Jesmond Skilled Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview, and records reviewed, the facility failed to provide a dignified experience for one Resident (#11) out of a total sample of 15 residents. Specifically: for Resident #11 the facility failed to ensure the Resident was provided dignity during activities of daily living (ADL) care.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure for one Resident (#5), out of total of 15 residents that the Health Care Proxy (a document executed in advance which designates a Health Care Agent, to make informed medical decisions, when a person is determined by a medical provider to lack the capacity to make health care decisions) was activated in accordance to standards of practice.

Inspectors wroteBased on observations, interviews and records reviewed, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#10) out of sample of 15 residents. Specifically, for Resident #10, the facility failed to assess the Resident's respiratory status and response to therapy.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to notify the physician of a change in nutritional status resulting in a hospitalization for dehydration and hypernatremia for one Resident (#24), out of a total sample of 20 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to address the nutrition and hydration status of two Residents (#24, #32) out of a total sample of 20 residents. Specifically, the facility failed to: 1) provide one Resident (#24) with nutritional intervention leading to a diagnosis of severe dehydration. 2) Ensure Resident #32's documented significant weight losses and weight gains were addressed by the Registered Dietitian and develop a resident focused care plan for nutrition care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for five dependent Residents (#1, #2, #38, #19, #12) out of a total sample of 20 Residents. Specifically, the facility failed to: 1) Provide incontinence care timely and in accordance with the plan of care for Resident #1. 2) Provide supervision while eating for three Residents (#2, #38, #19). 3) Provide showers as ordered for Resident #12.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure advanced directives were followed, resulting in one Resident (#24) being transferred to the hospital, out of a total sample of 20 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure one Resident (#1) was free from neglect, out of a total sample of 20 residents. Specifically, the facility failed to implement an established care plan for incontinence care resulting in incontinence care not being provided in a timely manner.

Inspectors wroteBased on observations, interviews and record review, the facility failed to complete a restraint assessment for one Resident (#36) out of a total sample of 20 residents. Specifically, the facility failed to complete a bed safety assessment prior to adding a bolster pillow in the Resident's bed.

Inspectors wroteBased on observations, record review and interview, the facility failed to follow the plan of care for three Residents (#25, #26 and #41) out of a total sample of 20 residents. Specifically, the facility 1) Failed to follow a physician's order to provide an air mattress for Resident #25. 2) Failed to offload Resident #26's heels as written in his/her care plan. 3) Failed to offload Resident #41's right heel as ordered by the physician.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to ensure a physician's order was implemented as ordered for one Resident (#25) out of a total sample of 20 residents. Specifically, the facility failed to obtain blood pressure parameters as ordered.

Inspectors wroteBased on observations, record review and interview, the facility failed to implement the medical plan of care for two Residents (#28, #32) who are assessed as high risk for developing pressure ulcers, out of a total sample of 20 residents. Specifically, the weekly skin assessments for both residents were not completed in accordance with the physician's orders.

Inspectors wroteBased on observation, record review and interview the facility failed to implement the use of a hand splint in accordance with the rehabilitation plan of care for one Resident (#38), out of a total sample of 20 residents.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to complete an investigation of a fall for one Resident (#12) out of a total sample of 20 residents.

Inspectors wroteBased on observations, policy review and interviews, the facility failed to ensure medications with short expirations dates were dated when opened, expired medications were removed from supply, medications were securely stored and medication carts were locked when unattended.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the correct diet texture was implemented for one Resident (#38) out of a total sample of 20 residents. Specifically, the facility failed to ensure that Resident #10 received a minced textured diet as ordered by the physician.

Inspectors wroteBased on observations, record review and interview, the facility failed to maintain an accurate medical record for one Resident (#25) out of a total sample of 20 residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to implement the infection prevention and control program. Specifically: the facility failed to ensure nursing implemented infection control standards for blood glucose meter cleaning. Review of the facility policy, infection control, undated indicated the following but not limited to: -Equipment if disinfecting is not possible, clean and disinfect equipment using the same guidelines as for environmental cleaning, after contact with the resident and prior to using the equipment on another resident. -All equipment must be cleaned with PDI sani-cloth germicidal disposable cloth. On 8/13/24 at 7:45 A.M., the surveyor observed Nurse #2 gather supplies to obtain a Resident's blood sugar. On 8/13/24 at 7:45 A.M., the surveyor observed Nurse #2 obtain Resident #2's blood sugar. [...]

Inspectors wroteBased on observations, policy review, record review and interviews, the facility failed to provide assistance for meals for 4 Residents (#31, #23, #5, and #6) out of a total sample of 15 residents.

Inspectors wroteBased on observations, policy review and interviews, the facility failed to provide a dignified dining experience to the residents on the first floor.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to accommodate one Resident (#8)'s needs by having the bed remote within reach, out of a total sample of 15 residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure resident Protected Health Information (PHI) was secure and not visible to others on one of two nursing units.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide a dietary supplement as ordered for one Resident (#6) out of a total sample of 15 residents. Findings Include: Resident #6 was admitted to the facility in May 2016 with diagnosis including abnormal weight loss, dementia, and dysphagia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #6 was unable to complete a Brief Interview for Mental Status (BIMS) due to being rarely or never understood. Further review of the MDS indicated Resident #6 is totally dependent on staff to assist with eating. Review of Resident #6's diet orders indicated the following: *Magic cup (a high calorie, nutrient fortified ice-cream) all meals for meals On 6/20/23 at 8:44 A.M., the surveyor observed a card on Resident #6's breakfast tray indicating Magic Cup three times a day with meals. [...]

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to ensure one Resident (#4) was provided with services and/or materials to maintain communication in his/her own language, out of a total sample of 15 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure physician wound recommendations were addressed for a resident with a coccyx pressure ulcer for 1 Resident (#19) and failed to ensure that an air mattress was at the ordered setting and heel protective booties were applied for 1 Resident (#8) with a pressure ulcer out of a total of 15 sampled Residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure it was free from a medication error rate of greater than 5%. Two out of two nurses observed made three errors in 28 opportunities resulting in a medication error rate of 10.71%. These errors impacted 2 Residents (#17 and #11) out of 4 residents observed.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medications were appropriately stored per policy for one Resident (#25) out of a total of 15 sampled Residents.

Inspectors wroteBased on observations and interviews, the facility failed to properly handle food to prevent the spread of food borne illnesses during mealtimes on the first floor.