Marysville Post-Acute

Inspectors wroteBased on interview and record review the facility failed to follow their wound prevention, maintenance, and wound care policies and procedures (P&P) for three out of three sampled residents (Residents 1, 2, and 3) when: 1A. Resident 1 was provided wound care without a physician's order; and 1B. Skin assessments did not consistently reflect the condition of the skin or wound, and the discharge skin assessment was not completed; and 1C. A change of condition was not documented; and 2. Residents 1, 2, and 3 were not provided with repositioning every two hours. These failures contributed to Resident 1's wound development and placed residents at an increased risk for a delay in wound healing, decline in health status, and could negatively impact their psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure discharge planning needs were met for one out of two sampled residents (Resident 1) when: 1. Resident 1 and his wife (CG, caregiver) were not provided required instructions or education on how to properly care for a wound; and 2. Resident 1 was not discharged from the facility with home health services (care provided in the home to include a nurse who would perform wound care, assessments, and education on wound care and dressing changes). This failure had the potential for the wound to worsen and become infected.

Inspectors wroteBased on interview and record review the facility failed to ensure the discharge Minimum Data Set (MDS, a resident assessment tool) was accurate for one out of two sampled residents (Resident 1) when the discharge MDS did not reflect Resident 1's stage 4 (a deep wound that could expose muscle, tendon, or bone) coccyx (also known as the tailbone, located between the buttocks) wound at discharge. This caused an inaccurate reflection of Resident 1's health status and skin condition at discharge and had the potential to impact the discharge planning process.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide a bed-hold notice upon transfer to the hospital or within 24 hours following an emergency transfer, which affected 2 (Resident #7 and Resident #47) of 3 residents reviewed for hospitalizations.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that 1 (Resident #38) of 4 residents reviewed for medication administration was assessed for their ability to self-administer medications. Specifically, Resident #38 expressed a desire to self-administer their medications, and without first assessing the resident to determine if they were clinically appropriate and safe to do so, the facility allowed the resident to self-administer a nebulizer treatment while unsupervised by staff and denied the resident the right to self-administer their inhaler.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was accurately coded for pressure ulcers and restraints for 1 (Resident #62) of 21 sampled residents.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three residents sampled for patient rights (Resident 1) was treated with dignity and respect when the Marketing Director (MD) had spoken with Resident 1 on the phone with the hospice nurse (HN) available and stated, What the hell are you doing. We would've never brought you back if we knew you weren't going on hospice. Nobody wants you here, This resulted in Resident 1 becoming tearful and had the potential to result in psychosocial harm.

Inspectors wroteBased on interview, and record review, the facility failed to implement resident-directed care consistent preferences and rights for one of three residents sampled for patient rights (Resident 1) when the facility did not maintain a valid copy of Physician Orders for Life-Sustaining Treatment (POLST- a voluntary option for people to use to communicate their end-of-life decisions) in Resident 1's medical record when transfer from the facility via ambulance was made. This failure resulted in Resident 1's right to decline specific treatment in the event of a medical emergency to not be followed.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received supervision to prevent falls for one of four residents sampled for falls (Resident 1). Resident 1 was assessed as high risk for falls and the Interdisciplinary team (IDT) (a facility group composed of a physician, a registered nurse, a social worker and additional appointed facility staff) did not revise Resident 1's fall care plan interventions based on Resident 1's fall risk factors and resident-centered needs to include increased supervision following 14 falls between 8/7/24 and 9/13/24. [...]

Inspectors wroteBased on interviews, observations and record review, the facility did not meet this requirement when it failed to provide evidence of incontinent (no ability to control one's bowels or bladder and requires staff to clean), care for two of 17 sampled residents (Resident 1 and 2). This resulted in the potential for skin breakdown and a loss of dignity for both residents, who were dependent on staff for care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 13 sampled residents (Resident 2) was treated with dignity and respect during direct patient care. This deficient practice had the potential to negatively affect Resident 2's psychosocial well-being and did cause Resident 2 to become angry.

Inspectors wroteBased on observation, interview, and record review the facility failed to have or follow policies and procedures for Quality Assurance and Performance Improvement (QA/PI) nor any formalized QAPI projects as required. This failure demonstrated a lack of quality and performance improvement that could lead to a decrease in Resident quality of life, enjoyment and happiness, causing adverse clinical outcomes.

Inspectors wroteBased on observation, interview and record review the facility failed to have records of Quality Assurance and Performance Improvement (QA/PI) meetings to obtain feedback, use data, and take action in conducting structured, systematic investigations and analysis of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility failing to have a structured, functional QA/PI process addressing potentially harmful and preventable issues creates the potential for resident harm and adverse clinical outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control program was properly maintained or implemented to reduce the spread of infection when: 1. Personal protective equipment (PPE, gloves, gowns, eye protection, and masks) was not consistently and correctly used by staff when providing care for Coronavirus disease (COVID-19: an infectious disease caused by the SARS-CoV-2 virus) positive residents; and 2. Tuberculosis (TB-a bacterial infection that mainly attacks the lung. A tuberculosis screening test checks to see if a person has the bacteria (germs) that cause TB in the body) screen was not done per the facility's policy for one out of six sampled employees. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its Administrating Medications policy and procedure (P&P) for one out of one resident (Resident 53) when Resident 53 was provided a suppository (a meltable medication placed into the rectum) for self-administration. This failure had the potential for incorrect medication administration and could cause Resident 53 negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the facility in a safe and operable manner and provide a homelike environment when: 1. A handrail at the end of Hall 3 was not attached securely to the wall, sections of the ceiling had missing and peeling popcorn texture (a sprayed on bumpy texture that was applied to the ceiling) on Hall 3 and near the nurse station. 2. Five of 13 sampled residents (Residents 18, 75, 46, 55, and 27) expressed that their belongings were missing. This failure had the potential to cause resident harm and resulted in residents' inability to access their own belongings and had the potential to foster an environment that was not home-like.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide sufficient staffing that met the needs of the residents when: 1. Two out of 11 residents (Resident 45 and 50) stated they did not receive a shower due to the facility not having enough staff. 2. Eight out of 11 residents stated they experienced long call light wait time due to the facility not having enough staff. This failure had the potential to result in resident inability to attain or maintain their highest practicable level of physical, mental, and psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review the facility did not post daily staffing for public viewing as required by regulation. This failure created the potential for staffing issues including, short staffing, staffing and workload misinformation leading to decreased quality of care and adverse clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the five rights of medication administration had been followed for one resident (Resident 53) when Licensed Nurse (LN) F did not know the name or dosage of a medication that LN F provided to Resident 53 and LN F did not document the medication had been given. This failure had the potential for incorrect medication administration, duplication for medication administration, and could cause Resident 53 negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide routine showers and/or baths consistent with the residents' needs and choices for 11of 23 (Resident 5, 8, 9, 10, 11, 14, 16, 17, 20, 25, and 26) sampled residents. This failure had the potential to result in depression, poor self-esteem, skin breakdown, infection, and denial of resident rights, all of which could lead to negative clinical outcomes for all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the supervision required to keep all residents free from potential accidents and hazards when: 1. One of seven residents (Resident 1) eloped unsupervised (left without notice) from the facility without staff being aware he was gone. 2. Wanderguard alarms (prevent wander-prone residents from leaving unattended) were not working at two of four facility exit doors. These failures had the potential to compromise the safety and well-being of all residents from unsupervised wandering/elopement with the potential for accident or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' linens were being clean and sanitized using infection control standards. This failure resulted in residents' linens not being cleaned and sanitized properly and had the potential to spread disease and infection throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain essential equipment necessary to ensure resident safety and activities of daily living needs were met when: 1 The Wanderguard Alarm System (prevents wander-prone residents from leaving the facility unattended) did not work for three weeks or more. This failure led to the potential for unsupervised resident elopement (leaving without notice), leading to the potential for harm and preventable accidents/hazards for all residents. 2. One of two facility water heaters did not work for two weeks or more. This failure led to residents not getting baths or showers due to no hot water in the facility with the potential to result in poor self-esteem, depression, denial of resident rights, contribution to skin breakdown, infection, and negative clinical outcomes for all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide consistent administrative oversight to ensure the residents received the care and services to meet their needs when: 1. Pain management and Hospice services were not coordinated and monitored to meet the needs of residents. Refer to F 697, F 726 and F 849. 2. Pharmacy services related to administration, labeling, and storage did not meet standards. Refer to F 755, F 759, F 880 3. Resident council complaints were unresolved. Refer to F 565 4. Ensure safe smoking practices in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide full visual privacy to one out of two sampled residents (Resident 67) when a privacy curtain had been missing for one month. This failure had the potential to cause a decline in Resident 67's mental health and cause psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to address and resolve Resident Council identified issues and concerns for the past four months This failure resulted in pain management needs not to be met, call lights remained being unanswered for an extended amount of time, nutritional needs not to be met and residents felt their grievances were not listened to.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of eighteen smoking residents (Resident 74 and 49) smoked safely in the designated supervised area, securing smoking supplies, and use of safety equipment. This resulted in unsupervised smoking, hazards including cigarettes not properly being disposed of, lack of safety equipment, and had a potential to put all residents at risk for fire hazard and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders when the pain management needs for one of four sampled Hospice (supportive care to terminally ill residents that focuses on their comfort, quality of life, and being pain free) residents when; Resident 281 received a lower than the ordered dose of morphine (a strong pain medication) on 12 of 20 occasions. This failure had the potential for Resident 281 to have uncontrolled moderate or severe pain.

Inspectors wrote9. During a concurrent observation and interview on 8/8/22 at 11:30 am, Resident 74 stated pain medications are late and looked in his journal and gave examples. On 8/1/22 at 9:30 am, CNA showed up at 10 am, then another correct CNA comes at 10:19 am, then he called another CNA at 10:40 am then by 11:50 am, he received his pain medication. On 8/5/22, Resident 74 called CNA at 10:40 am due to reporting pain level was a 7/10 (severe) and by 11:50 am he received his pain medication. Resident 74 stated his pain level right now was a 7/10. Resident 74 stated it makes him feel not happy, frustrated and causes anxiety. Resident 74 stated his pain level after receiving medication is usually a level of 4-5 and was tolerable at that level. Resident 74 stated I'm not the waiting type and stand in the hallway. Resident 74 stated The Hospice nurse was aware. [...]

Inspectors wrote3. A review of Resident 74's record indicated he was admitted to the facility on [DATE], with diagnoses which included heart failure, lung disease, and palliative hospice (end of life) care. Resident 74 was able to make his own health care decisions. A review of physician order dated 4/13/22, Morphine Sulfate Continuous release (MS Contin- a strong, long-acting narcotic pain medication) 15 milligrams (mg) every 12 hours for chronic pain. Morphine concentrate (liquid) 100 mg/5 milliliter (ml), administer 0.25 ml every 2 hours for mild pain (1-3 on pain scale), 0.5 ml orally every 2 hours for moderate pain (pain scale 4-6) and 1 ml every 2 hours for severe pain (pain scale number 7-10). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: 1. Accurate accountability and disposition of the medications awaiting final disposition (means destroying the unused medications to render it ineffective and prevent abuse or diversion) in the facility with a census of 76, 2. The facility's Consultant Pharmacist (CP) documented medication refrigerator temperatures were checked and logged for three out of three months (April, May, and June) when the facility temperature logs had missing data. 3. Routine medications (medications given daily) were not available for use for three out of four residents. These failed practices could contribute to unsafe medication use and prevention of drug diversion in the facility which could lead to negative outcomes.

Inspectors wroteBased on observation, interview, and record review the facility had a 17.24 % (percent) medication error rate, when five medication errors out of 29 opportunities were observed during medication pass for two out of three residents (Resident 16 and Resident 19). These failures resulted in four medications not given and one medication administered at an incorrect dose, which did not follow physician orders. This had the potential for residents to have a decrease of therapeutic medication effects (symptoms the medication is treating), a decline in health status, and negative psychosocial outcomes.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide safe storage and labeling of medications and medical supplies when: 1a. the refrigerator and room temperatures were not consistently monitored in one out of one medication storage rooms. 1b. an unlabeled medication with wet, deteriorated packaging located in medication refrigerator was available for use. 2a. expired medication stored in one out of four medication carts (a locked cabinet on wheels where resident medication is stored). 2b. one out of four medication carts where medication was stored contained loose debris and was dirty. 2c. Expired and unlabeled medication were stored in one out of one treatment cart. These failures had the potential for unsafe medication use, and the use of medical supplies which would no longer be effective, which could lead to negative clinical outcomes.

Inspectors wroteBased on interview and record review the facility did not ensure the food service met resident needs as evidenced by unresolved food complaints surrounding the form, taste and temperature of the food that was served. These failures had the potential to result in decreased resident meal intakes, negatively impact their nutritional health status and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident preferences were honored and offered substitutes of similar nutritive value for 10 of 10 sampled residents (Residents 21, 33, 39, 44, 49, 50, 56, 66, 67, and 76) and four out of eight confidential resident interviews. This failure not to provide food in accordance with resident preferences may result in decreased meal satisfaction and overall caloric intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Hospice agreements and Hospice program ((a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) policy and procedures, and collaborate in the development of a coordinated plan of care, to ensure the physical, psychosocial, spiritual, and emotional needs were meet for four of four sample residents (Resident 57, 58, 74 and 281) when: 1.a. Resident 281 was given wrong dosage, wrong pain medication for the wrong pain level. This resulted in agitation and four falls. 1.b. Resident 281 wasn't provided with Oxygen concentrator on 4/15/22, 4/22/22 and 4/23/22 per physician ordered and hospice plan of care. This could potentially cause respiratory distress for Resident 281. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services met accepted standards of quality when the Quality Assurance and Performance Improvement (QAPI) did not identify and correct quality deficiencies when: 1. Pain management and Hospice services were not coordinated and monitored to meet the needs of residents. Refer to F 697, F 726 and F 849. 2. Pharmacy services related to administration, labeling, and storage did not meet standards. Refer to F 755, F 759, F 880 3. Resident council complaints were unresolved. Refer to F 565 4. Ensure safe smoking practices in the facility. Refer to F 689 This failure resulted in substandard quality of care and had the potential to put all residents at risk for safety and decreased quality of care and life.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance (QAA) committee failed to develop and implement plans of action to correct identified facility issues related to: 1. Pain management and Hospice services were not coordinated and monitored to meet the needs of residents. Refer to F 697, F 726 and F 849. 2. Pharmacy services related to administration, labeling, and storage did not meet standards. Refer to F 755, F 759, F 880 3. Resident council complaints were unresolved. Refer to F 565 4. Ensure safe smoking practices in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection control practices to prevent spread of infection when: 1. The blood pressure (BP) cuff was not effectively sanitized in-between resident care use on two out of two sampled residents (Resident 16 and Resident 19). 2. Licensed Nurse H (LN) touched medications with bare hands on two out of two sampled residents (Resident 16 and Resident 19). 3. a. Oxygen tubing was found on floor, outdated, and or undated for one out of two residents (Resident 43). b. Oxygen tubing was undated for one out two residents (Resident 38). c. Oxygen tubing was unlabeled for one out of one resident (Resident 77) while using a portable oxygen tank. 4. [...]