Nevins Nursing & Rehabilitation Center

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for three Residents, (#2, #136 and #66) out of a sample of 34 Residents. Specifically,1. For Resident #2, the facility failed to provide oxygen to the Resident as indicated in the physician's orders.2. For Resident #136, the facility failed to ensure oxygen equipment and tubing was labeled, when changed/dated and that respiratory assessments were documented as indicated in the physician's orders. 3. For Resident #66, the facility failed to ensure nebulizer equipment and tubing was labeled, when changed/dated.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments for three Residents (#16, #66, and #54) out of 34 total sampled residents. Specifically, the facility failed to:1. Ensure Resident #16's scheduled Tylenol was not left at the bedside while unsupervised by staff. 2. Ensure Resident #66's Augmentin Oral Tablet (antibiotic medication) was not left at the bedside while unsupervised by staff.3. Ensure Resident #54's Nasal Saline Solution was not left at the bedside while unsupervised by staff.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident meals were at an appropriate temperature and were palatable on 4 of 4 resident units.

Inspectors wroteBased on observation and interview, the facility failed to store and prepare food in accordance with professional food safety standards. Specifically, the facility failed to1. Ensure food items were stored appropriately in the main kitchen reach in and walk in refrigerator and2. Failed to ensure staff maintained proper hand hygiene while serving food on two of four units.

Inspectors wroteBased on record review and interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were consistently documented in the medical record for one Resident (#66), out of a total sample of 34 residents.

Inspectors wroteBased on record review and interview the facility failed to implement the plan of care for one Resident (#4) out of a total sample of 34 residents. Specifically, for Resident #4 the facility failed to obtain and document vital signs as indicated in the plan of care.

Inspectors wroteBased on observations, record review and interview the facility failed to ensure assistance with Activities of Daily Living were provided for two Residents (#62 and #129) out of a total sample of 34 Residents. Specifically,For Resident #62 the facility failed to provide supervision or touching assistance with meals as indicated in the Resident's plan of care. For Resident #129 the facility failed to provide continuous supervision with meals as indicated in the Resident's plan of care.

Inspectors wroteBased on observations, interviews and records reviewed, the facility failed to ensure standards of quality of care for one Resident (#36) out of a total sample of 34 residents. Specifically, the facility failed to follow up on a biopsy to Resident #36's nose, failed to identify a change in a skin condition on his/her nose, and failed to document the skin area on a skin assessment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide range of motion (ROM) care and treatment in accordance with professional standards of practice for one Resident (#36) out of a total sample of 34 residents. Specifically, the facility failed to ensure staff implemented physician's orders for his/her left-hand splint (a device to properly position and protect hand joints) use based on the Occupational Therapist's recommendation and failed to develop a comprehensive resident-centered care plan with individualized interventions for Resident #36 assessed left-hand contracture.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a dignified dining experience for one Resident (#140) out of a total sample of 29 residents and on 2 of 4 nursing units. Specifically: 1. For Resident #140 the facility failed to ensure a dignified dining experience in both his/her room and in the unit dining room; and 2. on Units A and C the facility failed to ensure a dignified dining experience when Certified Nursing Assistants (CNAs) used their phones while feeding residents.

Inspectors wroteBased on observations and interviews the facility failed to ensure drugs and biologicals were stored in accordance with accepted professional standards of practice. Specifically, nursing staff failed to secure their medication and treatment carts on three of four units.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that staff labeled food and that staff did not store drinks with resident food and ingredients.

Inspectors wroteBased on record review and interview the facility failed to ensure the physician/nurse practitioner were notified of lab results for one Resident (#103) out of a total of 29 residents. Specifically the facility failed to : 1. notify the physician/nurse Practitioner of the recommendations, made by the covering nurse practitioner, to review labs on Monday; and 2. notify the physician/nurse practitioner of lab results reported to the facility on [DATE].

Inspectors wroteBased on observation, record review and interview the facility failed to ensure comprehensive plans of care were developed for three Residents (#98, #52 and #22) out of a total sample of 29 residents. Specifically: 1. for Resident #98 the facility failed to develop a care plan regarding the Resident's history of Suicidal Ideation (SI); 2. for Resident #52 the facility failed to implement the physician's order for an air mattress; and 3. for Resident #22 the facility failed to develop a plan of care regarding the level of assistance the Resident requires with feeding.

Inspectors wroteBased on interview and record review the facility failed to ensure for one Resident (#140) out of a total sample of 29 residents, that the interdisciplinary team reviewed and revised the plan of care after the quarterly review assessment. Specifically, for Resident #140, the facility failed to review and update a plan of care when the level of assistance with feeding increased.

Inspectors wroteBased on observation, record review and interview, the facility failed to meet professional standards of practice for two Residents (#32 and #74) out of a total of 29 sampled residents. Specifically, 1. For Resident #32, the facility failed to implement a physician's order to apply air boots when in bed. 2. For Resident #74, the facility failed to obtain a physician's order for a wound treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure assistance was provided with Activities of Daily Living (ADLs) for one Resident (#140) out of a total sample of 29 residents. Specifically, for Resident #140, the facility failed to provide assistance with bed mobility and feeding.

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure physicians orders for the prevention and care of pressure ulcers were followed for two Residents (#94 and 26) out of a total sample of 29 residents. Specifically: 1. for Resident #94, the facility failed to elevate his/her heels while lying in bed; and 2. for Resident #26, the facility failed to review or implement wound physician recommendations for a wound treatment.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide adequate supervision per the plan of care to prevent falls for one Resident (#92) out of a total of 29 sampled residents. Specifically, the facility failed to monitor and assist Resident #92 when he/she was displaying symptoms of agitation and walking independently resulting in Resident #92 falling.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide fortified foods for one Resident (#23) out of a total of 29 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Resident (#87), out of a total sample of 29 residents. Specifically, for Resident #87, the facility failed to obtain weekly measurements for the external length of Resident #87's PICC line to ensure the PICC line had not migrated (moved from the heart to another area, which could have a significant impact on treatment, or cause serious harm).

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident (#92) was free of unnecessary medications out of a total of 29 sampled residents. Specifically, for Resident #92, the facility failed to include a stop date for the use of a PRN (as needed) antipsychotic medication.

Inspectors wroteBased on record review, interview and observation, the facility failed to accurately document the completion of physician orders in the clinical record for 3 Residents (#94, #124, and #52) out of a total sample of 29 residents. Specifically: 1. For Resident #94, the facility failed to correctly document that his/her heels were not elevated while in bed; 2. For Resident #124, the facility failed to document the administration of acetaminophen; and 3. For Resident #52 the facility failed to document accurately in the Medication Administration Record/Treatment Administration Record (MAR/TAR) when the nurse documented that an air mattress function was checked when it was not.

Inspectors wroteBased on observations, records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and whose comprehensive plan of care indicated he/she required the use of monitoring devices (bed and chair alarms) to alert staff when he/she attempted to stand or transfer alone, the Facility failed to ensure staff consistently implemented and followed interventions identified in his/her plan of care, when on 05/22/24, Nurse #1 left Resident #1 alone, without an alarm in place, seated on the commode in his/her room, Resident #1 fell, later complained of pain, was transferred to the Hospital Emergency Department and was diagnosed with a fractured right hip which required surgical intervention to repair.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, was known to be impulsive and whose fall risk interventions included the use of monitoring devices (bed and chair alarms) to alert staff when he/she rose from a sitting or lying position, the Facility failed to ensure he/she was provided with the necessary level of staff supervision to maintain his/her safety, when on 05/22/24, after disabling his/her alarm, Nurse #1 left Resident #1 unattended on the commode, Resident #1 fell to the floor, complained of pain, and was transferred to the Hospital Emergency Department where he/she was diagnosed with a fractured right hip, which required surgical intervention to repair

Inspectors wroteBased on observation and interviews, the facility failed to provide a dignified dining experience for the residents on 1 of 4 residents units, specifically the B Unit.

Inspectors wroteBased on observations, record review and interviews, the facility failed to investigate a newly acquired bruise. Specifically, the facility failed to investigate a bruise identified on the left hand for one Resident (#67) out of a sample of 28 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement care plans for three Residents, (#47), (#20) and (#101). Specifically, 1. For Resident #47, the facility failed to develop a cardiac pacemaker care plan 2. For Resident #20, the facility failed to maintain accurate air matteress settings as indicated in the physician's order 3. For Resident #101, the facility failed to implement a physician's order for an air mattress out of a total of 28 sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide assistance with meals as needed for two Residents (#82 & #99) out of a total of 28 sampled residents.

Inspectors wroteBased on record review and interview the facility failed to ensure a plan of care was developed for Trauma-Informed Care for one Resident (#24), who was admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total sample of 28 residents.

Inspectors wroteBased on observations, record review, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when one out of three nurses observed made four errors out of 33 opportunities, resulting in a medication error rate of 12.12 %. Those errors impacted one Resident (#77), out of four residents observed.