Eastman Trails of Journey LLC

Inspectors wroteBased on observations, staff interviews, record review, and review of facility policy titled Food Safety Requirements Policy, the facility failed to ensure food was stored, sealed, and labeled correctly. This deficient practice had the potential to cause food contamination and foodborne illness among 63 residents consuming facility-prepared food.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the resident and/or resident's responsible party when their personal funds were within $200 of the Social Security Income (SSI) limit and when accounts had exceeded the limit for four of 63 Residents (R) (R3, R27, R31, R38) with accounts reviewed for personal funds. The deficient practice placed residents at risk related to resource limits of qualifying for Medicaid during the renewal period.

Inspectors wroteBased on observation, interviews and review of the facility's policy Resident Environmental Quality, the facility failed to provide a safe, clean, comfortable, and homelike environment for two of five hallways (200 Hall and 400 Hall) and four of 41 occupied rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER].) Specifically, the hallways had flooring that was missing, creating an uneven walking surface and the rooms exhibited dirty fans, missing floor tiles and one dirty bathroom. The deficient practice had the potential to affect residents' comfort and safety. Findings Include: Review of the facility policy titled Resident Environmental Quality, not dated, documented The facility will be designed, constructed, equipped and maintained to provide safe, functional sanitary, and comfortable environment for residents, staff, and the public. [...]

Inspectors wroteBased on resident and staff interviews, record reviews, and review of the facility policy titled Bed Hold and Returns Policy, the facility failed to ensure two of two residents (R) (R67 and R5) reviewed for hospitalizations were provided with a written bed hold notice upon transfer. This failure had the potential to place the resident and/or resident representative at risk of being uninformed about their rights related to their return to the facility.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure that one of 13 residents (R) (R1) receiving oxygen was administered oxygen therapy in accordance with the physician orders. This deficient practice had the potential to place R1 at risk for respiratory complications and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled Food Receiving and Storage and Refrigerators and Freezers, the facility failed to label and date food items with a use-by date in the walk-in cooler and walk-in freezer. In addition, the facility failed to ensure a sanitary environment in the kitchen and failed to ensure dietary staff properly used the three-compartment sink for sanitation to prevent cross-contamination. The deficient practices had the potential to place residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. The facility census was 78.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled Resident Self-Administration of Medication, the facility failed to ensure two of 37 sampled residents (R) (R48 and R11) did not have unauthorized and unsecured medicated treatment products at the bedside. This deficient practice had the potential to cause adverse effects for R48 and R11 and allow unsecured medicated treatment accessible to other residents and visitors.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Resident's Rights Regarding Treatment and Advanced Directives, the facility failed to ensure that an Advance Directive Acknowledgement form was completed or all components of the document were thoroughly completed for five of eight residents (R) (R22, R46, R25, R31, and R51) reviewed for Advance Directives. This deficient practice had the potential to affect R22, R46, R25, R31, and R51's ability to make informed decisions about their care.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Safe and Homelike Environment, the facility failed to ensure a clean and comfortable environment for six resident rooms (Rooms 105,107, 501, 503, 502, 504) with shared bathrooms and one shower room (300 Hall), failed to replace the door cover for one resident room (room [ROOM NUMBER]), and failed to ensure one shower room (500 Hall) was functional on three of five units. These deficient practices had the potential to place residents at risk of living in an unsanitary and unsafe living environment and a potential for diminished quality of life. The census was 78 residents.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure that dietary orders were followed for one of 37 sampled residents (R) (R2). Specifically, the facility failed to ensure that a non-spill cup (sippy cup) was provided with meals for R2. The deficient practice had the potential to prevent the maintenance of adequate nutritional (or hydration) status to the extent possible for R2.

Inspectors wroteBased on observations, staff interviews, and facility-provided documents, the facility failed to ensure that dietary staff followed recipes and measured ingredients when preparing puree food to prevent compromising the nutritional value and flavor for five residents who received a puree consistency diet. This deficient practice had the potential to cause the residents who received a puree diet to have a decreased nutritional intake and the potential for weight loss.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policies titled Enhanced Barrier Precautions (EBP) and Clean Dressing Change, the facility failed to put on (don) Personal Protective Equipment (PPE) and failed to wash/sanitize hands and change gloves during wound treatment for one of 37 sampled residents (R) (R65). The deficient practices had the potential to increase R65's risk of infection due to cross-contamination and the potential to increase the risk of spread of infection to other residents.

Inspectors wroteBased on staff interviews, and record review the facility failed to ensure that one of 24 residents (R) (#67) was assessed for level two Pre-admission Screening/Resident Review (PASRR) and coordinate services, if warranted.

Inspectors wroteBased on record review and staff interviews, the facility failed to apply for Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for four of five residents (R) (#7, #8, #69, and #75) that had a positive Level I PASRR for mental illness.

Inspectors wroteBased on staff interviews, record review, and a review of the facility's policy titled Care Plans, Comprehensive Person-Centered, the facility failed to develop a comprehensive person-centered care plan for one resident (R) (#71) related to Preadmission Screening and Record Review (PASRR) Level II out of six residents reviewed for PASRR.