Harrison Pointe Healthcare and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare and distribute food in accordance with professional standards for food service safety. Specifically, the dish machine washing temperature was not meeting the manufacturer requirements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment. Specifically, for 3 out of 29 sampled residents, a resident with a surgical wound did not have Enhanced Barrier Precautions (EBP) posted or in place; appropriate hand hygiene and glove changes were not performed between dirty and clean tasks or resident contact; and during a dressing change a clean field was not maintained and bandages were contaminated. Resident identifiers: 9, 32, and 59.

Inspectors wroteBased on observation, interview, and record review, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, for 1 out of 29 sampled residents, a resident that did not have exit seeking behavior had a wander guard put on. Resident identifier: 32.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the services provided met professional standards of quality. Specifically, for 2 out of 29 sampled residents, a resident's tube feeding did not have the formula bag labeled with the correct date and time of the formula preparation, or the nurse's initials who initiated the infusion. In addition, a resident's tube feeding was not labeled with all of the required information. Resident identifiers: 4 and 44.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 29 sampled residents, a resident with a bilevel positive airway pressure (BiPAP) machine was unable to use the machine due to missing parts. Resident identifier: 5.

Inspectors wroteBased on observation, interview and record review it was determined, for 2 of 14 sampled residents, 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' choice. Specifically, two residents received their morning medications late. Resident Identifiers: 12 and 13. Finding Included: 1. Resident 12 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, chronic respiratory failure with hypoxia, cognitive communication deficit, mild cognitive impairment of uncertain or uncertain or unknown etiology, chronic pain syndrome, and personal history of pulmonary embolism. On 9/24/24 at 10:32 AM, an observation was made of Registered Nurse (RN) 2 during the morning medication pass. [...]

Inspectors wroteBased on observation, interview and record review, it was determined for 1 of 14 sampled residents, that the facility did not ensure that a resident who was assessed to be an elopement risk received adequate supervision to prevent accidents. Specifically, a resident did not have adequate interventions in place to mitigate the risk for elopement for 4 days following an elopement risk assessment that determined the resident was a high elopement risk. Resident identifier 6.

Inspectors wroteBased on observation and interview it was determined, for 1 of 26 sampled residents, that the facility did not ensure that drugs and biologicals were labeled and stored in accordance with currently accepted professional principles. Specifically, a nurse was observed to place an unused portion of a medication back inside the pharmacy dispensed blister pack and tape the back closed. Resident identifier: 40.

Inspectors wroteBased on observation, it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the kitchen, dry storage room, and walk-in freezer were open to air, and food items in the snack cooler and walk-in refrigerator were not labeled and dated.

Inspectors wroteBased on observation and interview it was determined that the facility did not ensure that the medical records on each resident were complete and accurately documented. Specifically, the nurse was witnessed to alter the timestamp of blood sugar checks according to approximations of when the task was completed.

Inspectors wrote4. On 1/9/24, the following observations were made during the lunch meal in the main dining room: a. At 12:30 PM, a resident took some garbage and soiled dishes to the serving window and left them on the metal counter area. At 12:58 PM, CNA 3 approached the serving window, and prepared a cup of tea with sugar directly next to where the soiled dishes had been placed. b. At 1:00 PM, CNA 3 picked up a resident's garbage and placed it on top of his plate. CNA 3 took the soiled plate to the serving window. CNA 3 then returned and repositioned a second resident in his wheelchair by touching the resident and the wheelchair handles. CNA 3 then picked up a third resident's plate and garbage and placed the soiled items in the serving window. CNA 3 then left the dining room. At no time was CNA 3 observed to perform hand hygiene after touching multiple residents' soiled items and equipment. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 26 sampled residents, that the facility did not ensure that a resident who self-administered medications was evaluated to determine that the practice was clinically appropriate. Specifically, a resident reported that they self administered an albuterol inhaler as needed and the facility did not evaluate the resident's ability to safely administer the medication. Resident identifier 37.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 26 sampled residents, that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene. Specifically, a resident requiring assistance with bathing was not provided regular showers or bed baths. Resident identifier 37.

Inspectors wroteBased on interview and record review it was determined for 2 of 26 sample residents, the facility did not ensure that each resident was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; excessive duration; without adequate monitoring; without adequate indication for its use; or in the presence of adverse consequences which indicated the dose should have been reduced or discontinued. Specifically, insulin, pain medications, and blood pressure medications were administered outside of prescribed physician parameters. Resident identifiers: 5 and 22.

Inspectors wroteBased on interview and record review, the facility did not ensure that the antibiotic stewardship program that included antibiotic use protocols and a system to monitor the antibiotic use were implemented. Specifically, for 1 of 26 sampled residents, a resident who was prescribed an antibiotic for a urinary tract infection during an emergency room visit was provided the full course of the antibiotic without obtaining the results of the culture and sensitivity, which revealed the resident had MRSA and VRE infections. The resident was not placed on contact precautions and started on the effective antibiotic until 1/2/24. Resident identifier: 38.

Inspectors wroteBased on observation, interview and record review the facility did not assure full visual privacy for 2 of 16 sample residents. Specifically, a resident did not have a curtain that extended around his bed to provide total visual privacy. Resident identifiers: 2 and 23.