Madison Carriage Cove Short Stay Rehabilitation

Inspectors wroteBased on the FDA Food Code, policy review, observation, and interview, the facility failed to ensure food was appropriately stored, distributed, and labeled. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses.

Inspectors wroteBased on policy review, observation, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained when 1) residents consumed meals prepared in the facility kitchen, and 2) residents received insulin injections to manage their diabetes. These failures put residents at risk for adverse outcomes including potential infections or food-borne illness due to cross contamination.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) Level 1, was completed prior to admitting 1 of 3 residents (Resident #32) whose medical records were reviewed for PASARR Level 1 screenings. This failure created the potential for harm if residents required but did not receive specialized services for mental health while residing in the facility.

Inspectors wroteBased on observation, CPAP manufacturers warning guidelines, record review, and interviews, it was determined the facility failed to provide respiratory services consistent with manufacturers warning guidelines and professional standards of practice. This was true for 1 of 2 residents (Resident #8) whose respiratory equipment was observed. This failure created the potential for residents' respiratory equipment to malfunction and possibly increase the risk of fire.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure daily nurse staffing sheets were maintained for a minimum of 18 months. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents were free of medication preparation and administration errors for 1 of 1 resident (Resident #2) observed for medication preparation and administration of insulin. This failed practice placed the resident at risk for not receiving their prescribed medication dosage and other adverse outcomes.

Inspectors wroteBased on observations, policy review and staff interviews it was determined the facility failed to ensure medications were properly stored, not expired, and disposal of unused medications. This was true for the facility. This failure created the potential for residents to receive expired medications with decreased efficacy or cross contamination from topical products.

Inspectors wroteBased on policy review, I&A review, record review, and staff interview, it was determined the facility failed to ensure adequate supervision and implement interventions to prevent falls. This was true for 1 of 1 resident, (Resident #24) whose records were reviewed for falls. This resulted in harm to Resident #24.

Inspectors wroteBased on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to appropriately store, label, and serve foods. This deficient practice had the potential to affect all residents who received meals from the facility kitchen served in the dining room and resident rooms. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure residents were assessed to determine if they were safe to self-administer medications. This was true for 1 of 1 residents (Resident #13) reviewed for self-administration of medications. This failure created the potential for adverse effects if residents self-administered medications inappropriately.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an advanced directive. This was true for 3 of 4 residents (#7, #185, and #186) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented.

Inspectors wroteBased on policy and record review, and staff interview it was determined the facility failed to ensure pertinent health information was provided to the receiving hospital for 1 of 1 resident (Resident #14) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if the residents were not treated in a timely manner due to a lack of information provided upon transfer.

Inspectors wroteBased on policy and record review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives upon transfer to the hospital. This was true for 2 of 2 residents (#14 and #24) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to develop, review with the resident, and implement a baseline care plan. This was true for 1 of 13 residents (Resident #7) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in their baseline care plans.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure resident comprehensive care plans were completed and reviewed with residents and update care plans when changes occur to resident's care. This was true for 3 of 13 residents (#7, #13, and #24) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided as residents needs changed.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and stored appropriately; this was true for 1 of 2 medication storage rooms inspected, and 1 of 2 medication carts audited for labeling and storage of medication. This failure created the potential for residents to miss doses of medication, to receive expired medications with decreased efficacy, and created the potential for misappropriation of resident's medications.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.

Inspectors wroteBased on interview, document review, review of the Centers for Disease Control and Prevention (CDC) guidance, and review of facility policy, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional Antibiotic Stewardship Program that followed the McGeer Criteria for antibiotics for 1 of 13 residents (Resident #185) whose medical records were reviewed. This had the potential to affect residents being prescribed antibiotics that were potentially unnecessary.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 3 residents (Resident #188) reviewed for insulin administration. This failed practice created the potential for harm should residents experience adverse outcomes from low blood sugar when the hypoglycemic (low blood sugar) protocol was not followed.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure expired medications and wound care supplies were not available for administration to residents. This was true for 2 of 2 medication storage rooms inspected. This failed practice created the potential for residents to receive expired medications or supplies with decreased efficacy.