Kadima Rehabilitation & Nursing at North Strabane

Inspectors wroteBased on review of facility policy, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information for one of nine residents observed (R1).

Inspectors wroteBased on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly secure a treatment cart for one of three carts observed (treatment supply cart).

Inspectors wroteBased on a review of select facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections.

Inspectors wroteBased on review of facility policy and procedure, clinical record review, and staff interview, it was determined that the facility failed to offer the COVID-19 vaccine as indicated by the Centers for Disease Control (CDC) for five of five residents reviewed (Residents R6, R18, R21, R23, and R40).

Inspectors wroteBased on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for four of 10 residents (Resident R14, R22, R48, and R57). Review of facility policy Flow of Care dated 2/22/24, indicated the provision targeted care needs shall be documented on Care Tracker/Point of Care/ADL Flow Records (clinical documents). Residents are to have 2 showers a week unless resident states otherwise. Review of the admission record indicated Resident R14 admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/13/24, indicated the diagnoses of Diabetes Mellitus, kidney disease, Schizoaffective disorder, and morbid obesity. [...]

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain call bells were in reach for three of eight residents as required (Resident R30, Resident R35, and Resident R36).

Inspectors wroteBased on review of facility policy, observation, clinical record review and resident and staff interview, it was determined that the facility failed to provide adequate hygienic care for four of seven residents (Resident R15, R25, R38 and R54).

Inspectors wroteBased on facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that a pneumococcal immunization was offered to two of five residents (Resident R18, R40).

Inspectors wroteBased on a review of vendor invoices, facility financial documents, and interviews with vendors and staff, it was determined that facility failed to pay bills in a timely manner.

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for four of seven Residents (Residents R5, R12, R15, and R29).

Inspectors wroteBased on review of clinical records reviews and staff interview, it was determined that the facility failed to sure residents maintain basic rights preserved in the Federal and State laws and regulations for five of seven residents (Residents R27, R43, R46, R47, and R49) by having residents sign an Assumption of the Risk and Waiver of Liability Relating to Coronavirus/Covid-19 (Covid-19 waiver). Findings Include: The facility form Assumption of the Risk and Waiver of Liability Relating to Coronavirus/Covid-19 states The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. [...]

Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for six of eight residents reviewed (Resident R1, R26, R47, R52, R54, and R259).

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate injuries of unknown origin for three of six residents (Residents R310, R9, R25).

Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to assess a resident for smoking safety for one of three residents (Resident R54).

Inspectors wroteBased on review of facility policy, clinical record reviews, and staff interviews, it was determined the facility failed to make certain monthly Medication Regimen Reviews (MRR) were conducted for four of nine residents (Residents R8, R36, R40, and R46).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to date multi-dose over the counter (OTC) medication bottles in one of four medication carts (Avalon Hall Med Cart).

Inspectors wroteBased on a review of the facility's infection control policies and procedures, documents, and staff interview, it was determined the facility failed to implement an antibiotic stewardship program for eleven of twelve months (January, February, March, April, May, June, July, August, September, October, and November 2022).

Inspectors wroteBased on review of facility documentation, clinical records, and staff interview it was determined that the facility failed to provide accurate and timely documentation related to the COVID-19 vaccine for 15 of 56 residents (Resident R4, R10, R13, R18, R24, R32, R38, R43, R45, R47, R48, R52, R53, R54, and R259). During an interview on 11/30/22, at 1:00 p.m. the Director of Nursing confirmed that all vaccination information for residents was maintained in the electronic medical record. Review of the electronic medical record for Residents R4, R10, R13, R18, R24, R32, R38, R43, R45, R47, R48, R52, R53, R54, and R259 failed to include documentation if the COVID-19 vaccine was provided, previously received, or refused. During an interview on 12/1/22, at 11:15 a.m. [...]

Inspectors wroteBased on a review of observations, clinical records, facility employee vaccination data, and staff interviews, it was determined that the facility failed to implement policies and procedures to ensure that all staff were vaccinated for COVID-19 four six of 46 staff members (Therapy Employees E7, E8, E9, E10, E11, and E12).

Inspectors wroteBased on a review of facility policy, resident interview, resident observation, and staff interview, it was determined the facility failed to assess the clinical appropriateness of medication self-administration for two of 14 residents (Resident R1 and R259).

Inspectors wroteBased on review of facility policy, clinical records, incident reports, and staff interview, it was determined that the facility failed to make certain residents were free from neglect by not providing appropriate assistance and assistive devices for two of four residents (Resident R25 and R12).

Inspectors wroteBased on observation, review of facility policy and clinical records, and resident and staff interviews, it was determined that the facility failed to assess residents for appropriate use of an alarming device for one of three residents (Resident R49).

Inspectors wroteBased on review of clinical record, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan that includes smoking and interventions needed to provide effective and person-centered care for one of 14 residents (Resident R54).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to assess a resident for signs and symptoms of hypoglycemia and notify a physician of a change in condition for one of six residents with high glucose (blood sugar) levels (Resident R10),.

Inspectors wroteBased on observations, interview, clinical record review, and professional standards, the facility failed to ensure respiratory services were provided according to physician orders and professional standards for one of two residents reviewed (Resident R34). [NAME] Respironics, manufacturer of respiratory devices recommends mechanical ventilator (A mechanical ventilator is a machine that helps a patient breathe when he or she cannot breathe on his or her own for any reason) equipment including tubing, masks and headgear should be cleaned weekly to prevent growth of bacteria and mold in equipment. A review of the clinical record revealed that R34 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on facility document review and interviews with residents and staff, it was determined that the facility failed to maintain sufficient nursing staff levels to provide nursing care and services for one of eleven residents (Resident R45).