Othello Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plans were updated timely for 3 of 3 sampled residents (Residents 6, 7 and 47), reviewed for individualized plans of care. This failure created the potential for resident needs to go unaddressed, and potential related adverse events.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, food was not covered, labeled, dated or discarded when expired for 2 of 3 refrigerators. The facility failed to perform hand hygiene when indicated during the meal service and did not maintain food at acceptable temperatures for service. These failures placed residents at risk for foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to obtain consent for psychotropic medications (medications that affect the mind, mood, and emotions) prior to administration of the first dose, as required, for 1 of 5 sampled residents (Resident 47), reviewed for unnecessary medications. This failure placed the resident and representative at risk of not being fully informed of the risks and benefits of medications and making a fully informed choice about their medical care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR, an assessment done to identify if potential nursing facility residents required services to support any behavioral health needs once admitted to the nursing facility) was completed after a 30-day hospital exempted stay expired for 2 of 5 sampled residents (Residents 6 and 34), reviewed. This failure placed the residents at risk for inappropriate placement, and/or not receiving timely and necessary services to meet their behavioral health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen and nebulizer delivery equipment was maintained as ordered and oxygen was administered per provider orders for 1 of 2 sampled residents (Resident 34), reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and use of assistance devices when consuming hot beverages, and to consistently assess hot beverage temperatures for safety prior to serving to prevent accidents for 1 of 3 sample residents (Resident 1). Resident 1, who was severely cognitively impaired, experienced harm when they were provided a cup containing a hot beverage that had not been checked for temperature without a lid and unsupervised which the resident spilled in their lap and resulting in a third-degree burn. According to the American Burn Association, thinner skin of older adults burns faster and deeper, and a serious burn can occur within five seconds of exposure to a liquid at a temperature of 140 degrees Fahrenheit (F). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained as ordered and followed-up timely, for 1 of 3 sampled residents (Resident 2), reviewed for laboratory (lab) services. This failure placed the resident at risk for delayed treatment, and a decline in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were disposed of timely, in accordance with currently accepted professional standards, in 1 of 1 medication storage rooms. The facility further failed to maintain temperatures to ensure medications were properly stored. This failure placed residents at risk for receiving compromised or ineffective medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to repeatedly review care plan intervention effectiveness and timely revise ineffective interventions for 3 of 14 sampled residents (Residents 3, 6, and 12), reviewed for care planning. This failed practice placed residents at risk of unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to repeatedly implement the bowel management protocol when indicated for 2 of 5 sampled residents (Resident 7 and 16), reviewed for bowel management. This failure placed residents at risk of medical complications, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consistently implement appropriate interventions to reduce fall hazards and monitor for intervention effectiveness for 1 of 3 sampled residents (Resident 4), reviewed for falls. This failure resulted in Resident 4 sustaining repeated falls and placed residents at risk for avoidable accidents, significant injury, and diminished quality of life.

Inspectors wroteBased on observation and interview the facility failed to ensure rooms containing sharps, chemicals, and tools were secured in 3 of 4 shower rooms and 1 of 22 resident rooms (room [ROOM NUMBER]), and failed to ensure a wheelchair and seatbelt were maintained in a clean manner for Resident 2 reviewed for physical environment. This failure placed residents at risk of potentially avoidable accidents, lack of dignity and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's choice for community outings for 1 of 4 sampled residents (Resident 4), reviewed for resident rights. This failure placed residents at risk of violations to their resident rights, unmet social needs, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary services to support activities of daily living (ADLs) for 2 of 4 sampled residents (Residents 1 and 22) reviewed. Specifically, Resident 1 was not receiving restorative nursing services as careplanned, and a robust system was not implemented for Resident 22, who had communication challenges after suffering a stroke.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received consistent showers for 1 of 3 dependent sampled residents (Resident 2), reviewed for activities of daily living (ADL's). This failure placed the resident at risk for not being bathed per their preferences and poor hygiene.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop treatment goals and care-planned interventions after a resident developed a pressure ulcer for 1 of 3 sampled residents (Resident 1) reviewed for pressure ulcers. This failure placed the resident at risk for further deterioration of their skin, unintended health consequences and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to prevent reduced range of motion (ROM) and/or prevent further decrease in ROM for 1 of 3 sampled residents (Resident 12), reviewed for limited ROM. This failure placed residents at risk of contracture (permanent tightening of muscles, tendons, ligaments, or skin that limits movement in a joint or body part) development, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain respiratory equipment in a clean manner for 2 of 2 sampled residents (Residents 8 and 18) reviewed for respiratory care. This failure placed the residents at risk for illness and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have the practitioner reevaluate the continued use of antipsychotic medication (a type of medication used to treat symptoms of psychosis) as required after 14 days of use for 1 of 5 sampled residents (Resident 18) reviewed for unnecessary medications. These failures placed the residents at risk for unintended medication side effects and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Three medication errors were identified for 2 of 10 sampled residents (Residents 23 and 176), observed during 30 medication administration opportunities that resulted in an error rate of 10%. This failure placed residents at risk of receiving subtherapeutic effects of their medications, possible adverse side effects, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Failure to ensure expired foods were discarded for 2 of 2 refrigerators, 1 of 1 dry storage areas and opened dates were placed on food items in the freezer. These failures placed residents served from the kitchen and snacks out of the refrigerator at risk for consuming expired food and food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration agreement (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) in a manner and language the resident and/or their legal representative understood for 1 of 3 sampled residents (Resident 22), reviewed for arbitration agreement. This failure placed residents at risk of losing legal protection, forfeiture (loss or giving up of something) of the right to a jury or court, lack of understanding of the legal document signed, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) for 1 of 3 sampled residents (Resident 13), reviewed for isolation precautions. In addition, the facility failed to perform hand hygiene when indicated during medication administration. These failures placed residents at risk of development of multi-drug-resistant organisms (MDROs), contracting communicable diseases, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician ordered foot care referral for a podiatrist was followed up on, and a change in foot wound condition was reported to the medical provider for 1 of 3 sampled residents (Resident 1), reviewed for wound care. Resident 1 experienced harm when they required additional surgery and amputations to their foot. These failures constituted Past Non-Compliance (the facility was not in compliance at the time the situations occurred; however, there was sufficient evidence that the facility corrected the non-compliance after they were identified) at harm level. The facility immediately implemented and completed a plan of correction which was verified by surveyors. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure treatment of a viral illness was provided in accordance with professional standards of practice for 1 of 3 residents (Resident 2), reviewed for quality of care. This failure placed the residents at risk for negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate the cause(s) of falls and assess the need for additional effective interventions for 2 of 3 sampled residents (Resident 1 and 3), reviewed for accident hazards. This failed practice resulted in actual harm to Resident 3 who was not provided supervision following a decline in health status and experienced a hip/pelvic and coccyx (tailbone) fracture that required hospitalization and surgery, and placed Resident 1 at risk for additional falls, injury secondary to falls, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to timely obtain and implement a physician order for X-ray services for 1 of 3 sampled residents (Resident 3), reviewed for diagnostic testing. This failure resulted in actual harm for Resident 3, who sustained a blood clot secondary to a fracture, which required medical intervention.

Inspectors wroteBased on interview and record review the facility failed to ensure substantial injuries were reported to the State Survey Agency for one of three sample residents (Resident 3), reviewed for abuse and/or neglect. This failure placed the resident at risk unidentified abuse and/or neglect, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely care and services to detect and treat urinary tract infections (UTI; a condition where bacteria enter the urinary system and infect the kidneys or bladder) for one of three sample residents (Resident 3), reviewed for quality of care. This placed the resident at risk of developing medical complications, secondary to an infection in the bladder.

Inspectors wroteBased on interview and record review, the facility failed to have Interdisciplinary Team (IDT) care plan meetings at least every 3 months (after each comprehensive assessment), to review and revise the care plan for 2 of 19 sampled residents (Residents 3 and 18), reviewed for care planning. This failure placed the residents at risk for unmet care needs, lack of participation in planning their care, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a skin alteration (bruising) was identified, the cause determined, and monitoring occurred 1 of 4 sampled residents (Resident 175), reviewed for skin alterations. This failure placed the resident at risk for a delay in identification and treatment of new skin impairments, and having preventative measures put in place to prevent recurrence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide behavioral health care services for 1 of 1 sampled residents (Resident 4), reviewed for behavioral health. This failure placed the resident at risk of unmet behavioral health needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow-up on pharmacist recommendations for medication changes, and to implement recommended changes in a timely fashion for 2 of 5 sampled residents (Residents 18 and 9), reviewed for unnecessary medications. This failure placed the residents at risk for unidentified medication complications, or adverse effects from medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure antipsychotic medication (medication that alters brain chemistry to help reduce psychotic symptoms) was not prescribed unless clinically necessary, and failed to ensure nonpharmacological behavioral interventions were implemented for 1 of 5 sampled residents (Resident 9), reviewed for unnecessary medications. These failure placed the resident at risk of receiving unnecessary medications, potential medication side effects, and a diminished quality of life.