Imperial Manor

Inspectors wroteBased on interview and record review, the facility staff failed to limit Resident 25's as needed psychotropic medication to 14 days and did not re-evaluate the resident for appropriateness of the medication Hydroxyzine (used to help control anxiety and tension caused by nervous and emotional conditions) 25 mg (milligram). This failure had the potential for an increased risk of adverse effects related to prolonged use of antipsychotics [a class of prescription medications primarily used to manage symptoms of psychosis, such as hallucinations (seeing or hearing things that aren't there) and delusions (false, fixed beliefs)]. Per the facility admission record, Resident 25 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a complex chronic brain disorder that alters how a person perceives reality). [...]

Inspectors wroteBased on interview and record review, the facility staff failed to complete a medication regiment review (MRR -a systematic check of all the medications and supplements you take, conducted by a pharmacist or doctor with the goal of promoting positive outcomes and minimizing adverse. consequences associated with medication) for one of six sampled residents (25). This failure had the potential for a medication error for Resident 25's nicotine patch (a medicated adhesive bandage worn on the skin to help people quit smoking or vaping). Per the facility admission record, Resident 25 was admitted to the facility on [DATE] with diagnoses that included tobacco use. [...]

Inspectors wroteBased on observations, interview, and record reviews, the facility failed to implement a comprehensive systemic approach, to ensure nutritional status were maintained for two of two sampled residents (Resident 12 and Resident 2) when: 1. Resident 12's unplanned significant weight loss (loss of body weight greater than 5% in a month) was not identified and addressed. 2. Resident 2's unplanned weight loss was not identified and addressed. As a result, the facility's system was not effective at identifying and addressing progressive weight loss. The staff were not consistent in identifying unplanned weight loss and significant weight loss. The interdisciplinary team (IDT - a group of professionals from different disciplines who collaborate to treat a patient's needs) did not developed a plan to monitor and address the residents' weight loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a registered nurse (RN) was on duty for 8 consecutive hours per day, for three months, October 1 to December 31, 2024. This failure had the potential for advanced care activities, that needed an RN, to not be provided to the residents due to the unavailable RN.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure scales were calibrated per manufacturer's instructions. This failure had the potential for inaccurate weights to be obtained.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent when two out of 31 medications were administered incorrectly. The facility's error rate was 6.45%. These failures had the potential to negatively affect the residents' health and safety.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure pureed food was prepared in a consistency that met the needs for two of two sampled residents sampled residents (12, 13). This failure placed the residents at risk for choking and/or aspiration (inhaling food into the lungs).

Inspectors wroteBased on interview and record review, the facility failed to identify weight loss trends in their Quality Assurance Performance Improvement (QAPI- a plan developed by the facility with the goal of improving conditions in the facility) as an area of improvement that required an action plan. As a result, the facility did not provide a systemic approach in adressing Resident 12 and Resident 2's weight loss. (Refer to F-692)

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their own infection prevention and control program for two of two sampled residents (5, 12) when: 1. Resident 5's uncovered urinary bag touched the floor on multiple occasions for one of 12 residents (Resident 5). 2. The Centers for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBPs, an infection control intervention using protective gown and gloves) was not implemented for Resident 12. These failures could potentially contribute to Resident 5 acquiring a urinary tract infection. Also, failure to implement the CDC guidelines had the potential to result in the spread of Multiple Drug Resistant Organisms (MDROs, microorganisms, mainly bacteria, that are highly resistant to many types of antibiotics) throughout the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist Nurse (IP) completed required annual specialized training related to infection control. This deficient practice had the potential to affect the facility's ability to maintain a safe environment and to prevent and manage transmission of diseases and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care that promoted dignity and respect for one of 12 residents (Resident 5) reviewed for resident rights, when Resident 5's urinary catheter bag (tube inserted to drain urine) was not covered. As a result, Resident 5's urinary bag was visible to anybody passing by.

Inspectors wroteBased on observation and record review, the facility failed to ensure that 1 of 9 resident rooms (room [ROOM NUMBER]) accommodated 4 or less residents.

Inspectors wroteBased on observation and record review, the facility did not meet the minimum requirement of 80 square feet per resident in rooms 1, 2, 3, 6, 7 and 8.

Inspectors wroteBased on interview and record review the facility failed to implement its abuse reporting policy when it had knowledge of an allegation of genital exposure by Resident 3 to Resident 4 and did not report it to the State Agency (SA). This failure resulted in continued proximity of Resident 4 to Resident 3 who was the alleged aggressor, and prevented investigation by the SA. Resident 3 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder bipolar type (a mental illness that can affect your thoughts, mood and behavior) and schizophrenia (a mental disorder characterized by disruptions in thought processes). [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically submit staffing information based on payroll data on a quarterly schedule to Centers for Medicare & Medicaid Services (CMS) for one of four fiscal quarters (1st quarter of 2023 [10/01/23 to 12/31/23]). This failure resulted in lack of reporting of facility's direct care staffing as required by CMS.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. Food items were not properly labeled with the expiration or use by date, 2. Oven exhaust fan and the air vent were not kept cleaned; and, 3. Kitchen staff did not calibrate the food thermometer correctly. These findings had the potential to expose the facility's residents to unsafe and unsanitary food practices that could lead to widespread forborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to follow infection control practices when the facility did not do water testing for germs. This failure had the potential to spread germs and placed residents at risk for infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 2 sampled residents (8, 24) had end of life wishes or a POLST (physician orders for life sustaining treatment) completely signed by the RP(responsible party) and physician respectively in their record. As a result there was a potential to not have their life end of life wishes honored.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) in minimum data set (MDS, an assessment tool) for one of 12 sampled residents (Resident 5). This was when Resident 5 had developed stage III pressure ulcer (full thickness tissue injury, open wound that goes deeper into the tissue beneath) of her coccyx (tailbone). This failure had the potential to result in Resident 5 to be unable to achieve or maintain optimal status of health, function, and quality of life.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to develop a person-centered care plan for a resident (5) at risk for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin), and for a resident (19) involved in a resident-to-resident altercation for two of 12 sampled residents reviewed for care plans. These failures had the potential of Resident 5 and Resident 19 to not receive the care and services needed to preserve optimal health status and prevent further decline.

Inspectors wroteBased on observation and review of the Analysis of Client Accommodations, the facility failed to ensure one resident room accommodated no more than four residents. One of nine resident rooms (room [ROOM NUMBER]) accommodated six residents.

Inspectors wroteAn observation of resident rooms was conducted from 4/15/24 through 4/18/24 during the annual recertification survey. The following resident rooms contained less than 80 square feet for each resident: Room number Number of Residents Room Size 1 3 216 (allowing 72 square feet per resident) 2 3 222 (allowing 74 square feet per resident) 3 3 216 (allowing 72 square feet per resident) 6 3 210 (allowing 70 square feet per resident) 7 3 221 (allowing 73.66 square feet per resident) 8 4 283 (allowing 70.75 square feet per resident) There were no observed quality of care or quality of life concerns that negatively impacted the residents residing in those rooms. Continuance of a waiver allowing the six rooms that contained less than 80 square feet per resident was therefore recommended.

Inspectors wroteBased on record review, the facility failed to correlate the Minimum Data Set (MDS) assessment with the elopement risk assessment prior to a facility outing that one resident, Resident 1, attended with four other residents supervised by one Certified Nursing Assistant (CNA). This failure resulted in Resident 1 ' s elopement from the outing and attempts to walk into oncoming traffic.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision to Resident 1 who eloped during a facility outing. This failure had the potential for Resident 1 to suffer harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure access to a telephone for one resident (Resident 1). This failure prevented Resident 1 from calling his mother.

Inspectors wroteBased on observation, interview and record review, the facility failed to supervise Resident 1. As a result, Resident 1 eloped from a secured mental health facility and suffered a laceration (cut) on his right hand and abrasions on his legs when he climbed over the facility gate to leave the facility.

Inspectors wroteBased on observation, interview and record review, the facility to ensure a resident (Resident 1) was free from physical abuse when an employee 1 continued to work after an alleged incident of abuse was reported as witness by another staff member. This failure had the potential to negatively affect the resident's psychosocial well-being and the potential to expose all residents in the facility to abuse, increasing risk for resident injury and harm.