Medical Center Convalescent Hospital

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere with established food safety and sanitation standards when:1. A plastic wrapped container of beef roast was observed without a label indicating the preparation date, freeze by date, or discard date.2. Clean wet dishes were stacked on top of each other and not air dried. These had the potential to place susceptible residents who receive food from Dietary Services at risk for food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 17) did not self-administer medication, when the facility assessment indicated Resident 17 was unable to do so. Resident 17 was given medications to self-administer while out on pass ([OOP] a temporary, authorized absence from a medical facility for social, family, or therapeutic reasons, with the explicit requirement that they return for continued treatment from the facility). This failure had the potential for Resident 17 to have adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was accessible for use for one of one sampled resident (Resident 2). This failure had the potential for Resident 2's care needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the survey binder (a binder containing the results of the most recent survey which includes the Statement of Deficiencies (Form CMS-2567) which contains any deficiencies resulting from a complaint investigation or recertification survey) was readily accessible to the residents and visitors. This failure had the potential to limit residents' and visitors' ability to review the facility's compliance history and make informed decisions regarding care and services.

Inspectors wroteBased on interview and record review, the facility failed to provide written information concerning the right to formulate an Advance Directive (a written document specifying an individual's medical care wishes) for 4 of 14 sampled residents (Residents 1, 11, 49, 83). This failure had the potential for the residents' decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on interview and record review, the facility failed to follow up with the Preadmission Screening and Resident Review ([PASARR] - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) to determine the resident's needs for specialized services and appropriate placement for one of one sampled resident (Resident 6). This failure had the potential to result in inappropriate placement and unidentified specialized services for Resident 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 3) with an indwelling urinary catheter (a catheter inserted through the urethra into the bladder to drain urine) had accurate intake and output (I&O) monitored and documented as ordered. This failure had the potential to result in delayed identification of changes in urinary output, fluid imbalance, and other complications related to the use of an indwelling catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three out of three residents (Residents 17, 25, and 84) were kept free from accident hazards. 1. The facility failed to ensure Resident 17 was properly assessed to be safe prior to sending the resident out on pass ([OOP] - a temporary, authorized absence from a medical facility for social, family, or therapeutic reasons, with the explicit requirement that they return for continued treatment from the facility.) 2. The facility failed to ensure Resident 25's had a physician order for floor mats and failed to implement care plan interventions. 3. The facility failed to identify and assess Resident 84 as a smoker upon admission and was observed smoking in the patio without a smoking assessment. These failures posed a risk for an unsafe environment for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 3) with an indwelling urinary catheter (a catheter inserted through the urethra into the bladder to drain urine) received proper care and services by failing to ensure indwelling catheter care was consistently completed and documented as ordered. This failure had the potential to result in Resident 3 developing a urinary tract infection (UTI - an infection in the bladder/urinary tract) and other complications related to the use of an indwelling catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services when:1. For one of four residents (Resident 84), a medication was not administered in accordance with prescriber's orders. This failure resulted in a medication error and the potential to result in unnecessary medications.2. In one of two medication rooms (Medication Room A), four normal saline (saltwater) IV (intravenous - into a resident's vein) solution bags were stored undated outside the plastic overwrap. This failure had the potential to compromise the stability of the IV solution bags.3. In one of two medication rooms refrigerators (Medication Room A), two opened and undated multiple-dose Aplisol (tuberculin purified protein derivative - aid to diagnose the tuberculosis infection) vial was observed stored in the medication refrigerator. [...]

Inspectors wroteBased on the observation, interview, and record review, the facility failed to ensure safe medication labeling practices and medications were stored at the proper temperature range in accordance with accepted standards of practice and/or manufacturer's instructions when:1. One of one opened inhaler mouthpiece for Resident 36 was not properly labeled with sufficient information to clearly identify the specific resident. This failure had to potential to cause medication errors and preventable infections from cross-contamination (transfer of germs) if accidently mixed up with other residents' similar or same drugs.2. Medications were observed stored at the incorrect temperature.a. An undated insulin (drug to manage high blood sugars) pen (portable device) for Resident 39 in one of three medication carts.b. [...]

Inspectors wroteThe facility failed to maintain an accurate Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for one of one sampled resident (Resident 17) when the facility indicated Resident 17 was hospitalized , while the resident was out on pass ([OOP] - a temporary, authorized absence from a medical facility for social, family, or therapeutic reasons, with the explicit requirement that they return for continued treatment from the facility). This failure had the potential for omission of necessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when: 1. In the laundry room, two dryers were set below the facility policy requirement of 180 degrees Fahrenheit (°F- unit of measurement), to comply with infection control, on February 5, 2025. 2. Resident 192's Intravenous (IV- flexible tube used to give fluids, medicine, or nutrients through a vein) tubing was not dated as per facility policy. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 71 highly vulnerable residents whose health conditions are already compromised.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper management and disposal of expired medications was being implemented when: 1. One expired bisacodyl (used to treat constipation- when a person cannot poop) suppository (solid form of medications that dissolve inside the body) was found in the medication storage room and was available for use. 2. One expired alginate dressing (absorbent wound care product) was found in the treatment cart and was available for use. These failures had the potential for the dressing and medication to not be effective or safe for resident use in 71 highly susceptible medically compromised residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to store food in a way that conserves nutritive value, flavor, and appearance, when cups of pudding, which were designated to be used during medication pass (process of delivering and administering medications to residents at scheduled times) were not accurately dated to reflect when it was prepared. This failure had the potential for staff to serve outdated pudding to residents, which could lead to dissatisfaction. (Each day, two residents receive pudding as a snack, while 68 residents potentially receive pudding during the medication pass.)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their restorative nursing services (RNS; also known as RNA program; nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible; generally initiated when a resident is discharged from formalized rehabilitation therapy) policies and procedures were being implemented for one of three residents reviewed for position and mobility (Resident 61) when Resident 61 was not placed on the RNS program after his Physical Therapy (PT- medical treatment that uses physical techniques to help people regain movement and function after an injury or disease) treatment was completed. This failure had the potential for Resident 61 to be at risk for falls, further decline in ambulation, and a loss of independence.

Inspectors wroteBased on the observation, interview, and record review, the facility failed to meet the regulatory requirement to ensure the resident environment remains as free of accident hazards as possible when a resident (Resident 1) accidentally released a bear spray ( a spray which is twice as concentrated as pepper spray, a chemical can cause burning pain, watery eyes, and coughing upon contact with skin or eyes) which affected five other residents (Residents 2 , 3, 4 ,5 and 6) on July 23, 2024. This failure resulted in Residents 2 , 3, 4, 5 and 6 to experience red, watery eyes and coughing. Residents 2, 3, 5, and 6 required hospitalizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a full-time qualified Dietary Services Supervisor, who was responsible for overseeing daily food production for breakfast, lunch, and dinner. This failure led to sanitation issues in the kitchen (cross-reference F-tag 812), staff who were not competent (cross-reference F-tag 802), deficiencies with food palatability when kitchen staff were using disposable dishware for resident meals (cross reference F-tag 804), and had the potential to affect 92 medically compromised residents at nutrition risk who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to store and serve food that conserved flavor and appearance and was an appetizing temperature when: 1. A 20-pound box of carrots was stored in the freezer, open and unsealed, and was available for use. 2. In the cooking area, there was a container with onions sprouting and growing mold, and potatoes that were sprouting, and was available for use. 3. Residents were served lunch on May 2, 2023, on Styrofoam take-out containers and with plastic utensils These failures had the potential to cause 92 medically compromised residents who received food from the kitchen not to enjoy their food which could affect their nutrition status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary condition in the kitchen in accordance with professional standards for food safety when: 1. Three-compartment sink was not sanitizing dishes. It required 200 ppm (part per million- unit of measurement) of quaternary ammonia (chemical used to kill bacteria, viruses, and mold). The test was conducted and resulted to 100 ppm of quaternary ammonia. 2. The stainless steel shelf, used to store clean metal pans, had a sticky residue and food crumbs. 3. The floor, under the stainless steel shelves, had dirt, food crumbs, and black grime. 4. Three cupcake pans, stored on a shelf, had black burn residue and were available for use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection (establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms) control practices were being implemented when: 1. The facility did not follow their policy and procedure for Legionella (bacteria that can cause a lung infection) water management program when the last results found were from March 25, 2020 (approximately 25 months ago). 2. Licensed Vocational Nurse (LVN 4) did not perform hand hygiene after checking Resident 44's blood sugar level. 3. LVN 1 did not perform hand hygiene when she provided Residents 26's wound care treatment. 4. LVN 1 did not perform hand hygiene when she provided Resident 289's wound care treatment. 5. Resident 290's oxygen tubing was found on the floor of her room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate completion of a Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one resident (Resident 3) reviewed for PASARR . This failure had the potential for Resident 3 not to receive the care and services she needs due to her not being evaluated further.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified of wound care treatment refusals for one of four residents (Resident 82) reviewed for skin conditions when Resident 82 refused his treatments for three consecutive days (May 1, 2023 through May 3, 2023). This failure had the potential for Resident 82 to be at risk of increased infection, poor wound healing, hyperglycemia (elevated sugar levels in blood), and/or re-hospitalizations.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure their urinary catheter (a flexible tube used to empty the bladder) removal policy and procedure was implemented for one of three residents reviewed for urinary care when Resident 76's urinary catheter was removed without a physician's order. This failure had the potential for Resident 76 to be at risk of urinary retention (inability to completely empty the urinary bladder by urinating.)

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain acceptable parameters of nutritional status (factors that reflect that an individual ' s nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values) for one of six residents (Resident 51) reviewed for nutrition, when the nutrition interventions recommended by the Registered Dietitian were not implemented for Resident 51. This failure had the potential for Resident 51, a medically compromised individual, to be at risk of impaired wound healing and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe oxygen administration were provided for one of three residents (Resident 32) reviewed for respiratory care when: 1. Resident 32's oxygen therapy order was not carried out as prescribed by the physician. 2. Resident 32's oxygen tubing (a device which facilitates oxygen delivery) was not labeled to indicate the date when it was changed. These failures had the potential to result in a decline in Resident 32's oxygen status, causing shortness of breath, oxygen toxicity (too much oxygen), respiratory infection, and lung damage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to the facility's policies and procedures for two of 13 residents (Resident 33 and 77) reviewed for medication administration observation when: 1. Resident 33 had an order to receive Sevelamer (medication to treat high levels of phosphorus). The medication was not available for administration. 2. Resident 77 refused to receive Pantoprazole (a medication to treat acid reflux). It was documented as administered. These failures had the potential for Residents 33 and 77 to not be administered prescribed medication and increased the resident's risk for adverse reactions and side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacy recommendation identified from the Drug Regimen Review (DRR- thorough evaluation of a resident's medication regimen to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities) was followed up in accordance with federal regulations, for one of five residents (Resident 66) reviewed for unnecessary medications. Resident 66 had an order to receive Xanax (medication to treat anxiety) as needed. The Consultant Pharmacist reviewed her medications and recommended for it to be limited for 14 days. This failure had the potential for Resident 66 to receive unnecessary medication and had unrecognized adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rate was less than five percent. There were two medication errors identified out of 29 opportunities for errors, affecting two of 13 residents (Residents 33 and 77), resulting in an overall medication error rate of 6.9 percent when: 1. Resident 33 had an order to receive Sevelamer (medication to treat high levels of phosphorus). The medication was not available for administration. This failure had the potential for Resident 33 to have increased levels of phosphorus in the blood which could lead to low calcium which may cause muscle cramps. 2. Resident 77 refused to receive Pantoprazole (a medication to treat acid reflux). It was documented as administered. This failure had the potential for Resident 77's health care needs towards his acid reflux not being addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have dietary staff with appropriate competencies when: 1. Dietary Aide 1 (DA 1) did not know how to check the quaternary ammonia (chemical used to kill bacteria, viruses, and mold) level of the three-compartment sink (3 sinks, one for each step of the ware wash procedure, wash, rinse and sanitize) and the quaternary ammonia level was not the correct concentration. 2. Dietary Aide 2 (DA 2) did not know how to check the chlorine level of the dish machine. These failures had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) for a medical compromised population of 92 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hospice (specialized end-of-life care for all patients with a terminal illness with a prognosis of 6 months or less) care was coordinated in accordance with the facility's policy and procedure for one of two residents (Resident 23) reviewed for hospice, when there was no current hospice recertification (the certification and recertification regulations require a physician certify the patient is terminally ill with a prognosis of 6 months or less) and current plan of care available in Resident 23's health record. This failure had the potential for Resident 23 not to receive hospice care services based on a comprehensive person-centered care plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their bed inspection policy were implemented for two of seven residents (Residents 12 and 69) reviewed for accidents when: 1. For Resident 12, her bed had a 10-centimeter (cm- unit of measurement) gap between the mattress bed and footboard. 2. For Resident 69, her bed had a 15-centimeter gap between the mattress and the footboard. These failures had the potential to place Residents 12 and 69 at risk for entrapment (being caught between the mattress and bed rail), falls, and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call systems for two of three shower rooms (Shower Rooms A and B) were accessible and functional. This failure had the potential to place 92 residents at risk of harm, as residents experiencing an emergency or needing assistance would not be able to call for help.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program (measures to eradicate and contain common household pests e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice, and rats) when the presence of pests in the facility within the last year were not reported to the Maintenance Supervisor as indicated in the facility's policy and procedure. This failure had the potential to negatively affect the health and safety of 92 highly vulnerable residents through the direct and indirect exposure to the contaminants the cockroach may carry.