King David Nursing and Rehabilitation Center

Inspectors wroteBased on review of Geriatric Nursing Assistant (GNA) personnel records and staff interviews, it was determined that the facility failed to provide documentation the yearly clinical performance evaluations/reviews occurred at least every 12 months for 3 (GNAs #8, #21, and #22) out of 6 GNA personnel records reviewed. Additionally, the facility failed to provide documentation of the annual mandatory 12-hour clinical education training for 3 (GNA #8, #21, #22) out of 6 GNA personnel files reviewed during an annual survey.

Inspectors wroteBased on complaint, reviews of a closed clinical record and administrative records, and staff interviews, it was determined that the facility nursing staff failed to follow the physician's order for specific pulse and blood pressure parameters before administering cardiac medications. This was evident for 1 (Resident #7) of 7 residents reviewed during a complaint survey.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined that the facility failed to provide supervision during a medication pass to ensure the medication was taken by the resident and remove the medication when it was refused. This was observed for 1 (Resident #6) of 7 residents reviewed during a complaint survey.

Inspectors wroteBased on observations and interview, it was determined that staff failed to provide dietary services in a safe and sanitary environment. This deficient practice was evident during observations in the kitchen and the Nourishment Room on Sudbrook unit during the complaint survey.

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to ensure the waste refuse containers were closed and not overflowing with waste. This deficient practice was evidenced in 4 of 4 waste containers observed on the facility's property during the complaint survey.

Inspectors wroteBased on observations and interview it was determined that the facility staff failed to maintain the building in a safe, comfortable, homelike environment. This deficient practice was discovered during the complaint survey.

Inspectors wroteBased on the review of an investigation and interviews it was determined that the facility staff failed to ensure a resident was free from verbal abuse This deficient practice was evidenced in 1 (#1) of 3 investigations reviewed for an allegation of abuse during the complaint survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to develop and implement abuse policies and procedures. This was evident for 1 of 3 abuse policies reviewed.

Inspectors wroteBased on record review and review of the facility's investigation and interview it was determined that the facility staff failed to report allegations of abuse within the required timeframe. This deficient practice was evidenced in 2 (Residents #3, #5) of 5 residents reviewed for abuse allegations.

Inspectors wroteBased on the review of the facility's investigations and interviews it was determined that the facility staff failed to complete thorough investigations of incidents reported to the state agency and failed to ensure that residents were safe by allowing an alleged abuser to continue to work with vulnerable residents. This deficient practice was evidenced in 2 (Residents #1 and #3) of 3 facility reported incident investigations reviewed during the complaint survey.

Inspectors wroteBased on record review and interviews it was determined that the facility staff failed to clarify a physician's order, failed to follow a physician's order, and failed to ensure a resident received their medication as ordered. This deficient practice was evidenced in 1 (#9) of 5 medical records reviewed during the complaint survey.

Inspectors wroteOn the review of the electronic health record and interview it was determined that the facility staff failed to document when a resident received activities of daily living (ADL) assistance. This deficient practice was evidenced in 1 (#6) of 5 resident records reviewed during the complaint survey.

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to maintain infection control practices. This deficient practice was discovered during three observations of linen carts and shower rooms during the complaint survey.

Inspectors wroteBased on record review and interview, it was determined that the facility admission agreement failed to include special characteristics and service limitations related to a kosher diet, and requested residents waive their rights as well as waive potential facility liability for personal property losses.

Inspectors wroteBased on record review and interview it was determined the facility staff failed to make prompt efforts to resolve grievances and keep the resident/representative appropriately apprised of progress toward resolution. This was evident for 1 (#8) of 6 residents reviewed for neglect.

Inspectors wroteBased on record review and interview it was determined the facility staff failed to report an allegation of neglect to the State Survey Agency. This was evident for 1 (#8) of 6 residents reviewed for neglect.

Inspectors wroteBased on medical record review and interview with resident and facility staff, it was determined that the facility failed to put interventions in place to prevent the future occurrence of abuse and neglect allegations. This was evident during the review of 2 of 2 allegations of abuse reported by Resident #2.

Inspectors wroteBased on record review and interview with staff it was determined that upon resident admission to the facility the physician failed to address a hospital discharge plan to provide CPAP (Continuous Positive Airway Pressure) at night and to wean a resident off supplemental oxygen. This was evident for 1 (#8) of 8 residents reviewed for Quality of Care.

Inspectors wroteBased on record review and interview it was determined the facility failed to develop and implement a comprehensive person-centered plan to meet the residents' needs. This was evident for 1 (#8) of 8 residents reviewed for Quality of Care.

Inspectors wroteBased on medical record review and interview with resident and facility staff, it was determined that the facility failed to revise a care plan related to a resident's specific identified and individualized needs. This was evident during the review of 1 of 3 (Resident #2) resident care plans reviewed for facility self-reports.

Inspectors wroteBased on record review and interview it was determined the facility staff failed to ensure hospital discharge treatment plans for supplemental oxygen weaning and CPAP use were implemented upon the residents' admission to the facility and failed to have an effective process to wean residents off supplemental oxygen. This was evident for 1(#8) of 8 residents reviewed for Quality of Care.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure bed rails were securely affixed to the bed frame to limit entrapment zones. This was evident for 1 (#1) of 1 resident reviewed for Physical Environment.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to provide a resident with a reasonable accommodation of need. This was found evident of 3 out of the 4 observations made in Resident #1's room.

Inspectors wroteBased on observation and interviews, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and homelike environment. This was evident for 2 ([NAME] view and [NAME]) of 4 units observed during the annual survey.

Inspectors wroteBased on record review, and interviews, it was determined the facility failed to notify the Ombudsman of resident's transfers. This was found evident of 3 (Resident #4 #16 & #96) of 3 residents reviewed for hospitalization during the survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to comprehensively assess a resident who has had a significant change in status using the CMS-specified Resident Assessment Instrument (RAI) process and weight change. This was evident for 2 (Resident #101 and #16) out of 55 residents reviewed for change of condition.

Inspectors wroteBased on observation, record review, and interviews it was determined that the facility failed to ensure that a resident received treatment to promote healing of a pressure ulcer. This was found evident in 1 (Resident #4) out of 2 Residents reviewed for pressure ulcers.

Inspectors wroteBased on observations, medical record review and interviews it was determined that the facility failed to 1) ensure that a resident's room was free from hazards and 2) adequately monitor a resident with known behaviors. This was found evident for 1 (Resident #68) out of 3 residents reviewed for accidents and 1 (Resident #23) out of 3 Residents reviewed for behaviors.

Inspectors wroteBased on record review and interviews, it was determined that the physician failed to document a note addressing a resident's significant weight loss. This was evident for 1 out of 2 residents reviewed for nutrition.

Inspectors wroteBased on record reviews, and interviews from resident and staff, it was determined that the facility failed to ensure medications were administered to a resident as ordered. This was evident for Resident #62 in 2 out of the 4 months reviewed for Metformin administrations.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to have an effective pest control program. This was found evident in one room on the [NAME] View Unit.

Inspectors wroteBased on record review and interview it was determined that the facility failed to inform and give written notice for the reason for a room change to a Resident's Representative (RP). This occurred on 3 out of 3 bed reassignments made for Resident #23.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to protect a resident from abuse from another resident. This was found evident of 1 (Resident #47) out of 8 Residents reviewed for abuse allegations during an annual and complaint survey.

Inspectors wroteBased on a complaint, medical record review and interviews with a resident and staff, it was determined the facility staff failed to report an allegation of abuse to the regulator agencies and Office of Health Care Quality (OHCQ). This was found evident in 1 (Resident #47) out of 8 residents reviewed for abuse.

Inspectors wroteBased on review of a complaint, review of facility investigations, record review, and interviews it was determined that the facility failed to: 1) prevent potential abuse after a documented incident occurred and 2) failed to complete a thorough investigation and maintain the records of their investigation. This was found evident of 1 (Resident #47) out of 8 residents reviewed for abuse and 1 (Resident #68) out of 9 residents reviewed in facility reported incidents.

Inspectors wroteBased on medical record review and interview, the facility failed to accurately document medical information in a resident's medical record and in accordance with acceptable professional standards and practices by keeping complete documentation. This was evident for 2 (Resident #104 and #23) out of 57 residents reviewed during a facility's complaint survey.

Inspectors wroteBased on surveyor observation throughout the annual recertification survey it was determined that the facility staff failed to maintain a sanitary, orderly, and comfortable interior in four locations: Resident #211's room, the dining room, Resident #3's oxygen concentrator, and the facility's parking lot.

Inspectors wroteBased on clinical record review, observation, and staff interview it was determined that the facility staff failed to prevent unplanned weight loss for 1 out of the 45 residents that were part of the survey sample (Resident #21) and failed to promptly address a significant weight loss for 1 of 45 residentw that were reviewed as a part of the survey sample (Resident #39).

Inspectors wroteBased on observation, clinical record review, and staff interview it was determined that the facility's staff failed to adequately monitor oxygen use for 1 of 48 residents in the survey sample Resident #383).

Inspectors wroteBased on observation, medical record review and interview with resident and staff it was determined that the facility failed to initiate a pain regimen timely for a resident with reported and verbalized pain. This was evident for 1 of 5 residents reviewed for pressure ulcers (#47)

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure staffing information was posted in clear, readable, and complete manner. This was evident for 1 out of 3 shifts.

Inspectors wroteBased on observations, record reviews, and interviews it was determined that the facility failed to 1) Ensure medications requiring refrigeration were stored safely 2) Ensure medications were stored and labeled properly 3) Ensure expired medications were properly disposed and; 4) Ensure medications were kept in secured locations. This was found to be evident in 1 out of 2 medication storage rooms, 4 out of 4 medication carts and 2 out of 2 treatment carts during observation of medication storage and labeling and has the potential to affect all residents.

Inspectors wroteBased on observation and interview, it was determined the facility staff failed to provide the most practical dignified existence for 4 of 45 for resident's reviewed during the survey by: 1) Entering Resident #36's room without knocking and waiting for an invitation to open the door; 2) Allowing Resident #44 to wait a minimum of 12 minutes after the resident's roommate was served prior to serving Resident #44; 3) Standing over (Resident #1) during assistance with a meal; providing care to Resident #36 in manner that did not provide full privacy for the resident. This was evident for 4 of 4 residents selected for review of dignity, a total of 45 residents were reviewed during the survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to notify the physician of a resident's ongoing refusal to take medication. This was evident for 1 of 45 residents selected for review during the survey process (Resident #333).

Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to notify the residents or their responsible party in writing of the reason for a resident's transfer to the hospital (Residents #69). This was evident for 1 of 3 residents reviewed for hospitalization during the annual recertification survey.

Inspectors wroteBased on resident record review and staff interview it was determined that the facility failed to conduct a comprehensive assessment within 14 days of a significant change for 1 of 48 residents reviewed during the complaint survey (Resident #66).

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to initiate a care plan to address hearing impairment/bilateral hearing aids for Resident (#69). This was evident for 1 of 1 resident selected for care plan review during the annual survey process.

Inspectors wroteBased on observation, medical record review and interview it was determined the facility staff failed to provide grooming and personal hygiene services (Resident #56 ). This is evident for 1 of 4 residents selected for review for ADL care during the annual survey process.

Inspectors wroteBased on medical record review, observation, and interview, it was determined the facility's staff failed to provide care for 3 of 45 residents in accordenance with professional standards of practice (Residents #2, #68, and #69). In regards to Resident #2, the faciliy failed to: 1) Administer medications to the resident as ordered, Administer the lesser pain medication based on the resident's stated level of pain, and Provide the resident with un-interrupted care. In regards to Resident #68, the facility failed to: 2) Document the outcome of finger sticks as ordered by the resident's physicians. In regards to Resident #69, the facility failed to: 3) Arrange routine pacemaker checks for the resident.

Inspectors wroteBased on observation and interview, it was determined the facility staff failed to provide treatment/services to prevent potential pressure ulcer to (Resident #2). This is evident for 1 of 5 residents selected for review of pressure ulcers during the annual survey process and 1 of 45 residents selected for review during the annual survey.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to ensure resident safety when the resident was transferred from the floor to bed. This was found to be evident for 1 out of 1 resident observed for transfer (resident #74).

Inspectors wroteBased on medical record review, observation, and interviews with facility staff it was determined the facility staff failed to provide support and security for indwelling urinary catheters. This was evident for 2 of 5 residents reviewed for indwelling urinary catheters during the annual survey (Residents #47 and #27).

Inspectors wroteBased on medical record review and interview, it was determined the facility's staff failed to consistently administer medication according to vital sign parameters as outlined in physician's orders. The facility's staff also failed to report the outcome of a resident's vitals signs to the physician as ordered. This was evident for 1 of 5 residents selected for medication review (Resident #11).

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to clearly identify target symptoms for the administration of psychotropic medications and establish a plan for the ongoing monitoring of those symptoms for Resident 2 of 5 residents selected for review of unnecessary medication and 1 of 45 residents selected for review during the annual survey process (Residents #68 and #93).

Inspectors wroteBased on medical record review, observation and interview it was determined the facility staff failed to obtain a medication error rate less than 5%. This was evident for 2 medication errors out of 26 medication observation opportunities. This resulting in an error rate of 7.69%.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain dental consultations for 1 of 3 residents (Resident #22) selected for review of dental care and 1 of 45 residents selected for review during the annual survey.

Inspectors wroteBased on observation and interview with facility staff it was determined that the facility failed to 1) Ensure that sanitary practices were followed and kitchen equipment was well maintained and 2) Ensure the nourishment refrigerator contained products that were not expired and safe for resident consumption. This was evident during the initial tour of the facility. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on observation and staff interview, it was determined the facility staff failed to dispose of garbage and refuse properly.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to maintain the medical record in the most complete and accurate form for 1 of 48 residents in the final sample (Resident #66).

Inspectors wroteBased on observation and staff interview it was determined that the facility failed to maintain kitchen and resident equipment in safe operating condition. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on an interviews with a resident it was determined the facility failed to enhance and promote a resident's dignity when entering into their room to provide care. This was found to be evident for 1 out of 36 residents (Resident #6) during the survey.

Inspectors wroteBased on interview and review of pertinent documentation it was determined that the facility failed to allow a resident the autonomy to choose activities of his/her liking. This was evident in the review of 1 of 1 residents (Resident #83) reviewed for choices during the survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to have a survey results sign posted identifying the location of the survey results. This was found to be evident during a resident council meeting with residents during the facility's annual survey.

Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to ensure that a resident was kept free from restraints as evidenced by the use of a tab alarm without a physician order, care plan or documented indication for the use of the alarm. This was found to be evident for 1 out of 2 residents (Resident #43) reviewed for restraints during the survey.

Inspectors wroteBased on medical record review and staff interview it was determined that facility staff failed to report a resident's injury of unknown origin to the Office of Healthcare Quality. This was evident for 1 of 36 residents (Resident #244) reviewed during survey investigation.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to document accurate Minimum Data Set (MDS) assessments for a Resident. This was evident for 1 of 34 residents (Resident #96) selected for review during the survey process.

Inspectors wroteBased on medical record review and interview with facility staff it was determined that the facility failed to develop care plans addressing a resident's individualized needs related to 1) a resident's dental concerns and 2) a transfer plan of care for a physically dependent resident. This was found to be evident for of 2 of 36 residents (Resident #1 and #244) reviewed during the investigative portion of the survey.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to revise a resident care plan to meet the specific care needs for a resident with history of falls. This was found to be evident for 1 out of 3 residents (Resident # 17) reviewed for falls during the facility's annual survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure a resident received twice weekly showers and skin assessments as ordered. This was found to be evident for 1 out of 36 residents (Resident #2) reviewed during the survey.

Inspectors wroteBased on observation and review of pertinent facility records it was determined that the facility failed to provide activities for individuals based on their identified care plans and choices. This was evident for 3 of 3 residents (Resident #83, #12 and #49) reviewed for activities.

Inspectors wroteBased on medical record review and staff interview it was determined that facility staff failed to maintain a resident's bed in low position as outlined in the resident's plan of care. This was evident for 1 of 36 residents (Resident #244) reviewed during survey investigation.

Inspectors wroteBased on medical record review and interview with facility staff it was determined that the facility failed to maintain a pain management regimen according to the resident's needs, rights and choices. This was evident for 1 of 1 resident reviewed for pain (Resident #194).

Inspectors wroteBased on observation, medical record review and interview it was determined that the facility failed to keep a resident safe from a significant medication error as evidenced by the placement of a pain relief patch on the wrong area of the body. This was found to be evident for 1 out of the 4 residents (Resident #78) observed during medication pass administration observation completed during the survey.

Inspectors wroteBased on medical record review and staff interview it was determined that facility staff failed to maintain residents' medical records in a complete and readily accessible manner as evidenced by 1) failure to ensure primary care physician notes were available in the resident's chart for review by other health care providers; and 2) failure to ensure documentation of the resident's history of transfers and the level of assistance required with transfers. This was evident for 2 of 36 residents (Resident #43 and #244) reviewed during the survey.