Millennium Post Acute Rehabilitation

Inspectors wroteBased on review of facility policy, observation, interview, and record review, the facility failed to (1.) ensure linen and resident clothing was washed at appropriate temperatures or with proper disinfection to prevent the potential spread of infection and or diseases, in 1 of 1 laundry room. Specifically, the washing machine failed to maintain adequate hot water temperature. Additionally, the facility failed (2.) to ensure that medications were administered to residents utilizing proper hand hygiene and use of Personal Protective Equipment (PPE) while performing medication pass, for 2 of 2 residents reviewed.

Inspectors wroteBased on record review and interview, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) assessment tool for Residents (R)84 and R108, prior to their admission to the facility, for 2 of 7 residents reviewed. Findings Include:The facility does not have a policy related to PASARR assessments. Review of R84's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, chronic respiratory failure, type 2 diabetes mellitus, major depressive disorder, and anxiety disorder. Review of R84's PASARR Level 1, revealed it was completed on 01/02/25, by the facility. Review of R108's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, rheumatoid arthritis, mood (affective) disorder, anxiety disorder, schizophrenia, and major depressive disorder. [...]

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure Resident (R)1's adaptive equipment was clean, for 1 of 4 residents reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to employ a full-time qualified Licensed Medical Social Worker (LMSW), as required for facilities with more than 120 certified beds. 130/130 certified beds, all of which are potentially affected by the lack of a full-time LMSW to provide necessary psychosocial support and services.

Inspectors wroteBased on facility policy review, observation, and interviews, the facility failed to ensure the confidentiality and security of resident Protected Health Information (PHI) for two of two residents (R)3 and R4) observed for resident rights. Specifically, a resident's code status document containing PHI was observed uncovered and unsecured in a clear wall-mounted mailbox, located in a hallway accessible to staff, residents, and visitors. Additionally, a staff member left a computer unattended in a common area with the screen displaying a resident face sheet, which included personally identifiable information such as the resident's name, photograph, and medical details.

Inspectors wroteBased on review of the facility policy, observations, and interviews, the facility failed to ensure proper tracheostomy care, in relation to documentation and changing the tracheostomy neck tie, according to professional standards of practice for 1 of 1 resident reviewed.

Inspectors wroteBased on facility policy review, record review, observations and interviews, the facility failed to ensure medications were properly stored and secured for one of one resident (R)1, observed for pharmacy services. Specifically, a cup containing Guaifenesin (Robitussin) was observed left unattended on R1's bedside table without documentation of a self-administration assessment or physician authorization.

Inspectors wroteBased on review of the facility policies, Resident [NAME] of Rights, record review, observations and interviews, the facility failed to ensure the nutritional well-being of Resident (R)5,while respecting an individual's right to make choices about their diet.

Inspectors wroteBased on review of the facility policy, record review, observations, and interviews, the facility failed to ensure the call bell was within reach for one of one resident (R)2) reviewed for physical environment, which resulted in a delay in care. Specifically, R2 was observed in bed with the call bell positioned out of reach, on the opposite side of the bed. During the observation, R2 stated they were unable to call for assistance and had waited over 30 minutes to request pain medications.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure all medications were appropriately administered on dialysis days for one of one resident (Resident (R)34) reviewed for dialysis out of a total of 22.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure one of two residents (Resident (R)109) reviewed for falls out of a total sample of 22 had adequate supervision, which resulted in a fall from bed. In addition, the facility failed to ensure there was an accurate root cause analysis which identified the events which led to R109's fall and the corrective action taken as a result. This had the potential to cause harm.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure adequate interventions were provided to establish proper nutrition for one of five residents (Resident (R) 75) reviewed for nutrition in a total sample of 22. The facility failed to provide the resident with a dietary supplement as per physician order. This placed the resident at risk for further weight loss. Cross Reference:

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to monitor target behaviors for the use of Risperidone (an antipsychotic medication) for one of five sampled residents (Resident (R) 33) reviewed for unnecessary medications out of a total sample of 22. This had the potential to cause the resident to receive unnecessary antipsychotic medications.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure that clinical records were complete and contained accurate documentation for one of 22 residents (Resident (R)75) whose records were reviewed. This had the potential for the resident not to receive accurate care.

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility failed to develop a comprehensive care plan to include concerns about allegations of family member interfering with care and whom to notify in change of condition for 1 of 3 residents (R)105, reviewed for comprehensive care plan.

Inspectors wroteBased on observation, interview, and facility policy the facility failed to provide dignity for 1 of 1 Resident (R)27 related to his urinal.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure that two residents (Resident (R) 69 and 49) of two residents reviewed were clinically appropriate to self-administer medications.

Inspectors wroteBased on review of facility policy, observations, interviews, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 residents reviewed for respiratory care, Resident (R)69.

Inspectors wroteBased on review of the facility policy, observation, interview, and record review, the facility failed to ensure a medication error rate of less than five (5) percent for 1 of 7 residents observed for medication administration. The medication error rate was 42.31 percent. Findings Include: Review of the facility's undated policy titled, Administering Medication through an Enteral Tube, revealed Preparation: #23 Administer medication by gravity flow. Review of the facility policy titled, Medication Administration, Medication Administration Standards and Principles dated 7/2014, revealed, Medication will be administered based on the Eight Rights. 1. Right time- medications are administered within prescribed timeframe. Review of Resident (R)75's medical record revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to; [...]

Inspectors wroteBased on review of the facility policy, observation, and interviews, the facility failed to ensure proper infection control protocols were followed for 1 of 1 Resident (R)82.