Garfield County Nursing Home

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there was undated food in the refrigerator and freezer, kitchen staff were observed to not be wearing hairnets and beard coverings, and the sanitizer bucket was not testing at the required sanitation levels.

Inspectors wrote3. Resident 5 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, depression and insomnia disorder. Resident 5's medical record was reviewed. A physician's order dated 1/29/19, documented sertraline (Zoloft) 25 mg. Administer 12.5 mg daily for a diagnosis of depression. A physician's order dated 1/29/19, documented zolpidem (Ambien) 5 mg daily at bedtime for a diagnosis of insomnia. A physician's order dated 2/14/20, documented diphenhydramine (Banophen) 25 mg daily at bedtime for a diagnosis of allergies and insomnia. A physician documented clinical contraindication was unable to be located and the medications had not received the appropriate GDR. 4. Resident 14 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, anxiety. Resident 14's medical record was reviewed. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure an assessment accurately reflected the resident's status. Specifically, for 3 out of 12 sampled residents, residents were coded as taking antipsychotic medications when they were not taking them. Resident identifiers: 1, 8, and 12.

Inspectors wroteBased on observation, interview, and record review, the facility did not 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, for 3 out of 12 sampled residents, Enhanced Barrier Precautions (EBP) were not implemented for residents with wounds and indwelling urinary catheters. Resident identifiers: 2, 9, and 10.

Inspectors wroteBased on interview and record review it was determined, for 1 of 3 sampled residents, that the facility in response to an allegation of neglect did not have evidence that the allegation was thoroughly investigated and did not prevent further abuse while the investigation was in progress. Specifically, the facility did not have evidence of a thorough investigation and allowed the alleged perpetrator to continue to provide resident care while the investigation was being conducted. Resident identifier: 1.

Inspectors wroteBased on interview and record review it was determined, for 1 of 14 sampled residents, that the facility did not consult with the resident's physician and notify when there was an accident involving the resident that resulted in injury; a significant change in the resident's physical, mental, or psychosocial status; or a need to alter treatment or commence a new form of treatment. Specifically, the staff injured a resident while providing nail care which resulted in the need for wound care and the physician was not notified. Resident identifier 15.

Inspectors wroteBased on observation, interview, and record review it was determined for 2 of 14 sampled residents, that the facility did not provide the necessary assistance to ensure each resident maintained or improved their ability to perform activities of daily living, including eating. Specifically, residents with swallowing issues were not provided supervision while eating when it was identified as a need based on the comprehensive assessment. Resident identifiers: 1 and 12.

Inspectors wroteBased on interview and record review it was determined, for 2 or 14 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident was receiving wound care without a physician order for the care and a resident sustained an injury from staff improperly clipping the residents' fingernails. Resident identifiers: 9 and 15.

Inspectors wroteBased on interview and record review it was determined, for 1 of 14 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, a resident's narcotic pain medication was not administered per the physician ordered parameters. Resident identifier 4.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 14 residents sampled, that the facility did not ensure that residents who used psychotropic drugs received a gradual dose reduction (GDR) unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, a resident's Quetiapine order did not have any GDR's in the first year of use and no documentation could be found for a clinical contraindication to the GDR. Resident identifier 5.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 14 sampled residents, that the facility did not 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, during wound care multiple observation were made of cross contamination and no hand hygiene was performed. Resident identifier 4.

Inspectors wroteBased on interview and record review it was determined, for 2 of 5 sampled residents, that the facility failed to ensure each resident received the pneumococcal immunization when the resident consented to the immunization and when it was not contraindicated. Specifically, the facility failed to administer the pneumococcal immunization when the offer was accepted by the resident. Resident identifiers: 7 and 8.

Inspectors wroteBased on observation and interview, it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, items within the facility's walk-in fridge were observed stored uncovered and unlabelled, and the sanitizer level within the dish machine and sanitizer buckets was not maintained at manufacturer recommended levels.

Inspectors wroteBased on interview and record review it was determined the facility did not ensure that each resident's medical record included documentation that indicated the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza immunization. Specifically, for 4 out of 12 sampled residents, the medical record did not include the influenza informed consent that included information on influenza risks, benefits, and potential side effects. Resident identifier: 2, 7, 9, and 11.

Inspectors wroteBased on interview and record review it was determined the facility did not ensure the individual financial record was available to the resident through quarterly statements and upon request. Specifically, for 1 out of 12 sampled residents, the quarterly financial statements were not being issued. Resident identifier: 6. Resident 6 was admitted to the facility on [DATE] with diagnoses which included but not limited to anxiety, weakness, pain management, communication impairment, and hypothyroidism. On 9/13/21 at 2:21 PM, an interview was conducted with resident 6. Resident 6 stated she did not receive quarterly statements for the funds the facility managed for her. On 9/14/21 at 11:29 AM, an interview was conducted with the Recreational Therapy Aid (RTA). The RTA stated there was a safe under the desk in her office. [...]