Downs Care and Rehab

Inspectors wroteBased on observation, record review, and interview, the facility failed to store, distribute, and serve food by professional standards for food service safety in the facility's kitchen. The facility failed to label, seal, and date food stored in the refrigerator/freezer and dry storage area. The facility also failed to consistently log freezer/refrigerator temperatures.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement adequate infection control practices when staff failed to change gloves during incontinent care for Resident (R) 26. Staff also failed to place Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) signage for R11 and R44's and failed to ensure personal protective equipment (PPE- gowns and gloves) was readily available for use for R11 and R44, who shared a room, cares. Staff also failed to provide appropriate complete urinary catheter care for R44. Additionally, the facility failed to have a complete water management plan to prevent the spread of Legionella and other waterborne bacteria.

Inspectors wroteBased on observation, record review, and interview, the facility staff failed to treat Resident (R) 11 with dignity when staff ambulated beside R11 down the hall to the dining room with wet pants.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure an appropriate indication or a documented physician rationale, which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R)7's and R39's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the Consult Pharmacist identified and reported the lack of appropriate indication or required physician documentation for Resident (R)'7 and R39's use of an antipsychotic (a class of medication used to treat any major mental disorder characterized by a gross impairment testing) medication.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate not greater than five percent (%) when errors were observed for Resident (R) 7, resulting in an error rate of 5.13 percent (%).

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 40 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide a clean, homelike environment when staff failed to clean the dining chairs in the dining room. This placed the residents who ate meals in the dining room at risk for impaired comfort and decreased quality of life.

Inspectors wroteThe facility had a census of 40 residents. Based on observation, record review, and interview, the facility failed to provide a safe environment in the facility kitchen. This deficient practice placed the facility residents and staff at risk for impaired safety. Findings Included: - On 07/30/24 at 12:15 PM, during kitchen follow up tour, observation revealed the following: Four 2-foot x 4 -foot fluorescent lights, located between the food preparation area and the stove area that lacked a plastic light diffuser (cover). Each fixture had two fluorescent tube glass light bulbs per fixture. Five 2-foot x 4 -foot fluorescent light, located above the dishwasher area lacked a plastic light cover. Each fixture had two fluorescent tube glass light bulbs per fixture. [...]

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise one sampled resident's care plan to include guidance to staff regarding Resident (R) 25 exiting the building without staff supervision. This placed R25 at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on record review and interview, the facility failed to develop a discharge summary that included a complete recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post-discharge plan for Resident (R)42. This placed the resident at risk of receiving inadequate care.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents with one resident reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene, including bathing, for Resident (R)37. This placed the resident at risk for poor personal hygiene and impaired dignity.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure an appropriate indication for the use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) or the required physician documentation for two of five residents, Resident (R) 31 and 38, reviewed for unnecessary medications. This placed the residents at risk for unnecessary psychotropic (alters mood or thought) medications.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to record the open or discard date on residents' insulin (a hormone that lowers the level of glucose in the blood) vials when they opened a new, multi-use insulin vial. This deficient practice placed Residents (R)13 and R30 at risk for ineffective insulin medication.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to appropriately maintain the chest freezer in the store room to ensure proper function and sanitary food storage. This placed the 38 residents who reside in the facility at risk for food borne illness.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review and interview the facility staff failed to assess and record washing machine temperatures in one of one laundry room to ensure adequate temperatures to prevent the spread of infection. This placed the 38 residents at risk for a communicable disease or infection.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents with one reviewed for dialysis (a treatment to filter wastes and water from your blood, by the use of a dialysis machine). Based on observation, record review and interview, the facility failed to provide ongoing assessment of Resident (R) 37's condition and failed to monitor for complications before and after dialysis treatments. The facility further failed to adhere to a 1500 milliliter (ml) fluid restriction. This deficient practice placed R37 at risk for complications related to dialysis.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents with one reviewed for dialysis (a treatment to filter wastes and water from your blood, by the use of a dialysis machine). Based on observation, record review and interview, the facility failed to ensure staff possessed the knowledge and skills necessary to provide care to the standards of practice for residents who received dialysis when facility staff failed to assess Resident (R) 37 for complications before and after dialysis treatments and failed to correctly identify a dialysis access site and monitor for complications. This deficient practice placed R37 at increased risk for adverse effects and negative outcomes.