Oneida Nursing and Rehab Center

Inspectors wroteBased on facility policy review, facility job description review, observations, and interviews, the facility failed to identify quality deficiencies related to Enhanced Barrier Precautions (EBP) and put action plans in place to prevent deficient practice. The facility's failure had the potential to affect 37 out of 37 residents.

Inspectors wroteBased on facility policy review, Infection Preventionist (IP) Job Description review, Centers for Disease Control and Prevention (CDC) website review, observations, and interviews, the facility failed to ensure the facility staff followed the most used up to date guidance for infection control procedures related to Enhanced Barrier Precautions (EBP). The failure was identified by a sample selected of 3 residents (Resident #21, Resident #5, and Resident #36) to review, the findings had the potential to affect the census population of 37 residents.

Inspectors wroteBased on facility policy review, Infection Preventionist (IP) job description review, Centers for Disease Control and Prevention (CDC) website review, observation, and interview, the facility failed to ensure the IPs practiced using the most current guidance for infection control procedures related to Enhanced Barrier Precautions (EBP). The failure had the potential to affect 37 of 37 residents in the facility.

Inspectors wroteBased on medical record review and interviews, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) was provided to 1 resident (Resident #44) of 3 residents reviewed for beneficiary notices.

Inspectors wroteBased on facility policy review, facility professional standards documentation, medical record review, and interviews the facility failed to ensure basic nursing standards for the rights of medication administration were followed for 1 resident (Resident #5) of 5 residents reviewed for Unnecessary Medications.

Inspectors wroteBased on facility policy review, professional standards review, medical record review, observation and interview, the facility failed to provide services which met professional standards of practice when a Registered Nurse (RN) #1 failed to administer essential medications, including anti-hypertensives, cardiac medications, and insulin, as ordered by the resident's physician, and failed to notify the physician when the essential medications had been withheld for 3 residents (Resident #3, #13, and #22) of 7 residents reviewed for medication administration. The facility's failure had the potential to create negative adverse outcomes to Residents #3, #13 and #22 and had the potential to affect all residents of the facility. [...]

Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to ensure essential medications were administered as ordered by the physician and failed to notify the physician when the medications had been withheld, which had the potential to alter therapeutic drug levels and create negative adverse outcomes for 3 residents (Resident #3, #13, and #22) of 7 residents sampled for medication administration. The facility's failure placed Resident #3, Resident #13, Resident #22 in immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, impairment, or death to a resident) and had the potential to affect all residents of the facility. The Immediate Jeopardy (IJ) of F684 was cited at a scope and severity of K and was effective 8/12/2023-9/21/2023. [...]

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to ensure 3 residents (Residents #3, #13, and #22) of 7 residents reviewed for Medication Administration were free of any significant medication errors when a Registered Nurse (RN) #1 failed to administer anti-hypertensives, cardiac medications, and insulin to the residents and failed to notify the physician after the essential medications had been omitted. The RN's failure to administer essential medications as ordered by the physician placed Residents #13 and #22 in immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, impairment, or death to a resident) and had the potential to affect all residents in the facility. [...]

Inspectors wroteBased on facility policy review, observation, and interview the facility failed to ensure food items were properly stored in 2 of 3 freezers, failed to ensure expired food items were not available for resident use on 1 of 1 bread cart, failed to properly store food items in 1 of 2 refrigerators, and failed to ensure pots and pans were stored appropriately in 1 of 1 pot and pan storage area, which had the potential to effect 34 of 35 residents.

Inspectors wroteBased on medical record review and interview, the facility failed to refer 1 resident (Resident #3) of 4 residents reviewed for Pre-admission Screening and Resident Review (PASRR), to the state-designated authority for a Level II PASRR after the resident was identified with possible serious mental disorder diagnosis.

Inspectors wroteBased on facility policy review, record review, observation, and interview, the facility failed to develop a comprehensive care plan to meet the person-centered dementia care needs for 2 residents (Resident #3 and #29), and activities of daily living (ADL) care needs for 1 resident (Resident #33) of 16 residents reviewed for care plans.

Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility failed to implement appropriate infection control practices by improperly storing a Continuous Positive Air Pressure (CPAP) mask and tubing and improperly securing a catheter bag for 2 residents (Residents #15 and #33) of 35 residents reviewed for infection prevention.