Falls Run Nursing and Rehabilitation

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for three of 37 residents in the survey sample, Residents #32, #31, and #6.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete pain management program for two of 37 residents in the survey sample, Residents #32 and #6.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for one of 37 residents in the survey sample, Resident #6.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to initiate a written grievance for one of 37 residents in the survey sample, Resident #6.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide adequate supervision for one of 37 residents in the survey sample, Residents #272. This deficiency is cited as past non-compliance.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for a urinary catheter for one of 37 residents in the survey sample, Resident #53.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services per physician orders, for two of 37 residents in the survey sample, Residents #18 and #31.

Inspectors wroteBased on observations, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to properly store medications for one of 37 residents in the survey sample, Resident #59.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for one of 37 residents in the survey sample, Resident #26.

Inspectors wrote2. The facility staff failed to provide Resident # 14 and the resident's representative written notification of a facility-initiated transfer on 05/19/2021 and 06/22/2021 for Resident # 14. Resident # 14 was admitted to the facility with diagnoses that included but were not limited to: rectal bleeding and diabetes. Resident # 14's most recent MDS [minimum data set], a quarterly assessment with an ARD (assessment reference date) of 05/30/2021, coded Resident # 14 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. The facility's Progress Note for Resident # 14 dated 05/19/2021 at 3:05 p.m., documented in part, Resident currently transferred to [Name of Hospital] for evaluation of possible GI [gastrointestinal (stomach and intestines)] bleed. [...]

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to ensure food storage in a safe manner, and failed to clean the kitchen stove. The walk-in refrigerator contained expired milk cartons and pudding. The stove top contained areas of built-up grease that was burned on to the grates, elements, and stove top surface. The stove top also contained ashy material that scraped up easily with a gloved finger.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a call bell within reach for one of 28 residents in the survey sample, Resident #8. The facility staff failed to maintain Resident #8's call bell within reach on 8/24/21. Resident #8 was lying in bed and the resident's call bell was on the floor under the bed.

Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to develop a baseline care plan for one of 28 current residents in the survey sample, Resident #430. The facility failed to develop a baseline care plan to address the physician prescribed anticoagulant medication Warfarin and monitoring for the medication for Resident #430 upon admission.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the comprehensive care plan for one of 28 residents in the survey sample, Resident #8. The facility staff failed to implemented Resident #8's comprehensive care plan for maintaining the resident's call bell within reach.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory services in a sanitary manner for two of 28 residents in the survey sample, Resident #130 and Resident #72. 1. Resident #130's nebulizer mask and medication delivery tank was observed on separate occasions uncovered when not in use and the residents oxygen tubing was observed uncovered and wrapped around the top of an oxygen tank on the back of the resident's wheelchair. 2. The facility staff failed to store oxygen equipment in a sanitary manner for Resident #72. Nasal cannula tubing was observed uncovered and wrapped around the top of the tank that was not in use, located on the back of Resident #72's wheelchair.

Inspectors wroteBased on employee record review and staff interview, it was determined that the facility staff failed to perform an annual performance review for one of five CNA (certified nursing assistant) records reviewed.

Inspectors wroteBased on staff interview, facility document review and clinical record review it was determined the facility staff failed to ensure one the drug regime for one of 28 residents in the survey sample, Resident #72, was free of unnecessary pain medications. The facility staff administered Tylenol prescribed for Resident #72, for pain scale ratings above below the physician ordered parameters of 1-4 and administered Tramadol HCL for a pain rating 4, for which the physician prescribed Tylenol.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement infection control practices for one of eight residents in the medication administration observation, Resident #281. The facility staff failed to administer medication in a sanitary manner to Resident #281 on 8/25/21. LPN (Licensed practical nurse) #1 touched and administered a dropped pill to Resident #281 with gloved hands that were worn while touching the medication cart and vital sign machine.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to implement the Advanced Directives policy to ensure periodic reviews with resident and/or responsible party, were provided to formulate Advance Directives, or, if applicable, make changes to their existing Advance Directives or maintain them as written, for seven of 40 residents in the survey sample, Residents #22, #15, #30, #20, #57, #36, and #14.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in the main kitchen freezer. In the main freezer a box of frozen green beans and lima beans were observed not closed and sealed exposing the food to the environment.

Inspectors wroteBased on observation, staff interview, and facility document review it was determined facility staff failed to protect confidentiality of the medical record for one of 40 residents in the survey sample, Resident #25.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that any of the required documentation was provided to the receiving health care institution on transfer to the hospital for one of 40 residents in the survey sample, Resident #43.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that written notification of a hospital transfer was provided to the resident representative upon a hospital transfer for two of 40 residents in the survey sample, Residents #43 and #22.

Inspectors wrote2. The facility staff incorrectly coded Resident #15's quarterly MDS dated [DATE] for the administration of insulin. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of but not limited to peripheral vascular disease, intervertebral disc disorders, ischemic heart disease, diabetes, depression, bladder dysfunction, osteoporosis, high blood pressure, and anxiety. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/13/19 coded the resident as cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive care for mobility, transfers, dressing, hygiene, and toileting; limited assistance for bathing; and supervision for eating. [...]

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop a complete baseline care plan for two of 40 residents in the survey sample, Residents #67 and #222. The facility staff failed to develop Resident #67's baseline care plan to include the use of an incentive spirometer and staff failed to develop a baseline care plan related to the use of bed rails for Resident #222.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement the plan of care for two of 40 residents in the survey sample, Residents #222 and #57. Resident #222 and Resident #57 were observed receiving oxygen at a rate that was not prescribed by the physician.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice, the comprehensive person-centered care plan, for three of 40 residents in the survey sample, Residents #222, #57, and #67. The facility staff failed to administer oxygen at the physician-ordered rate during multiple observations conducted for Resident #222 and #57, and failed to obtain a physician's order for Resident #67's use of an incentive spirometer.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for two of 40 residents in the survey sample, Residents #61 and #222. The facility staff failed to assess Resident #61 and Resident #222 for the use of bed rails, and staff failed to review risks and benefits for use of bed rails, and failed to obtain informed consent for the resident's use of bed rails.