Lebanon South Nursing & Rehab

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure all residents were treated with respect and dignity when one staff (Certified Nurse Aide (CNA) B) laid on one resident's (Resident #5) bed, next to the resident, while the resident was sleeping to try and wake the resident. The facility census was 71. Review of the facility policy titled, Resident Rights not dated, showed the following: -The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. A facility much protect and promote the rights of each resident;-Resident Rights are to be fully respected and adhered to. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an effective and complete grievance policy when staff failed to document and track residents' grievances,failed to make prompt efforts to resolve the residents' grievances and failed to provide a written summary of conclusions regarding the residents' grievances filed in resident council when the resident council members filed grievances/complaints regarding missing items, untimely responses to call lights, and rude/disrespectful staff. The facility census was 71. Review of the facility's policy titled, Grievance Protocol, not dated, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to ensure staff obtained, clarified, and followed physician's orders for the use of one resident's (Resident #1) implanted port (device placed under the skin that provides long-term access to a vein for treatments like chemotherapy, intravenous (IV) fluids, nutrition, or for drawing blood, eliminating repeated needlesticks through the skin) to administer an IV antibiotic when staff failed to de-access the port as ordered and failed to obtain orders regarding port site dressing changes. A sample of four residents were reviewed. The facility census was 65. Review of facility policies showed the facility did not provide a policy or procedure pertaining to the use of a port for treatments or medications. 1. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management when the Dietary Manager's certified was expired. The facility census was 65. Review of the facility policy titled, Dining Services Department, dated May 2015, showed the following: -Dining services department supervision was to be under the guidance of a full-time person qualified by training and experience; -The Dining Services Manager (DSM) was to make sure that procurement and production and food products was carried out to ensure the resident a sufficient quantity of wholesome and nourishing food acceptable variety and quality. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards of practice and in a manner to prevent possible contamination when the facility staff failed to keep dented cans separate from other canned goods, failed to maintain contact surfaces in a manner that would prevent possible contamination of food, failed to sanitize the food thermometer between items, failed to ensure all food items were properly labeled and sealed, and when staff failed to use only food items stored in a safe manner when preparing food. The facility census was 65. 1. Review of the 2022 Food and Drug Administration (FDA) Food Code showed the following information: -Depending on the circumstances, rusted, and pitted or dented cans may present a serious potential hazard; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when the facility staff failed to follow standard precautions (the infection prevention measures that apply to all resident care, regardless of suspected or confirmed infection status of the resident, in any setting where healthcare is being delivered) during medication passes, when the facility staff failed to perform hand hygiene between residents during medication passes, and failed to disinfect the multi-use glucometers (a medical device that measures the amount of glucose (sugar) in the blood stream. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sanitary environment for all staff and residents, when staff failed to maintain the floors, deep fryer, and plastic containers clean and free of dirt. The facility census was 65. Review of the facility policy titled, Nutrition and Dining Services Manual, dated May of 2015, showed the following: -It is the responsibility of the Dining Services Manager (DSM) to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; -Daily, weekly, and monthly cleaning schedules prepared by the DSM with all cleaning tasks listed will be posted in the dietary department; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate less than 5 percent when facility staff made three mediation errors out of 25 opportunities resulting in in a medication error rate was 12 % affecting three residents (Resident #15, #39, and #61). The facility census was 65. Review showed the facility did not provide a policy regarding insulin administration. Review of Humalog (insulin lispro injection - a rapid acting insulin) Manufacturer's Instructions, dated 03/2013, showed the following: -Pull the pen cap straight off and wipe the rubber seal with an alcohol swab; -Pull off the paper tab from outer needle shield; -Push the capped needle straight onto the pen and turn the needle forward until it is tight; -Pull off the outer needle shield, but do not throw it away; -Pull off the inner needle shield and throw it away; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident were free of significant medication errors when staff failed to prime insulin pens before insulin administration for three residents (Resident #15, #39, and #61). The facility census was 65. Review showed the facility did not provide a policy regarding insulin administration. Review of Humalog (insulin lispro injection - a rapid acting insulin) Manufacturer's Instructions, dated 03/2013, showed the following: -Pull the pen cap straight off and wipe the rubber seal with an alcohol swab; -Pull off the paper tab from outer needle shield; -Push the capped needle straight onto the pen and turn the needle forward until it is tight; -Pull off the outer needle shield, but do not throw it away; -Pull off the inner needle shield and throw it away; -Turn the dose knob to select 2 units; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all food was prepared in a manner that conserved the nutritional value of the food when staff failed to follow approved recipes for preparation of pureed recipes potentially affecting the nutritional value of the food prepared. The facility census was 65. Review of the facility policy titled, Types of Diets, dated May of 2015, showed the following: -Regular mechanical soft was a diet that followed the regular diet and was modified mainly in the method of preparation to accommodate residents when chewing is difficult/limited. Meat will be chopped or ground; -Pureed diet was the diet for the edentulous resident and residents with swallowing difficulties. Foods were blended to mashed potato consistency or altered to meet the needs of the resident, using as little liquid as possible. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean, comfortable, and homelike environment, for all resident when the facility failed to maintain a sanitary and orderly interior room for two residents (Resident #10 and Resident #15. The facility census was 65. Review of the facility's policy titled, Cleaning Guidelines-Bed Mattress, undated, showed the following information: -Mattress are to be cleaned when soiled, on bath days, and when the room is deep cleaned; -Bed linen should be removed and placed in dirty linen barrel and any debris should be removed; -Spray the mattress with disinfectant and wipe clean. Allow the bed to air dry; -Make the bed with fresh linen after mattress has dried. Review of the facility's policy, titled Pest Control, undated, showed the following information: [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete a significant change Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) within the required 14 days after hospice service admission for one resident (Residents #4) of twenty sampled residents. The facility had a census of 65. 1. Review of Resident #4's face sheet showed the following: -admission date of 06/01/23; -Diagnoses included Alzheimer's dementia, anxiety, arthritis, and type 2 diabetes. Review of the residents physician's orders showed an order, dated 06/25/24, for hospice consultation. Review of the resident's hospice agreement showed the agreement signed on 06/27/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that met professional standards of quality when the facility failed to document completion of proper notification and post fall assessments/monitoring for one resident (Resident #16) who was found on the floor by staff. The facility census was 65. Review of the facility's policy, titled Event Investigation, undated, showed the following information: -Complete a report of event form as soon as possible whenever there is an unusual, unexpected, and/or unintended event that is not consistent with the routine operation of the facility, the routine care of the resident and/or adversely effects or has the potential to adversely affect a resident or visitor; -The form should be completed with falls or when a resident is found on the floor; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards when facility staff failed to complete an ordered x-ray and follow-up with the ordering provider for one resident (Resident #1) who had complaints of leg pain and swelling until, three days after the initial order resulting in delayed treatment of a fractured ankle. The facility census was 74. Review showed the facility did not provide a policy related to resident change in condition. 1. Review of the Resident #1's face sheet (brief information sheet about the resident), showed the following: -admission date of 11/18/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice when staff failed to ensure oxygen and nebulizer tubing were stored properly when not in use when the nebulizer tubing and mouthpiece was noted to be on the floor and not in protective cover for one resident (Resident #2 ), noted to be on the chair and not in protective covering for one resident (Resident #4), and oxygen nasal cannula (thin, flexible tube that delivers oxygen through the nose) and tubing was on the back of the resident's wheelchair not in a protective bag for one resident (Resident #3) in a common area. The facility census was 74. Review of facility policy titled Oxygen Administration, undated, showed the following: -Purpose of policy was to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to establish and maintain an effective infection prevention and control program when staff failed to educate staff on and implement a process for Enhanced Barrier Protection (EBP - are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) policy and procedure when staff did not wear gowns when completing catheter (a flexible tube that drains urine from the bladder) care for two residents (Resident #2 and #4). The facility census was 74. Review of the Centers for Disease Control and Prevention (CDC)'s Considerations for Use in Skilled Nursing Facilities, dated 06/2021, showed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep all food safe from potential contamination when staff stacked clean, wet dishes tracking water in them, when staff failed to keep food containers sealed, when staff failed to keep the walk-in freezer clean, and when failed to complete proper hand hygiene and used bare hands to touch ready to eat food while proving meal assistance to six residents (Resident #36, #31, #8, #9, #20, and #62). The facility. The facility census was 64. 1. Review of the facility's policy titled General Dish Room Sanitation, by Nutrition and Dining Services Manual, dated May 2015, showed the following information: -All items are to be air dried; -No moisture can be found on any stacked item. Review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and/or the resident's representative of a transfer or discharge to the hospital, including the reason for the transfer, in writing for three residents (Residents #23, #45, and #21) of 21 residents sampled. The facility census was 64. Review showed the facility did not provide a policy regarding written transfer notices. Review of a facility form letter Emergency Transfer Notice showed the following: -Staff should fill in the spaces for: date, resident name, responsible party/representative name and address, transferring facility name, effective date, Ombudsman information, hospital/facility name and address, facility contact phone number, and name of Administrator. 1. Review of Resident #23's face sheet (gives basic profile information) showed the following: -admission date 12/28/19; [...]

Inspectors wroteBased on record review and interview, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for three residents (Residents #23, #45, and #21) who were transferred out to the hospital. A sample of 21 residents was selected for review in a facility with a census of 64. Review of the facility's form entitled Bed Hold Guidelines, undated, showed the following: -This facility will notify all residents and/or their representative of the bed hold guidelines. This notification shall be given on admission to the facility, at the time of transfer to the hospital, and at the time of non-covered therapeutic leave; -Medicare does not pay for any type of bed hold. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to store refrigerated medications at the medication's recommended temperatures and failed to have a system in place to monitor and adjust the temperature as needed. The facility census was 64. Review of the facility's policy titled Storage of Medications, undated, showed the following: -All medications are stored in a safe and secure area; -Medications requiring refrigeration are stored in a refrigerator located in the medication room located behind the nurses' station. -Medications are stored separately from food and are labeled accordingly. Review of the Centers for Disease Control and Prevention (CDC) guidelines for vaccines, dated 03/26/21, showed the following: -Never freeze refrigerated vaccines; -Ideal temperature of refrigerated vaccines is 40 degrees Fahrenheit (F); [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their infection control policies and procedures when staff failed to ensure the first and second step of a required two step tuberculosis (TB-a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test was administered timely for three out of ten randomly chosen employees. The facility census was 64. Review of the facility's TB policy titled Tuberculosis Control, undated, showed the following information: -If a new hire is unable to show documentation of a current TB two step and the results, then the first step PPD (Mantoux method purified protein derivative (PPD - a skin test to determine if someone has tuberculosis)) will be administered by the nursing department; -This will be documented on the employee immunization record; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated all residents with dignity and respect when they failed to ensure two residents (Residents #8 and #20) were appropriately dressed in common areas. A sample of four residents was selected for review in a facility with a census of 64. Review showed the facility did not provide a facility policy addressing residents' right to dignity and respect. 1. Review of Resident #8's face sheet (gives basic profile information) showed the following information: -admission date of 01/17/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate self-determination when staff failed to honor two residents' (Resident #15 and #35) reasonable shower preferences. The facility census was 64. Review of the facility's policy titled Bath (Shower), undated, showed the purpose was to maintain skin integrity, comfort, and cleanliness. 1. Review of Resident #15's face sheet (admitting demographic and payee information) showed the following: -admission date of 07/21/13; -Diagnoses included age-related cognitive decline, personal history of (healed) traumatic fracture, anxiety disorder, atrial fibrillation, and retention of urine. Review of the resident's admission Minimum Data Set (MDS - federally mandated assessment completed by facility staff), dated 7/26/23, resident required assistance of one person for showering. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide consistent and timely showers/baths for all residents to maintain good grooming and personal hygiene when one dependent resident (Resident #8) did not receive timely showers and had hair that appeared oily and unkept. The facility's census was 64. Review showed the facility did not provide a policy specific to the scheduling of and/or providing assistance with residents' showers. 1. Review of Resident #8's face sheet (gives basic profile information), showed the following information: -admission date of 01/17/22; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain physicians orders for use, complete a pre-use assessment, obtain informed consent, and ensure measurements were within safety guidelines prior to bed rails being placed on the beds of two residents (Residents #12 and #55) of two residents sampled. Staff failed to care plan the use of bed rails for one resident (Resident #12). The facility census was 64. Review of a facility policy and procedure entitled Bed Rails, undated, showed the following: -Bed rails (also referred to as side rails, safety rails, mobility bars, etc.) are constructed of metal or plastic, and are available in various sizes (e.g., full length rails, half rails, quarter rails). Bed rails may be positioned in various locations on the bed; upper or lower, one or both sides; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to maintain a system that accounted for all controlled medications when staff failed to document administration of a controlled medication on the Control Substance and failed to ensure an accurate count of the controlled medication for one resident (Resident #14). The facility census was 64. Review of the facility policy titled, Controlled Substance Medication Policy, undated, showed the following: -Nurses are to count all narcotics at the beginning and end of every shift and sign the narcotic sheet prior to taking over the narcotic cart. 1. Review of Resident #14's face sheet (brief resident profile) showed the following information: -admission date of 07/06/23; -Diagnoses included weakness, anxiety, pain, hypertension (high blood pressure), and transient ischemic attack (TIA - a brief stroke-like attack). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form to meet each resident's needs when staff staff failed to serve one resident (Resident #62) a physician ordered pureed diet. The facility had a census of 64. 1. Review of Resident #62's face sheet (a brief resident profile) showed the following information: -admission date of 08/04/23; -Diagnoses included cerebral infarction (stroke) and weight loss. Review of the resident's Physician Order Sheet (POS), current as of 10/06/23, showed the following orders: -An order, dated 08/04/23, for pureed diet; -An order, dated 08/04/23, for speech therapy to evaluate and treat as needed. Review of the resident's Speech Therapy Treatment Encounter notes showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four residents (Resident #9, Resident #18, Resident #21 and Resident #28) remained free from misappropriation of property, when the business office manager (BOM) withdrew cash from residents' bank accounts and did not give the money to the residents. The facility's census was 49. Record review of the facility's policy, Abuse, Neglect, and Misappropriation of Property, dated 11/28/16, showed the following: -The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Record review of the facility's policy titled Facility/BOM Resident Trust Workflow, undated showed the following: -Withdrawals: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to maintain sufficient staff to provide timely monitoring of two residents (Resident #26 and #31) for needed incontinent care; to provide bath/showers as preferred/needed for two residents (Resident #31 and #46); to provide adequate staff to assist four residents (Resident #7, #20, #26, and #41) with meals; and to answer call lights timely. The facility census was 49. Record review showed the facility did not provide a policy regarding frequency of showers or how often staff should make rounds/observations on residents. 1. Record review of the Resident Census and Conditions form, (form staff required to complete on annual survey) completed by the Director of Nursing, dated 3/29/21, showed the following information: -Census of 49 residents; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to administer the correct dose of insulin per the physician's order for three residents (Resident #33, Resident #34 and Resident #39). The facility census was 49. Record review showed the facility did not provide a policy regarding administration of sliding scale insulin 1. Record review of Resident #34's face sheet showed the following: -Resident admitted to the facility on [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to wash or sanitize hands per nursing standards for infection control when providing incontinent care and/or grooming for six residents (Resident #7, #20, #26, #31, #41 and #152). The facility had a census of 49. Record review of the facility's policy titled, Nursing Guidelines Manual, Handwashing, dated March 2015, showed the following information: -Turn on the water and adjust temperature; -Soap hands well; -Rub hands briskly, paying special attention to area between fingers; -Use brush to clean under nails as necessary; -Rinse with hands lowered to allow soiled water to drain directly into sink; -Do not splash water onto clothing; -Do not allow hands to touch sink; -Use disposable hand towel to turn off faucet and dry hands well, especially between fingers; -Apply moisture barrier if desired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate nail care and personal hygiene assistance for two dependent residents (Resident #31 and #152) following incontinent episodes. The facility census was 49. Record review of the facility's policy titled, Bath (Partial) (Nursing Guidelines Manual, March 2015), showed the following information: -Care of fingernails and toenails is part of the bath. Be certain nails are clean. 1. Record review of Resident #152's face sheet showed the following: -Resident admitted to the facility on [DATE]; -Diagnoses included psoas (lower back) muscle abscess (an enclosed collection of liquefied tissue) and intervertebral disc degeneration, lumbar region. Observation on 3/30/21, at 11:08 P.M., showed the following: -Certified Nurse Aide (CNA) C and CNA E entered the resident's room to answer the call light; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff followed physician orders regarding administration of the oxygen at the correct liters per minute (LPM - measurement of oxygen) and failed to keep water in the humidifier (bubble-type humidifier provides long-lasting moisture for utmost patient comfort during oxygen therapy) used with supplemental oxygen for one resident (Resident #48). The facility census was 49. Record review of the Journal of Respiratory Care, Volume 58, Issue 8, article titled, Humidification of Inspired Oxygen, dated August 2013, showed the following information: -Exposure to dry and undiluted oxygen may cause mucosal dryness and irritation; -Chronic exposure may cause local inflammation, bleeding of the mucosa, and possibly nasal-septal perforation; [...]