Lebanon Center, Genesis Healthcare

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to adhere to its policies and procedures for infection control and Legionella prevention. The facility failed to follow the established water management plan by neglecting remediation or testing of the water system after a confirmed resident case of Legionella. Furthermore, the facility failed to document the results of control measures as required by the Water Management Plan. Additionally, the facility allowed the use of a humidifier in a resident's room, which creates a potential risk for the spread and growth of Legionella. Collectively, these failures in following policies, procedures, and the Water Management Plan expose the facility's census of 80 residents to the potential spread and growth of Legionella.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to determine if self-administration of medications was clinically appropriate for 2 of 3 residents reviewed for choices in a final sample of 18 residents. (Resident identifiers are #6 and #8.)

Inspectors wroteBased on record review and interview, it was determined that the facility failed to hold routine interdisciplinary care plan meetings for 2 of 18 residents and failed to develop and update comprehensive care plans for 1 of 18 reviewed in a final sample of 18 residents. (Resident identifiers are #13, #24 and #47.)

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow menu preferences, allergies, and intolerances for 1 resident of 1 resident reviewed for food concerns and 1 resident of 1 resident reviewed for nutrition in a final sample of 18 residents. (Resident Identifiers are #17 and #73.)

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure proper storage of washed linens and ensure proper processing of linens to reduce risk of accidental contamination for 1 of 1 laundry observed.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to implement their smoking policy for 1 of 1 residents reviewed for smoking in a final sample of 18 residents. (Resident identifier is #1.)

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 4 residents in a final sample of 18 residents. (Resident identifiers are #1, #2, #4, and #24).

Inspectors wroteBased on record review and interview, it was determined that the facility failed to obtain written authorization of a resident to act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility for 3 of 5 residents reviewed. (Resident identifiers are #1, #2, and #3.)

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide Quarterly statements in writing to the resident or the resident's representative within 30 days after the end of the quarter for 2 of 5 residents reviewed for personal funds. (Resident identifiers are #1 and #2.)

Inspectors wroteBased on record review and interview, it was determined that the facility failed to notify a resident when the amount in the resident's personal fund account reaches or exceeds $200 less than the SSI (supplemental security income) recourse limit for 1 of 5 residents reviewed for personal funds. (Resident identifier is #1.)

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide sufficient nursing staff as determined by their facility assessment. Findings Include: Review on 7/9/24 of the facilities Payroll Based Journal Staffing Data report Quarter 2, 2024 (January 1-March 31) revealed the facility had excessively low weekend staffing. Review on 7/11/24 of the facility assessment nursing staff and personnel total number needed revealed that the facility assessment determined the required Hours Per Patient Day (HPPD) for nurses aides was 1.63 HPPD. Review on 7/10/24 of the nursing staff punch reports for 6/9/24-7/10/24 revealed the following weekend dates had staffing that was below the staffing numbers determined by the facility assessment: Sunday 6/9/24- Nurse aides 1.57 HPPD; Saturday 6/22/24- Nurses aides 1.49 HPPD; Sunday 6/23/24- Nurse aides 1.45 HPPD; [...]

Inspectors wroteBased on interview, observation, review of facility policy, and review of the facility menu, it was determined that the facility failed to offer the residents a nourishing snack at bedtime while having 15 hours between the evening meal and the breakfast meal.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that a resident received medication as ordered for 1 out of 26 medications observed (Resident Identifier #32).

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure that orders for psychotropic drugs are limited to 14 days for 1 of 1 residents reviewed for psychotropic/opiod side effects (SE) in a final sample of 19 residents reviewed (Resident Identifier #83).

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that a resident was free from a significant medication error for 1 out of 26 medications observed. (Resident identifier is # 32.)

Inspectors wroteBased on observation, interview, record review, and policy review, it was determined that the facility failed to follow Centers for Disease Control and Prevention (CDC) guidance for Enhanced Based Precautions (EBP) for 1 of 1 residents with an Intravenous (IV) access in a final sample of 19 residents (Resident Identifier #32).

Inspectors wroteBased on interview, review of the facility's policy for antibiotic stewardship, review of the facility's antibiotic stewardship program, and review of the facility's antibiotic line listings from March 2024 - June 2024, the facility failed to use antibiotic use protocols that identify unnecessary or inappropriate antibiotic use for 2 out of 4 months reviewed, which could affect all residents prescribed antibiotics.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that training and education was provided to staff on abuse, neglect, exploitation, and misappropriation of resident property for 1 of 5 staff reviewed (Staff Identifier is Staff L (Licensed Nursing Assistant)).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure the activities program was directed by a qualified professional for a facility census of 88 residents.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to update the posted daily nurse staffing information of the actual hours worked at the beginning of each shift on a daily basis.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the required committee members attended meetings at least quarterly for 3 of the 4 quarterly meetings reviewed in 2023/24.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to notify the resident and/or representative of quarterly care plan meetings for 1 of 19 residents reviewed for care plans (Resident Identifier #52).

Inspectors wroteBased on interview, observation, and record review, it was determined that the facility failed to ensure that the residents' Minimum Data Set (MDS) accurately reflected the resident's status for 4 of 19 residents (Resident Identifiers #11, #24, #53, and #76).

Inspectors wroteBased on interview and record review it was determined that the facility failed to inform the resident's representative of a treatment change for 1 of 1 resident reviewed for resident rights (Resident identifier is #1).

Inspectors wroteBased on observation and interview it was determined that the facility failed to provide a sanitary environment for its residents, staff, and public. Observation on 11/21/23 at 09:20 a.m. of the hallway ceiling tiles outside of rooms 101, 110, 108, and 126 (the left 100 hallway) revealed that the ceiling tiles surrounding the metal vents were soiled with a black spotted substance that had been smeared in places. Interview on 11/21/23 at 10:00 a.m. with Staff B (Infection Preventionist) revealed that the tiles had the above substance on them for a few months and he/she was unaware of the cause of the soiling of the tiles. Interview on 11/21/23 at 10:30 a.m. with Staff C (Maintenance Director) confirmed the above findings.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to honor residents' choice for showers for 1 out of 5 residents reviewed for Activities of Daily Living in a final sample of 19 residents (Resident identifier is #52).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that expired vaccines were removed from use for 1 of 2 medication rooms reviewed and that all medication was secured.

Inspectors wroteBased on observation, interview, and policy review, it was determined that the facility failed to follow professional standards for labeling and storage of food items brought to residents by visitors to the facility for 2 out of 2 kitchenettes reviewed.

Inspectors wroteBased on record review and interview it was determined that the facility failed to follow the comprehensive care plan for 2 out of 2 residents reviewed for psychotropic drugs in a final sample of 19 residents (Resident identifiers are #26 and #62).

Inspectors wroteBased on record review and interview, it was determined that the facility failed to update the comprehensive care plan for 1 out of 1 residents reviewed for advance directives (Resident identifier is #26).