Englewood Post Acute and Rehabilitation

Inspectors wroteBased on record review and interviews, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected residents' status based on the criteria outlined in the resident assessment instrument (RAI) for three (#15, #36 and #63) residents out of 40 sample residents. Specifically, the facility failed to: -Ensure the MDS assessments for Resident #15 and Resident #36 accurately documented that the residents had a preadmission assessment screening and resident review (PASRR) Level II qualifying diagnosis; -Ensure the MDS assessment for Resident #15 accurately documented the resident was receiving hospice services; and, -Ensure the MDS assessment for Resident #63 accurately documented the resident was receiving dialysis.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of four hallways. Specifically, the facility failed to: -Ensure appropriate infection control practices were followed during wound care; and, -Ensure housekeeping staff followed appropriate hand hygiene practices and disinfectant dwell times when cleaning residents' rooms.

Inspectors wroteBased on observations and interviews, the facility failed to provide a comfortable and homelike environment in one of four units. Specifically, the facility failed to ensure: -Resident room [ROOM NUMBER], #204, #206, #209, and #212 were in good repair; and, -Baseboards in the common areas on the second floor unit were clean.

Inspectors wroteBased on interviews and record review, the facility failed to thoroughly investigate resident-to-resident allegations of physical abuse and staff-to-resident allegations of neglect of care to prevent further instances of abuse and residents from feeling neglected for two (#60 and #18) of four residents out of 40 sample residents. Specifically, the facility failed to: -Develop a care plan focus for Resident #18, who had a known history of aggressive behaviors towards others and a history of discharge from other facilities due to aggressive behavior; -Gather all pertinent unbiased observations to identify pertinent facts of the events that occurred before, during and immediately following the incident to determine necessary interventions to prevent further abuse. This could include but not limited to observations of the assailant's behavior; words; gestures; facial expression; demeanor; [...]

Inspectors wroteBased on record review and interviews, the facility failed to refer one (#20) of one resident reviewed out of 40 sample residents to the appropriate state-designated authority for Level II preadmission screening and resident review (PASRR) evaluation and determination for services. Specifically, the facility failed to: -Ensure Resident #20 was properly assessed on the PASRR Level I screen to gain and maintain their highest practicable medical, emotional and psychosocial well-being; and, -Submit a new PASRR Level I on three separate occasions when Resident #20 received qualifying mental illness diagnoses.

Inspectors wroteBased on observation and interviews, the facility failed to ensure that services provided met professional standards of quality for one (#21) of one resident out of 40 sample residents. Specifically, the facility failed to: -Ensure medications were not left unattended on top of the medication cart; and, -Ensure medications were not left unattended in Resident #21's room.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide needed care of services, resulting in an actual decline in physical, mental and psychosocial well-being for one (#275) out of four residents reviewed out of 33 sample residents. Resident #275, who had a severe cognitive impairment, was admitted to the facility 1/26/23. The resident did not have a medical decision maker, so the facility proceeded to implement a medical health proxy on 3/5/23. The facility failed to notify and coordinate with the health care proxy regarding the resident's care, the contact documented with the health care proxy was 5/20/23. Resident #275 had lost weight since her admission to the facility on 1/26/23, 21.6% in total in four months, which was considered severe. Her admission weight was 108.4 lbs. (pounds) on 2/5/23 and on 6/1/23 she weighed 85 lbs. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that self-administration of medications were stored and clinically appropriate for two (#31 and #38) of two residents reviewed for self-administration out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #31 stored medication she was assessed to self administer and the medications she was able to self-administered were stored appropriately; and, -Ensure Resident #38 was assessed for the appropriateness and safety for self-administration of medications.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure the residents personal privacy for one (#10) out of four residents reviewed for dignity out of 33 sample residents. Specifically, the facility failed to ensure a resident's personal privacy by offering a leg bag for the urinary catheter for Resident #10.

Inspectors wroteBased upon observation, interviews and record review, the facility failed to ensure that a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty received the appropriate treatment and services to correct the assessed problem or to attain the highest practicable physical, mental and psychosocial well-being for one resident (#65) reviewed for a mental disorder out of 33 sample residents. Specifically, the facility failed to ensure interventions were in place to address Resident #65's verbally aggressive behavior.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, needs for one (#28) of three residents reviewed for quality of care out of 33 sample residents. The facilities failure to provide Resident #28 with a wheelchair of the appropriate size to accommodate his weight and to provide a pressure relieving cushion that was the correct size for the wheelchair seat, contributed to the development of multiple stage 2 pressure ulcers on the resident's posterior thighs, causing undue discomfort. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (#28) of five residents reviewed for pressure ulcers out of 33 sample residents, received the care and services necessary to prevent pressure injuries and to promote healing. The facility failed to complete routine skin evaluations, evaluate his wheelchair for size and positioning, and failed to evaluate the size and effectiveness of the pressure relieving cushion in the wheelchair, contributing to the development of stage 2 pressure ulcers to Resident #28's thighs. The facility also knew Resident #28, who presented with multiple risk factors for skin breakdown due to co-morbidities and his dependence on one staff member for mobility, was at risk. Futhermore, the resident was observed with open areas to his right posterior thigh which were undocumented. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Specifically the facility failed to: -Properly clean and store blood glucose meters used for multiple residents requiring blood glucose monitoring; and, -Implement and maintain a water management program to test for legionella in their water systems.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to honor resident choices for three out of 25 resident ' s reviewed for self-determination. Specifically, the facility failed to ensure Residents #11, #42, and #43 received showers according to their choice of frequency.

Inspectors wroteBased on record review and interviews, the facility failed to resolve grievances in a timely manner, including taking immediate action to prevent further violations of any resident right for eight (#13, #58, #56, #43, #26, #27, #61 and #28) out of 33 sample residents. Specifically, the facility failed to resolve grievances in a timely manner related to call light response for Residents #13, #58, #56, #43, #26, #27 and #28 and missing personal items for Resident #27. I. Facility policy and procedure Review of the Grievances policy, provided by registered nurse (RN) #2 on 3/9/2020 at 4:10 p.m. revealed in part, The facility ' s grievance official is responsible for overseeing the grievance process, receiving and tracking grievances; [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for three of three kitchens. Specifically, the facility failed to ensure: -Thermometers were cleaned properly; and, -Dietary supplements were disposed of upon expiration. I. Facility policy and procedure Review of the Checking Food Temperatures policy, revised 8/2018, provided by the dietary director (DD) on 3/10/2020 at 1:44 p.m. revealed in part, Thermometers should be clean and sanitized before and after use using an alcohol probe wipe or through a 3-step clean/rinse/sanitize process Review of the Food Storage policy, revised 8/2017, provided by the DD on 3/10/2020 at 8:49 a.m. [...]