Jamestown Health and Rehabilitation

Inspectors wroteBased on observation, interview, clinical record review and facility documentation, the facility staff failed to provide routine and emergency drugs and biologicals to 1 Residents, (# 240) in a survey sample of 25 Residents.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed ensure Residents were free from significant medication errors for 2 Residents in a survey sample of 25 Residents.

Inspectors wroteBased on observations, interviews, clinical record reviews, and facility documentation, it was found that the facility staff failed to provide drinks, other than water, consistent with the needs and preferences of one resident in a survey sample of 25 residents.

Inspectors wroteBased on interview, clinical record review, and facility documentation, it was determined that the facility staff failed to provide a therapeutic diet as ordered by the physician for 1 Resident (#240) in a survey sample of 25 residents.

Inspectors wroteBased on interviews, clinical record reviews, and facility documentation, it was found that the facility staff failed to ensure residents were provided with necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one resident in a survey sample of 25 residents.

Inspectors wroteBased on interviews, clinical record review, and facility documentation, it was determined that the facility staff failed to ensure that pain management services were provided to residents who required such services, specifically for Resident #190, within a survey sample of 25 residents.

Inspectors wroteBased on staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to mitigate a fall hazard for 1 Resident (Resident #135) and failed to utilize a mechanical lift during a transfer from the wheelchair to the bed for 1 resident (Resident #32) in a sample of 33 Residents, resulting in harm for both Residents.

Inspectors wroteBased on observation, Resident interview, and staff interview, the facility failed to post survey results in a place readily accessible to Residents.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to implement their immunization policy and ensure each Resident is offered influenza and pneumococcal immunization, for 3 Residents (Resident #9, #81, and #287), in a sample of 5 Residents reviewed for immunizations.

Inspectors wroteBased on staff interviews and facility documentation review, the facility staff failed to conduct routine COVID-19 testing in accordance with the CDC recommendations for 5 facility staff (RN D, CNA B, CNA D, LPN D and LPN E), who were not up-to-date with COVID vaccinations, in a survey sample of 5 staff reviewed for COVID testing.

Inspectors wroteBased on observation, Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure a Resident's right to a dignified existence for 1 Resident (#24) in a survey sample of 33 Residents. For Resident #24, the facility staff failed to dress the Resident in her own clothing, and instead dressed her in a hospital gown. The Resident expressed embarrassment and requested her own clothing for appointments and anytime she was out of her room or out of the facility.

Inspectors wroteBased on staff interview, facility documentation review and clinical record review, the facility staff failed to complete a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) for 1 Resident (Resident #286) in a survey sample of 3 Residents reviewed for Beneficiary Notifications. For Resident #286, the facility staff failed to provide a SNF ABN notice prior to skilled care services ending. As a result of this deficient practice Resident #286 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services, known as a demand bill.

Inspectors wroteBased on observation, Resident interview, staff interview, and clinical record review the facility staff failed to provide one Resident (Resident #28) with a homelike environment, in a survey sample of 33 Residents. For Resident # 28, the facility staff failed to hang a framed picture (a portrait of the resident as a young child drawn by her brother).

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review facility staff failed to revise the resident's care plan for one resident (Resident 7) in a sample size of 33 residents. Resident #7's care plan was not re-evaluated or additional interventions added related to the ongoing complaints of tooth pain.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to provide care and services based on the professional standards of nursing practice for Two Residents (Resident # 168 & Resident #7) in a survey sample of 33 residents.

Inspectors wroteBased on observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to treat a pressure sore for one Resident (Resident #84) of the 33 residents in the survey sample. For Resident #84, the staff failed to assess, and treat, an unstageable coccyx pressure sore.

Inspectors wroteBased on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide consistent oxygen therapy for one Resident (Resident #29) in a survey sample of 33 Residents.

Inspectors wroteBased on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide consistent social services for one Resident (Resident #14) in a sample size of 33 Residents.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to adhere to infection control practices to minimize the spread of COVID-19 within the facility based on CDC (Centers for Disease Prevention and Control) recommendations and facility policy, on one of three nursing units, having the potential to affect multiple Residents residing on that unit.

Inspectors wroteBased on observation, Resident interviews, staff interviews, and clinical record reviews, the facility staff failed to maintain a functioning call bell system for two Residents (Resident #30, Resident #34) in the sample size of 33 Residents. 1) For Resident #30, the facility staff failed to ensure the call light was functioning on 05/10/2022. 2) For Resident #34 (roommate of Resident #30), the facility staff failed to ensure the call light was functioning on 05/10/2022. Also, the outer covering at the distal end of the call light cord was torn exposing the inner wire insulation.

Inspectors wroteBased on observation, interview, facility documentation and clinical record review the facility staff failed to maintain the Resident dignity for 1 Resident (#7) in a survey sample of 26 Residents.

Inspectors wroteBased on resident interview, staff interview and clinical record review and facility documentation review, the facility staff failed to accommodate the needs of one Resident (Resident # 46) in a survey sample of 26 Residents. The Findings Include: 1. For Resident # 46, the facility staff failed to ensure the opportunity to vote on 3/3/2020. Resident #46 was admitted to the facility in 2018 with diagnoses that included, but were not limited to: Chronic Obstructive Pulmonary Disease, Diabetes, Gastroesophageal Reflux Disease, Chronic Congestive Heart Failure, and Hypertension. Resident #46's most recent Minimum Data Set (MDS) Assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 1/21/2020. The Brief Interview for Mental Status (BIMS) coded Resident #46 at 15 out of 15, indicating no cognitive impairment. [...]

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to provide respiratory care according to the professional standards of care for two Residents (Residents # 44 and # 46) in a survey sample of 26 residents.

Inspectors wroteBased on interview, facility documentation and clinical record reviews the facility staff failed to ensure Residents were free from unnecessary psychotropic medications for 1 Resident (#5) in a survey sample of 26 Residents.

Inspectors wroteBased on interview, facility documentation and clinical record review and in the course of an investigation the facility staff failed to provide laboratory services that were timely for one (resident #133) of 26 sampled residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide food prepared to conserve appearance for one resident (Resident #69) in a sample size of 26 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement an effective infection control & isolation program concerning handwashing during medication pour and pass, and for 3 specific Residents (Residents #284, 70, and #72) in a survey sample of 26 residents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to accommodate for individualized need and preference for two residents (Resident #78 and #2) in a sample size of 26 residents. This happened over multiple days.

Inspectors wroteBased on observation, resident interview, staff interview, the facility staff failed to ensure a clean comfortable home environment for two residents (Residents # 65 and # 46) in a survey sample of 26 residents. This happened over multiple days. The Findings Include: 1. For Resident # 65, the facility staff failed to fix a hole in the wall behind the door across from the bed. During the initial tour on 3/3/2020, a large hole was observed behind the door to the room where Resident # 65 resided. The hole measured approximately 8 inches wide and 3 inches tall. On 3/4/2020 at 10:30 AM, an interview was conducted with Resident # 65 who stated she didn't like seeing the hole behind the door. Resident # 65 stated she complained about it a few weeks before but the Maintenance Director works on his own schedule. [...]