Harry and Jeanette Weinberg Care Center

Inspectors wroteBased on record review and staff interview the facility failed to identify and submit a significant change for one Resident (R) 21 of three sampled for Nutrition. This deficient practice placed the resident at risk for further functional decline. Findings Include: The facility failed to identify a significant weight loss of greater than 5% in a month, and a decline in Activities of Daily Living (ADLS) which resulted from a fall with major injury and subsequently a fall with dislocation of hardware placed in R21's right hip. During a record review of R21's Electronic Health Record (EHR) found the facility was in the process of reporting a Significant Change for R21 to Center of Medicaid and Medicare Services (CMS) with an Assessment Reference Date (ARD) of 02/05/25. R21 had an unwitnessed fall in the facility in his room on 11/24/24 at 02:58 PM and was sent to the hospital. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide respiratory care in accordance with the Resident's choice for one Resident (R) 19 of three residents sampled for respiratory care. This deficient practice placed the resident at risk of feeling anxious and uncomfortable without the daily use of oxygen. Findings Include: Resident (R) 19 was observed to self-administer and wear oxygen daily. Her use of the oxygen was not reflected in the plan of care, progress notes or ordered by the Physician. Observation on 01/27/25 at 01:50 PM with R19 in her room who was sitting at the bedside in her wheelchair and wearing Oxygen (02) with the nasal cannula, (NC). She was awake and alert and briefly spoke with the surveyor. Observation on 01/28/25 at 09:55 AM in R19's room, who was in her bed wearing O2 via NC. [...]

Inspectors wroteBased on observation and staff interview the facility failed to assure staff locked one of one treatment cart. The treatment cart contains supplies for dressing changes and prescribed ointments and creams for residents. This deficient practice has the potential to affect residents' safety, residents access to the contents of the cart may result in inappropriate use of ointments and creams. Findings Include: On 01/27/25 at 10:10 AM, the surveyor observed an unlocked treatment cart outside of room [ROOM NUMBER]. Opened the unlocked cart and noticed it contained sterile gauze, foam dressing, tape, and prescribed creams and ointments. After closing the drawer, Registered Nurse (RN) 2 appeared. Inquired of RN2 if the cart was her cart and she said no. Right afterwards RN5 came out of room [ROOM NUMBER]. Inquired if the cart was hers and she said yes. [...]

Inspectors wroteBased on observations and interview the facility failed to assure staff placed an indwelling urinary catheter covered by a privacy bag off the floor for one Resident (R) 16 of one sampled resident reviewed for urinary catheter. This deficient practice placed the resident at risk for infection. Findings Include: On 01/27/25 at 10:33 AM during an interview with R16 observed her urinary indwelling catheter that was placed in a privacy bag resting on the floor. Inquired with resident if she knew when this occurred but she was not aware when this occurred or by whom. On 01/27/25 at 10:52 AM interviewed Registered Nurse (RN) 5. Asked RN5 to observe where the covered urinary catheter bag was located and she confirmed it was laying on the floor. RN5 stated it is supposed to hang from the bed frame and lifted the privacy bag up off the floor and hung it higher up on R16's bed frame. [...]

Inspectors wroteBased on record review and interview the facility failed to provide written notification of transfer/discharge for one resident sampled for hospitalization, Resident(R) 26. The deficient practice has the potential to affect all residents at the facility who are transferred or discharged . Findings Include: Review of R26's Electronic Health Record (EHR) on 02/13/24 at 01:15 PM found R26 was transferred to the hospital on [DATE] due to altered mental status. R26 was admitted to the hospital on [DATE] with a diagnosis of encephalopathy (disease of the brain) which was found to be related to a reaction she had to the IV antibiotic (Cefepime) she was receiving. During RR, found R26's daughter was notified by phone of transfer and made aware of R26's clinical situation. No documentation was found R26 or her representative was notified in writing of the transfer/discharge. [...]

Inspectors wroteBased on record review and interview the facility failed to develop and implement a comprehensive care plan (CP) for three residents sampled of the 35 residents at the facility. Resident (R) 17, R22 and R27. R17 did not have a care plan for an indwelling urinary catheter and it's care to prevent urinary tract infection (UTI). R22 did not have a care plan for fall prevention after a fall with a head injury. R27 was taking an anticoagulant (blood thinner) for his diagnosis of paroxysmal atrial fibrillation (a rapid erratic heartbeat) and did not have a care plan for bleeding precautions. These deficient practices place the residents at an increase risk for injury and infection. Findings Include: (Cross reference to F880 Infection Prevention & Control) 1) Review of R17's Electronic Health Record (EHR) was done on 02/14/24 at 10:00 AM. [...]

Inspectors wroteBased on observations and interview the facility failed to update comprehensive care plans (CP) for four residents sampled, Resident(R) 7, 17, 20 and 84. The deficient practice places all residents at risk for infection or skin breakdown. Findings Include: 1) On 02/12/24 at 02:57 PM met with R17 in his room and observed resident had a peripheral intravenous (IV) catheter on his left arm which was used to administer his IV antibiotic medication to treat his urinary tract infection (UTI). R17 also had an indwelling urinary catheter. On 02/14/24 at 10:00 AM record review of R17's Electronic Health Record (EHR) was done. R17 is a [AGE] year old resident who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure that three residents requiring maximum assistance with eating meals and snacks, were assisted by staff to eat their meal in a reasonable amount of time for three residents (R)7, R13 and R24 of five in the sample (see F550 for more information on R10 and R30). Three residents waited after their meal was placed on the table in front of them for a staff member to feed them. The staff were observed to rotate among the residents, starting to feed a resident then stopping to leave and help another resident. During the lunch observation, the time from start of the meal until the last resident completed their meal was over one hour. This deficient practice has the potential to affect the residents in the facility who require maximum assistance with eating.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions for falls for one Resident (R)22 of one in the sample. R22 had a fall that resulted in a head injury. The deficient practice placed R22 at an increased risk for injury, (refer F656).

Inspectors wroteBased on interviews and record review, the facility failed to ensure nursing staff had the appropriate competencies to provide nursing services to assure resident safety for one of five residents (Resident (R)14) sampled for unnecessary medication. On 11/27/23 and 01/12/24, Nursing Staff (NS)36 entered erroneous medication orders of a high-risk/high-alert diuretic (Lasix) for R14. As a result of this error, R14 was administered excessive doses of the medication which could have had serious adverse consequences related to dehydration, electrolyte imbalance, and kidney damage for the resident.

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident's drug regimen is free from excessive dose of a medication and to adequately monitor use of an anticoagulant (blood thinner) for two of five residents (Resident (R)14 and R27 sampled for unnecessary medications. As a result of a medication entry error, R14 was administered excessive dose of a high alert/high risk diuretic (Lasix) medication. The deficient practice has the potential for serious adverse consequences related to dehydration, electrolyte imbalance, and kidney damage. R27 had multiple bruises on his upper extremities with an unknown origin and placed at increased risk of bleeding.

Inspectors wroteBased on observation, interview and record review facility staff failed to perform hand hygiene (hand washing or using a hand sanitizer) between glove use, when providing perineal care (washing the genital and anal area) for resident (R) 17 who has an indwelling urinary catheter. This deficient practice places all residents who have an indwelling urinary catheter at risk for a urinary tract infection (UTI). Findings Include: (Cross reference to F656 Develop/implement Comprehensive Care Plan) On 02/14/24 at 10:50 AM observed Certified Nurse Aide (CNA) 8 perform perineal (peri) care for R17. CNA8 gathered her supplies, placed a barrier and made sure R17 was comfortable. CNA8 performed hand hygiene and put on clean gloves before performing peri care. Once CNA8 was done with cleaning R17's genital area she took off her gloves and was about to put on a new pair of gloves. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor one Resident's antibiotic that was prescribed prophylactically (to prevent an infection) and without an end date. Resident (R)25 was prescribed an antibiotic on 12/23/23 to prevent a respiratory infection. This deficient practice has the potential to affect residents in the facility who are on antibiotics at a risk for the development of an antibiotic resistant organism. Per the Centers for Disease Control and Prevention (CDC, October 21) on Antibiotic use .anytime antibiotics are used, they can cause side effects and contribute to antibiotic resistance .unnecessary antibiotic use happens when a person is prescribed antibiotics when there not needed .

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure food was stored and prepared in a safe and sanitary manner. As a result of this deficiency, residents are at risk for potential harm from the side effects of consuming spoiled and/or contaminated food(s).

Inspectors wroteBased on observation, interview with staff members, and record review, the facility failed to ensure infection control practices were implemented to help prevent the development and transmission of communicable diseases and infections. Reusable medical equipment was not sanitized between use for multiple residents; Oxygen tubing and humidifier was not labeled with a date or time implemented; Oxygen tubing was in direct contact with the ground; Personal protective equipment (PPE) used in infection precaution room(s) were not properly discarded; PPEs were not used according to professional standards of use; Transmission-based precautions were not implemented in accordance with facility practices; and linens/laundry were not properly handled to prevent the spread of infection/communicable diseases. [...]

Inspectors wroteBased on observation, interviews, record review and review of policy, the facility 1) failed to ensure comprehensive person-center care plans were developed/ implemented for each resident that includes measurable objectives, timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, 2) failed to develop a comprehensive person-centered care plan to include interventions for Resident (R) 25's psychosocial wellbeing when expressing she wants to die and while on Transmission Based Precautions (TBP), 3) failed to develop and implement a specified care plan to monitor for the possibility of bleeding as a result of taking Plavix medication for one resident (R)81 out of four residents reviewed. As a result of this deficiency, R81 had the potential to have a side effect of bleeding that would not have been identified and monitored for by the facility.

Inspectors wroteBased on record review, staff interview and review of policy, the facility failed to provide follow up documentation on Advanced Health Care Directive (AHCD) for one resident (R)17 of the four residents sampled. The facility failed to follow up with R17's right to update their AHCD.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a Resident(R)1's comprehensive person-centered care plan (CP) was revised. R1 had multiple falls and the CP was not revised to mitigate the likelihood of the resident falling. As a result of this deficient practice, R1 is at risk of sustaining an avoidable major injury that has the potential for harm to the resident.

Inspectors wroteBased on observation, review of policy and procedures, and interview with staff member, the facility failed to ensure one of two medication carts was locked or attended. This deficient practice potentially increases the risk of injury for any resident, visitor who can access the medication cart.