Mansion Nursing and Rehab Center

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure residents were free from significant medication errors for 1 of 1 resident reviewed. Resident ID #1 was inadvertently administered multiple medications by the nurse assigned to Resident ID #1's roommate, Resident ID #2. The medications included, an insulin injection, two antipsychotics, an antidiabetic, a benzodiazepine, an anticonvulsant, two antidepressants, a laxative, and eye drops. Additionally, Resident ID #1 was previously administered his/her prescribed morning medications from the Medication Aide prior to mistakenly receiving his/her roommate's medications. As a result of the errors, Resident ID #1 became unresponsive and hypoglycemic (a condition that occurs when your blood sugar level drops below a healthy range) and required hospitalization.

Inspectors wroteBased on clinical record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following provider orders for 40 of 48 residents reviewed, Resident ID #s 1 through 40.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that before a resident is transferred to a hospital or the resident goes on therapeutic leave that the facility provides written information to the resident or resident representative that specifies information about the bed hold policy, for Resident ID #1.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that residents are free of any significant medication errors for one of three residents reviewed, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to measure success and track performance of Quality Assurance and Performance Improvement (QAPI) actions to ensure that problem areas are identified, and good faith efforts for improvements are achieved and sustained demonstrated by measurable objectives with statistical data documented.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharmacist Medication Regimen Review (MRR) were acted upon for 4 of 4 residents reviewed, Resident ID #s 5, 7, 14, and 25.

Inspectors wroteBased on record review, staff and resident interviews, it has been determined that the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, for a resident who is diagnosed with a mental disorder and has a history of trauma, for 1 of 1 resident reviewed, Resident ID #28.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for a medication with blood pressure parameters, Resident ID #3.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to notify each resident, or resident representative, that receives Medicaid benefits upon death of a resident with a personal fund deposited with the facility, within 30 days of the resident's funds, and provide a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate, in accordance with State law for 2 of 2 residents reviewed who expired with funds remaining at the facility, Resident ID #s 57 and 58.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to prepare, store, and distribute food according to professional standards of food service safety, relative to 1 of 1 ice machine and 1 of 1 kitchenette observed.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections related to the implementation of water system management control measures to mitigate the development of Legionella (a very serious type of lung infection caused by the bacteria called Legionella which can be found in water) and other opportunistic waterborne pathogens for 1 of 1 ice scoop and designated container. Additionally, the facility failed to maintain Enhanced Barrier Precautions (EBP; [...]

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store all drugs and biological's in accordance with currently accepted professional principles for 1 of 1 medication storage room observed, 1 of 1 medication refrigerator, and 2 of 3 medication carts observed ([NAME] One and Two).

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public relative to resident rooms and furnishings in disrepair on 3 of 6 units observed.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to following a physician's order for 1 of 1 residents reviewed for significant weight gain, Resident ID #38.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 residents reviewed for respiratory care, Resident ID #47.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to obtain written authorization for residents whom the facility is holding personal funds relative to 2 of 6 residents reviewed Resident ID #s 10 and 38.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that each resident was given a written accounting of his/her deposits, withdrawals, and balances at least quarterly for 2 of 6 residents reviewed, Resident ID #s 3 and 38.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to notify each resident, or resident representative, that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the Social Security Income (SSI) resource limit for 3 of 6 residents reviewed for personal needs funds handled by the facility, Resident ID #s 10, 16 and 17.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide residents with the right to personal privacy and confidentiality of his/her personal and medical records relative to the posting of past survey results.

Inspectors wroteBased on surveyor observations and staff interview, it has been determined that the facility failed to properly store, distribute, and serve food, in accordance with professional standards for food service safety, relative to the main kitchen and 1 of 1 kitchenette.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies which must be reviewed and updated as necessary, and at least annually. Additionally, the facility failed to review and update the assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the medical care of each resident is supervised by a physician for 1 of 2 residents reviewed receiving anticoagulant therapy (medication that prevents or reduces the blood from clotting), Resident ID #45.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 3 residents reviewed for nutrition, Resident ID #8 and 1 of 2 residents reviewed for opioid administration, Resident ID #s 8 and 26.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to provide training to their staff, that at a minimum includes Resident's rights and facility responsibilities, for 7 out of 15 staff reviewed.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to provide training to their staff, that at a minimum includes abuse, neglect, exploitation, and misappropriation of resident property and dementia management, for 7 out of 15 staff reviewed.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality regarding following a physician's order for 1 of 13 residents reviewed, Resident ID #8.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to provide mandatory training to all their staff, that outlines and informs staff of the elements and goals of the facility's QAPI (Quality Assurance and Performance Improvement) program, for 15 out of 15 staff reviewed.