North Shore Health & Rehab Facility

Inspectors wroteBased on record review and interviews, the facility failed to notify a resident's representative of changes in medication for one (#6) of seven residents out of 11 sample residents. Specifically, the facility failed to notify Resident #6's representative when the resident's donepezil (medication used to manage cognitive symptoms) was discontinued.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to their diet order of level six soft and bite-sized texture as indicated on their meal tray cards.

Inspectors wroteBased on observations, interventions and record review, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically the facility failed to: -Ensure the high temperature dish washing machine functioned at the proper temperatures for one of two facility dish washing machines; -Ensure, for a high temperature dish washing machine, an irreversible registering surface temperature indicator (test strip) was present at the facility and readily accessible for measuring the utensil surface temperature; and -Ensure staff performed proper hand hygiene while plating and serving resident meals.

Inspectors wroteBased on observations, record review and interviews, the facility failed to assess, accurately document and provide treatment for one (#32) of four residents reviewed for pressure ulcers out of 31 sample residents. Specifically, the facility failed to: -Ensure the progress of Resident #32's pressure ulcers was documented consistently and accurately; -Identify Resident #32 had a pressure wound which had reopened on her coccyx; and, -Obtain appropriate physician's orders for wound care treatment for Resident #32's reopened coccyx pressure ulcer.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#32 and #1) of five residents reviewed for pain management out of 31 sample residents received timely, adequate pain control. Specifically, the facility failed to: -Ensure pain was effectively managed during incontinence care for Resident #32; -Ensure Resident #32 was provided as needed (PRN) pain medication prior to brief changes per physician's orders; -Ensure staff consistently documented Resident #32's pain levels every shift; and, -Ensure individualized non-pharmacological interventions were documented for Resident #32 and Resident #1.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure one (#1) of five residents reviewed for unnecessary medications out of 31 sample residents were free from unnecessary medications. Specifically the facility failed to: -Ensure Resident #1 had appropriate non-pharmacological interventions for behaviors initiated; -Ensure Resident #1 was monitored for side effects of a psychotropic medications; and, -Ensure Resident #1 was monitored consistently for behaviors to justify the use of psychotropic medications.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections in one of three units. Specifically, the facility failed to: -Follow proper infection control processes for cleaning and disinfecting lifts and vital signs equipment on the Parkview unit; and, -Use proper infection control procedures during a vaccination clinic.

Inspectors wroteBased on observations, record review and interviews, the facility failed to follow an effective infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to: - Implement a comprehensive program of infection surveillance to determine the event of transmission and causes of the spread of infections; - Identify, through surveillance, correlations between staff practices and the spread of infections; - Follow effective isolation precaution practices to prevent the potential spread of infection; - Prevent the potential for cross contamination during dining services; and, - Follow proper housekeeping and laundry protocols to prevent the potential for cross-contamination.

Inspectors wroteBased on record review and interviews, the facility failed to ensure five (# 6, #43, #61, #67, #85) of eight Medicaid funded residents reviewed, out of 54 sample residents, deposited the residents' personal funds in excess of $50.00 in an interest bearing account and credited all interest earned on the resident's funds to that account. Specifically, the facility failed to: -Allocate interest accrued to medicaid funded Resident #6, Resident #43, Resident #61, Resident #67, and Resident # 85 who had accounts with funds over $50.00 and under $100.00 for February 2020. I. Policy and procedure The undated, Personal Funds Account policy, was received from the business office manager (BOM) on 3/10/2020 at 12:28 p.m. The policy did not include information on interest accrued by any resident with a fund balance over $100.00, or for Medicaid funded residents with balances over $50.00. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in two out of three medication carts and three out of three medication rooms. Specifically, the facility failed to: -Date medications when opened; -Discard expired medications; and, -Ensure Medications were stored at appropriate temperatures.

Inspectors wroteBased on record review and interviews the facility failed to ensure two (#71 and #81) out of two residents who were Medicaid funded out of 54 sample residents were notified when account balances were within $200 of the eligibility resource limit. Specifically, the facility failed to notify Resident #71 and Resident #81 they were approaching the eligibility resource limit for Medicaid.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for one (#23) of two residents reviewed for abuse out of 54 sample residents. Specifically, the facility failed to provide sufficient interventions to protect Resident #23 from a physical abuse altercation with Resident #64.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one (#29) of four residents reviewed for activities of 54 sample residents had an ongoing program of activities based on comprehensive assessments, care plan and resident preferences. Specifically, the facility failed to properly develop and implement an individualized plan of activities, based on Resident #29's interests, to help him adjust to his unexpected admission to the facility.

Inspectors wroteBased on observations and staff interviews, the facility failed to store, prepare and serve food in a sanitary manner in one of one facility kitchens, and two of two unit kitchenettes. Specifically, the facility failed to follow accepted food service industry standards to minimize the risk of foodborne illness in a highly susceptible population in the following practices: -Proper glove use and hand hygiene; -Reheating of foods in the microwave oven; -Sanitization of probe thermometer; and, -Monitoring of temperatures in one of four unit resident food refrigerators.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to ensure: -Manufacturer recommendations were followed regarding disinfectant surface contact times; -Proper process for resident room cleaning was followed (clean to dirty); and, -A water management program to prevent the transmission of legionella was developed and implemented.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide services to achieve the highest practicable state of wellbeing for one (#70) of one resident reviewed for accommodations of needs out of 40 sample residents. Specifically, the facility failed to promote toileting in a dignified manner for Resident #70 as evidence by: -Not ensuring the residents needs were accommodated for a larger bathroom to prevent a decline in her toileting status; -Not ensuring the occupational therapist recommendations were followed; -Not ensuring the certified nurse aide followed the residents care plan; and, -Not ensuring staff followed up with the resident after she was discovered to be incontinent with a bladder study or toileting program to promote and maintain bladder and bowel status.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure residents had the right to and the facility promote/facilitate self-determination of resident choices for one (#42) of one out of 40 sample residents. Specifically, the facility failed to: -Ensure the resident received a minimum of two baths each week according to the resident ' s preferences.

Inspectors wroteBased on record review and interviews, the facility failed to report an alleged violation of abuse to the State survey and certification agency in accordance with State law, for one (#47) of one residents reviewed for abuse out of 40 sample residents. Specifically, the facility failed to report allegations of verbal abuse to the state agency.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#258, and #24) of five out of 40 sample residents, who were unable to carry out activities of daily living (ADL) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, the facility failed to ensure: -Resident #258 was provided with meal assistance according to the plan of care; and -Resident #24 was provided with timely toileting assistance.