Elmwood Nursing and Rehabilitation Center

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that residents who are appealing a transfer or discharge notice from the facility, remain in or return to the facility, pending their appeal for 1 of 1 resident reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, it has been determined the facility failed to provide care in accordance with a resident's plan of care to prevent falls for one of three residents reviewed, Resident ID #1, who sustained a fall with injury requiring hospitalization.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to inform the resident's appointed representative, in advance, of the care to be furnished by the physician or other provider, of the risks and benefits of proposed care or treatment alternatives relative to the ordering and administration of an antipsychotic medication for 1 of 1 resident reviewed, for the use of Zyprexa (an atypical antipsychotic medication), Resident ID #2.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician's orders for a neurology consult and psychiatric services for 1 of 1 resident reviewed, Resident ID #2.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide the mandatory effective communication training for 7 of 7 direct care staff members, Staff K, L, M, N, O, P, and Q regarding Resident ID #63 who only speaks Cantonese (a traditional variety of Chinese language originating from the city of [NAME]).

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to the utilization of a heel offloading device for 1 of 2 residents reviewed, Resident ID #3.

Inspectors wroteBased on surveyor observation, record review, representative and staff interview, it has been determined that the facility failed to ensure that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs for 1 of 1 resident reviewed who is unable to speak or understand the English language, Resident ID #63.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to develop, implement, and maintain an effective training program for all newly hired employees and annual training for existing employees consistent with their expected roles, relative to education involving abuse, infection control, dementia behavioral health management, trauma informed care and Quality Assurance and Performance Improvement (QAPI) per the facility assessment, for 5 of 7 staff members reviewed, Staff K, L, M, N, and O.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with recommendations from a urologist (a medical practitioner that specializes in the diagnosis and treatment of disorders of the urinary system), Resident ID #40.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure each residents' medication regimen is free from a medication error rate of 5% or greater. Based on 28 opportunities for errors observed during the medication administration task, there were 2 errors resulting in an error rate of 7.14%, affecting Resident ID #s 2 and 64.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to staff wearing the appropriate personal protective equipment (PPE) while handling soiled linen, for 1 of 1 staff member observed, Staff I.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment as required for 1 of 1 staff reviewed, Registered Nurse, Staff A .

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to oxygen administration during an acute medical event for 1 of 2 residents reviewed, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure residents are free from abuse related to involuntary seclusion for 1 of 3 residents reviewed, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors receive trauma informed care in accordance with professional standards of practice and accounting for residents' experiences for 1 of 1 resident reviewed who was re-traumatized relative to water on his/her face, Resident ID #4. Additionally, the facility failed to assess 6 of 17 residents reviewed for Trauma Informed Care, Resident ID #s 1, 2, 4, 25, 28, and 29.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality for 1 of 5 residents reviewed relative to positioning, Resident ID #25.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents identified as an elopement risk received adequate supervision for 1 of 4 residents reviewed, Resident ID #516.

Inspectors wroteBased on surveyor observation, record review, and staff interview it has been determined that the facility failed to meet professional standards of practice relative to a peripherally inserted central catheter (PICC) for 1 of 1 resident observed for intravenous (IV) antibiotic administration via a PICC line, Resident ID #520.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 4 residents reviewed for elopement, Resident ID #516.