Fianna Hills Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interviews, record review and facility policy review, it was determined that facility staff failed to follow care planned interventions for two (Resident #2 and Resident #3) of three residents reviewed for assistance and supervision.

Inspectors wroteBased on interviews, observations, record review, and facility policy review, the facility failed to ensure chemical solutions were available to effectively clean and sanitize dishware and kitchen equipment; failed to store, prepare, distribute and serve food in accordance with professional standards of safety; failed to ensure dietary staff washed their hands following the removal of gloves and between task during meal preparation; failed to ensure food preparation surfaces were cleaned and sanitized using a sanitizing solution; failed to ensure equipment was clean and sanitized between uses; and failed to ensure the dietary staff cleaned and sanitized the test thermometer between testing the temperatures of food items on the steamtable. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medication was not left at the bedside for one of one observation and the facility failed to ensure insulins and antianxiety medications were stored at manufacturer recommended temperature for one of one observation of medication storage.

Inspectors wroteBased on observations, interviews, record review, and policy review, it was determined that the facility failed to properly store oxygen canisters while not in use for 1 (Resident #53) of 4 residents reviewed for accidents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure foods stored in the freezer were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; failed to ensure 1 of 1 dietary staff washed their hands before handling clean equipment. These failed practices had the potential to affect 86 residents who received meals from the kitchen (total census: 86) as documented on a list provided by Dietary Supervisor on 04/25/23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's dining space was not infringed upon by other residents to ensure residents were able to have a pleasant dining experience for 1 (Resident # 25) sampled resident and meals for residents at the same dining table in the Main Dining Room were served together to promote dignity and respect for 1 (Resident #62) of 24 (Residents #5, #12, #15, #24, #25, #26, #39, #44, #48, #51, #53, #54, #58, #60, #61, #62, #65, #67, #72, #77, #79, #84, #291 and #342) sampled residents. This failed practice had the potential to affect 87 residents who had the ability to dine in the Main Dining Room as documented on the Census and Conditions of Residents provided by the Administrator on 04/24/23 at 11:52 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) was completed accurately related to an indwelling foley catheter for 1 (Resident #54) and a Discharge MDS for 1 (Resident #88) of 24 (Residents #5, #12, #15, #24, #25, #26, #39, #44, #48, #51, #53, #54, #58, #60, #61, #62, #65, #67, #72, #77, #79, #84, #291 and #342) sampled residents whose MDS's were reviewed.

Inspectors wroteBased on record review, and interview, the facility failed to ensure an updated determination evaluation and review was received after the 60 day expiration date for a resident with a mental disorder diagnosis to ensure the resident received care and services in the most integrated setting appropriate to their needs for 1 (Resident #72) of 23 (Residents #5, #10, #12, #15, #20, #25, #32, #39, #46, #48, #49, #53, #54, #58, #60, #61, #63, #65, #67, #72, #79, #86 and #342) sampled residents with serious mental disorders as documented on a list provided by the Minimum Data Set (MDS) Coordinator on 04/27/23 at 3:38 PM.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation, interview, and record review, the facility failed to ensure residents' who had a new service or level of care ordered or provided, individualized Care Plans were updated to ensure appropriate care was received for 4 (Residents #54, #61, #72 and #79) of 24 (Residents #5, #12, #15, #24, #25, #26, #39, #44, #48, #51, #53, #54, #58, #60, #61, #62, #65, #67, #72, #77, #79, #84, #291 and #342) sampled residents whose Care Plans were reviewed. This failed practice had the potential to affect 87 residents as documented on the Census and Conditions of Residents provided by the Administrator on 04/24/23 at 11:52 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, as evidenced by failure to ensure physician ordered interventions were consistently implemented to promote healing and prevent new ulcers from developing for 1 (Resident #84) of 3 (Residents #5, #54 and #84) sampled residents who had pressure ulcer. This failed practice had the potential to affect 5 residents according to a list provided by the Director of Nursing (DON) on 04/25/23 at 2:11 PM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with suprapubic/indwelling foley catheters received care and treatment in accordance with professional standards of nursing practices for 2 (Residents #54 and #79) of 3 (Residents #42, #54 and #79) sampled residents, as evidenced by failure to ensure the indwelling foley catheter drainage bag and tubing was contained and off the floor for Resident #79; and failed to ensure Residents #54's indwelling foley catheter/tubing/anti-reflux chamber were free of sediment to prevent cross contamination and possible infections. This failed practice had the potential to affect 6 residents according to a list provided by the Administrator on 04/25/23 at 1:50 PM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Oxygen (O2) was running at the prescribed rate as ordered by the physician and the humidifier and tubing were dated and properly stored in a closed bag or container when not in use, to prevent potential cross contamination that could result in respiratory infections for 5 (Residents #24, #54, #67, #79 and #84) of 11 (Residents #5, #12, #24, #25, #26, #41, #54 #67, #79, #84 and #342 ) sampled residents who required O2. This failed practice had the potential to affect 21 residents who required O2 according to a list provided by the Administrator on 04/27/23 at 1:05 PM.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 7 residents who received pureed diets as documented on the List Dietary Supervisor provided by the Food Service Supervisor on 04/25/23 at 9:21 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure visitors wore personal protective equipment while visiting a resident on contact isolation for 1 (Resident #54); staff performed hand hygiene and/or changed gloves during incontinent care for 1 (Resident #58); and staff performed hand hygiene before serving/setting up of a meal tray for 1 (Resident #291) of 3 (Residents #54, #58 and #291) sampled residents. This failed practice had the potential to affect 87 residents according to the Census and Conditions of Residents provided by the Administrator on 04/24/23 at 11:52 a.m.

Inspectors wroteSurveyor: [NAME], [NAME] L Based on record review, and interview, the facility failed to ensure education provided to residents/responsible parties regarding the benefits and potential side effects associated with COVID-19 vaccines and the residents/responsible parties' choice was documented in the facility's electronic medical records for 3 (Residents #60, #72 and #86) of 5 (Residents #60, #72, #86, #291 and #342) sampled residents whose immunization records were reviewed for COVID-19 vaccine information to ensure residents were able to make informed decisions as to whether or not to receive the vaccine.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure call lights were kept within reach to allow the residents to summon assistance to accommodate their individual care needs for 1 (Resident #60) of 12 (Residents #5, #12, #15, #20, #23, #24, #25, #39, #41, #46, #58 and #67) sampled residents who were dependent on staff assistance and could utilize the call light system. This failed practice had the potential to affect 62 residents as documented on a list provided by the Administrator on 04/25/23 at 1:50 PM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 7 residents who received pureed diets, 23 residents who received mechanical soft diets and 58 residents who received regular diets from 1 of 1 kitchen (total census: 86) according to a list provided by the Dietary Supervisor on 04/25/23

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Binding Arbitration Agreements provided for the selection of a venue convenient to both parties for 5 (Residents #58, #61, #79, #84 and #342) of 5 sampled residents who had signed the Binding Arbitration Agreements upon admission since 09/16/19. This failed practice had the potential to affect 59 residents who had signed the facility's Arbitration Agreement since September 16, 2019, as documented on a list provided by the Business Office Manager (BOM) on 04/24/23 at 2:09 PM.

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff received complete primary vaccinations, had an approved or pending medical or religious exemption, or a temporary delay per the Center for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) COVID-19 Health Care Staff Vaccination Regulations Quality Service and Oversight (QSO) Memo dated October 26, 2022, and failed to ensure staff COVID-19 vaccinations were accurately tracked, documented, and updated timely.