Midtown Manor

Inspectors wroteBased on observation, interview, and record review, for 14 out of 36 sampled residents, the facility did not 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. Specifically, observations were made of staff not performing hand hygiene during meal service and dining assistance; hand hygiene was not performed during wound care and cross contamination of the wound bed was observed; Enhanced Barrier Precautions (EBP) were not implemented for any residents with wounds, indwelling urinary catheters, enteral feeding, or any other indwelling medical device; and the Personal Protective Equipment (PPE) cart was not sanitized prior to use and a cockroach was observed crawling on the PPE. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure an effective pest control program so that the facility was free of pests and rodents. Specifically, an observation was made of a live cockroach in the facility and residents and staff reported that cockroaches were found in the resident rooms.

Inspectors wroteBased on interview and record review, the facility failed to complete transmitting annual and quarterly Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) for 4 out of 36 sampled residents. Specifically, resident's MDS assessments were not accepted by the facility after being exported. Resident identifiers: 32, 38, 62, and 71.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who used psychotropic drugs received behavioral interventions, unless clinically contraindicated, in an effort to discontinue those drugs. Specifically, for 3 out of 36 sampled residents, a resident taking an antidepressant for skin picking did not have behavior tracking for the medication and residents taking an antidepressant for insomnia did not have their hours of sleep tracked. Resident identifiers: 14, 41, and 55.

Inspectors wroteBased on interview and record review, for 3 out of 36 sampled residents, the facility did not ensure that the antibiotic stewardship program included antibiotics use protocols and a system to monitor antibiotic use. Specifically, a resident was prescribed an antibiotic to treat an infection and the organism was resistant to that antibiotic, and two residents were prescribed antibiotics to treat an infection without a culture and sensitivity report to indicate if the antibiotic was susceptible to the organism. Resident identifiers: 1, 33, and 64.

Inspectors wroteBased on observation and interview it was determined, for 1 out of 36 sampled residents, that the facility did not ensure that residents were treated with respect and dignity and cared for in a manner that promoted the maintenance or enhancement of their quality of life, recognizing each resident's individuality. Specifically, a staff member was observed standing next to a seated resident while assisting them with dining. Resident identifier: 70.

Inspectors wroteBased on observation, interview, and record review, for 1 out of 36 sampled residents, that the facility did not ensure that the resident had the right to communicate with individuals and entities within and external to the facility with reasonable access to a telephone, including the right to privacy of such communications. Specifically, a resident on the secure unit was not provided access to a private area to make phone calls.

Inspectors wroteBased on interview and record review, for 2 out of 36 sampled residents, the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made to the Administrator of the facility, the State Survey Agency (SSA), and adult protective services (APS); report to law enforcement any reasonable suspicion of a crime; and report the results of the investigation to the SSA within 5 working days of the incident. Specifically, the facility did not report an allegation of abuse to APS or law enforcement and the facility final investigation results were not submitted to the SSA. Resident identifiers: 61 and 79.

Inspectors wroteBased on interview and record review, for 2 out of 36 sampled residents, in response to allegations of abuse the facility did not have evidence that all alleged violation were thoroughly investigated. Specifically, the facility did not have evidence that an incident of physical abuse between two residents was thoroughly investigated. Resident identifiers: 61 and 79.

Inspectors wroteBased on interview and record review, for 1 out of 36 sampled residents, the facility did not ensure that the transfer was documented in the resident's medical record and that the appropriate information was communicated to the receiving provider. Specifically, the documentation did not include contact information of the practitioner responsible for the care of the resident; resident representative contact information; Advanced Directive information; all special instructions or precautions for ongoing care; comprehensive care plan goals; a copy of the discharge summary; and all other necessary information to ensure a safe and effective transition of care. Resident identifier: 6.

Inspectors wroteBased on interview and record review, for 1 out of 36 sampled residents, the facility did not develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality care within 48 hours of a resident's admission. Specifically, a resident was admitted to the facility and his baseline care plan was not developed until 10 days after his admission. Resident identifier: 70.

Inspectors wroteBased on interview and record review, for 1 out of 36 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, a care plan was not developed for the treatment, monitoring, and assessment of a resident's arteriovenous fistula (AVF). Resident identifier: 32.

Inspectors wroteBased on observation, interview, and record review, for 2 out of 36 sampled residents, the facility did not ensure that the services provided met professional standards of practice. Specifically, two residents did not have their tube feed formula bag labeled with the formula name, the administration route, rate, and duration, and the initials of who prepared, hung and checked the enteral formula against the order. Resident identifiers: 14 and 54.

Inspectors wroteBased on observation, interview, and record review, for 2 out of 36 sampled residents, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident sustained multiple falls without continued attempts at interventions to prevent additional falls and a cognitively impaired resident had access to cleaning chemicals. Resident identifiers: 37 and 76.

Inspectors wroteBased on observation, interview, and record review, for 1 out of 36 sampled residents, the facility did not ensure that the resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities. Specifically, a resident was observed lying flat during an enteral tube feed infusion. Resident identifier: 54.

Inspectors wroteBased on observation, interview, and record review, for 2 out of 36 sampled residents, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice. Specifically, residents oxygen tubing was not properly labeled. Resident identifiers: 33 and 37.

Inspectors wroteBased on interview and record review, the facility did not ensure that the individual working in the facility as a nurse aide was not employed for more than 4 months unless that individual had completed a training and competency evaluation program approved by the State and had been deemed competent to provide nursing related services. Additionally, the facility may not use a temporary, per diem, or any other than a permanent employee who does not meet the competency evaluation program. Specifically, a staff member who did not complete the nurse aide competency evaluation program within 4 months continued to provide nursing related services to residents. Staff identifier: Nurse Assistant (NA) 1.

Inspectors wroteBased on interview and record review, the facility did not ensure that each residents drug regimen was free from unnecessary drugs. Specifically, for 2 out of 36 sampled residents, a resident taking an anticoagulant medication did not have adequate monitoring and a resident taking a vasodilator for high blood pressure did not have that medication held per the physician's ordered parameters. Resident identifiers: 7 and 41.

Inspectors wroteBased on interview and record review, for 1 out of 36 sampled residents, the facility did not provide or obtain laboratory services only when ordered by a physician. Specifically, a lab was obtained for a Valproic acid level without a physician order. Resident identifier: 14.

Inspectors wroteBased on interview and record review, for 2 out of 36 sampled residents, the facility did not maintain medical records on residents that were complete, accurately documented, readily accessible, and systematically organized. Specifically, a resident had omissions on the Medication Administration Record (MAR) and a resident had medication documented as administered when it was not. Resident identifiers: 14 and 79.

Inspectors wroteBased on interview and record review, for 1 out of 36 sampled residents, the facility did not ensure that residents were free from abuse. Specifically, a resident with a history of aggressive behavior,who required supervision, struck another resident. Resident identifiers: 18 and 33.

Inspectors wroteBased on observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food safety. Specifically, the facility did not date several items in the freezer and stored ground meat for greater than 7 days was located in the kitchen refrigerator. Findings Include: On 8/27/23 at 8:24 AM, an initial walk through of the kitchen was conducted. Inside the walk in fridge there was ground beef dated 8/19/23. Inside the freezer, there were several bags of frozen broccoli, hash brown cakes, and diced breakfast potatoes that had not been dated. A few of the diced breakfast potatoes bags had been opened and closed again and were not dated. On 8/28/23 at 12:09 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that food should not be in the fridge for more than 7 days. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee developed and implemented systematic analysis and action to ensure that improvements were effective and sustained to prevent adverse events. Specifically, the facility was found to be in non-compliance for some of the same deficiencies that were identified during last years recertification survey. Resident identifier 20 and 133.

Inspectors wroteBased on interview and record review, it was determined that for 3 of 32 sampled residents, that the facility did not ensure that each resident received an accurate assessment, reflective of the resident's status at the time of the assessment. Specifically, the facility submitted three Minimum Data Set [MDS] assessments with incorrect resident medical documentation. Resident Identifiers: 16, 17, and 58.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 out of 32 sampled residents, that the facility did not ensure that the resident had the right to self-determination through support of the resident choice. Specifically, a resident requested to have an additional cigarette during the scheduled smoke time and the resident was ignored. Resident identifier: 18.

Inspectors wroteBased on interviews and record review, it was determined for 1 of 32 sampled residents that the facility failed to ensure that each resident received adequate supervision. Specifically, the facility did not provide adequate supervision to prevent a resident from eloping from the secured facility without the consent or knowledge of the facility. Resident identifiers: 133.

Inspectors wroteBased on observation and interview it was determined that the facility did not store all drugs and biological's in locked compartments and permit only authorized personnel to have access. Specifically, observations were made of the medication cart left unlocked and unattended with medication on top during a medication administration observation. Resident identifier 6, 46, and 48.

Inspectors wroteBased on interview and record review it was determined, for 1 of 32 sampled residents, that the facility did not ensure that each resident received the food and drink that accommodates the resident allergies, intolerance's, and preferences Specifically, a resident reported that he was lactose intolerant, had requested Lactaid milk, and was still receiving regular cows milk. Resident 29.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to eliminate the risk of physical contaminates during food preparation.

Inspectors wroteBased on observation, interview and record review it was determined, for 3 of 38 sample residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, staff were standing over a resident to feed him, and two residents who were seated together were provided meals at different times. Resident identifiers: 33, 60, and 66.

Inspectors wroteBased on observation and interview, it was determined that the facility did not create a clean, safe and homelike environment. Specifically, the facility had holes in the ceilings, damaged walls and damaged or destroyed mini blinds in multiple resident rooms.

Inspectors wrote2. Resident 60 was initially admitted to the facility of 12/27/13 and readmitted on [DATE] with diagnoses that included schizoaffective disorder, malignant neoplasm of esophagus, unspecified dementia, and epilepsy. Resident 60's electronic medical record review was completed on 11/1/21. A quarterly minimum data set (MDS) assessment was completed with an assessment reference date (ARD) of 10/23/21. The quarterly MDS assessment was signed by the Director of Nursing on 10/26/21. The quarterly MDS assessment was submitted on 10/26/21 which was 3 days past the ARD date. On 10/27/21 at 8:30 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she was in charge of updating the MDS for resident 60. The ADON stated that she knew resident 60's MDS was not up to date. [...]

Inspectors wroteBased on observation, interview and record review, for 2 of 38 sample residents, it was determined that the facility did not keep, maintain and follow residents care plans. Specifically, the facility did not update and/or follow residents care plans for safety issues. Resident identifiers: 63 and 71.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 38 residents. Resident identifier: 278.

Inspectors wroteBased on observation, interview and record review, it was determined the facility did not ensure that each resident received adequate supervision and services to prevent accidents for 1 of 38 sample residents. Specifically, a resident was not provided adequate supervision to prevent elopement from the facility. Resident identifier: 59.

Inspectors wroteBased on observation, interview, and record review, it was determined for 1 of 38 sample residents that the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of the enteral feeding. Specifically, a staff member did not check gastric residual volume and did not check the placement of the feeding tube prior to initiating a tube feed. Resident Identifier:

Inspectors wroteBased on observation, interview, and record review it was determined for 1 of 38 sample residents that the facility did not prepare food in a form designed to meet individual needs. Specifically, a resident with physician orders for thickened liquids was provided thin liquids. Resident identifier: 18.

Inspectors wroteBased on record review and interview it was determined for 1 of 38 sample residents that the facility did not maintain medical records on each resident that were complete and accurately documented. Specifically, speech therapy assessments and documentation regarding a resident's difficulty swallowing were not included in the resident's medical record. Resident identifier: 18.

Inspectors wroteBased on observation and interview, the facility did not 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. Specifically, facility staff were not wearing personal protective equipment appropriately, staff were not washing their hands between residents when providing care, and uncovered food was transported to resident rooms.

Inspectors wroteBased on observation and interview, it was determined that the facility did not maintain handrails in hallways to ensure that handrails were secure. Specifically, the facility had loose handrails in the facility that were not secure to prevent a fall if utilized.

Inspectors wroteBased on observation and interview, it was determined that the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed practical nurses, Certified Nurse aides, and resident census. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Additionally, the information must be displayed in a prominent place readily accessible to residents and visitors.