Elderberry Health Care

Inspectors wroteBased on observations and staff interviews, the facility failed to date and label food stored in the walk-in refrigerator. The facility also failed to dispose of a box of apples stored past their usable life. This was for 1 of 2 refrigerators (walk-in refrigerator) and 1 of 1 cart observed and had the potential to affect food served to residents in the facility.

Inspectors wroteBased on record review and interviews with resident, staff, Medical Records Clerk, Minimum Data Set (MDS) Assistant and the Physician, the facility failed to have effective systems in place for updating advance directive information throughout the medical record for 1 of 1 resident reviewed for advance directive (Resident #1).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to obtain a physician order for the use of an indwelling urinary catheter and failed to use a securement device (anchor) to prevent pulling/tension or trauma from the catheter tubing for 1 of 1 resident reviewed for an indwelling urinary catheter (Resident #11).

Inspectors wroteBased on observations and staff interviews the facility failed to ensure ready to use dishware was clean and not stacked wet, label and date leftover perishable foods in the walk-in cooler. This occurred for 1 of 2 kitchen observations.

Inspectors wroteBased on observations and staff interviews the facility failed to contain trash when the dumpster doors were not closed and failed to keep the area around the dumpsters free of accumulated trash and debris for 2 of 2 dumpsters observed.

Inspectors wroteBased on staff interview and record review, the facility failed to protect a resident's right to be free from resident-to-resident abuse when Resident #74 struck Resident #73 on the left side of the head with a statue after Resident #74 believed Resident #73 was going to enter her room. Resident #73 sustained a laceration to the left side of his head requiring steri strips (an alternative to sutures). This affected 1 of 3 residents (Resident #73) reviewed for abuse.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to apply signage indicating the use of oxygen outside residents' rooms with supplemental oxygen for 2 of 2 residents reviewed for oxygen use (Resident # 69 and Resident # 273).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure their arbitration agreement explicitly stated: 1) the resident or legal representative has the right to rescind the arbitration agreement within a 30 day timeframe; and 2) that neither the resident nor his or her representative was required to sign an agreement as a condition of admission or as a requirement to continue to receive care in the facility. This deficient practice affected 1of 1 resident (Resident #60) reviewed for arbitration.

Inspectors wroteBased on observation and staff interviews, the facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, and the protection and advocacy network. This observation occurred for 3 of the 4 days during the onsite recertification survey.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure daily nurse staffing sheets were completed daily for 18 of the 59 days (07/05/2024, 07/06/2024, 07/07/2024, 07/13/2024, 07/14/2024, 07/20/2024, 07/21/2024, 07/28/2024, 07/29/2024, 08/01/2024, 08 /02/2024, 08/03/2024,08/04/2024, 08/10/2024, 08/11/2024, 08/17/2024, 08/18/2024, and 08/24/2024) reviewed for nurse staffing information.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain a complete and accurate medical record when 1) staff documented that they provided suctioning to a resident twice a day when suctioning had not been provided and 2) staff failed to document treatment provided to resident after they sustained a laceration to the left lower leg. This occurred for 2 of 2 residents (Resident #4 and Resident #75) reviewed for accurate medical record.

Inspectors wroteBased on observations, interviews and record review, the facility failed to wash dishes per manufacture recommendations, sanitize dishes in a chlorine solution of 50 - 100 parts per million (ppm), sanitize dishes in a quaternary solution of at least 150 ppm, perform hand hygiene between soiled and clean tasks, remove foods stored past manufacturer use-by-date, maintain cold foods in refrigeration at least 41 degrees Fahrenheit (F), restrain hair during meal prep/cleaning, store an ice scoop to drain, and cover foods during meal delivery. This failure had the potential to affect the food served to 74 of 74 residents.

Inspectors wroteBased on record review, resident interviews and staff interviews the facility failed to resolve group grievances that were brought to resident council meetings for 4 of 8 months (February, March, April, and May 2023).

Inspectors wroteBased on a lunch meal tray line observation, staff interviews and record review, the facility failed to serve capri vegetables in a four-ounce portion per the menu. This failure had the potential to affect 34 residents with diet orders for regular diet texture and 22 residents with diet orders for mechanical soft diet texture.

Inspectors wroteBased on a lunch meal tray line observation, staff interviews and record review the facility failed to provide capri vegetables (carrots, yellow squash, green beans, and zucchini) in a consistency required for residents with diet orders for a pureed diet texture. This failure had the potential to affect 12 of 74 residents with diet orders for a pureed diet texture.

Inspectors wroteBased on observations, record review, resident interview, and staff interviews the facility failed to assess the ability of a resident to self-administer medications that were kept at bedside for 1 of 1 sampled resident reviewed for self -administration of medications (Resident #28). Resident #28 was admitted to the facility on [DATE] with diagnoses inclusive of dementia and dysphagia. A revised care plan dated 3/21/23 revealed Resident #28 was not care planned to self-administer medications. A quarterly Minimum Data Set, dated [DATE] indicated Resident #28 had moderate cognitive impairment. [...]

Inspectors wroteBased on observations, record review and interviews with resident and staff, the facility failed to provide shaving assistance to 1 of 5 dependent residents reviewed for activities of daily living (Resident #7).

Inspectors wroteBased on observations, record review, resident interviews, and staff interviews the facility failed to maintain a hand sink in working order and provide clean bed linens for 2 of 2 residents (Resident #6 and Resident #33) on the 200 Hall reviewed for homelike environment.