McIntosh Care and Rehabilitation Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#88) of three residents reviewed for accidents received adequate supervision out of 38 sample residents. Resident #88 was admitted on [DATE] with diagnoses cerebral infarction (stroke), acute respiratory failure, atrial fibrillation, pacemaker, osteoarthritis, obesity, hypertension and acute kidney failureOn 12/16/26, Resident #88 was being transported to an appointment in the facility's transportation van. Resident #88's wheelchair was not properly secured in the transportation van. During the transportation, Resident #88's wheelchair slipped and the resident hit her head on the van. [...]

Inspectors wroteBased on record review and interviews, the facility failed to honor resident choices for four (#17, #29, #41, #77) of 12 residents reviewed out of 38 sample residents. Specifically, the facility failed to ensure Resident #17, Resident #29, Resident #41 and Resident #77 received showers consistently according to the resident's choices and plan of care.

Inspectors wroteBased on observation and interviews, the facility failed to provide a clean, comfortable and homelike environment for resident rooms on two of four units. Specifically, the facility failed to provide clean linen hand towels and washcloths on a daily basis.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for one of the two medication carts. Specifically, the facility failed to ensure there were no loose pills in the medication cart.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure meals were served according to the resident's preferences on three of four units. Specifically, the facility failed to provide menus to residents in order for the residents to choose their meals and honor food preferences.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the facility failed to ensure the laundry area and three soiled utility rooms were free from multiple environmental concerns.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate medical records for advance directives on each resident for one (#29) of six residents reviewed out of 38 sample residents. Specially, the facility failed to ensure Resident #29's medical orders for scope of treatment (MOST) form corresponded with the computerized physician orders (CPO) for no cardiopulmonary resuscitation (CPR).

Inspectors wroteBased on record review and interviews, the facility failed to properly store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure the facility's one dishwashing room was maintained and repaired in a timely manner.

Inspectors wroteBased on record review and interviews, the facility failed to ensure resident rights were promoted and dignity was maintained for one (#1) of three residents out of five sample residents. Specifically, the facility failed to ensure Resident #1's care was provided in a dignified and respectful manner by certified nurse aide (CNA) #1.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public in two of three units. Specifically, the facility failed to: -Keep space heaters in areas deemed safe; -Maintain comfortable room temperature; -Remove exposed wires when equipment was removed; -Keep ceiling panels closed in residential areas; -Maintain flooring condition without tripping hazards in the dining area, and, -Keep emergency water sprinklers uncovered.

Inspectors wroteBased on record review and interviews, the facility failed to have a registered nurse (RN) scheduled eight hours consecutively a day for seven days a week. Specifically, the facility failed to have an RN on duty for eight consecutive hours on a consistent basis from 11/1/23 to 2/5/24.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications were stored in accordance with accepted professional standards for two of two medication refrigerators. Specifically, the facility failed to: -Ensure controlled medications were in a locked storage container that was permanently secured to the refrigerator; and, -Ensure all medications were stored under two separate locking devices.

Inspectors wroteBased on observations and staff interviews, the facility failed to establish and 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 in two out of four units. Specifically, the facility failed to follow proper personal protective equipment (PPE) procedures when entering resident rooms in isolation.

Inspectors wroteBased on record review and interviews, the facility failed to provide services under currently accepted professional standards. Specifically, the facility failed to ensure registered nurse (RN) #3 followed accepted professional standards for keeping controlled medications in a locked medication cart on 12/9/23 and 1/1724.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide food that accommodated resident preferences for one (#45) of two residents out of 19 sample residents. Specifically, the facility failed to offer food choices according to resident preferences for Resident #45.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice for one (#4) of three residents reviewed for pain out of 12 sample residents. Specifically, the facility failed to: -Ensure documentation for Resident #4's acceptable level of pain goal was documented consistently in the pain assessments, care plan and physician orders; and, -Ensure Resident #4's pain was managed appropriately and consistently to meet the resident's stated level of acceptable pain.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to provide adequate supervision and assistance to prevent accidents for 2 (Resident #122 and Resident #224) of 4 sampled residents reviewed for falls/accidents. Specifically, the facility assessed Resident #122 to be at high risk for falls upon admission but did not develop interventions to prevent falls, and on 6/8/2022 (five days after admission to the facility) Resident #122 fell and sustained a fractured hip. Additionally, the facility assessed Resident #224 to require the assistance of two staff for transfers; however, an incident report revealed the resident sustained an injury to the knee during a transfer with the assistance of only one staff person.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that before residents were allowed to self-administer medications, the interdisciplinary team (IDT) conducted an assessment to determine if self-administration was clinically appropriate and safe for 2 (Resident #56 and Resident #37) of 6 sampled residents reviewed for medication self-administration.

Inspectors wroteBased on interviews, record reviews, and facility policy review, it was determined the facility failed to report an allegation of neglect or abuse to the state survey agency (SSA) related to a resident's report of rough handling and pain during transfers performed by a facility certified nursing assistant (CNA) for 1 (Resident #224) of 3 sampled residents reviewed for abuse/neglect.

Inspectors wroteBased on interviews, record reviews, and facility policy review, it was determined the facility failed to investigate for possible abuse or neglect related to a resident's allegation of rough handling and pain during transfers performed by a facility certified nursing assistant for 1 (Resident #224) of 3 sampled residents reviewed for abuse.