Halstead Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation in the facility's one kitchen to prevent the spread of food borne illness to the residents of the facility.

Inspectors wroteBased on observation and record review the facility failed to maintain an effective infection control program related to Enhanced Barrier Precaution (EBP- infection control interventions designed to reduce transmission of resistant organism which employ targeted gown and gloves use during high contact care) during wound care. Additionally, staff failed to keep laundry cart covered during delivery of clean clothing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete the [NAME] Data Set for Resident (R) 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free of accident hazards when staff failed to provide the necessary foot pedals when assisting propelling Resident (R)3 in a wheelchair.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and treatment of a suprapubic catheter (tube surgically inserted through the abdominal wall into the bladder to drain urine) when staff anchored the suprapubic tubing to Resident (R)6's leg instead of his abdomen as indicated by current standards of practice to prevent pulling or dislodgement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional maintenance for Resident (R) 27. The facility failed to follow the registered dietitian's recommendations for providing facility meal shakes to R27 three times daily and R27 had a 3.16% weight loss in 14 days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure emergency equipment, that included an Ambu bag (a handheld, manual, self-inflating resuscitator used to deliver positive pressure ventilation to patients with inadequate or no breathing) was readily available in the event of an accidental extubation (removal of a medical tube) of Resident (R)2's tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted) cannula.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide written notification to the Office of the Long-Term Care Ombudsman (LTCO) regarding six residents transferred from the facility, five transferred home and one resident transferred to another facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information to include the name of the facility and total hours worked, as required.

Inspectors wroteThe facility identified a census of 41 residents with 12 residents sampled, which included one resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record review, the facility failed to assess and provide treatment to prevent a pressure injury for Resident (R)13. On 05/08/24, staff observed two intact blisters on R13's coccyx (area at the base of the spine). Staff failed to notify the provider until 05/14/24, six days later, when the two areas developed into stage two (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcers. This placed the resident at risk to worsen her pressure ulcers and delayed healing.

Inspectors wroteThe facility census totaled 41 residents with 12 residents included in the sample, including one resident reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure a safe environment for one cognitively impaired Resident (R)35, when staff failed to check the temperature of a bowl of soup before serving it to the resident. Resident (R35) suffered burns, that developed blisters, on two fingers of his right hand when he placed them in the hot bowl of soup during mealtime.

Inspectors wroteThe facility reported a census of 41 residents with one main kitchen. Based on observation, interview, and record review, the facility failed to store foods safely and under sanitary conditions to the residents of the facility to prevent the potential for food borne bacteria by the staff's failure to date and reseal open food items in the refrigerators and freezer, and the failure to clean the thermometer between food items while taking food temperatures prior to serving. This had the potential to affect all 41 of the residents' receiving meals from the main kitchen.

Inspectors wrote- Resident (R)42's Electronic Health Record (EHR) revealed diagnoses of obstructive sleep apnea (disorder of sleep characterized by periods without respirations), schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and epilepsy (brain disorder characterized by repeated seizures). The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R42 was independent with ADLs (activities of daily living such as walking, grooming, toileting, dressing and eating). The 03/14/24 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R42 was independent in ADLs, except required set-up to complete showers. [...]

Inspectors wroteThe facility census totaled 41 residents. Based on observation, interview, and record review the facility failed to provide a sanitary environment by the failure to have lids on the linen cans in the shower rooms, failure to have a lid on the biohazard container in the soiled utility room and failure to maintain appropriate flooring in the laundry area. These deficient practices had the potential to be an unsanitary environment which would affect all residents in the facility.

Inspectors wroteThe facility had a census of 41 residents. Based on observation, record review, and interview, the facility failed to maintain a clean, comfortable and homelike environment to the residents that resided in the facility.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for Resident (R)13's pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The facility further failed to develop a care plan for R19's care and maintenance of respiratory equipment. The facility further failed to develop a care plan for R42's dysphagia (swallowing difficulty). The facility further failed to develop a care plans' for R26's monitoring of behaviors for psychotropic (alters mood or thought) medications. This deficient practice placed the residents at risk for inadequate care and services.

Inspectors wrote- R26's signed physician orders dated 05/15/24 revealed the following diagnoses that included ,anxiety disorder, type 2 diabetes mellitus with diabetic chronic kidney disease (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), sleep apnea (disorder of sleep characterized by periods without respirations), encounter for attention to tracheostomy (opening though the neck into the trachea through which an indwelling tube may be inserted), dysphagia (swallowing difficulty), malignant neoplasm of nasopharynx (a rare type of cancer that occurs in the nasopharynx, behind your nose and above your throat.), and chronic respiratory failure with hypoxia (inadequate supply of oxygen). [...]

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to reply in a timely manner and act upon the Consultant Pharmacist of Medication Regimen Review (MMR) and Gradual Dose Reduction (GDR) recommendations for Residents (R) 8, R24, R26, R33 and R 35 medication regimen review. This deficient practice placed these residents at risk for receiving unnecessary medications.

Inspectors wroteThe facility identified a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)13 received care in a dignified manner during incontinent care when the window blind was left open. This deficient practice placed the resident at risk for decreased psychosocial well-being.

Inspectors wroteThe facility reported a census of 41 residents, with 12 residents sampled, including one resident sampled for advanced directives (a written document which indicated the medical decisions for health care professionals when the person could not make their own decisions). Based on interview and record review, the facility failed Resident (R)16 by having the guardian sign a completed Do Not Resuscitate (DNR- or no code, a legal document or order that means the person does not desire CPR in the event of cardiac arrest).

Inspectors wroteThe facility reported a census of 41 residents with 12 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for two sampled residents, Resident (R)19 related to oxygen use, and R9 related to completion of sections C and D of the Minimum Data Set (MDS). This placed the residents at risk for uncommunicated care needs.

Inspectors wroteThe facility reported a census of 41 residents with 12 residents sampled. Based on observation, interview, and record review, the facility failed to review and revise the person-centered care plan for one resident, Resident (R)30 related to use, care and maintenance of nebulizer equipment. This deficient practice had the potential to place the resident at risk for not receiving appropriate cares and treatments.

Inspectors wroteThe facility identified a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)13 received care for removal of facial hair. This deficient practice placed the resident at risk for decreased psychosocial well-being.

Inspectors wroteThe facility reported a census of 36 residents. Based on observation and interview, the facility failed to maintain food preparation equipment in a clean manner and failed to ensure a two-inch air gap between the ice machine drainage pipes and floor drain to prevent the spread of food borne illness.

Inspectors wroteThe facility reported a census of 36 residents. Based on observation and interview, the facility failed to ensure that staff contained trash in the dumpster and the lids to the dumpster were closed to prevent the spread of infection.

Inspectors wroteThe facility reported a census of 36 residents. Based on observation, record review and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly environment in the storage closets that contained supplies for the residents of the facility.

Inspectors wroteThe facility reported a census of 36 residents. The 15 residents selected for review included three residents reviewed for quality of care including one resident for non-pressure wounds. Based on observation, interview and record review, the facility failed to provide adequate non-pressure wound care to resident (R)188 to prevent possible infection.

Inspectors wroteThe facility reported a census of 36 residents with 15 selected for review which included three residents reviewed for bowel and bladder/urinary tract infection. Based on observation, interview and record review the facility failed to provide sanitary peri-care for one resident (R) 5, of the three residents reviewed for bowel and bladder/urinary tract infections.

Inspectors wroteThe facility reported a census of 36 residents with 15 residents sampled, including one resident reviewed for respiratory needs. Based on interview, record review, and observation, the facility failed to obtain a physician order to appropriately administer oxygen to the one sampled Resident (R)27, who used oxygen.

Inspectors wroteThe facility reported a census of 36 residents with 15 selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to obtain a physician's order for the discontinuation of insulin for one Resident (R)4 of the five residents reviewed for unnecessary medications.

Inspectors wroteThe facility reported a census of 36 residents, with 15 residents sampled, including five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to administer as needed (PRN) medications to one Resident (R)6 for lack of bowel movements (BM) and failed to obtain ordered labs for one Resident (R)17.