Guilford Health Care Center

Inspectors wroteBased on observations and staff interviews, the facility failed to label and date leftover food stored for use, discard food past its use-by-date and discard food showing signs of spoilage in 1 of 1 walk-in cooler and 1 of 1 walk-in freezer. The facility also failed to maintain clean walls and ceilings that were free from damage and black substances in the facility's main kitchen area including the dish washing area, steamtable/food line, and food preparation area. These practices had the potential to affect food served to all residents.

Inspectors wroteBased on record review and Family Member and staff interviews, the facility failed to report an allegation of employee to resident physical abuse to law enforcement and State Survey Agency for Resident #82 within the required time frame. Adult Protective Services (APS) was not notified of the allegation of employee to resident abuse. The deficient practice occurred for 1 of 3 residents reviewed for reporting of abuse allegations (Resident #82).

Inspectors wroteBased on record review and interviews with resident, Assisted Living Executive Director, contracted Transportation Aide, Nurse Practitioner, and staff, the facility failed to provide the assisted living facility Resident #117 was discharging to with an accurate FL2 Form (a mandatory medical documented completed by a physician to certify a patient's medical needs and required level of care) resulting in the resident being denied admission. This was for 1 of 3 residents reviewed for discharge (Resident #117).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to post cautionary, safety signage that indicated the use of oxygen for Resident #3 and Resident #13 and failed to have a physician order for oxygen use for Resident #13 for 2 of 3 residents reviewed for respiratory care (Resident #3 and Resident #13).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to secure a medication cart that was left unlocked and unattended, failed to secure insulin syringes that were left unsecured on top of an unattended medication cart, failed to dispose of medications that were refused and dropped on the floor that were stored in 1 of 6 medication carts reviewed for medication storage (100 Hall Bottom Medication Cart).

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to provide snacks when requested for 4 of 4 residents reviewed for resident council and 1 of 1 resident who reported feeling hungry between meals (Resident #17, Resident #32, Resident #84, Resident #52, and Resident #90).

Inspectors wroteBased on record review, and staff and resident interviews, the facility failed to act upon grievances that were reported by the Resident Council, resolve repeat grievances, and communicate the facility's efforts to address grievances voiced during Resident Council meetings for 7 of 7 consecutive months: September 2024, October 2024, November 2024, December 2024, January 2025, February 2025, and March 2025.

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 5 medication errors out of 25 opportunities, resulting in a medication error rate of 20% for 1 of 5 residents (Resident #36) observed during the medication administration observation.

Inspectors wroteBased on a lunch meal tray line observation, staff interviews and record review the facility failed to follow the approved menu when pureed bread was not served to 11 of 11 residents on a pureed diet, salisbury steak was not served to 3 of 3 residents on a renal diet and 15 of 15 residents on a heart healthy diet, and the recipe for beef stroganoff was not followed for 55 residents receiving a regular and mechanical soft texture diet (200 Hall).

Inspectors wroteBased on staff and resident interviews, the facility failed to provide residents with access to their personal fund accounts for 2 of 2 residents reviewed for management of personal funds (Resident #17 and #52).

Inspectors wroteBased on observation, staff interviews and record review, the facility failed to maintain accurate advance directive information (code status) throughout both the electronic medical record and paper record kept at the Nursing Station for 1 of 32 residents reviewed for advance directives (Resident #5).

Inspectors wroteBased on record review, and interim Guardian and staff interviews, the facility failed to provide a safe and orderly discharge. The facility failed to make a referral to law enforcement and adult protective services on the day of discharge which caused a delay in Resident #203 receiving support in the home. This was for 1 of 2 residents reviewed for discharge (Resident #203).

Inspectors wroteBased on record review and staff interview the facility failed to complete the comprehensive Minimum Data Set (MDS) assessment within the regulatory timeframe as specified in the Resident Assessment Instrument (RAI) Manual for 1 of 1 resident reviewed for completion of a comprehensive MDS assessment (Resident #204).

Inspectors wrote2. Resident #36 was admitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition, adult failure to thrive, and gastrostomy status. A physician order dated 11/15/24 read Resident #36 was to receive the prescribed tube feeding formula continuously at 65 milliters per hour from 2:00 PM to 9:00 AM for a total of 19 hours via gastrostomy tube. Resident #36's annual Minimum Data Set (MDS) dated [DATE] noted she had impaired cognition, did not have any behaviors or rejection of care. The MDS did not code that Resident #36 took her nutrition and hydration through a feeding tube. [...]

Inspectors wroteBased on record review, resident, and staff interview, the facility failed to create a person-centered baseline care plan and provide a summary to the residents and/or responsible party within 48 hours of admission for 5 of 14 residents reviewed for new admission procedures (Resident #153, #159, Resident #94, Resident #26 and Resident #11).

Inspectors wroteBased on observation, record review, and Responsible Party and staff interviews, the facility failed to complete a smoking assessment for 1 of 1 resident reviewed for smoking (Resident # 94).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to secure an indwelling catheter tubing to prevent tension and/or trauma and to keep a urinary catheter bag and its tubing from touching the floor to reduce the risk of infection for 1 of 1 resident (Resident #153) reviewed.

Inspectors wroteBased on observation, record review, and staff and Registered Dietitian interviews, the facility failed to administer tube feedings via a gastrostomy tube as ordered by the physician for 1 of 3 residents reviewed for tube feeding (Resident #36).

Inspectors wroteBased on record review, observation, and interviews with residents and staff, the facility failed to provide fluids in accordance with the physician ordered fluid restriction and failed to provide a bagged meal/snack on dialysis days for 2 of 3 residents reviewed for dialysis (Resident #41 and Resident #159).

Inspectors wroteBased on observations and staff interviews, the facility failed to keep food preparation areas, food service equipment clean, free from debris, grease buildup, and/or dried spills during two kitchen observations. The facility failed to clean the floor and ceiling vents located over the food prep and food service area. This practice had the potential to affect food served to all residents.

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification and complaint surveys dated 12/8/22, and 7/30/21 and for the complaint investigation survey dated 11/9/23 to achieve and sustain compliance. These were for recited deficiencies on a recertification and complaint investigation survey on 1/24/24. The deficiencies were in the following areas: label/ store drugs and biologicals, food procurement, store/prepare/serve - sanitary and resident records- identifiable information. The continued failure during federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program.

Inspectors wroteBased on record review, and interviews with residents and staff, the facility failed to resolve group concerns (new and repeat concerns) reported during Resident Council meetings for 6 of 6 consecutive months (June 2023 to December 2023).

Inspectors wroteBased on observations and staff interviews, the facility failed to date opened multi-dose vials of insulin medication in 1 of 5 medication administration carts (100 hall), discard loose pills in the medication cart drawer for 2 of 5 medication administration carts (100 hall cart and 200 hall cart), and failed to lock 1 of 5 medication administration cart (200 hall cart). Findings Included: 1.a. On 1/21/24 at 9:10 AM, an observation of the medication administration 200 hall cart with Nurse #2 revealed one opened and undated multi-dose vial of Humalog insulin and two opened and undated Novolog Flex Pens (insulin). A review of the manufacturer's literature indicated to discard Humalog multi-dose vial and Novolog Flex Pen 28 days after opening. [...]

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to honor the food preferences for 4 of 10 residents observed during dining (Resident # 249, Resident # 86, Resident # 100, and Resident # 21).

Inspectors wroteBased on record review and staff interview, the facility failed to obtain orders related to an indwelling urinary catheter for 1 of 1 resident reviewed for urinary catheter (Resident # 95). Findings Included: Resident #95 was admitted on [DATE] with diagnoses that included Congestive heart failure, Acute respiratory failure, Diabetes mellitus Type 2, and Benign prostatic hyperplasia with lower urinary tract symptoms. Review of the resident's FL2 (a form that describes resident's medical condition and the amount of care needed when placed in the facility) revealed the resident had an indwelling urinary catheter. Review of the admission nursing note dated 12/11/23 revealed the resident was admitted to the facility with an indwelling urinary catheter. Note also read in part Voiding trial while inpatient. [...]

Inspectors wroteBased on record review, observation and staff interviews, the facility failed to provide food in the form prescribed by the physician for 1 of 8 residents observed during lunch (Resident # 95).

Inspectors wroteBased on record reviews, staff interviews, and interviews with the Nurse Practitioner, the facility failed to maintain complete and accurate medical records when Nurse #1 failed to document a change in a resident's status for 1 of 1 resident (Resident #1) reviewed for respiratory care.