Delaney Park Health and Rehabilitation Center

Inspectors wroteBased on interview, and record review, facility failed to ensure the facility had an Infection Preventionist responsible for the facility's Infection Prevention and Control Program (IPCP) with qualifications and current specialized training to ensure implementation, monitoring and managing the IPCP.

Inspectors wroteBased on observation, and interview, the facility failed to maintain a homelike environment in 30 resident rooms on one of two floors, (100 wing) by failing to maintain ceiling vent covers with a clean and sanitary surface.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control policies and procedures were followed to implement the infection prevention and control plan by failing to initiate enhanced barrier precautions for 24 residents on one of two floors (100 unit), failed to ensure transmission-based isolation was the least restrictive for one of two residents reviewed for transmission-based precautions, (#30); failed to document process surveillance, including identification of pertinent process surveillance from the infection control risk assessment, and failed to follow transmission-based precautions to help prevent the spread of infection on one of two wings, (100 wing) for 2 of 2 residents reviewed for transmission-based precautions (#82, and #30), of a total sample of 34 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the physician of a change in resident condition to ensure prompt diagnosis and treatment for 1 of 1 resident reviewed for patient rights, out of a total sample of 34 residents, (#61).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents reviewed for unnecessary drugs did not receive an unnecessary antipsychotic medication with subsequent increase in dose and a diagnosis of schizophrenia without clear documentation to support the indication for use and diagnosis in the medical record, of a total sample of 34 residents, (#68).[NAME], [NAME] (68)

Inspectors wroteBased on interview, and record review, the facility failed to document/investigate residents who discharged Against Medical Advice (AMA) to ensure the residents were not forced to leave the facility and to provide a safe discharge to the extent possible for 1 out 3 residents sampled for discharge, of a total sample of 34 residents, (#96).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident at risk for Deep Vein Thrombosis (DVT) formation was appropriately monitored and treated in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 resident reviewed for edema care, of a total sample of 34 residents, (#61).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice related to limited range of motion and splinting care, for 1 of 1 resident reviewed for limited range of motion and positioning, of a total sample of 34 residents, (#90).

Inspectors wroteBased on interview, and record review, the facility failed to maintain medical records that were accurately documented in accordance with professional standards of practice for 1 of 1 resident reviewed for splint care and limited range of motion, of a total of 34 residents, (#90).

Inspectors wroteBased on observation, interview, and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify an area of systemic non-compliance with the Infection Prevention & Control Program identified by the survey team.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen concentrators were maintained in safe, functional condition for 5 of 8 sampled residents who were oxygen-dependent, of a total sample of 12 residents, (#2, #8, #9, #10, and #11). The facility also failed to ensure that failed or potentially compromised concentrator units were promptly removed from use to avoid placing residents at risk of receiving inadequate oxygen support.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order for oxygen (O2) for 1 of 8 residents reviewed for O2 use, of a total sample of 12 residents, (#2).

Inspectors wroteBased on observation, interview and record review, the facility had a pattern of failing to follow physician prescribed respiratory therapy orders for 1 of 2 residents reviewed for respiratory care, of a total sample of 49 residents, (#10).

Inspectors wroteBased on observation and interview, the facility failed to store food in the freezer and walk-in refrigerator in accordance with food safety standards to prevent foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medication, of a total sample of 39 residents, (#74).

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge Minimum Data Set (MDS) Assessment for 1 of 2 residents reviewed for resident assessments, of a total sample of 39 residents, (#69).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessment was accurate for functional ability in regards to eating, vision and dental for 2 of 5 residents reviewed, of a total sample of 39 residents, (#20, and #36).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services according to standards of practice and plan of care for 1 of 2 residents reviewed for IV care, out of a total sample of 39 residents, (#55).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Transmission Based precautions to prevent the spread of infection for 1 of 1 resident reviewed for isolation precautions, (#192), of a total sample of 39 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food packages were re-sealed to prevent contamination and ensure supplements were discarded timely to prevent foodborne illnesses. Findings 1. On 5/22/23 at approximately 10:23 AM, the initial kitchen inspection was conducted. A large bag of corn flakes, less than half full was noted in the Dry Storage room. The bag had been previously opened and the staff used a sliver of plastic wrap as a make-shift twist tie in attempt to re-seal the bag. A previously opened bag of egg noodles and 2 bags of elbow macaroni were re-secured in a similar fashion, with a sliver of plastic wrap. The Registered Dietitian stated this was not the proper way to store/re-seal the bags. The facility's policy and procedure for food storage noted, Dry goods may be placed in plastic bags and sealed or placed in plastic containers. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow the menu for pureed foods and pureed portion sizes.