Jacob Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity and respect were maintained for six of six residents (1, 2, 3, 4, 5, 6) while providing care when:1. Certified Nursing Assistant (CNA) 1 was rude and used a vulgar ( F) word when Resident 1 asked for assistance and threw soiled towels and linens after care leaving stains on the wall.2. Resident 2 verbalized CNA 1 was rude and had an attitude when CNA 1 entered the room and stated, What do you want?3. Resident 3 verbalized CNA 1 would leave him wet all night and was rude and rough while changing him. 4. Resident 4 verbalized he preferred not to ask CNA 1 for help because CNA 1 was rude and rough in her patient care and would say, What the 'F.ck' do you want?5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a written notice of bed hold rights for one of two residents (Resident 26) reviewed for hospitalization. This failure had the potential for the resident and/or the resident's representative not to have information regarding bed hold rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a significant change Minimum Data Set (MDS- clinical assessment tool) assessment for one of 24 sampled residents (Resident 115). This failure had the potential to cause the resident to not receive appropriate care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a standard assessment to facilitate residents' care) related to hospice (medical care for residents expected to live six months or less) services were coded accurately for one of 24 sampled residents (Resident 9). This failure could affect the residents' plan of care.

Inspectors wroteBased on interview and record review, the facility failed to follow level 2 (evaluation and determination) screening process of the PASARR (Pre-admission Screening and Resident Review, a federally required document to ensure residents are appropriately placed and/or for services) for two of two residents (Resident 5 and 114) reviewed for PASARR. This failure had the potential for Residents 5 and 114, not to receive the care and necessary services in the most appropriate setting.

Inspectors wroteBased on observation, interview, and record review, the facility did not develop patient centered care plans for two of six residents (Resident 1 and 6) reviewed for care plans. 1. Resident 1 had no teeth. 2. Resident 6 had a GT (GT-a tube inserted into the stomach for nutrition) dressing with discharge. These failures had the potential to negatively affect the residents' (1, 6) needs, affecting their dignity, comfort, safety, and well-being.

Inspectors wroteBased on the interview and record review, the facility failed to ensure the Interdisciplinary Team (IDT- a group of healthcare professionals working together to create a person-centered care plan) meeting was documented for one of 24 sampled residents (Resident 9), when Resident 9 decided to revoke hospice service (medical care for residents expected to live six months or less). This failure had the potential to affect the revision of the care plan to reflect Resident 9's goals and preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six residents (128), who was unable to carry out activities of daily living (ADLs - self- care activities such as grooming, bathing, and toileting), received assistance with nail care [cleaning, trimming and/or filing of nails]) and shaving. As a result of this deficient practice, Resident 128 was unshaven with debris under Resident 128's fingernails which had the potential to affect Resident 128's comfort and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide social service assistance for one of six residents (Resident 1) reviewed for medically-related social services when:1. A dental referral was not provided, 2. A hearing consultation was missed, 3. The social services assessments were inaccurate. These failures had the potential to delay care and services for the resident which could affect the resident's health and wellbeing, and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an open food item was labeled with an open date and stored properly in the reach-in refrigerator in the kitchen. This failure had the potential to cause food borne illness.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure infection control procedures were followed when: 1. Licensed Nurse (LN) 11 did not wear a gown consistently while providing care to Resident 86 who was on enhanced barrier precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with medical devices]), during medication (med) pass. 2. A certified nursing assistant (CNA) failed to properly use personal protective equipment (PPE - equipment such as gown and gloves used to protect staff and residents from potentially infectious diseases) while providing care for one of 24 sampled residents (Resident 94). These failures had the potential for cross contamination and spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy regarding receipt and storage of controlled medications (drugs regulated by the government for its use, possession, and manufacture). This failure resulted in a medication card containing 60 tablets of Morphine (a controlled medication used for pain) to be missing and unaccounted for.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistance with activities of daily living (ADL - basic and everyday skills that are essential to living independently) were provided to two of three residents (Resident 28 and Resident 30) reviewed for ADL care when: 1. Resident 28 were not provided with incontinence (loss of bladder and/or bowel control) care in a timely manner and, 2. Resident 30 was not provided with nail care. This deficient practice placed Resident 28 and Resident 30 at risk for skin breakdown and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement non-pharmacological interventions (NPIs - ie. positioning, dark room, ice/heat, massage), as ordered by the physician, prior to the administration of PRN (as needed) pain medications for three of three residents (Residents 22, 99 and 312) reviewed for pain management. This failure had the potential for Residents 22, 99 and 312 not to receive non-prescription pain relief, prior to receiving narcotic pain medications with added side effects.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide sufficient staffing to meet care needs, when call lights were not answered timely for three of six confidential residents (CR 1, 2, 3) interviewed for sufficient staffing. This failure had the potential to result in residents' needs not being met, which had the potential to result in physical and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review II (PASARR II - a federal requirement to help ensure that individuals with mental disorders were not inappropriately placed in nursing homes for long term care) were conducted for two of five residents (Resident 6 and Resident 99) reviewed for PASARR screening. This failure had the potential for Residents 6 and 99, to be improperly placed and not have received additional qualified services.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident-centered care plan for one of six residents (Resident 6) when Resident 6's care plan did not include dementia care. This failure had the potential for Resident 6's needs to be unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six residents (Resident 81's) care plan was revised when Resident 81's gastrostomy tube (G-tube, a tube surgically inserted through the belly that brings nutrition directly to the stomach) was discontinued. This failure had the potential for Resident 81's care to be miscommunicated among caregivers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed for three of eight residents (Resident 5, Resident 6, and Resident 18) when: 1. A resident (Resident 5) was newly diagnosed at the facility with schizophrenia (a chronic mental illness characterized by delusions and hallucinations), without meeting the criteria for schizophrenia as indicated by The Diagnostic and Statistical Manual of Mental Disorders (DSM, a reference manual from the American Psychiatric Association to help define and classify mental disorders). 2. A resident (Resident 6) was newly diagnosed at the facility with schizophrenia without meeting the criteria for schizophrenia as indicated by the DSM. 3. A licensed nurse (LN 32) did not obtain the heart rate of Resident 18 prior to administering two blood pressure medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe environment was maintained when side rails were not installed for one of one residents (Resident 28) reviewed for side rails. As a result, there was a potential for Resident 28 to sustain injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dialysis (treatment to remove waste from the body) access care, including removal of dressing from the dialysis site for one of one sampled residents (Resident 71) reviewed for dialysis. As a result, there was a potential for complications after dialysis.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five residents (Resident 5 and Resident 6) were free from unnecessary medications when Resident 5 and Resident 6 were given antipsychotic medications (medication to treat psychosis) without clear indications. This failure had the potential for Resident 5 and Resident 6 to experience unnecessary medication side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it was free of a medication error rate of five percent or greater when two routine medications were not available for one of three sampled residents (Resident 72) observed for medication administration. This failure had the potential to negatively affect Resident 72's health.

Inspectors wroteBased on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify concerns related to unnecessary use of antipsychotic (drug used to treat clinical psychiatric symptoms or mental disorders) medication due to lack of indications. This failure had the potential for deficiencies to remain uncorrected and could result in residents being exposed to unnecessary medication side effects. (Cross reference F758)

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP, the use of gowns, gloves, and face mask during resident care to prevent the transmission of bacteria) for one of four residents (Resident 211) reviewed for infection control. This failure had the potential to spread infectious organisms to Resident 211 and others.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) was provided care/treatment to prevent the worsening of pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence as a result of prolonged pressure) when: 1. Certified nursing assistant (CNA) 1 removed Resident 1 ' s pressure ulcer dressings and the resident did not have his wounds covered while in bed. 2. Infection control was not maintained during pressure ulcer care when Resident 1 ' s open wounds were not re-cleansed after touching the resident ' s used bedding. 3. Resident 1 ' s pressure ulcer treatment orders were not followed. 4. Resident 1 ' s pressure ulcer treatment administration record (TAR) for November and December 2023 had blank entries and wound treatment could not be verified as having been done. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one licensed nurse (LN) 1 had the necessary competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) to perform pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence as a result of prolonged pressure) treatments for one of three residents (Resident 1). As a result of this deficient practice, there was the potential for Resident 1 ' s wound to deteriorate and/or become infected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dress one sampled resident in a dignified manner during a meal (31). This failure had the potential for Resident 31 to feel humiliated and isolated during meal time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's medical information was secured and protected for one sampled resident (32). As a result, Resident 32's medical information was exposed to unauthorized people.

Inspectors wroteBased on observation and interview, the facility did not ensure all ceiling vents were clean for one of twenty-four sampled residents, and one unsampled resident (resident 223, room [ROOM NUMBER]). As a result, there was an increased risk of poor air quality.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide requested grooming services to one of twenty-four sampled residents (44). As a result, Resident 44 had unwanted facial hair.

Inspectors wroteBased on interview and review of facility documentation, the Quality Assurance and Performance Improvement (QAPI) committee failed to identify the current Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccination. In addition, the facility failed to take the necessary corrective action to ensure that pneumonia vaccinations were offered, discussed, and provided in accordance with the current CDC standards. This failure had the potential to affect all 124 residents who currently live in the facility (refer to F883).

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure two staff wore the appropriate PPE when entering the room of one of one sampled residents on transmission based precautions. In addition, the facility failed to ensure staff in the kitchen donned (put on) gloves appropriately, to prepare food. (dietary aide 1- DA 1) These failures had the potential to spread infection to other residents, and to cause foodborne illness among the facility residents.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer 5 of 5 residents reviewed for flu/pneumonia vaccinations (Resident (R) 1, R2, R3, R4, R5) and/or their representatives, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer residents the opportunity to be vaccinated with PCV13 (pneumococcal vaccine- vaccine to prevent some cases of pneumonia, a respiratory disease) in accordance with CDC guidelines. Residents and/or their representatives were unable to share in clinical decision making with the medical provider as they were not given information or offered PCV 13. [...]