Ocean View Post Acute

Inspectors wroteBased on interview, and record review, the facility failed to provide care and services to prevent accidents for one of five sampled residents (Resident 1) who has left sided hemiplegia (paralysis affecting one side of the body) and hemiparesis (one-sided weakness). Resident 1 was left unattended in bed while she was turned on her left side and the bed raised in a high position. As a result, Resident 1 fell off the bed and sustained a femoral neck fracture (fractured hip), which required surgical intervention.

Inspectors wroteBased on interview and record review, the facility failed to allow one of three sampled residents (Resident 1) to return to the facility following a visit to the emergency department. This failure had the potential for Resident 1 to not receive continuity of care and violated his right to return to the facility per the facility's policy.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure infection control procedures were followed when staff did not wear a gown for residents (47, 52 and 306) with enhanced barrier precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with chronic wounds and medical devices and with history of multidrug-resistant organism- MDROs]). These failures had the potential for cross contamination, spread of infection and residents' decline of health.

Inspectors wroteBased on observations, interviews and record review, the facility failed to implement a care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to: A. Anticoagulant (blood thinner) therapy for Resident 47, B. Enhanced Barrier Precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with chronic wounds and medical devices]) practices when providing care to residents on EBP (Resident 47 and Resident 52), and, C. Dialysis (a process to remove waste from the blood for residents with kidney disease) access care of Resident 52. These failures had the potential to not meet the goals of treatment and needs of Resident 47 and Resident 52. Cross reference to F 757, F 880 and F 698.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow nursing standards of practice when: 1) A Licensed Nurse (LN) did not provide instructions related to an inhaler medication usage. 2) A LN did not follow physician's orders related to an insulin time of administration. These failures had the potential to compromise the residents' medical status. Cross Reference to F 759.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two persons assist when safely transferring a resident using a mechanical lift (a device used to safely transfer residents who cannot independently bear weight), for one of three sampled residents reviewed for accidents (Resident 52). This failure had the potential for Resident 52 to have accident and fall that could lead to injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen was administered per physician's order for one of two residents reviewed for oxygen use (Resident 28). This failure had the potential to worsen Resident 28's breathing and respiratory system (organs and tissues that enable breathing and gas exchange).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dialysis (a process to remove waste from the blood for residents with kidney disease) assessments were consistently and accurately completed for one of three sampled dialysis residents (Resident 52). These failures had the potential for miscommunication between the facility and dialysis center and to affect the continuity and quality of care of Resident 52.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure monitoring of medication management was conducted when: 1. A consent for a medication was not updated with the current dosage, and all behaviors were not being monitored for medication effectiveness (Resident 22), and 2. Potential adverse effects of an anticoagulant (a medication which prevents blood clots) were not evaluated (Resident 47). These failures had the potential for the residents to experience adverse effects or receive unnecessary medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 5.1 percent. Two medication errors out of 39 opportunities were observed during the medication administration process for two of five randomly observed Residents (154, 307) . These failures had the potential to compromise the residents' medical health and condition. Cross Reference F 658. Findings. 1) A record review of the facility's admission Record indicated Resident 307 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure menus and recipes were followed for pureed foods. This failure negatively affected the nutritional value of foods prepared in the kitchen, and had the potential for residents to receive the wrong caloric intake, further compromising their medical status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen staff utilized recipes when preparing foods. This failure had the potential to place residents at risk for poor intake and weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide alternate menu options of similar nutritional value to residents. This failure had the potential to result in meals not being equal in nutritive value, and may result in weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of an expired food product in a nursing unit refrigerator. This failure had the potential to place residents at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the flu vaccine (a vaccine which provides immunity to a variety of influenza viruses) was provided to one of five sampled residents (Resident 69). This had the potential for putting Resident 69 at risk for acquiring, transmitting or experiencing complications from influenza (an acute contagious viral infection characterized by inflammation of the respiratory tract).

Inspectors wroteBased on interview and record review, the facility failed to respond to a medical records request for one of two sampled patients (1). As a result, the requester did not know if the records were made available to her.

Inspectors wroteBased on interview and record review, the facility failed to prevent a hazardous situation when supervision was not provided for one resident (1) during an outpatient appointment and his whereabouts were unknown. This deficient practice placed Resident 1 at increased risk of injury when Resident 1 was found, sitting in the sun, outside the outpatient appointment location by a bystander and sent to the hospital.

Inspectors wroteBased on interview and record review, the facility failed to appropriately discharge on e of one resident (Resident 3) with elopement risk reviewed for discharge planning when; 1. There was no documentation regarding Resident 3's elopement risk and the appropriateness of a discharge to an independent living facility and, 2. A discharge care plan was not developed. As a result, Resident 3 was readmitted to the hospital.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a plan of care and adequate supervision to prevent one of three residents reviewed for elopements from leaving the facility (Resident 1). As a result, Resident 1 went missing from the facility without staff ' s knowledge and placed Resident 1 at risk for harm.

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party when sodium valproate (a medication that effects the mind) was discontinued for one of two sampled residents (1). As a result, Resident 1 ' s responsible party was not fully aware of what medications he was taking.

Inspectors wroteBased on interview and record review, the facility failed to apply a skin protective cream as ordered for one of two sampled residents (1). As a result, Resident 1 was at increased risk of skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure current infection control practices were followed when a facility employee did not wear a face shield inside a resident's room (Resident 3) who was on isolation for COVID-19 (an infectious respiratory disease). Failure to follow current infection control practices had the potential to spread infectious disease to all residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Perform and document neurological checks (assessing mental status, level of consciousness, eye response to light, motor strength, feeling sensation, and vital signs {blood pressure, pulse, respiratory rate} every 15 minutes for one hour, every 30 minutes for one hour, every hour for two hours, every two hours for four hours, every four hours for 16 hours, every 8 hours for 24 hours) after an unwitnessed fall per the nursing standard of practice for one of four residents (Resident 1) reviewed for falls; and 2. Accurately score (low, medium or high risk of future falls) for a fall assessment after an unwitnessed fall for one of four residents (Resident 1), reviewed for falls. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label the oxygen (O2) tubing and humidification water bottle for one of two residents (Resident 307). This failure had the potential to increase the risk of developing pneumonia and/or other infections, with an inadequately monitored oxygen delivery system.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. The facility's medication error rate was 8%. Two medication errors were observed, with a total of 25 opportunities, during the administration process for one of 5 randomly observed residents ( Resident 315). As a result, the facility failed to ensure medications were administered correctly to Resident 315.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the Notice of Transfer or Discharge form to the Ombudsman, when residents were discharged from the facility for three of three sampled residents (13,91,95). As a result, there was a potential for residents to not have access to an advocate who could inform them of their options and rights related to transfers and discharges.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed- hold, upon transfer to the GACH, for four of four sampled residents (13, 91, 95, 98). As a result, these residents' did not have information to accept or decline a bed-hold during their absence.

Inspectors wrote2. Resident 5 was admitted to the facility on [DATE], with a diagnosis of Alzheimer's Disease, unspecified (a progressive disease that destroys memory and other mental functions) per the facility's admission Record. On 8/14/19 at 9 A.M., Resident 5 was observed in the hallway, in her wheelchair, muttering to herself. On 8/15/19 at 3:30 P.M., Resident 5 was observed in the activity room, in her wheelchair, looking through a magazine. On 8/14/19 at 3:40 P.M., a review of Resident 5's medical record was conducted. No care plan for dementia was located. On 8/14/19 at 3:43 P.M., a concurrent interview and review of Resident 5's medical record was conducted with the DSD. The DSD stated there was no care plan for dementia care. Additionally, the DSD stated, We usually do one (care plan) for the behaviors associated with dementia. On 8/14/19 at 4 P.M., an interview was conducted with the DON. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to revise care plans that reflected resident preferences and needs for: 1. Three of six residents (42, 59, 60) sampled for activities, and; 2. One of five residents (60) sampled for communication needs. These failures had the potential to affect the residents' care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Label and date glasses of liquids, soup bowls of liquids, remove a watermelon with fuzzy brown spots, and cover cut celery from the walk in refrigerator; 2. Remove a dented can of peaches from the storage area; 3. Remove ice cream in the walk in freezer which was soft. As a result, there was a potential for food borne illness if expired or unsafe food was served to residents.

Inspectors wroteBased on oberservation, interview, and record review, the facility failed to label and date resident food stored in one of two nursing station refrigerators. As a result, there was a potential for food borne illness if expired or unsafe food was served to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medical records were stored in a secured location. This failure had the potential for residents' private medical information to be viewed by non-medical staff, other residents, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to implement an Antibiotic Stewardship Program (a system to monitor antibiotic use). This failure had the potential to increase the risk of adverse events from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a tile floor in good repair when tiles were chipped and missing, in 1 of 2 shower rooms. As a result, there was a potential for residents' feet to be cut in the shower room and there was a potential for a trip hazard.

Inspectors wroteBased on interview, and record review, the facility failed to code the MDS correctly, for one of 19 sampled residents (81). As a result, there was a potential to affect the provision of care, and provided inaccurate information to the Federal database.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently provide a method of communication, in a residents' preferred language, for three of three residents (53, 59, 60) sampled for communication. This failure had the potential to affect the residents' ability to effectively communicate with facility staff.

Inspectors wroteBased on observation, interview and record review, the facility did not provide person-centered, in-room activities that met the needs and preferences for three of five residents (42, 59, 60) sampled for activities. This failure had the potential to cause decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate urinary catheter (a tube placed in the bladder to drain urine) care was provided to one of three residents (53) sampled for catheter care. This failure placed Resident 53 at risk for a urinary tract infection (bacteria in the urine).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a CNA acted within their scope of practice when operating an enteral (through a tube inserted into the stomach) feeding pump (machine used to deliver liquid nutrition) for one unsampled resident (53). This failure had the potential to compromise Resident 53's nutritional status and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess the needs of one of three residents with dementia (5). This failure had the potential for Resident 5 to not achieve the highest practicable physical, mental and psychosocial well-being.

Inspectors wrote2. Resident 7 was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit (difficulty communicating), per the facility's admission Record. On 8/13/19, at 9:04 AM, an observation was conducted in Resident 7's room. A plastic bag with unknown contents was on the floor of Resident 7's closet. On 8/13/19 at 4:18 P.M., an observation and interview was conducted with LN 41. LN 41 examined the contents of a plastic bag on the floor in Resident 7's closet. LN 41 stated the bag contained a cleansing enema set. LN 41 stated the cleansing enema set should not have been in Resident 7's closet because it was a medication. On 8/13/19 at 5:05 P.M., an interview was conducted with the DON. The DON stated a cleansing enema set required a physician's order, should be kept locked in a medication cart and should be administered by licensed nurses. [...]

Inspectors wroteThe facility failed to ensure appropriate urinary catheter (a tube placed in the bladder to drain urine) care was provided to one of three residents (53) sampled for catheter care. This failure placed Resident 53 at risk for a urinary tract infection (bacteria in the urine).