Northway Health and Rehabilitation, LLC

Inspectors wroteBased on observations, interviews and the facility's Residents Rights, the facility failed to ensure rooms on three of five halls were not found in need of repair. This deficient practice affected seven residents' rooms on three halls. Findings Include: The facility's undated Residents Rights, documented, These are YOUR Rights: YOU have the right .to live in a safe, clean, comfortable and homelike environment. On 04/14/2024 at 1:18 PM, surveyor observed Resident Identifier (RI) #56's closet was missing a door. On 04/14/2024 at 4:09 PM, surveyor observed RI #100's wall behind bed with scraped paint. On 04/14/2024 at 4:25 PM, surveyor observed RI #67's wall behind bed with scraped paint. On 04/15/2024 at 8:28 AM, surveyor observed RI #18's wall behind bed with scraped paint and chipped paint and hole in the wall on the side of bed. [...]

Inspectors wroteBased on observations, interviews and a facility policy titled, Hand Hygiene, the facility failed to ensure: 1) staff sanitized their hands on 04/14/2024 while passing meal trays on Station 4. The facility further failed to ensure staff performed hand hygeine while assisting Resident Identifer (RI) #1 and RI #47 with their meal. This deficient practice affected residents residing on two of five halls, including RI #1 and RI #47. 2) staff followed Standard Precautions and properly disinfected the glucometer after routine testing of blood glucose. This affected RI #73, one of two residents observed for blood glucose testing. Findings Include: A facility policy titled, Hand Hygiene, with an effective date of 06/11/2020, documented, PURPOSE: To provide guidelines to employees for proper and approriate hand washing techniques that will aide in the prevention of the transmission of infections. [...]

Inspectors wroteBased on interviews, record review, review of the facility's investigation titled Verification of Investigation, and review of facility policy Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to ensure Licensed Practical Nurse (LPN) #6, did not misappropriate Resident Identifier (RI) #43's Percocet and Lyrica after signing the medication as administered. This was cited as a result of investigation of complaint/report number AL00045405, and affected one of one residents reviewed for misappropriation of resident property. Findings Include: Review of a facility policy Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, with an effective date of 05/01/2023 documented PURPOSE: . All of our resident/guest(s) have a right to be free from . [...]

Inspectors wroteBased on interview, record review, review of a facility policy Pre-admission Screening Resident Review, and review of Resident Identifier (RI) #103's PASRR (Preadmission Screening and Resident Review), the facility failed to ensure RI #103's PASRR was accurately marked with an admission diagnosis of Bipolar Disorder, which indicated a Level II was indicated. This affected one of two residents sampled for PASRR. Findings Include: A review of a facility policy titled Pre-admission Screening Resident Review, with a revised date of 06/2009 documented . 4. The nursing facility is responsible for ensuring that a level I screening is completed, submitted and has a Level I Determination on or before nursing home admission . Process for PASRR . 3. [...]

Inspectors wroteBased on interviews, record review, and review of the facility policy titled Medication Administration Documentation for Medication Administration, facility failed to ensure Resident Identifier (RI) #43's Medication Administration Record (MAR) was accurate. On 08/27/2023 Licensed Practical Nurse (LPN) #6 documented the administration of Lyrica and Percocet in RI #43's medical record and did not administer the medications to RI #43. This affected RI #43, and was cited as a result of investigation of complaint/ report number AL00045405. Findings Include: Review of a facility policy Documentation for Medication Administration with an effective date of 04/2020 documented . Procedures 1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. [...]

Inspectors wroteBased on an interview and a review of a policy titled, Federal Rights of Resident/Guest(s) the facility failed to ensure mail was delivered to residents on Saturday. This affected 13 residents who attended the Resident Council Meeting on 04/17/2024 and had the potential to affect all residents in the facility. Findings Include: A review of a policy titled, Federal Rights of Resident/Guest(s) with an effective date of November 28, 2016, documented the following: .(g)(8) The resident/guest has the right to . receive mail . On 04/16/2024 at 3:15 PM during the Resident Council Meeting, 13 residents reported mail was not delivered to them on Saturday. Residents reported that mail received by the facility on Saturday would be passed out to them on Monday. On 04/16/2024 at 4:18 PM an interview was conducted in the Social Services Director (MSW). [...]

Inspectors wroteBased on interviews, record review, and review of facilities Resident Handbook and the facility's document titled Resident - These are YOUR Rights, the facility failed to ensure residents had reasonable access to personal funds/petty cash after business hours and on the weekends. This affected Resident Identifier (RI) #64. Further affected RI #43, RI #55, RI #6, RI #81, RI #28, RI #69, RI #34, RI #85, RI #26, and RI #76 who attended Resident Council Group meeting on 04/16/2024 and reported they were unable to access funds on the weekends. This had the potential to affect all residents who have a Resident Trust Account established with the facility.

Inspectors wroteBased on observation, interviews, medical record review, and a review of [NAME] AND PERRY's, FUNDAMENTALS OF NURSING, the facility failed to ensure a licensed nurse: 1) did not lay the insulin pen, needles, Fentanyl pain patch, and alcohol swabs on Resident Identifier (RI) #90's bedside table without first laying a barrier down; Further, while administering medications to RI #90, the licensed nurse stored medications and supplies in her pocket, and used scissors from her pocket to cut up a used Fentanyl patch, then returned them to the pocket without cleaning or disinfecting them; and 2) did not stack medication cups, each containing medication, on top of each other, after the cups had been placed on the medication cart, prior to administering medication to RI #63. These failures affected two of six residents and two of three nurses observed during medication pass observations. [...]

Inspectors wroteBased on interview, the facility's policy for Master Meal Schedule, and the facility's Schedule of Meals, the facility failed to ensure the period between the facility's scheduled meal times for supper and breakfast did not exceed fourteen hours. The facility also failed to request or receive approval from the Resident Council for the period between the facility's scheduled meal times for supper and breakfast to exceed fourteen hours. This had the potential to affect all residents receiving meals from the facility, 91 of 93 residents. The facility's policy for Master Meal Schedule, dated April 23, 2012, included the following: . Standard: According to federal regulations, three meals should be served at regularly scheduled times. No more than a 14-hour span between supper and breakfast should occur. [...]

Inspectors wroteBased on observation, interview, the facility's policy for Insect and Rodent Control, and the 2017 Food Code, the facility failed to ensure the tile coving along the juncture of the floor/floor sink and the wall in the chemical/mop closet was not cracked and did not have holes, which allowed the potential for pests to enter the kitchen and for moisture to seep behind the walls. This had the potential to affect all residents receiving meals from the facility, 91 of 93 residents. The facility's policy for Insect and Rodent Control, dated February 1, 2002, included the following: . Purpose: To prevent the spread of bacteria that may cause food borne illnesses. Process: . f. Cracks in walls, floors, along baseboards or ceilings should be reported to maintenance for repair. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure Resident Identifier (RI) #24's admission Minimum Data Set (MDS) assessment, dated 04/02/18, reflected RI #24 had a colostomy. This affected RI #24, one of 42 sampled residents whose MDS assessments were reviewed. Findings Include: RI #24 was admitted to the facility on [DATE], with a diagnosis of Colostomy Status. A review of RI #24's admission MDS assessment, with an Assessment Reference Date (ARD) of 04/02/18, revealed RI #24 was not coded as having a colostomy. 06/06/18 04:29 PM Resident # 24 raised gown & said Someone needs to see about this. Colostomy bag VERY full of gas & stool. Staff LPN notified. On 06/07/18 at 11:28 a.m., the surveyor conducted an interview with Employee Identifier (EI) # 4, the RN (Registered Nurse), MDS Coordinator. The surveyor asked EI # 4 did RI #24 have a colostomy. [...]