Douglas Manor

Inspectors wroteBased on clinical record review, facility documentation/policies and interviews for one (1) of two (2) sampled residents (Resident #2) reviewed for abuse, the facility failed to ensure the resident was treated with dignity and respect when a staff member caused repeated discomfort when repositioning the resident and did not respect the resident's right to refuse care.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for allegations of abuse, the facility failed to ensure concerns reported by a resident representative were identified, documented, and investigated through the grievance process in accordance with facility policy.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for falls, the facility failed to adherence to the care plan-specifically by ignoring repeated observations of the resident's forward leaning and rocking and leaving a roommate's wheelchair as an obstruction and to ensure a wheelchair that was not in use was positioned in a way to maintain a clutter-free environment and prevent the resident from sustaining a laceration to left eyelid when the resident leaned forward and fell out of the wheelchair resulting in transfer to the ED for the treatment and evaluation.

Inspectors wroteBased on clinical record reviews, facility documentation, policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were at risk for falls, the facility failed to ensure a Fall Risk Evaluation was completed quarterly.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of four (4) sampled residents (Resident #1) who were reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to complete a PASRR Level 2 screening when the initial screen expired causing a delay in Resident #1's transfer to another long term care facility.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of four (4) sampled residents (Resident #1) who were reviewed for coordination of the plan of care, the facility failed provide the baseline and comprehensive care plans to the resident or the resident's family within forty-eight hours of admission to promote continuity of care and communication with the staff.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one (1) of four (4) sampled residents (Resident #1) who was symptomatic for a urinary tract infection and had an order to collect a urine specimen, the facility failed to collect the urine at the time of the order or notify the physician of the delay with obtaining the specimen.

Inspectors wroteBased on interviews, record review, and facility policy for 1 of 2 sampled residents (Resident #37) reviewed for choices, the facility failed to include a resident in the development and implementation of a person-centered Resident Care Plan.

Inspectors wroteBased on interview, review of facility documentation, and facility policy during a Resident Council meeting and review of Resident Council minutes, the facility failed to resolve ongoing issues with dietary, extended call bell wait times, locating staff for assistance, and inappropriate language used by staff.

Inspectors wroteBased on review of the facility's Personal Funds Account, review of facility policy, and interviews, the facility failed to provide access to personal funds outside of the facilities posted banking hours.

Inspectors wroteBased on record review, interviews, and review of facility policy for 5 of 5 residents, (Resident #26, #30, #50, and #70), reviewed for Resident Care Planning (RCP), the facility failed to provide documentation that quarterly Resident Care Conferences (RCCs) were held and failed to ensure revisions to the Resident Care Plan (RCP) within 7 days after completion of the resident's comprehensive assessment.

Inspectors wroteBased on record review, interviews, and review of facility policy for 2 of 2 residents (Resident#37 and #50) reviewed for choices, the facility failed to provide medically related social services to facilitate discharge.

Inspectors wroteBased on observation, staff interview, and facility policy for medication storage and labeling, the facility failed to ensure medication carts were locked when unattended and narcotics were secured properly.

Inspectors wroteBased on review of facility documentation, facility policy and interviews for 4 of 5 employee files, the facility failed to ensure that the mandatory employee training/in-services were completed.

Inspectors wroteBased on observations, interviews, clinical record review, and review of facility policy for 1 of 2 sampled residents (Resident #37) reviewed for choices, the facility failed to ensure the resident's wheelchair of choice was able to be utilized.

Inspectors wroteBased on interviews and record review for 1 of 3 residents, (Resident #19), sampled for advanced directives, the facility failed to identify a code status in the electronic health record.

Inspectors wroteBased on review of clinical records, facility documentation, facility policy, and interviews for 2 of 3 sampled residents, (Resident #28 and Resident #63), reviewed for abuse, for Resident #28, the facility failed to report an allegation of misappropriation of funds, and for Resident #63, the facility failed to report an allegation of neglect in a timely manner.

Inspectors wroteBased on review of clinical records, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #28) reviewed for personal property, the facility failed to investigate an allegation of misappropriation of funds, and for the only sampled resident (Resident #63) reviewed for abuse, the facility failed to thoroughly investigate an allegation of neglect, investigate an allegation of neglect in a timely manner, and prevent access to the resident by the staff member following the allegation of neglect.

Inspectors wroteBased on observations, review of clinical records, facility policy, and interviews for the only sampled resident, (Resident #28), reviewed for urinary catheter care, the facility failed to perform weekly skin assessments; for the only sampled resident, (Resident #35), reviewed for positioning, the facility failed to ensure a positioning plan for a resident in a customized wheelchair was followed, for the only sampled resident, (Resident #42), reviewed for a non-pressure skin related condition, the facility failed to report a change in a resident's skin condition to a licensed nurse, and for 2 of 2 sampled residents, (Resident #28 and #63) reviewed for abuse, the facility failed to provide timely incontinent care.

Inspectors wroteBased on observations, interviews, and record review for 1 of 3 sampled residents, (Resident #68), reviewed for accidents, the facility failed to follow a post fall care plan for safety interventions.

Inspectors wroteBased on observations, review of clinical record, facility policy and interviews for the only sampled resident (Resident #133) reviewed for respiratory care, the facility failed to obtain a physician's order for a resident who received oxygen.

Inspectors wroteBased on observation, record review, interviews, and review of facility policy for the only sampled Resident, (Resident #30), reviewed for dental services, the facility failed to accurately assess the residents oral status upon admission, failed to include a comprehensive Resident Care Plan (RCP) related to oral status, failed to code the Minimum Data Set (MDS) accurately related to dentition, and failed to ensure dental services were provided, as required, according to payor type.

Inspectors wroteBased on observation, staff interviews, record review, and facility policy for 2 residents requiring precautions (Resident #15, #70), who were reviewed for infection control practices, the facility failed to ensure the appropriate precaution sign was placed outside the door for 2 residents with a history of a Multi Drug Resistant Organism (MDRO) and 1 resident with an indwelling medical device.

Inspectors wroteBased on review of the facility's Personal Funds Account, review of facility documentation, and interviews, the facility failed to ensure necessary coverage through a surety bond for the Resident Trust Accounts.

Inspectors wroteBased on review of the facility's Personal Funds Account, review of facility documentation, and interviews for 13 of 22 sampled residents (Resident #3, #11, #14, #22, #30, #39, #45, #48, #49, #60, #62, #66, and #71), the facility failed to provide residents and/or their representatives with quarterly financial statements for personal funds held by the facility.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for an allegation of potential physical abuse, the facility failed to report the allegation to the Administrator and/or his/her designee immediately and to the state agency within two (2) hours after the resident reported the allegation to another staff member.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for an allegation of potential abuse, the facility failed to ensure the resident was transferred utilizing a mechanical device (Sara lift) and two (2) person assistance.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure staff removed smoking paraphernalia in a resident's possession timely when a resident was found in possession of smoking paraphernalia including lighters.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), reviewed for falls, the facility failed to complete an assessment on a resident who had a fall with a subsequent injuries.

Inspectors wroteBased on review of the clinical record, facility documentation and interviews for one (1) of three (3) residents reviewed for falls (Resident #2), the facility failed to supervise a resident in the bathroom who was cognitively impaired and required assistance, resulting in a fall with injury.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #20 and 479) reviewed for grievances, the facility failed to ensure the grievance policy was followed for a complaint regarding medications; and failed to ensure a grievance was completed when the resident reported missing personal items.

Inspectors wroteBased on review of facility documentation, facility policy and interview, the facility failed to conduct nursing staff competencies for years 2021 and 2022. Further, based on facility documentation and interviews, the facility failed to ensure adequate staff education and competency skills during an 11 month COVID-19 outbreak and failed to ensure competency for glucose testing and handwashing.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 10 residents (Resident #3) and 9 of 10 other residents who utilize adaptive equipment (Resident #14, 17, 35, 41, 48, 51, 54, 65, and 71) the facility failed to ensure adaptive equipment was provided during a GI outbreak (13 days).

Inspectors wroteBased on observation, review of facility documentation, facility policy and staff interview, the facility failed to record the dishwashing temperature for 2 meals during a facility GI outbreak.

Inspectors wroteBased on observations, facility documentation, facility policies, and interviews reviewed for infection control practices during multiple, concurrent outbreaks, the facility staff failed to redirect a visitor lacking Personal Protective Equipment (PPE) use, failed to implement appropriate environmental disinfecting following a lack of PPE use and lack of handwashing, failed to initiate timely contact tracing for a newly identified COVID-19 positive resident, failed to test COVID-19 symptomatic residents per CDC guidelines, failed to separate a COVID-19 symptomatic resident from a roommate, failed to maintain COVID-19 isolation protocols in accordance with standards, failed to appropriately cohort a resident with a multidrug resistant resident (MDRO) history, failed to perform appropriate hand hygiene with glove use, failed to follow appropriate blood glucose monitoring testing [...]

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #3 and 62) reviewed for dignity, the facility failed to ensure dignified care related to dining and urinary catheters.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #62 and 65) reviewed for resident rights, the facility failed the ensure the resident or resident representative had the opportunity to participate in the process of care planning and making decisions about his or her care; and failed to complete a care plan meeting following admission.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #20) reviewed for medication administration, the facility failed to notify the physician or APRN when medications were administered outside of the ordered time.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #3 and 36) reviewed for abuse, the facility failed to ensure the residents were free from abuse.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #3) reviewed for abuse, the facility failed to report an allegation of abuse/mistreatment to the state agency.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 1 of 5 sampled residents (Resident #529) who was reviewed for Preadmission Screening and Resident Review 2 (PASSR 2), the facility failed to implement a PASSR 2 recommendation. Review of PASSR 2 identified the following rehabilitative service recommendations: Service or Support for socialization, leisure and recreation activities; mental health counseling; ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms; supportive counseling from NF staff; a guardian/conservator for decisions regarding health and safety, and training in ADL's. All recommendations care planned except for appointment of guardian/conservator for decisions related to health and safety. 3/7/2023 at 10:00 am: [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #62 and 65) reviewed for care planning, the facility failed to revise and update the comprehensive care plan with a significant change of condition; and failed to complete a comprehensive care plan within seven days of completing a comprehensive assessment.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #58) reviewed for unnecessary medications, the facility failed to ensure the Abnormal Involuntary Movement Scale (AIMS) was conducted when required and by qualified staff per facility policy.

Inspectors wroteBased on clinical record review and interviews for the only sampled resident reviewed for activities of daily living, the facility failed to ensure weekly showers or bed baths were given to a dependent resident.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 7 residents (Resident #20 and 479) reviewed for medication administration, the facility failed to ensure medications were given in a timely manner; and failed to ensure medications were given as ordered.

Inspectors wroteBased on clinical record review and interviews for 1 of 2 residents reviewed for pressure ulcer/injury, the facility failed to ensure an accurate pressure ulcer assessment and failed to conduct weekly wound measurements.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 8 residents (Resident #10) reviewed for nutrition, the facility failed to ensure the dietitian completed nutrition assessments after a change in condition and/or quarterly.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #20) reviewed for pain management, the facility failed to ensure medications to treat pain were administered per physician's orders upon resident request.

Inspectors wroteBased on clinical record reviews, facility policy, and interviews during a review of facility immunizations records for four of five Residents (Resident #'s 16, 18, 43 and 71), the facility failed to offer and provide influenza and pneumococcal immunizations as required.

Inspectors wroteBased on observations, facility documentation, and interviews the facility failed to ensure that COVID-19 vaccination information was stored securely.

Inspectors wroteBased on clinical record review, facility policy and interviews for 1 of 2 residents reviewed for pressure ulcer/injury, (Resident #16) and for 1 of 5 resident reviewed for immunizations, (Resident #479), the facility failed to correctly code the Minimum Data Set (MDS) assessment.

Inspectors wroteBased on observation of the kitchen and dietary services and interviews, the facility failed to maintain the kitchen in a sanitary manner.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy and staff interviews for 4 of 10 sampled residents (Residents #3, #31, #72, and #180) reviewed for immunizations, the facility failed to ensure that pneumococcal vaccination history was complete and pneumococcal vaccinations and education concerning the vaccinations were offered.

Inspectors wroteBased on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #71) reviewed for mistreatment, the facility failed to ensure the resident was free from verbal abuse.

Inspectors wroteBased on review of the clinical record, review of facility documentation, and interviews for one of three sampled residents (Resident #50), reviewed for mistreatment, the facility failed to report a potential misappropriation of funds to the state agency.

Inspectors wroteBased on clinical record review and interview for one of three sampled residents (Resident #71) reviewed for mistreatment, the facility failed to implement its policy to ensure the resident was protected after an allegation of verbal abuse was identified.

Inspectors wroteBased on review of facility documentation and interviews, for three of four sampled nurse aides (NA) (NA #1, NA #2, and NA #3), reviewed as part of the sufficient and competent nursing staff review, the facility failed to ensure performance evaluations on a yearly basis.