Legacy Health and Rehabilitation of Pleasant Grove

Inspectors wroteBased on observations, interviews, and review of the facility policies titled, Sanitation Principles and Garbage and Refuse, the facility failed to dispose of garbage and refuse in a sanitary method and in accordance with their policy. This deficient practice had the potential to affect all residents and staff in the facility.

Inspectors wroteBased on record review, interviews, and observations, the facility failed to ensure: 1. Resident Identifier (RI) #107's electrical outlet was repaired, which had detached from the wall and was hanging by electrical wire approximately one to two feet from the resident while in bed; and 2. a handrail between a resident room and the linen room was securely affixed to the wall. This deficient practice affected one of 42 sampled residents and was observed with handrails located on one of four units in the facility.

Inspectors wroteBased on observations, interviews, record review, and review of a facility policy titled, Medication Administration - General Guidelines, the facility failed to maintain a medication error rate less than 5%. There were 3 errors in 26 opportunities, which resulted in a 11.54% medication error rate involving Resident Identifier (RI) #59 and RI #93 during medication pass. Specifically, the facility failed to ensure: 1. RI #59 received a multivitamin and chewable aspirin as ordered by the physician; and 2. RI #93 received the correct dilution of an intravenous medication. This deficient practice affected RI #59 and RI #93, two of seven residents observed during medication pass.

Inspectors wroteBased on observations, interviews, and review of an Abbott BinaxNOW COVID-19 Ag procedure card, the facility failed to ensure proper administration of the COVID-19 test for Employee Identifier (EI) # 27, the Maintenance and Environmental Services Director, on 02/08/2022, when the result of his COVID-19 testing card was interpreted as negative before completion of the 15 minute required testing time-frame. This was observed during one of three observations of staff performing COVID-19 testing.

Inspectors wroteBased on interviews, record review, and review of a facility policy titled, Person Centered Care Plans, the facility failed to ensure Resident Identifier (RI) #83 was invited to participate in care plan meetings. The deficient practice affected RI #83, one of one resident sampled for care plan meetings.

Inspectors wroteBased on medical record review, interviews, observations, and review of a facility policy titled, Hygiene and Grooming, the facility failed to ensure Resident Identifier (RI) #52 received assistance with personal grooming. This deficient practice affected RI #52, one of two residents sampled for activities of daily living.

Inspectors wroteBased on medical record review, interviews, observations, and review of a facility policy titled, Enteral Tube Administration, the facility failed to ensure Employee Identifier (EI) #4, a Licensed Practical Nurse (LPN), did not manually use the plunger of a syringe to force medications into Resident Identifier (RI) #34's percutaneous endoscopic gastrostomy tube during medication administration on 02/10/2022. This deficient practice affected RI #34, one of one resident observed receiving medications via percutaneous endoscopic gastrostomy tube during medication pass observations

Inspectors wroteBased on observations, interviews, record review, and review of a policy titled, Medication Monitoring Antipsychotics, the facility failed to monitor behaviors for Resident Identifier (RI) #45 who was receiving the psychotropic medication Seroquel (antipsychotic). This deficient practice affected RI #45, one of seven residents reviewed for psychotropic medication use and behavior monitoring.

Inspectors wroteBased on observation, interview, and review of the Food and Drug Administration (FDA) 2017 Food Code, the facility failed to: 1) prevent the potential for cross contamination by ensuring there were air gaps between the floor drain and the drain pipes from the dishwasher and the pot and pan sinks, 2) ensure the drain pipe of the only handwashing sink in the dishroom was connected to the sink so that it could be functional for staff use, and 3) ensure three of ten air vents in the kitchen were clean and free of a black substance, identified by facility staff as mold. This had the potential to affect all residents receiving meals from the facility, 119 of 125 residents.

Inspectors wroteBased on record review, interview and a document titled RAI (Resident Assessment Instrument) Version 3.0 Manual the facility failed to ensure Resident Identifier (RI) # 168's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/11/19 accurately reflected the residents level of assistance needed with transfers. This affected RI # 168, one of 31 sampled residents for whom MDS assessments were reviewed. Findings Include: RI #168 was admitted to the facility on [DATE]. A review of a document titled RAI Version 3.0 Manual documented the following: .G0110:Activities of Daily Living (ADL) Assistance .Code 4, total dependence: if there was full staff performance of an activity with no participation by resident for any aspect of the ADL activity and the activity occurred three or more times. [...]

Inspectors wroteBased on record review, interview, review of a policy tilted Person Centered Care Plans and review of a facility document tilted Resident Incident Report the facility failed to ensure four people were used to transfer Resident Indentifier (RI) # 8 on 6/12/19 as required per RI #8's care plan. This affected RI # 8, one of 31 sampled residents for whom care plans were reviewed. Findings Include: A review of a facility policy tilted Person Centered Care Plans, dated 8/15/18, revealed: .Person centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident/guest . RI # 8 was readmitted to the facility on [DATE] with a diagnosis of Morbid (severe) obesity. On 6/13/19 at 11:31 AM RI #8's family member stated RI #8 sustained a fall on 6/12/19 when staff were transferring the resident from the bed using a hoyer lift. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure four staff members were present on 6/12/19 during a transfer with a Hoyer Lift, that resulted in Resident Identifier (RI) #8 sustaining a fall. This affected RI # 8, one of two sampled residents reviewed for fall concerns. Findings Include: RI # 8 was readmitted to the facility on [DATE] with a diagnosis of Morbid (severe) obesity. On 6/13/19 at 11:31 AM RI #8's family member stated RI #8 sustained a fall on 6/12/19 when staff were transferring the resident from the bed using a hoyer lift. A review of a facility documented tilted Resident Incident Report documented the following: . Date/Time: 6/12/19 03:45 PM . Resident (RI #8) was being transferred from bed to chair using a Hoyer lift per 3 CNA's (Certified Nursing Assistants). The hoyer (lift) tipped over and resident fell to the floor . [...]

Inspectors wroteBased on observation, interviews, and review of a facility policy titled Hand Hygiene, the facility failed to ensure a licensed nurse washed her hands during medication administration for Resident Identifier (RI) #29 after putting a facemask on the resident, when changing gloves, after wiping the bedside table, and prior to leaving RI #29's room to return to the medication cart. This affected one of three licensed nurses observed during medication pass and one of three residents receiving medications during medication pass. Findings Include: A review of a facility policy titled, Hand Hygiene, with an effective date of 9/01/2017, revealed, Hand hygiene continues to be the primary means of preventing the transmission of infection . situations that require hand hygiene . After removing gloves . RI #29 was readmitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, interview, and review of the 2017 Food Code, the facility failed to ensure dietary staff did not use the same dirty washing cloth to lift the sanitized pots and pans from the sanitizing sink and wipe off the bottoms of the pots and pans. Further, the facility failed to ensure the dish machine reached 180 degrees during the rinse cycle. This had the potential to affect all residents receiving meals from the kitchen.

Inspectors wroteBased on observations and interviews, the facility failed to ensure Resident Identifier (RI) #36's room was homelike. This affected one of 24 sampled residents whose rooms were observed.

Inspectors wroteBased on review of Resident Identifier (RI) #227's Medication Administration Record (MAR), review of RI #227's medication card, a medication cart check, review of facility policies titled Medication Administration, and Disposal of Medications, and staff interviews, the facility failed to ensure an expired medication prescribed for RI #227 was removed from the medication cart and not administered to RI #227. This affected one of 24 sampled residents and one of two medication carts observed. Findings Include: A review of a facility policy titled Medication Administration dated, 03/11, documented: . Procedures . 15. Check expiration date on package/container . A review of a facility policy titled Disposal of Medications, dated 03/11, documented: . Policy . expired medications . are destroyed or disposed of per federal/state regulations. [...]

Inspectors wroteBased on observation during medication administration, review of the facility's policies titled Hand Hygieneand Infection Prevention & (and) Control Program, and staff interviews, the facility failed to ensure licensed staff washed her hands after picking up a dropped pill and before administering Resident Identifier (RI) #88's medications. Further the licensed staff used gloves from her pocket to administer eye drops to RI #88. This affected one of five residents, and one of two nurses observed during mediation administration. Findings Include: A review of a facility policy titled Infection Prevention & Control Program with an effective date of September 1, 2017 documented: . PURPOSE . To provide guidelines to employees for . hand washing techniques that will aide in the prevention of the transmission of infections . GOALS . A. Decrease the risk of infection to resident . [...]

Inspectors wroteBased on observation, interview, and review of the facility form titled REPORT OF NURSING STAFF DIRECTLY RESPONSIBLE FOR RESIDENT CARE and the facility protocol titled . Nurse Staff Posting Protocol, the facility failed to ensure nurse staffing was posted for the evening shift on 6/25/18 when surveyors arrived at the facility. This had the potential to affect all 117 residents residing in the facility.