Idylwood Care Center

Inspectors wroteBased on observation, interview, record review, the facility failed to follow its fall policy and procedure, FALL PREVENTION & MANAGEMENT, when staff did not assess, report, and document a fall for one out of three residents (Resident 1) when Resident 1 consistently reported falling and that staff helped her back to bed approximately a week ago; however, the reported fall was not handled according to the facility fall policy for assessment, documentation, post fall monitoring, and physician notification. Subsequent medical evaluation results identified injury the right great toe. This deficient practice left Resident 1 without timely interventions for her fall injuries, which was a change of condition, by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 18.75% when six medication errors occurred out of 32 opportunities during the medication administration for three out of seven residents (Resident 3, Resident 34, and Resident 139). The failures resulted in the nursing staff not following physician's orders and the facility's policy and procedures (P&P), and had the potential for medication complications or residents not receiving full therapeutic effects of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. Opened multi-dose vials/inhalers had no open date; 2. Expired medications were not removed from active stock; 3. A treatment cart was left unlocked and unattended. These failures had the potential for residents to receive medications with reduced efficacy and had the potential for residents to access the unlocked and unattended treatment cart.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1. A table mounted can opener had brownish colored substances; 2. Six food trays had black substances inside the corners of the trays; and 3. The back and side of a food cart parked inside the kitchen had whitish substances outside food cart surfaces. These failures had the potential to cause foodborne illnesses for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained dignity and respect for two of 32 residents when: 1. Maintenance staff intervened while staff attempted to de-escalate Resident 62's angry outburst. 2. Resident 88's urinal was on his bedside table next to food items. These failures had the potential to affect the emotional well-being of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform interdisciplinary team (IDT, staff from different departments who coordinate the residents care) assessment and obtain a physician order for self-administration of medication for one out of 32 sampled residents (Resident 78) when Resident 78 had over-the-counter medication (OTC, can be purchased without a prescription from medical doctor) bottle of expired Vicks VapoRub (used to treat to relieve coughs, congestion and minor pains) on the bedside tray table. This failure had the potential for unsafe and improper administration of OTC medication.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) for advance directive (AD, written instructions, such as a living will or durable power of attorney [a document that authorizes to act on behalf of resident] for healthcare when the individual is incapacitated) and physician orders for life-sustaining treatment (POLST, a document that specifies the medical treatments the resident wants to receive during serious illness) form for three of six sampled residents (Resident 17, 10, and 117). These failures could lead to the delivery of unnecessary or inappropriate medical services against a resident's goals and wishes.

Inspectors wroteBased on observation, interview, and facility's document review, the facility failed to maintain resident's rights to privacy and confidentiality for one of five sampled residents (Resident 34) when Resident 34's personal information and care instructions were posted in the room visible to roommate and visitors. This failure had the potential to compromise resident's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen (O2) was administered per physician's order for one of three sampled residents (Resident 79) when Resident 79 was receiving 5 liters per minute (LPM) of oxygen. This failure had the potential to affect Resident 79's respiratory health.

Inspectors wroteBased on interview and record review the facility failed to provide dialysis services consistent with professional standards for one of one resident (Resident 100) when: 1. Communication with the dialysis facility was not properly coordinated when Resident 100's dialysis communication records (DCR) were not completed; 2. Resident 100's dialysis care plan did not have a person-centered intervention and 3. Staff was not trained on emergency care for residents with renal diseases, dialysis care, and there was no emergency dialysis kit available. These failures may affect the quality of dialysis care being provided to the residents and had the potential to cause resident health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure when Registered Nurse I (RN I) did not use a pair of gloves while preparing a hazardous drug (medications that pose potential health risks to individuals who handle them). This failure had the potential to expose RN I to hazardous drug.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to provide adaptive equipment (a device specifically designed to assist with drinking/eating) with meals to one of two sampled residents (Resident 10). This failure had the potential to affect the swallowing ability, fluid intake, health, and well-being of Resident 10.

Inspectors wrote10. Review of Resident 27's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including COPD and pericardial effusion (build up of extra fluid in the space around the heart.) Review of Resident 27's physician order, dated [DATE], it indicated he had an order for continuous supplemental oxygen at 2 to 5 liters per minute. During an observation on [DATE] at 9:48 a.m., Resident 27 was receiving oxygen via nasal cannula being delivered via an oxygen concentrator. The filters on both sides of the oxygen concentrator machine were dusty, with an accumulation of whitish gray substances on the filter sponges. During an observation and concurrent interview with licensed vocational nurse A (LVN A) on [DATE] at 10:07 a.m., he confirmed both filters on Resident 27's concentrator were dirty and he stated the filters should be changed. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow up on diagnostic results timely for two of three residents (Resident 1 and 2) when: 1. Resident 1's dual-energy x-ray absorptiometry (DEXA or DXA, bone density scan used to diagnose osteoporosis [bone disease that causes a loss of bone density, weakens bones, and increases the risk of fractures]) scan results were not followed up timely. 2. Resident 2's order to schedule a DEXA scan was not followed up timely. This failure resulted in Resident 1's DEXA scan results not reported to the physician timely and a delay in starting medication to treat Resident 1's osteoporosis. This failure had the potential to result in Resident 2 not receiving necessary treatment/medication timely.

Inspectors wroteBased on interview, facility document and policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to retransmit Minimum Data Set (MDS) assessments within required timeframes for 8 (Residents #86, #67, #121, #108, #136, #22, #56, and #65) of 29 residents reviewed for MDS requirements.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure podiatry care, specifically toenail care, was provided for 1 (Resident #130) of 2 sampled residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the head of bed (HOB) was elevated 30 degrees during the infusion of enteral feeding as ordered by a physician for 1 (Resident #68) of 2 sampled residents reviewed for tube feeding management.

Inspectors wrote8. During an observation on 5/3/21 at 10:07 a.m., Resident 78 had signage outside his door and one pair of used gloves and two disposable gowns were exposed outside the garbage lid. During a concurrent observation and interview on 5/3/21 at 10:08 a.m., with LVN M, he confirmed the above observation and stated the garbage can was overflowing and the housekeeper should empty the garbage can. He further stated that Resident 78 is on contact isolation precaution and staff should have disposed the used gowns and pair of gloves inside the garbage can with fully covered by the lid. During an observation on 5/6/21 at 8:25 a.m., Resident 78 had signage outside his door and two pairs of used gloves, two disposable gowns were expose outside the garbage lid cover. During a concurrent observation and interview on 5/6/21 at 8:30 a.m., with LVN K, he acknowledged the above observation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for 3 of 25 sampled residents (38, 91, and 106) when: 1. Resident 38's privacy curtain was not drawn while she was voiding (passing urine from the body) on a toilet seat; 2. Resident 91 did not have appropriate covering or clothing and was exposed to view from her room; and 3. Resident 106's urinary catheter drainage bags (a urinary catheter is a thin, flexible tube used to drain urine from the bladder) was left uncovered. These failures had the potential to affect the emotional and psychosocial well-being of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medications and biologicals when: 1. An expired bottle of loperamide (anti-diarrhea) was found in one of the medication carts in Station B; 2. A bottle of Haloperidol (used to treat mental disorder) not kept in its original carton to protect from light was found in medication cart in Station A; 3. A Zioptan (sterile eye drop solution) single use containers not stored in refrigerator was found in the medication cart in Station A; and 4. Two boxes containing normal saline (NS, a mixture of sodium chloride in water that has a number of uses in medicine) were left outside the building. This failure had the potential to affect the efficacy and potency of the drugs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1. Ten dietary staff did not cover their hair completely with a hairnet; 2. Two cans of dried peas in the dry storage room were dented; 3. Chopping boards 2 of 7 had deep cuts; and 4. Two dietary staff used the same potholder that was dropped on the floor to hold the hot tray and pots. These failures had the potential to result in a food borne illness outbreak among a population of vulnerable residents with complex medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) in the minimum data set (MDS, an assessment tool) for one of 25 sampled residents (87) when the resident had significant weight loss, had declined in activities of daily living (ADL, daily self-care tasks, e.g., bathing, toileting, and transferring) and had declined bowel continence. These failures had the potential to result in Resident 87 unable to achieve or maintain optimal status of health, function and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan with measurable objectives, goal and person-centered interventions, for one of 25 sampled residents (118). This deficient practice had the potential to result not meeting the resident's needs.

Inspectors wrote2. Review of Resident 117's admission record indicated he was admitted to the facility on [DATE] with chronic obstructive pulmonary disease (COPD, a disease that causes airflow blockage and breathing-related problems.) Review of Resident 117's physician order indicated he had an order for oxygen 2 liter (L, a metric unit of volume) per minute (LPM) to 5 LPM as needed every shift related to COPD. During an observation with licensed vocational nurse C (LVN C) on 5/3/21 at 10:25 a.m., Resident 117 was lying in bed and was administered oxygen at 1.25 LPM. During a concurrent interview with LVN C, she confirmed Resident 117 was administered oxygen at 1.25 LPM. LVN C stated it should have been 2LPM. Review of the facility's 9/1/13 policy, Physician Orders indicated Licensed nursing personnel will ensure that telephone and verbal orders will be recorded and implemented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care to maintain good grooming and personal hygiene for one of four residents (84). This failure resulted in Resident 84 having long and dirty fingernails and long toenails.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bladder care was provided for one of five residents with indwelling urinary catheter (hollow tube that is inserted into your bladder to drain urine) when Resident 329's urinary collection bag was not emptied. This failure had the potential to cause resident's urinary tract infection (when bacteria gets into urine and travels up to bladder).

Inspectors wrote2. During an observation on 5/3/21 at 9:59 a.m., Resident 87's was lying in bed with his breakfast tray untouched and uncovered on top of his bedside table. During an observation and concurrent interview with LVN M on 5/3/21 at 11:17 a.m., he confirmed the above observation. He stated the CNA assigned to Resident 87 did not ask for food replacements and/or offer a food substitute; and lunch would be served soon. During an observation on 5/3/21 at 12:30 p.m., Resident 87's was lying in bed with his lunch tray untouched and uncovered on top of his bedside table. During an observation and concurrent interview with LVN M on 5/3/21 at 1:15 p.m., he confirmed the above observation. He stated the CNA assigned to Resident 87 did not ask for a food substitute and the lunch tray was served around 12:40 p.m. He further stated the food was already cold and needed to be replaced. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had 10.71 percent medication error rate when three (3) medication errors of 28 opportunities were identified during a medication pass for three of seven residents. These failures had the potential to result in an ineffective drug therapy and possible adverse events.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation was complete for two of six residents (84 and 94) when Resident 84 and Resident 94 restorative nursing assistance (RNA) order were not transcribed to the Restorative Flow Sheet (RFS). These failures resulted in Residents 84 and 94 not receiving a RNA as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure outlet wall plates for two of 12 residents (Residents 8 and 329), were installed in a way to protect residents from potentially dangerous open electrical outlets.