Loft Rehab & Nursing of Canton

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a burn injury caused by a homemade hot pack application for one (R1) of 14 residents reviewed for incidents and accidents. This failure resulted in R1 sustaining a blister thermal burn to R1's left outer knee requiring medical treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's anticoagulant therapy was maintained related to a diagnosis of Atrial Fibrillation, obtain a valid physician order prior to discontinuing the medication, and document clinical justification to discontinue a residents anticoagulant therapy for one of three residents (R1) reviewed for quality of care in a sample of three. These failures resulted in (R1) who was at high risk for thromboembolic (blood clots that form in one location and travel to another location, potentially blocking blood flow) events, experienced complications from a suspected complication of Acute Cerebrovascular Accident due to Cerebrovascular Disease and passed away after Xarelto was discontinued for 75 days without physician authorization or documented clinical justification.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's representative of a significant change of medication regimen for one of three residents (R1) reviewed for notification of change in a sample of three.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident's representative was involved with the interdisciplinary team quarterly to review and revise a resident's care plan for one of three residents (R1) reviewed for care plans in a sample of three.

Inspectors wroteBased on interview and record review, the facility failed to ensure coordination of care and communication between the facility and hospice provider for one of one resident reviewed for hospice services in a sample of three.

Inspectors wroteBased on record review and interview the facility failed to implement Infection Prevention and Control Practices after residents were subjected to direct contact from a staff member who tested positive for COVID-19 (Coronavirus 2019) and after residents exhibited symptoms of COVID-19. These failures have the potential to affect all 67 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to use extensive assistance of two staff members during a mechanical lift sit-to-stand transfer for one of four residents (R3) reviewed for falls in a sample of eight. This failure resulted in R3 falling during a mechanical lift sit to stand transfer, sustaining a severely painful dislocated left shoulder.

Inspectors wroteBased on observation, interview and record review the Facility failed to provide physician ordered treatments for three of three Resident's (R1, R2 and R3) reviewed for wound care in a sample of three.

Inspectors wroteBased on observation and record review, the facility failed to ensure food is prepared under sanitary conditions by not using Personal Protective Equipment (PPE) properly to prevent hair from contacting food. This failure has the potential to affect all residents with a current census of 65 residents.

Inspectors wroteThis citation has 2 deficient practice statements. A. Based on record review, observation and interview, the facility failed to wear Personal Protective Equipment (PPE) appropriately, failed to disinfect patient use items and failed to conduct hand hygiene per policy for one of three residents (R41) reviewed for infection control practices in a sample of forty residents. B. Based on observation, interview and record review the facility failed to pass medications in a manner to prevent contamination. This failure has the potential to affect the 19 residents who reside on the 400 hall (R1,R5,R6,R12,R16,R19,R23,R26,R27,R31,R32,R36,R29,R46,R50,R54,R56,R60 and R61) in a total sample of forty.

Inspectors wroteBased on record review and interview the facility failed to provide a completed transfer document for one resident (R68) of 2 residents reviewed for discharge in a total sample of forty. Findings Include: The Facility's Transfer and Discharge policy dated 1/30/24 documents Orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand. Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team. The Facility's Transfer and Discharge policy dated 1/30/24 documents for Emergency Transfers/Discharges that the nurse will Complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to perform personal care for one resident (R20) of twenty residents reviewed for clean and well kempt appearance in a total sample of forty. Findings Include: The Facility's Activities of Daily Living Policy dated 12/5/23 documents Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. The policy also documents A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal hygiene and oral hygiene. R20's Electronic Medical Record documents that R20 was admitted for Hospice Care due to adult failure to thrive and muscle wasting. R20's Point of Care Response History documents that on 8/17/24 R20 was totally dependent for bathing and grooming. [...]

Inspectors wroteBased on record review and interview, the facility failed to complete diabetic monitoring and care for one of two residents (R41) reviewed for quality of care in a sample of 40 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure catheter care was conducted for one of nine residents (R41) with indwelling catheters in a sample of forty residents.

Inspectors wroteBased on observation, interview and record review the facility failed to identify specific triggers of re-traumatization for two residents (R1, R6) reviewed for PTSD (Post Traumatic Stress Disorder) of three residents reviewed for Trauma Informed Care in the sample of 40.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify an appropriate indication for use and identify target behaviors for the use of an antipsychotic medications for three of five residents (R28, R32, R39) reviewed for unnecessary medications in a sample of forty residents.

Inspectors wroteBased on interview and record review, the facility failed to follow the Care Plan to ensure a fall did not occur for one (R1) resident of three residents reviewed for falls/accidents in a sample of three

Inspectors wroteBased on interview and record review, the facility failed to provide the service of a Registered Nurse (RN) eight hours a day seven days week. This has the potential to affect all 65 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately assess a newly acquired wound, implement new skin interventions, obtain a treatment order upon wound identification, revise a wound care plan, and follow physician orders for wound care for two of three residents (R2, R3) reviewed for wounds in the sample of five.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a care plan for a high fall risk resident for one (R42) of 26 residents reviewed for care plans in the sample of 26.

Inspectors wroteBased on interview and record review the facility failed to revise current resident care plans for two (R30 and R31) of 26 residents reviewed for Care Planning in the sample of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a physician ordered wound dressing was in place and ensure cross contamination did not occur during a wound treatment for one (R31) and failed to turn and reposition one (R30) of two residents reviewed for positioning and wound care in the sample of 26.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure infection control practices were maintained to prevent cross contamination during pressure ulcer wound care and ensure physician ordered wound dressing was in place for one (R30) of four residents reviewed for pressure ulcers; and failed to follow its policy and physician orders for wound treatment for one (R35) of four residents reviewed for wound treatments in the sample of 26.

Inspectors wroteBased on observation, interview and record review the facility failed to investigate a fall and conduct a root cause analysis and failed to implement new interventions or increase supervision for one (R42) of two residents reviewed for falls in the sample of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure there was a clinical indication for use of an indwelling urinary catheter for one (R34) and failed to ensure infection control procedures were performed during indwelling urinary catheter cares for one (R30) of three residents reviewed for indwelling urinary catheters in the sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy and physician orders for PICC (Peripherally Inserted Central Catheter) line dressing change treatments for one (R35) resident reviewed for PICC lines in the sample of 26.