did not wear gloves when directly handling a capsule during medication pass. 2. One licensed nurse did not remove contaminated gloves and wash hands before adjusting Resident 242's nasal cannula These failures had the potential of exposing residents to infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample selected residents (Resident 1) was free of accidents in the facility when Resident 1 had a fall and fracture while she was residing at the facility. This failure in practice resulted in Resident 1 ' s hip fracture, suffering from pain, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food under sanitary conditions when multiple food items stored in the refrigerator were expired, did not have labels, or did not have use by dates. These failures had the potential to result in food borne illness.