Forest City Nursing and Rehab Center

Inspectors wroteBased on a review of clinical records, facility policy, documentation provided to residents regarding transfers from the facility, records obtained from the acute care hospital, facility census records, and staff interviews, it was determined the facility failed to ensure an appropriate discharge by failing to permit a resident to return to the facility following hospitalization in accordance with its policies for one of five residents reviewed (Resident 1).

Inspectors wroteBased on a review of clinical records, resident interviews, staff interviews, facility documentation, and facility policy, it was determined the facility failed to ensure residents who were dependent on staff for assistance with activities of daily living consistently received the care and services necessary to maintain personal hygiene and dignity for one of 10 residents reviewed (Resident 1).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to develop and implement a person-centered baseline care plan that incorporated individualized interventions for wound management for one resident out of five sampled (Resident 1).

Inspectors wroteBased on clinical record review, physician order review, nursing documentation review, wound care consultation notes, diagnostic testing, and staff interview, it was determined the facility failed to ensure care and treatment was provided in accordance with professional standards of practice and physician orders for one of five sampled residents (Resident 1).

Inspectors wroteBased on observation and staff interview, the facility failed to maintain proper storage and service practices for food in the dietary department and second-floor resident pantry/nourishment room. This failure created the potential for contamination, microbial growth, and an increased risk of foodborne illness.

Inspectors wroteBased on a review of clinical records and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of 3 out of 19 sampled (Residents 7, 42, and 17).

Inspectors wroteBased on clinical record review, select facility review and staff and resident interview, it was determined the failed to reassess a resident's pain status and the repeated daily use of opioid pain medication prescribed on an as-needed (PRN) basis to ensure the development and implementation of an effective, individualized pain management plan for one of 19 residents sampled. (Resident 28).

Inspectors wroteBased on review of controlled drug records and select facility policy and staff interview, it was determined the facility failed to implement procedures to promote accurate controlled medication records and failed to ensure medication availability for one of 19 residents sampled (Resident 28).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that residents are free from unnecessary drugs to include duplicate pain medications for one of 19 sampled residents (Resident 28).

Inspectors wroteBased on review of clinical records and staff interview it was determined the facility failed to provide care and services in accordance with accepted professional standards of practice by inaccurately identifying a diagnosis of delusional disorder for one (1) of 19 residents (Resident 44) sampled without documented clinical evidence to support the diagnosis.

Inspectors wroteBased on clinical record review, staff interviews, and observations, the facility failed to ensure medications were labeled in accordance with currently acceptable principles of medication storage and administration, including appropriate resident identification, medication information, and expiration/open dates for one of 19 sampled residents (Resident 28).

Inspectors wroteBased on a review of clinical records and select investigation reports and staff interview, it was determined that the facility failed to implement effective fall prevention interventions including timely and necessary staff supervision of resident with a history of falls and known unsafe behaviors that increased the resident's risk for falls, to prevent a fall with serious injury, a fractured wrist, for one resident out of 18 sampled (Resident 49).

Inspectors wroteBased on review of select facility policy and interviews with residents and staff, it was determined that the facility failed to review the continued appropriateness and revise the resident's plan of care in response to a significant weight loss for one resident out 18 residents (Resident 18).

Inspectors wroteBased on a review of clinical records, select facility policy and investigative reports and staff interviews it was determined that the facility failed to assess and implement individualized measures to meet the toileting needs of one resident (Resident 70) and failed to evaluate the clinical necessity of an indwelling urinary catheter for of one resident (Resident 49)out of 18 sampled.

Inspectors wroteBased on review clinical records and staff interviews, it was determined that the facility failed to ensure that a resident was free from unnecessary psychoactive drugs by failing to assure the presence of the documented prescriber clinical rationale for the use of a psychotropic medication and justification for the use of duplicate drug therapy for dementia with psychosis for one of five residents reviewed (Resident 11).

Inspectors wroteBased on observation, a review of select facility policy and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and two of three resident pantries.

Inspectors wroteBased on observations, review of the facility's infection control tracking logs and policy and staff interviews it was determined that the facility failed to maintain a comprehensive program to monitor the development and spread of infections within the facility and plan preventative measures accordingly, failed to store resident care equipment in a manner to deter the spread of infection and failed to appropriately dispose of PPE after use.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to incorporate the recommendations from the Pre-admission Screening and Resident Review (PASARR) level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for two of 18 residents reviewed (Resident 2 and 45).

Inspectors wroteBased on a review of clinical records and staff interviews it was determined that the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of 18 residents sampled (Resident 2).

Inspectors wroteBased on clinical record and staff interview, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary drugs by failing to clinically justify the use of an antihistamine medication for treatment of anxiety that is contraindicated in the elderly due to anticholinergic adverse side effects for one resident out of 18 sampled residents (Resident 5).

Inspectors wroteBased on a review of clinical records and staff interviews it was determined that the facility failed to ensure that results of laboratory studies were present on the resident's clinical record for one resident out of 18 sampled (Resident 2)