Electra Healthcare Center

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain an effective training program for 14 (ADMN, DON, SW, AD, DM, MS, ADON, LVN A, CNA B, CMA C, TA D, CNA E, LA F, HK G) of 16 existing staff reviewed for training records . The facility failed to ensure 2 of 16 staff (CNA B, LVN A) were not trained in Fall Prevention. The facility failed to ensure 2 of 16 (ADMIN, CNA B) staff were not trained in Infection Control. The facility failed to ensure 1 of 16 (ADMIN), staff were not trained in Abuse and Neglect. The facility failed to ensure 13 of 16 (ADMIN, DON, SW, AD, DM, MS, ADON, LVN A, CMA C, CAN B, LA F, HK G, TA D.) staff were not trained in HIV.The facility failed to ensure 2 of 16 (LVN A, CNA E) staff were not trained in Restraint Reduction. These failures could place residents at risk of receiving care from incompetent/untrained staff.

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 15 residents (Resident #8) reviewed for Minimum Data Set (MDS) assessment accuracy. (Resident #8) The facility failed to code Resident #8's behavioral status accurately during the MDS look back period. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on record review, and interviews, the facility failed to develop and implement a comprehensive care plan to reflect current condition for 1 of 2 Residents (Resident #8) reviewed for care plan accuracy, in that: Resident #8's care plan was not revised to address the residents' hallucinations and delusions. This failure could place Resident #8 at risk of not having a comprehensive plan of care to address their needs.

Inspectors wroteBased on record review and interview, the facility failed to provide the required minimum of 80 square feet of space per resident in multiple occupancy rooms for 27 of 31 rooms (Room #s 3, 5, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, and 35) reviewed for square footage. The facility failed to ensure multiple-bed resident rooms had the required 80 square feet of floor space per resident for room #s 3, 5, 8, 9, 10, 11, 12,13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 34, and 35. This failure could place residents residing in these rooms at risk for not having adequate living space and could adversely affect residents from attaining his or her highest practicable well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. These failures could place residents at risk of food-borne illness and a diminished quality of life. 1. The trash can at the hand sink was full, smelled of rotten food, and had a pan of individually wrapped cookies on top of the lid. 2. Staff B touched food surfaces while filling plates with food. 3. The kitchen drawers had an accumulation of food debris in the bottom. 4. The dry storage room had plastic bins that were greasy and had debris in the bottoms. 5. The freezer had chicken and ham in it with freezer burn. 6. Dietary staff had hair that was not completely covered and hand washing was not done correctly. 7. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 3 of 6 (DON, DM, SW) staff reviewed for abuse protocol. The facility failed to complete annual Criminal Background Checks for the DON, DM, and SW. This failure could place residents at risk for abuse, neglect, and exploitation.

Inspectors wroteBased on interview and record review, the facility failed to ensure all Preadmission Screening and Resident Review (PASARR) Level I (PL1) Screening residents diagnosed with mental illness were provided with a PASARR Level II (PE) Screening for 2 of 3 residents (Resident #10 and Resident #15) reviewed for a mental illness, intellectual disability, or developmental disability. The facility failed to ensure Resident #10 and #15 who had a diagnosis of mental illness had a PASARR Level II (PE) screening completed. This failure placed residents at risk of mental health needs not being met.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 14 residents (Residents #120) reviewed for care plans. The facility failed to have a care plan for Resident #120's Hospice status. These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to include resident or the resident's representative in the IDT (Interdisciplinary team) in the comprehensive care planning within 7 days after completion of the comprehensive assessment for 2 of 4 residents (Resident #8 and Resident #10) reviewed for care plan timing/revision. The facility failed to ensure Resident #8 and Resident #10's care plan was reviewed by the IDT (Interdisciplinary team), which failed to include the resident or the resident's representative after the Comprehensive MDS assessment. This failure placed the residents at risk for not having individual needs identified and care and services provided to meet their needs and promote quality of care, feelings of well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate supervision and assistance devices was provided for 1of 2 residents reviewed for transfers. (Resident # 119). The facility did not assess Resident #119 for use of a lift device even though he was non-weight bearing. The facility failed to ensure staff transferred Resident #119 in a manner to prevent injuries. The staff performed one-person lifts by hugging the resident or hooking their arms under his shoulders. This failure could place residents who required assistance during transfers at risk for pain and injury.

Inspectors wroteBased on record review and interview, the facility failed to provide the required minimum of 80 square feet of space per resident in multiple occupancy rooms for 35 of 36 rooms (Rooms #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36) reviewed for square footage. The facility failed to ensure multiple-bed resident rooms had the required 80 square feet of floor space per resident for rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36. This failure could place residents residing in these rooms at risk for not having adequate living space and could adversely affect residents from attaining his or her highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, observed for kitchen sanitation. The facility failed to ensure the following: A. Appliances were clean. B. Food items in the refrigerator had not expired. C. Floors were clean. D. Dish machine temperature and sanitizing logs were documented. These failures could affect residents who received their meals from the facility's kitchen, by placing them at risk for food-borne illness and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment remained free of accidents and hazards and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Resident #2 and # 170) whose records were reviewed for accidents and supervision. The facility failed to ensure Resident #2 and Resident #170's wander guards were checked for functionality. This failure could place residents at risk of elopement or leaving area without supervision.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with state and federal laws for 2 of 2 med carts ( Med Cart A and Med Cart B ). The facility failed to keep loose unidentified pills secured in their pharmacy labled packaging in medication cart A drawer . The Controlled Drug change of shift count logs were missing signatures on both medication carts. These failures could affect residents who receive medications in the facility and place them at risk of receiving incorrect medications, ineffective therapeutic doses, and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents with PRN orders for psychotropic drugs were limited to 14 days for 1 of 4 residents (Resident #1) whose medication regimens were reviewed for unnecessary medications in that: Resident #1 had an order for the benzodiazepine medication Alprazolam (Xanax) 0.5 mg by mouth 1 tablet daily as needed (PRN) for anxiety, dated 10/21/2023, which did not have an end/stop date. This failure could place residents administered PRN and routinely scheduled psychotropic medications at risk of adverse side effects from prolonged use of psychotropic medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured and labeled in accordance with currently accepted professional principles for 1 of 2 medication carts (med Cart A) reviewed for proper drug storage and labeling. In medication cart A there was an opened vial of insulin belonging to Resident # 7 that was not dated when opened and was not in the original pharmacy labeled box that it was dispensed in. This failure could affect residents who receive medications in the facility and place them at risk of receiving incorrect medications or ineffective therapeutic doses related to expired medication.

Inspectors wroteBased on record review and interview, the facility failed to provide the required minimum of 80 square feet of space per resident in multiple occupancy rooms for 35 of 36 rooms (Rooms #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36) reviewed for square footage. The facility failed to ensure multiple-bed resident rooms had the required 80 square feet of floor space per resident for rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36. This failure could place residents residing in these rooms at risk for not having adequate living space and could adversely affect residents from attaining his or her highest practicable well-being.