Empress Care Center, LLC

Inspectors wroteBased on observation, interview, and record review, the facility failed 1. To complete the bed rail entrapment assessment for 48 of 48 residents (1, 28, 8, 3, 26, 14, 5, 25, 99, 37, 19, 24, 15, 44, 2, 13, 6, 10, 33, 32, 42, 249, 39, 31, 36, 250, 21, 4, 251, 252, 23, 20, 38, 199, 40, 46, 34, 30, 17, 11, 18, 29, 9, 7, 22, 12, 27, and 200); 2. To attempt alternatives measures for 6 of 48 residents (4, 33, 44, 99, 249, and 250) prior to implementing the bed rails; and 3. To complete the bed rail care plan for one of 48 residents (40). These failures had the potential to place the residents at risk of entrapment and serious injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure palatability and nutritive value of cooked foods were maintained when: 1. Two of forty-nine facility residents (Residents 12 and 4), receiving food from the kitchen, complained that the food tasted bland (lacking taste or flavor); and 2. Regular (no modifications to food texture or consistency) oven barbecue roast beef and pureed foods (smooth, thick liquid or paste made by crushing or grinding solid foods and often made using a food processor and has a consistency that's thicker than juice) were held in the heated oven for an extended period. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were stored and prepared in accordance with professional standards for food safety when: 1. There were unsanitary cooking equipment in the kitchen; 2. A bucket of corrosive chemical was kept beside the food utensils; 3. Ice scoop for the ice machine was placed in the area near the ice machine that was accessible to everyone; and 4. Kitchen staff was not observing hand hygiene and sanitation during the tray line preparation. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contaminated food for the forty-nine residents who received foods from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the license of the administrator (ADM) was current when the ADM was working as the facility's administrator without supervision after his license was expired more than 10 days. This failure violated the state licensure requirements for nursing home administrator (NHA).

Inspectors wroteBased on interview and record review, the facility failed to ensure their policy and procedure (P&P) was followed for an advance directive (AD: a written instructions, such as a living will or durable power of attorney that authorizes to act on behalf of resident for healthcare when the individual is incapacitated) for six of eight sampled residents (Resident 6, 20, 23, 31, 42, and 249). This failure could lead to the delivery of unnecessary or inappropriate medical services against sampled resident's goals and wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Certified Nursing Assistant G (CNA G) did not sanitized her hands before feeding Resident 3; 2. Certified Nursing Assistant H (CNA H) grabbed the door knob of Resident 24's room, the curtain, Resident 24's glass with her contaminated gloved hands, walked out of Resident 24's room and in the hallway with the same contaminated gloves on her hands; 3. Resident 34's oxygen tubing was not dated; 4. The filter of Resident 99's oxygen concentrator was dusty; 5. Face mask below the nose for certified nursing assistant A (CNA A); 6. Resident's ADL (active daily living) care supplies for not labeled; 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dryer's lint filter was free from lint. This failure had the potential to adversely affect safety of residents, laundry equipment and facility environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan for two out of eighteen sampled residents, (Residents 27 and 20), when: 1. for Resident 27, there was no care plan for his continuous oxygen inhalation use and 2. for Resident 20, there was no care plan as well for her significant weight loss for six months. These failures had the potential to result in the residents, not receiving the intervention and monitoring necessary to maintain their highest level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received the necessary care and services for one of six residents (99) when the licensed nurses administered hydrocodone-acetaminophen (used to relieve severe pain) 5-325 milligrams (mg, a metric unit of mass) for Resident 99's moderate pain. This failure had the potential for the residents to experience unnecessary adverse effects from the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received oxygen therapy as ordered by the physician for two of 13 residents (34 and 99). This failure had the potential for the residents to have complications related to improper oxygen treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the effective use of medications for one of 13 residents (28) when Resident 28 received ferrous sulfate (iron, used for prevention/treatment of iron deficiency) and Calcium (a medication used to prevent or treat low blood calcium levels) at the same time. This failure had the potential for the residents to not receive the amount of prescribed iron supplements.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacy consultant (PC: a licensed pharmacist provides expert clinical advice and guidance on medication use) identified and reported drug irregularities to the facility during the monthly medication regimen review (MRR: a thorough evaluation of resident's medications) for one of three sampled resident (Resident 31); and facility failed to follow up MRR recommendations for one of thirteen sampled resident (Resident 2). These failures resulted in Resident 31 received more than therapeutic (safety of medication with regard to risk of overdose) dose of medication for over ten months; and Resident 2 received medication for over one month.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications (medications capable of affecting the minds, emotions, and behaviors) for three of four sampled residents (Resident 14, 31, and 249) when: 1. There was no documented evidence of non-pharmacological (treatments and strategies that mange health conditions without using medications) approaches attempted before administered medication quetiapine (used to treat mental health condition) for Resident 14. 2. There was no documented evidence of non-pharmacological approaches attempted before administered medication olanzapine (used to treat mental health conditions) for Resident 31 and 249. This failure had the potential to place sampled residents at risk to receive unnecessary psychotropic medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure an alleged violation involving abuse was reported immediately to administrator or other officials in accordance with State law for one (Resident 1) out of three residents. This failure had the potential to cause further psychosocial and/or physical harm to the residents.

Inspectors wrote7. Review of Resident 18's clinical records indicated, Resident 18 was an [AGE] year-old female, initially admitted to the facility on [DATE], with diagnoses including recurrent (occurring often) enterocolitis (inflammation that occurs throughout the intestines) due to clostridium difficile (a germ that causes diarrhea and inflammation of the colon), hemiplegia (paralysis of one side of the body) and dysphagia (difficulty swallowing). Resident 18 did not have advance directive and her POLST forms' section D, which indicate if an advance directive is available, dated 8/10/22 and 12/9/23, were left blank. During an interview with the social services director (SSD) on 12/21/23 at 2:57 p.m., SSD verified, Resident 18 did not have advance directive. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure to follow their policy and procedure (P&P) for bed side rails (adjustable metal or rigid plastic bars that attach to the bed) for six of six sampled residents (Resident 5, 11, 36, 37, 40, and 48). This failure had the potential to place sampled residents at risk for accidents, entrapment, and unsafe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. For Residents 23 and 35, the nurse did not perform hand hygiene between glove changes, 2. For Resident 45, the nurse did not perform hand hygiene after medication administration, 3. Staff's face mask below nose 4. Staff did not perform hand hygiene 5. Nursing staff did not use required PPE 6. Urine drain bag on floor for Resident 5 These failures could result in the spread of infection and cross-contamination that could affect the 49 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR, screening for residents with a mental disorder and residents with intellectual disability) screening document was accurately completed for one out of two residents (Resident 36). This failure had the potential for mentally ill Resident 36 not to receive benefit from specialized mental health care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive, person-centered, care plans for four out of fifteen sampled residents, (Residents 3, 18, 30 and 35), when: 1. for Residents 3, 18 and 30, their activity care plans were not comprehensive and person-centered and 2. for Resident 35, no comprehensive and person-centered care plan for his hearing aids. These failures had the potential to result in the residents, not receiving the interventions necessary to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents received the necessary care and services for seven out of nineteen residents investigated, (Residents 18, 30, 41, 23, 35, 39 and 48), when: 1. for Resident 18, the physician was not notified of her weight loss and weight gain of more than 5 pounds (lbs, unit for measuring weight) and there were no alert charting by nurses for 72 hours of her weight loss and weight gain; 2. for Resident 30, there were no alert charting by nurses for 72 hours of her weight loss of more than 5 lbs; 3. for Resident 23, 35 and 39, the nurses used alcohol wipes to wipe the blood after the needle punctures; 4. for Resident 41, the physician orders for blood pressure (BP) medications without holding parameters and 5. for Resident 48, management for his diabetes, not being followed. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a physician's order for a PRN (as needed) psychotropic medication (medication capable of affecting the mind, emotions, and behavior) was limited to 14 days of use, for one of 15 sampled residents (Resident 101). This failure had the potential to lead to the administration of unnecessary medication to the resident.

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 7.41 % when two medication errors occurred out of 27 opportunities during the medication administration for two residents (Residents 45 and 24). The failure resulted in medications not being given according to the manufacturer's specifications and physician's order and had the potential to affect residents' health and well-being in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately label the lubricant eye drops bottle for 2 out of 15 sampled residents (Residents 24 and 43). This deficient practice resulted in the nurse administering the wrong eye drops and had the potential to affect residents' health and well-being in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate food preferences for two out of six sample residents (Residents 35 and 40). This failure had the potential for decreased meal intake, negative effect on health and well-being for sample residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and sanitary food service operations were carried out according to standards of practice when: 1. dented can was found in the dry storage area, 2. the two-compartment sink did not have air gaps (an unobstructed vertical space between the water outlet and the flood level of a fixture) and 3. the Maintenance Supervisor (MS) did not follow safe sanitary practice in the kitchen. These failures had the potential to cause food contamination and spread food-borne illness to the forty-three residents who received their food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to follow facility's written policy and procedure (P&P) for pneumococcal (PNA- an serious infection of one or both of the lungs caused by bacteria, viruses, fungi, or chemical irritant) vaccine (a preparation that is used to stimulate the body's immune response against diseases) for four out of five sampled residents (Resident 5, 11, 26, and 36). This failure had the potential for acquiring PNA and its associated health complications for sampled residents.

Inspectors wroteBased on observation, and interview, the facility failed to ensure to install and conduct inspections to identify loose fitting bed side rails (SR adjustable metal or rigid plastic bars those attached on both sides of to the bed) for three out of eight sampled residents (Resident 11, 36, and 40)'s beds. These failures had the potential to place sampled residents at risk for accidents and unsafe environment.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for three of 15 sampled residents (Residents 21, 26, and 30) when: 1. Resident 21's anxiety and antipsychotic care plan was incomplete and not person-centered; 2. For Resident 26, there was no care plan developed for the hearing difficulty and the bleeding precautions related to the use of Rivaroxaban (an anticoagulant or blood thinning medication); and, 3. For Resident 30, there was no care plan for use of antipsychotic medication (Haldol). These failures had the potential for inaccurate development and implementation of personalized and resident-centered care plans that would address the residents' identified concerns and needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist's (CP) medication regimen review (MRR) recommendations were acted upon for three out of 15 sampled residents (Residents 7, 37, and 44). This failure resulted in unnecessary medications due to inadequate monitoring, prolonged medication use, etc. and had the potential for adverse side effects that could negatively impact the residents' physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 10.71% when three medication errors occurred out of 28 opportunities during the medication administration for three residents (Residents 30, 37, and 40). The failure resulted in medications not given according to manufacturer's specifications, and had the potential for residents not receiving the full therapeutic effects of medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the planned menu was followed when 11 of 11 residents on mechanical soft diet (texture modified diet that restricts foods that are difficult to chew or swallow) were to be served roast beef. This failure had the potential to result in residents not meeting the nutritional needs thus further compromising the nutritional status of the residents.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food was stored and prepared under safe and sanitary conditions when: 1. Frozen meatballs were thawed at room temperature. 2. A sanitizing bucket (contains concentration of chemical sanitizer used for cleaning) was placed too near with clean pots. 3. Sanitizing wipes (pre moistened towelettes that contain disinfecting ingredients) were placed next to potholders and liquid seasonings (vinegar, soy sauce). 4. The oven door was broken. 5. The can opener base was not kept in sanitary condition. 6. There were crumbs seen under the microwave oven. 7. Personal items were seen in the food storage and preparation areas. 8. The log sheet for cleaning the ice scooper was recorded incomplete. These failures had the potential to cause food contamination, spread illness to 45 out of 48 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Resident 4's and Resident 43's oxygen tubing were not changed every week; 2. Certified Nursing Assistant I (CNA I) did not wash or sanitize her hands before feeding Resident 13; 3. Licensed Vocational Nurse D (LVN D) did not wash her hands and change the gloves before cleansing Resident 42's pressure ulcers; 4. CNA L did not perform hand hygiene between residents; 5. The nurse supervisor (NS) did not wipe the medication tray with the disinfectant wipe after use for each resident. These failures could result in the spread of infection and cross-contamination in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the Physician for one of two closed sampled selected resident (Resident 49) upon discharge. This deficient practice had the potential for Resident 49 to be discharge home inappropriately.

Inspectors wroteBased on an observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) in minimum data set (MDS, an assessment tool) for one of 12 sampled residents (Resident 48). When Resident 48 had significant weight loss, had declined in activities of daily living (ADL, daily self-care tasks, e.g., bathing, toileting, and transferring), incontinency and communication. This failure had the potential to result in Resident 48 unable to achieve or maintain optimal status of health, function and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) quarterly assessments was transmitted (sent electronically) to the Centers of Medicare and Medicaid Services (CMS, a government agency) for one of 12 residents (Resident 44). This failure could potentially affect the provision of care or services to the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess the skin of one of three residents (Resident 22) when the resident's skin abrasion (surface of the skin has been broken) was not monitored. The failure resulted in progression of skin blisters (skin condition where fluid fills a space between layers of skin) and potential for skin infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prescribed treatment for pressure ulcer (an area of the skin that breaks down when something keeps rubbing or pressing against the skin) was followed for two of three residents (Residents 43 and 44). This failure had the potential for decreased healing and further injury to the residents' wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a fall prevention order for one of four sampled residents (Resident 20) when the pad alarm (device that makes a loud noise to alert caregivers if a resident is getting up from bed) was not placed in bed. This failure had the potential for falls and injury to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen (02) according to professional standards of practice for one of one resident (Resident 3). This failure could affect the resident's health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 15 sampled residents (Resident 7) was free from unnecessary medications when Resident 7 received long-term diuretic (medication that remove water from the body which can affect the electrolyte levels in the body) without routine electrolyte (such as potassium, calcium, magnesium) monitoring; and levothyroxine (thyroid medication) without periodic lab work for its use. The failure had the potential to result in electrolyte imbalance and inadequate thyroid response, that can cause serious medical conditions such as irregular heartbeats, fatigue, confusion, etc. for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 9 residents (36 and 44) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 36 received Abilify for schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood), and the electrocardiogram (ECG, a test that measures the electrical activity of the heartbeat) was not done as ordered; and 2. Resident 44 received Latuda for schizoaffective disorder and haloperidol for schizophrenia (a mental disorder in which people interpret reality abnormally), and the liver function tests (LFTs, blood tests used to help diagnose and monitor liver disease or damage) was not done as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and ensure food were under sanitary conditions for one of three residents (Resident 6) when the resident's food brought from outside was not properly stored, labeled, and dated. This failure had the potential for food borne illness and food contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and functional environment for one of 12 sampled residents (Resident 21) when Resident 21's bathroom sink was clogged and the toilet bowl had a leak with water spilled on the floor. The facility must provide a safe, functional, sanitary, and comfortable environment for residents and staff.