Devereux Skilled Nursing & Rehabilitation Center

Inspectors wroteBased on observation, record review and interview the facility failed to ensure for one Resident (#1), out of a total sample of 14 residents that a PRN (as needed) psychotropic medication order included a duration for continued use.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide routine dental services for one Resident (#26) out of a total sample of 14 residents. Specifically, for Resident #26, the facility failed to address and initiate replacement of lost/missing lower dentures timely.

Inspectors wroteBased on observation, record review and interview the facility failed to implement enhanced barrier precautions for one Resident (#2), out of a total of 14 sampled residents.

Inspectors wrote5. Resident #19 was admitted to the facility in October 2022 and has diagnoses that include Severe Vascular Dementia with Agitation. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/05/24, indicated that on the Brief Interview for Mental Status exam Resident #19 scored a 6 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated Resident #19 had no behavior of rejecting care, required supervision or touching assistance with eating and had complaints of difficulty or pain when swallowing. Review of the Quarterly Nursing Assessment, dated 7/05/24, indicated Resident #19 requires supervision or touching assistance for eating. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure the Physician/Nurse Practitioner were notified of recommendations made by a Wound Physician for one Resident (#1) out of a total sample of 15 residents. Specifically, for Resident #1 who had facility acquired pressure injuries, the facility failed to ensure the Physician/Nurse Practitioner were notified of recommendations made by the Wound Physician on 10/6/23 and 10/11/23, and the Resident was subsequently hospitalized on [DATE] with a wound infection.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure a physician's order was implemented for one Resident (#6) out of a total sample of 15 residents. Specifically, for Resident #6, the facility failed to ensure his/her weight was obtained weekly, as ordered. Findings Include: Resident #6 was admitted to the facility in February 2022 with diagnoses that included chronic respiratory failure with hypoxia, heart failure, and dementia. Review of Resident #6's most recent Minimum Data Set (MDS) assessment, dated 7/19/24, indicated Resident #6 scored a 12 out of a possible 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. The MDS further indicated Resident #6 is on a physician prescribed weight gain regimen. Review of Resident #6's weights indicated; - 8/02/24: 120.6 Lbs (pounds) - 7/23/24: 119.6 Lbs - 7/01/24: [...]

Inspectors wroteBased on record review and interview the facility failed to ensure Wound Physician recommendations were followed for one Resident (#1) out of a total sample of 15 residents. Specifically, for Resident #1 who had facility acquired pressure injuries, the facility failed to implement recommendations made by the Wound Physician on 10/6/23 and 10/11/23, and the Resident's wound worsened and Resident #1 was subsequently hospitalized on [DATE] with a wound infection.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure medications were not left on top of the medication cart unsupervised during medication pass.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure accurate medical records were maintained for two Residents (#14 and #38) out of a total sample of 15 residents. Specifically, for Resident #14 and #32, the facility failed to accurately document the level of supervision received during meals. Findings Included: 1. Resident #14 was admitted to the facility in March 2020 with diagnoses including hemiplegia and hemiparesis following unspecified cerebral vascular disease affecting left non-dominant side, dysphagia (difficulty swallowing) and unspecified severe protein-calorie malnutrition. Review of Resident #14's most recent Minimum Data Set (MDS) assessment, dated 5/31/24, indicated Resident #14 had a Brief Interview for Mental Status exam score of 15 out of a possible 15, indicating intact cognition. [...]

Inspectors wroteBased on observations, policy review, and interview, the facility failed to ensure infection control standards of practice for the prevention of infections were implemented. Specifically, the facility failed to: 1. ensure nursing staff performed hand hygiene appropriately during the medication administration task; and 2. ensure infection control practices were maintained to prevent the spread of infection during medication administration.

Inspectors wroteBased on observation and interview the facility failed to handle ready to eat food in accordance with professional standards for food service safety. Specifically, during an observation of the breakfast tray line the [NAME] handled ready to eat food with contaminated gloves.

Inspectors wroteBased on record review, policy review, and interview, the facility failed for three out of five sampled Residents (#3, #26, and #11) to ensure that each Resident was up to date with pneumococcal vaccinations in line with the Centers for Disease Control and Prevention (CDC) recommendations or had documentation in their medical records regarding their pneumococcal vaccination status.

Inspectors wroteBased on observation, record review and interview the facility failed to implement the plan of care for three Residents (#14, #9 and #28) out of a total sample of 15 residents. Specifically: 1.) For Resident #14 the facility failed to apply the physician ordered palm guard. 2.) For Resident #9 the facility failed to provide supervision with meals as indicated in the plan of care. 3.) For Resident #28 the facility failed to ensure supervision with meals was provided as indicated in the plan of care.

Inspectors wroteBased on observation, record review and interview the facility failed to revise the person centered care plan for one Resident (#9) out of a total sample of 15 residents. Specifically, for Resident #9 the facility failed to update his/her behavior care plan to reflect behaviors of fabricating tremors for attention during meals.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to provide assistance with meals as needed for one Residents (#27) out of a total sample of 15 residents.

Inspectors wroteBased on observations, record review, policy review, and interviews, the facility failed to ensure for one Residents (#20), who required dialysis, that they receive such services consistent with professional standards of practice, out of a total of 15 sampled residents. Specifically, for Resident #20, the facility failed to ensure nursing maintained a visible and accessible emergency equipment kit at the bedside.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure accurate documentation in the medical record for one Resident (#20), out of a total sample of 15 residents. Specifically, for Resident #20, the nurses documented in the Treatment Administration Record (TAR) that vitals were taken in the left arm, when they were not.

Inspectors wroteBased on record review and interview, the facility failed to inform 3 out of 3 Residents, or their representative, of potential liability for payment for non-covered services including estimated cost of services.