Lea Hill Rehabilitation and Care Center

Inspectors wroteBased on observation, interview and record review the facility failed to implement their abuse policies and procedures including identification of an allegation of verbal abuse and neglect, protecting residents after an allegation of verbal abuse and neglect, making required notifications, logging the allegation on the abuse/incident log, completing an incident report, a thorough investigation, and post incident resident monitoring for psychological harm for 2 of 2 residents (Resident 1 & 2) reviewed for staff and resident incidents. These failures placed all residents at risk for unidentified abuse and neglect, on-going abuse, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 2 residents (Resident 8 & 7) reviewed for English as a second language, were provided a functional communication system. Failure to provide and follow the services which enhanced and/or ensured effective communication placed the residents at risk for unmet care needs, social isolation and a diminished sense of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure cold food was held at 41-degree Fahrenheit (F) or lower during lunch preparation. Failure by the facility to ensure food was at the proper temperature when served, placed residents at risk for food borne illness, less than adequate nutritional intake, dissatisfaction with meals, and other negative outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure privacy for 1 of 1 resident (Resident 7) observed for medication administration via Gastric Tube (GT -tube inserted through the wall of the abdomen directly into the stomach). The failure to provide privacy during medication administration via GT placed residents at risk for a loss of privacy and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer nonpharmacological interventions to 3 of 5 residents (Residents 3, 29, & 45), monitor specific target behaviors for 1 of 5 residents (Resident 45), complete an Abnormal Involuntary Movement Scale (AIMS - an assessment) for 1 of 5 (Resident 45), and monitor for adverse side effects from psychotropic medications for 1 of 5 residents (Resident 45) reviewed for unnecessary medications. Failure to monitor resident specific target behaviors, monitor for psychotropic medication adverse side effects, and provide nonpharmacological interventions placed residents at risk of mismanaged behaviors, discomfort, receiving unnecessary psychotropic medications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident's representative and Ombudsman with a written notice of the transfer/discharge, at the time of transfer or within 24 hours, for 2 of 4 sample residents (Resident 2 & 18) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right while hospitalized that was necessary for decision-making.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 3 (Residents 2, 8, & 5) of 12 sample residents Minimum Data Sets (MDS - an assessment tool) were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a mental health screening required before transfer to a nursing home) assessments were revised to reflect mental health changes for 1 of 5 residents (Resident 8) reviewed for PASRRs. This failure left residents at risk for not receiving timely and necessary services to meet their mental health care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement comprehensive Care Plans (CP) for 3 of 16 residents (Resident 29, 7, & 3) whose CPs were reviewed. Failure to develop comprehensive, individualized CPs to address resident care needs placed residents at risk for unmet care needs, frustration, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to clarify physician orders to include medication dosing and pain medication parameters for 2 (Resident 45 & 3) of 5 residents reviewed for unnecessary medications and 2 (Resident 5 & 48) supplemental residents. The facility failed to obtain/monitor labs for medications requiring lab monitoring, failed to ensure pain management included nonpharmacological interventions, and failed to ensure staff monitored for signs and symptoms of low/high blood glucose levels for 2 (Residents 3 & 29) of 5 sample residents reviewed for unnecessary medications. These failures placed residents at risk for unmet needs, and ineffective and/or delayed treatments.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs - i.e. grooming, bathing, eating, etc.) received the assistance they required for 3 of 7 sample residents (Residents 2, 8, & 7) reviewed for ADLs. The failure to provide nailcare, bathing, getting out of bed, and shaving left residents at risk of embarrassment, poor personal hygiene, decreased quality of life, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure weekly skin assessments were completed for 1 (Residents 15) of 1 residents reviewed and 1 (Resident 5) supplemental resident who were reviewed for skin impairments, ensure post fall assessments were completed for 1 (Resident 20) of 4 residents who were reviewed for falls, ensure the therapy department provided a referral for a restorative nursing program to maintain range of motion once a resident discharged from therapy services for 1 of 4 residents (Resident 31), and ensure accurate weight monitoring was done per physician orders for 1 of 1 residents (Resident 7) reviewed for nutritional status. These failures placed residents at risk for skin breakdown, injuries, malnutrition, decreased range of motion, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach) was administered in accordance with physician orders and professional standards for 1 of 1 resident (Resident 7) reviewed for enteral nutrition. The facility failed to accurately document the amount of enteral formula (liquid food products) and fluids a resident received were reconciled with the amount they were ordered to receive and deliver per physician order. This failure placed residents at risk for inadequate nutrition, dehydration, and other adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage of medications for 1 of 2 staff (Staff F - Registered Nurse) observed during medication administration and proper labeling of medications on 1 of 1 medication carts (West Medication Cart) reviewed for medication storage. These failures placed residents at risk of injury, receiving expired medications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 3 residents (Resident 46, 7, & 19) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms), ensure staff used appropriate Hand Hygiene (HH) during resident care/resident contact (Staff D - Certified Nursing Assistant - CNA & Staff N - CNA) who were observed for care, and staff failed to provide sanitary practices when delivering meals to residents (Staff N) who were reviewed. These failures placed residents and staff at risk for exposure to and development of contagious, communicable infectious diseases.

Inspectors wroteBased on interview and record review, the facility failed to implement a system to ensure residents received required written notices at the time of transfer/discharge, or as soon as practicable for 2 (Residents 21 & 29) of 2 residents reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident meals were prepared in accordance with professional standards of food safety for 2 of 2 facility kitchens. The failure to ensure surface sanitizer solutions were maintained at effective concentrations, food was stored in a manner to preserve its quality, and food preparation areas were free from potential contaminants, placed residents at risk for food contamination, food borne illnesses, and spoiled food.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Physician's Orders (POs) were clarified as needed for 3 residents (Residents 2, 242, 238) of 13 sample residents reviewed, followed for 6 residents (Residents 13, 240, 8, 28, 238, & 240) of 13 sample residents reviewed, and nurses signed only for care provided for 1 resident (Resident 8) of 13 sample residents. These failures left residents at risk for unmet care needs, unnecessary care, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently perform Hand Hygiene (HH) before and after resident care/contact, change gloves after dirty care/before clean care, and failed to ensure glucometers were maintained clean and sanitary. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on interview and record review, the facility failed to obtain and/or have Advanced Directives (AD - a document describing a resident's wishes for care if they became incapacitated) readily available in resident records for 3 of 5 residents (Residents 240, 241, & 13) and 1 supplemental resident (Resident 238) reviewed for ADs. This failure left residents at risk for losing the right to have their preferences and choices honored during emergent and end-of-life care.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate unwitnessed falls for 1 of 2 sampled residents (Resident 3) reviewed for falls, and 1 supplemental resident (Resident 13). Facility failure to complete thorough investigations placed residents at risk for further falls and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment accurately reflected the residents' mental health conditions for 1 (Resident 238) of 5 residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated as needed to reflect current care needs for 2 residents (Residents 3 & 21) of 13 sample residents reviewed. The failure to ensure CPs were updated as needed left residents at risk for unmet care needs, frustration, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 resident (Resident 3) of 3 reviewed for vision and hearing were provided the assistance and/or adaptive devices they were assessed to require. This failure left Resident 3 at risk for unnecessary barriers to communication and frustration.

Inspectors wrote<Resident 21> According a 04/18/2024 Significant Change MDS, Resident 21 had moderate memory impairment. The assessment showed Resident 21 had a diagnosis of non-Alzheimer's dementia. Review of a revised 04/18/2024 Fall CP showed, Resident 21 was at risk for falls and had two unwitnessed falls since admission. The CP showed to keep the bed in the lowest position as a preventative fall intervention. Review of Resident 21's medical records showed a PO to keep bed in lowest position while resident was in bed initiated on 07/11/2023. Observations on 06/26/2024 at 12:59 PM, 06/27/2024 at 8:56 AM, 06/27/2024 at 12:37 PM, 06/28/2024 at 9:28 AM, and 07/01/2024 at 8:17 AM showed Resident 21 in bed with the bed raised halfway between medium and maximum height. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure continent residents were provided toileting for 3 of 4 residents (Residents 339, 340, & 18) reviewed for Urinary Catheters (tube inserted into the bladder to empty the bladder) and Urinary Tract Infections (UTI). These failures placed residents at risk for UTI, dignity issues, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess, monitor, and record intake for 1 (Resident 8) of 1 resident reviewed for enteral feeding (a medical process used to provide nutrition for residents who cannot obtain nutrition orally) services. These failures placed Resident 8 at risk for inadequate nutritional support and adverse consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 3 residents (Residents 2, 88, & 241) reviewed for oxygen were provided care consistent with professional standards of practice. Failure to provide oxygen treatments as ordered (Resident 2 & 241) and place oxygen signs outside the rooms of residents using supplemental oxygen (Residents 2, 88, & 241) left residents at risk for over or under oxygenation, respiratory discomfort, oxygen-related accidents, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure, 1 of 5 (Resident 13) residents reviewed for unnecessary medications was adequately monitored to prevent excessive duration of medication use. These failures placed residents at risk to receive unnecessary medications and/or adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 (Residents 21 & 238) of 5 residents reviewed for unnecessary medications were free from unnecessary psychotropic medications. Facility staff failed to identify/monitor target behaviors or attempt a Gradual Dose Reduction (GDR) for an Antidepressant (AD) medication. These failures placed residents at risk to receive unnecessary psychotropic medications and experience adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 3 residents (Resident 23) reviewed for pressure ulcers (PU) received physician ordered wound care, and a recommended air mattress on a timely basis to prevent skin breakdown and the development and worsening of PUs. These failures resulted in harm to Resident 23 due to worsening of PU on the heels and increased risk for severe infection and further deterioration of skin integrity.

Inspectors wroteBased on observation and interview the facility failed to ensure expired foods were identified and discarded, did not ensure equipment was clean and secure, and ensure staff implemented proper hand hygiene practice. These failures placed residents at risk for consuming expired/spoiled foods, potential exposure to food borne illness, and safety hazards placing residents at risk for harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure incident investigations were completed according to professional standards for 2 of 5 residents (Residents 11 & 6) reviewed for accidents. The failure to 1) conduct timely and thorough investigations, 2) rule out abuse and/or neglect, 3) ensure the identified resident feels safe, 4) gather statements at the time of the incident from the staff, witnesses, identified resident, and other similar or affected residents, 5) implement immediate interventions related to the incident to prevent future incidents, 6) identify the root cause of the incident, and 7) maintain documentation that an alleged violation was thoroughly investigated, placed residents at risk for potential unidentified abuse or neglect, repeated accidents/incidents/injuries and resident's diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a competency-based education program to ensure 4 of 8 (Staff B, C, I & Z) and 1 supplemental (Staff D) nursing staff had the appropriate competencies and skill sets to provide nursing care and related services according to professional standards to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being determined by resident assessments and individual plans of care. The failure to ensure nursing staff were competent to: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain infection control practices that provided for a safe and sanitary environment to help prevent and contain the transmission of communicable diseases. The facility failed to ensure 1 staff (Staff C) completed hand hygiene on 2 occurrences during wound evaluation and 1 staff (Staff N) on 5 occurrences during resident care for Resident 16. The facility failed to ensure 3 staff (Staff K, L, & M) followed the Transmission-Based Precautions (TBP) outlined for Resident 178. These failures placed the residents at risk for the development and transmission of infections and compromised the safety of residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review the facility failed to inform a resident or the resident's representative of treatment risks and benefits, treatment options, and treatment alternatives in a timely manner when concerns were expressed, questions were raised, and when a change in treatment was proposed for 1 of 1 resident (Resident 178) reviewed for resident rights. These failures prevented the opportunity for the resident to exercise their right to leave their room and to make an informed decision related to fluid restriction. The delayed communication from staff brought mental, emotional, and psychosocial distress (Resident 178), and placed all residents at risk for unmet care needs and a decreased quality of life. Facility Policy The 2022 Infection Prevention and Control Program (IPCP) facility policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a process to ensure residents have an Advanced Directive (AD) for 3 of 15 residents (Residents 9, 11, & 20) reviewed for AD. The failure to obtain a copy of an existing AD and/or ask residents if they wish to formulate or decline to formulate an AD, placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored if they were not capable of making their own decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and assess changes in skin condition, follow Physician Orders (POs) for treatment, implement monitoring and interventions for skin care, and ensure residents received wound care consistent with professional standards of practice to prevent skin breakdown for 3 of 5 residents (Residents 20, 1 & 23) reviewed for skin integrity concerns. These failures resulted in worsening of wounds, pain, and a diminished ability to participate with therapy/rehabilitation to Resident 20, placed all residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic drugs (medications that affect mental state). The failure to provide non-medication behavior interventions for 1 of 5 residents (Resident 25), and the failure to have an As Needed (PRN) psychotropic medication re-evaluated every 14 days, for 1 of 5 residents (Resident 16) placed residents at risk for receiving unnecessary medications, experiencing medication-related adverse side effects, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 percent (%). Failure of 1 of 2 nurses (Staff H) to properly administer 2 of 30 medications for 2 of 4 residents (Resident 5 and 17) observed during medication pass resulted in a medication error rate of 10%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication.