Newport Meadows Health and Rehabilitation Center

Inspectors wroteBased on review of facility policy, medical records, and staff interview the facility failed to maintain medication administration records that were complete and accurate for one out of three residents reviewed (Resident 1).

Inspectors wroteBased on review of facility's policy, observation, clinical records review and staff interviews, it was determined that the facility failed to ensure incontinent care was provided for one of two residents reviewed (Resident 1).

Inspectors wroteNumber of residents sampled: Number of residents cited: Based upon review of facility policy and procedure and observation, it was determined that the facility failed to ensure appropriate storage and labeling of medications in three of four medication carts observed (Chestnut Medication Cart 2, Evergreen Medication Cart, and Birch Medication Cart 1).

Inspectors wroteNumber of residents sampled: Number of residents cited: Based upon interview and clinical record review, it was determined that the facility failed to ensure appropriate notification was provided to a resident prior to a room change for one of twenty-five residents reviewed (Resident 16).

Inspectors wroteBased on observation, it was determined that the facility failed to ensure that privacy curtains were clean on one of five units (Dogwood unit).

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on facility policy and procedure review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow physician orders and appropriately monitor fluid intake for one of one resident reviewed (Resident 3)

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on review of facility records and interview with staff, it was determined that the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to the resident or resident's representative when Medicare services ended for two of two residents (Residents 7 and 72).

Inspectors wroteThe facility did not ensure physician was notified of change in resident's condition/status. Based on review of clinical record, facility policy, and staff interviews, it was determined that the facility failed to notify the physician of a change in condition/status for one of three residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview it was determined that the facility failed to ensure that residents were free from significant medication error for one of three residents, resulting in Resident R1 needing emergency medical treatment (Resident R1). This situation was identified as past non compliance.

Inspectors wroteBased on review of facility policy and procedure and clinical record and staff interview, it was determined the facility failed to safely reheat a beverage for one of 32 residents reviewed causing actual harm to Resident 32 who developed a 2nd degree burn. Findings Include: Review of facility policy and procedure titled Microwave Use, undated, revealed staff should remove beverage from microwave, uncover, stir and insert thermometer probe into center of beverage item ensuring contact with beverage only. Check digital display for a maximum temperature of <165. Let sit for three minutes before serving. Review of Resident 32's Progress Notes revealed a nursing entry dated July 10, 2024 at 8:16 a.m. indicating While administering medication [resident] states that [resident] burned [himself/herself] while drinking [his/her] coffee. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to accurately monitor and assess residents for side effects of antipsychotic medications for three of five residents reviewed for unnecessary medications (Residents 2, 84, and 93).

Inspectors wroteBased on review of facility policy and procedure and observation, it was determined the facility failed to ensure adequate adherence to Infection Prevention measures in regard to COVID-19 for one of five units observed (1st Floor Chestnut Unit).

Inspectors wroteBased on observation, review of the clinical record, and interview with staff, it was determined that the facility failed to develop a plan of care with interventions for two of 31 residents reviewed (Residents 26 and 93).

Inspectors wroteBased on clinical record review, it was determined the facility failed to follow physician orders in regard to fluid restriction for one of 25 residents reviewed (Resident 11).

Inspectors wroteBased on review of Consultant Pharmacy Reviews, it was determined the physician failed to ensure a rationale was provided in declining a Consultant Pharmacist recommendation for one of five residents reviewed (Resident 102).

Inspectors wroteBased on clinical record review, it was determined the facility failed to ensure the radiological diagnostic studies were done in a timely manner for one of 25 residents reviewed (Resident 2).

Inspectors wroteBased on review of clinical records, hospital records, and staff interviews, it was determined that the facility failed to ensure the physician medication orders were accurately entered and followed for one of four residents reviewed (Resident CL1).

Inspectors wroteBased on a review of the facility's policy, observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for three of three residents reviewed (Residents R1, R2, and R3).

Inspectors wroteBased on review of the clinical record, and staff interview, it was determined that the facility failed to ensure that physician's orders for immediate care were obtained at the time of admission for one of three residents reviewed (Resident R2).

Inspectors wroteBased upon review of staffing records and inservice documentation, it was determined the facility failed to ensure nurse aides received required 12 hour annual re-training for four of five records reviewed. Findings Include: Review of five staffing records and inservice documentation revealed one nurse aide received the required 12 hour annual retraining. Further review of the staffing records and inservice documentation revealed four of the five records reviewed failed to reveal evidence of retraining. Interview with the Nursing Home Administrator on October 20, 2023 at 1:00 p.m. confirmed that the nurse aides did not received the required in-service retraining. 28 Pa.

Inspectors wroteBased upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for five of five staffing records reviewed.

Inspectors wroteBased on clinical record review, facility documentation review, and staff interview it was determined the facility failed to develop and implement care plan goals/interventions for one of 24 residents reviewed. (Resident 62) Findings Include: Review of Resident 62's Progress Notes revealed a nursing entry on June 11, 2023 at 6:38 a.m. stating Witnessed fall CNA (Certified Nursing Assistant) was ambulating (walking) with resident in hall holding her right hand. Resident lost her balance and fell to her right knee then onto her buttocks. Review of Resident 62's Incident Report, dated June 11, 2023 for the fall revealed an intervention of a UA (urinalysis) and C+S (culture and sensitivity) (lab studies to determine if there is an infection of the urinary tract and which bacteria it is and what antibiotics it is sensitive to). [...]

Inspectors wroteBased on observations, clinical record review, and resident and staff interview it was determined the facility failed to follow physician orders for two of 24 residents reviewed and failed to notify physician of a change in condition for one of 24 residents reviewed. (Residents 74, 116, and 123) Findings Include: Review of Resident 74's diagnosis list revealed diagnoses including enlarged prostate, sepsis (blood stream infection) and Fournier's Gangrene (potentially fatal infection of the genital and perineum). Review of Resident 74's progress notes dated August 23, 2023, revealed Resident noted with very foul-smelling urine output in foley [catheter] with hematuria [blood in urine]. Supervisor made aware. T. [temperature] 97.9 MD [physician] will be notified for further instruction. [...]

Inspectors wroteBased upon clinical record review and staff interview, it was determined that the facility failed to comprehensively assess a resident who developed a pressure ulcer for one of five residents reviewed (Resident 37).

Inspectors wroteBased on interviews and observation, it was determined that the facility failed to effectively communicate updated meal times to residents, resident representatives, and staff on two of five units (Dogwood and Chestnut).

Inspectors wroteBased on staff interview and facility documentation review, it was determined that the facility administration failed to provide timely information for the documentation and calculation of the facility's nursing care hours, causing a delay in the survey process.