Nancy Hart Operation LLC

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled, Handwashing/Hand Hygiene and Infection Prevention and Control Program, the facility failed to ensure proper hand hygiene practices were followed, failed to implement Enhanced Barrier Precautions (EBP), and failed to establish a water management program to address the risk of waterborne pathogens, including Legionella. These failures had the potential to contribute to the transmission of infectious diseases among residents and staff. The census was 65.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure a safe, clean, and comfortable homelike environment in seven of 26 resident rooms. This deficient practice had the potential to impact the quality of life and safety of all residents occupying the areas.

Inspectors wroteBased on staff interviews and record review, the facility failed to implement care plan interventions for one of 36 sampled residents (R) (R33). This deficient practice had the potential to place R33 at increased risk of medical complications and unmet care needs.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled, Policy and Procedure Manual: Clinical P&P Respiratory Care, the facility failed to ensure that oxygen therapy was provided as ordered for two of six residents (R) (R69 and R46) with oxygen orders. In addition, the facility failed to ensure respiratory circuits were cleaned as ordered for two of six residents (R46 and R48) with respiratory circuits. This deficient practice had the potential to place R69, R46, and R48 at increased risk of respiratory complications.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Administration of Insulin, the facility failed to ensure that one of 15 residents (R) (R33) with physician orders for insulin received the insulin as prescribed by the physician. This deficient practice had the potential to place R33 at risk of medical complications and unmet needs.

Inspectors wroteBased on observation, staff and resident interviews, record review, and review of the facility's policy titled Elopement Protocols, the facility failed to provide adequate supervision, frequent monitoring, and to ensure one of four exit doors was functioning properly to prevent the elopement for one out of three sampled Residents (R) (R1).

Inspectors wroteBased on observations, staff Interviews, record review and review of the facility's policy titled Food Receiving and Storage, the facility failed label and date food items stored in the refrigerator. In addition, the facility failed to maintain the appropriate concentration of sanitizing solution in the three-compartment sink. The facility census was 58 residents.

Inspectors wroteBased on staff interview, record review and review of the facility's policy titled Antibiotic Stewardship Program, the facility failed to establish an Antibiotic Stewardship Program that included antibiotic use protocols and a monitoring system to track and trend antibiotic use. The facility census was 59.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled P&P Resident Council Meeting, the facility failed to provide documented responses to residents' grievances and concerns regarding resident care and life expressed during Resident Council meetings in six of eight meetings. The facility census was 58.

Inspectors wroteBased on observations, staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for nine of 23 rooms (Rooms 100, 101, 107, 201, 202, 203, 204, 205, 206) and two of three hallways (Hallways 200 and 300). Specifically, the bathrooms in rooms 100, 201, 203, 204, and 206 contained unstable floors, cracked and broken tile, soiled toilets and sinks, and broken lights. Additionally, the residents' rooms and hallways contained loose tiles, holes in the walls, chipped and peeling paint, missing cabinet faces, and sticky hallway floors. The facility census was 58 residents.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled Storage of Medications, the facility failed to assess and obtain a physician order for one of 29 sampled Residents (R) (R56) to safely self-administer and store medication at bedside.

Inspectors wroteBased on record review, staff and resident interview, the facility failed to assure residents who have authorized the facility in writing to manage any personal funds have ready and reasonable access to those funds for one Resident (R) (R5) of 29 sampled residents.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled, Standards and Guidelines: SG Resident Rights, Dignity, and Visitation Rights, and Blood Glucose Monitoring, the facility failed to ensure visual privacy during treatment for two of 29 sampled Residents (R) (R39) and (R21).

Inspectors wroteBased on observations, staff interviews, record review, and review of facility's policy titled ''P&P Restraints,'' the facility failed to ensure one of one Resident (R) (R49) reviewed for physical restraints was free from an unnecessary physical restraint. Specifically, R49 did not have the necessary consent, physician's order, or a completed assessment in place for lap tray to be applied and used with a Geri chair.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled P& P Hemodialysis, the facility failed to have ongoing communication and collaboration with the dialysis center for one out of 29 sampled Residents (R) (R20) reviewed for dialysis.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Use of Psychotropic Medication, the facility failed to ensure one of five Residents (R) (R30) was evaluated for use of as needed (PRN) psychiatric medications beyond 14 days.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Storage of Medications, the facility staff failed to store physician ordered medications in a locked compartment when unattended for one of three medication carts in the facility. The facility census was 59.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Handwashing/Hand Hygiene, and Blood Glucose Monitoring, the facility failed to help prevent the development and transmission of communicable diseases and infections for two of 29 sampled Residents (R) (R39 and R21). Specifically, the facility failed to follow proper procedures for hand hygiene, donning and removing gloves while performing a blood glucose test. In addition, the facility failed to clean and disinfect the glucometer per the manufacturer's instructions.

Inspectors wroteBased on record review, resident and staff interviews, and review of the facility's policy titled, Commingling of Resident Funds, the facility failed to ensure quarterly statements were provided to the resident or the resident's representative within 30 days after the end of the quarter for three of three residents ((R) R#21, R#33, and R#34) reviewed for personal funds. This had the potential to affect all residents who had a personal funds account with the facility.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure their surety bond provided financial security of all the residents' personal funds deposited with the facility. This deficient practice affected all 34 residents whose funds were managed by the facility.

Inspectors wroteBased on observation, staff interviews, and review of the facility policy titled, Food Safety Requirements, the facility failed to store foods under sanitary conditions. Specifically, the facility failed to put food away upon receipt from the delivery company, which included refrigerated and frozen foods, and the food sat in a shed for several hours. This deficient practice had the potential to affect all residents who received food from the kitchen.

Inspectors wroteBased on record review, resident and staff interviews, and review of a facility document titled, Resident Trust Fund Notification and Authorization,, the facility failed to ensure the resident and/or the resident's representative received notification when their personal fund balance approached the supplemental security income (SSI) resource limit for three of three residents ((R) R#21, R#33, and R#34) reviewed for personal funds. This had the potential to affect all residents who received Medicaid benefits and had a personal funds account with the facility.

Inspectors wroteBased on observations and resident and staff interviews, the facility failed to maintain a safe, comfortable, and sanitary environment in resident rooms and facility communal areas. Specifically, the flooring system on two halls of three halls (A Hall and B Hall) in the facility were observed to be cracked, uneven, and had bare wood exposed. This deficient practice had the potential to affect the residents' ability to ambulate safely throughout the A and B Halls.

Inspectors wroteBased on record review, resident and staff interviews, and review of the facility policy titled, Transfer and Discharge (including AMA [Against Medical Advice]), the facility failed to ensure one of four residents (R) (R#23) reviewed for discharge was allowed to remain in the facility. Specifically, the facility failed to ensure the resident's condition was fully evaluated before the resident was immediately discharged from the facility.

Inspectors wroteBased on record review, resident and staff interviews, and review of the facility's policy titled, Transfer and Dischrge(including AMA[Against Medical Advice], the facility failed to allow one resident of four residents (R) (R#23) reviewed for discharges to return to the facility after it was determined by the hospital staff that the resident did not pose a danger to self or others. This deficient practice had the potential to affect the care and services R#23 received.