Portside Health & Rehab Center

Inspectors wrote4. For Resident #10 (R10), the facility staff failed to complete the pain assessment interview of section J of the MDS (minimum data set) assessment. Review of the annual MDS with an ARD (assessment reference date) of 9/12/2024, R10 was assessed as scoring 7 out of 15 on the BIMS (brief interview for mental status) assessment indicating that they were moderately impaired for making daily decisions. Section J documented in part, J0200. Should Pain Assessment Interview be Conducted? Attempt to conduct interview with all residents. If resident is comatose, skip to J1100, Shortness of Breath (dyspnea). Enter Code. 0. No (resident is rarely/never understood). Skip to and complete J0800, Indicators of Pain or Possible Pain . Section J0800 was observed to be blank. On 12/12/24 at 8:41 a.m., an interview was conducted with LPN (licensed practical nurse) #5, MDS coordinator. [...]

Inspectors wroteBased on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to develop/implement a baseline care plan for two of 43 residents in the survey sample, Resident #176 (R176) and R177.

Inspectors wrote4. For Resident #70 (R70), the facility staff failed to develop the comprehensive care plan to include the use of an elbow splint. On 12/9/24 at 8:16 p.m., an observation was made of R70 in bed. R70 was observed with limited range of motion (ROM) in the right hand. No splinting device was observed in use. Additional observation on 12/10/24 at 8:25 a.m. revealed R70 in bed with no splinting device and limited ROM in the right hand. The comprehensive care plan for R70 failed to address the limited range of motion or use of any splinting devices. The most recent OT (occupational therapy) evaluation and plan of treatment dated 8/14/24-9/11/24 documented treatments including but not limited to splinting and increasing finger flexion. The evaluation documented a right upper extremity contracture and impairment of the right hand. [...]

Inspectors wrote4. For Resident #89, the facility staff failed to review and revise the comprehensive care plan for the use of an indwelling catheter. The comprehensive care plan dated, 7/11/24, documented in part, Problem: Urinary Incontinence: Incontinence d/t (due to) dx (diagnosis) of muscle weakness, lack of coordination, dementia and Alzheimer's. The Approach failed to evidence any documentation related to the use of an indwelling catheter. On 12/10/24 at 8:45 a.m. Resident was observed in bed, an indwelling catheter bag was noted hanging off the bedframe. The physician orders dated, 7/8/24, documented, Change foley (indwelling) catheter as needed. 18 fr (french) 10 cc (cubic centimeters). Special Instructions: Document catheter (french) and balloon (ml - milliliters) size inserted PRN (as needed). Further review of the physician orders failed to evidence an order for indwelling catheter care. [...]

Inspectors wroteBased on resident interview, observation, staff interview, and clinical record review, it was determined the facility staff failed to administer medications and/or treatments per the physician orders for two of 43 residents in the survey sample, Residents #32 and #8.

Inspectors wroteBased on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide monitoring for fluid restriction and intake for one of 43residents, R177.

Inspectors wrote2. The facility staff failed to ensure R176 was free of unnecessary medications by monitoring anticoagulant as ordered. R176 was admitted to the facility on [DATE] with diagnosis that included but were not limited to PTSD (post-traumatic stress disorder), CHF (congestive heart failure) and CVA (cerebrovascular accident). The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 12/3/24, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for mobility/transfers and eating. Section N: anticoagulant: yes. A review of the physician's order dated 11/27/24 revealed, Eliquis 5 mg po twice daily. [...]

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to maintain fans in a sanitary manner in one of one kitchen and dispose of expired supplements in one of two facility nourishment rooms.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence bed inspections for four of 43 residents in the survey sample, Residents #23, #70, #10 and #20.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to assess a resident for the self-administration of medication for one of 43 residents in the survey sample, Resident #32.

Inspectors wroteBased on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to accommodate resident needs for one of 43 residents in the survey sample, R25.

Inspectors wrote3. The facility staff failed to evidence provision of required written RP (responsible party) notification at the time of discharge for Resident #90. Resident #90 was transferred to the hospital on [DATE]. Resident #90 was admitted to the facility on [DATE] with diagnosis that included but were not limited to colon cancer, dementia, falls and femur fracture. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 12/2/24, coded the resident as scoring a 02 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the comprehensive care plan dated 5/27/24 revealed, PROBLEM: Resident at risk for falling related to generalized weakness with dementia and history of colon cancer. APPROACH: Observe frequently and place in supervised area when out of bed. [...]

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to evidence bed hold notice provided for a facility-initiated transfer for one of 43 residents in the survey sample, Resident #9.

Inspectors wroteBased on observation, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide services to maintain or improve mobility for one of 43 residents in the survey sample, Resident #70.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for an indwelling catheter for one of 43 residents in the survey sample, Resident #89.

Inspectors wroteBased on observation, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to obtain a physician's order for oxygen administration for one of 43 residents in the survey sample, Resident #9.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide trauma informed care for one of 43 residents in the sample Resident #176 (R176).

Inspectors wroteBased on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to ensure timely physician visits for 1 of 43 residents in the survey sample, Resident #127.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to ensure one resident was safe from falling during ADL Care, which constituted harm for 1 of 8 residents (Resident #4), in the survey sample.

Inspectors wroteBased on clinical record review, staff and resident interview and review of facility documents, it was determined that the facility staff failed to ensure 3 out of 42 residents (R#453, #457 and #456) in the survey sample had the opportunity to formulate an Advance Directive.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that facility staff failed to maintain hot foods at a temperature of 135 degrees or higher while holding on the steam table.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that facility staff failed to serve food at palatable temperatures.

Inspectors wroteBased on observation, staff interviews, clinical record review and facility documentation review the facility staff failed to follow 2 physician orders for 1 of 42 residents in the survey sample, Resident #82.

Inspectors wroteBased on observations, resident interviews, staff interviews, clinical record review, and a review of the facility's policy, the facility staff failed to ensure medically related social services to include resident's appointments and assessments were provided for 4 of 42 residents in the survey sample, Resident #57, #453, #457, and #456.

Inspectors wroteBased on observation, resident interviews, staff interviews, clinical record review, and a review of the facility's policy, the facility staff failed to ensure one resident receive the services needed to meet their dental needs for 1 out of 40 residents (Resident #57), in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interviews, clinical record review, and review of the facility policy the facility staff failed to identify a pressure ulcer and institute appropriate interventions, care and treatment for 1 of 42 residents (Resident #44), in the survey sample. The facility staff failed to identify Resident #44's sacral pressure ulcer prior to it advancing to a stage three pressure ulcer; which presented with 70% slough (non-viable) tissue, 30% granulation tissue and measured 0.8 centimeters x 1.0 centimeters x 0.1 centimeters, requiring surgical debridement (removal) to promote healing, which constituted harm.

Inspectors wroteBased on observation and staff interview it was determined that facility staff failed to provide a dignified dining experience for five of 42 residents in the survey sample; Resident #33, #20, #2, #7 and #58 in the activity room on unit one. Facility staff failed to provide Resident #33 a dignified dining experience during dinner on 4/28/19; and failed to provide Residents #20, #2, #7 and #58 a dignified dining experience for lunch on 4/30/19 in the activity room on unit one.

Inspectors wroteBased on observation and staff interview, facility staff failed to provide a homelike environment during the dining observation on two separate occasions on 4/28/19 and 4/30/19 in the activity room of unit one. Facility staff served resident meals on trays during the dining observation in the unit one activity room for dinner on 4/28/19 and for lunch on 4/30/19.

Inspectors wroteBased on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's Care Plan to include their goals for 3 of 42 residents (Resident #73, 32, and 70) after being transferred to the hospital. 1. The facility staff failed to ensure that Resident #73's Plan of Care Summary to include their care plan goals was sent upon transfer/discharge to the hospital on [DATE]. 2. For Resident #32, facility staff failed to evidence that all required documentation was sent with the resident upon transfer to the hospital for a facility-initiated transfer on 2/9/19. 3. [...]

Inspectors wroteBased on staff interviews, facility documentation review and clinical record review the facility staff failed send a copy of the Bed-Hold Policy for 3 of 42 residents (Resident #73, 32 and 70) after being transferred to the hospital. 1. The facility staff failed to issue the resident/representative with a written copy of bed hold policy for Resident #73. Resident #73 went to his doctor's appointment and was transferred to the local hospital and admitted on [DATE]. 2. Facility staff failed to evidence that written bed hold notification was provided to the resident/responsible party at the time of a facility initiated transfer to the hospital on 2/9/19. 3. The facility staff failed to ensure Resident #70 or Resident Representative (RR) was issued a written notice of the bed hold reserve policy upon transfer to the local hospital on 6/1/18, 6/3/18, 10/5/18 and on 12/21/18.

Inspectors wroteBased on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure a Level II PASRR (Preadmission Screening and Resident Review) was conducted for 2 of 40 residents (Resident #18 and #32) in the survey sample with diagnoses of either a mental disorder and or intellectual disability. 1. The facility staff failed to ensure Resident #18, who was identified with a mental illness and had a Level I PASRR screening with recommendation for a Level II assessment, had the Level II conducted per standard protocol. 2. The facility staff failed to ensure a Level II PASRR was completed for Resident #32.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that facility staff failed to review and revise the care plan for five (5) of 42 residents in the survey sample, Resident # 71, #58, #32, #6 and #73. 1. For Resident #71, facility staff failed to revise the care plan when she was diagnosed with MRSA (Methicillin-resistant Staphylococcus aureus) in her sputum. 2. For Resident #58, facility staff failed to revise the care plan when she was diagnosed with pneumonia and receiving antibiotic therapy. 3. For Resident #32, facility staff failed to revise the care plan when a stage II pressure ulcer was found to her right hip; and a wound from trauma was found to her left lateral ankle on 4/2/19. 4. [...]

Inspectors wroteBased on resident interview, staff interviews and clinical record review the facility staff failed to provide personal care to include showers for one resident in the survey sample (Resident #62) who was unable to independently carry out activities of daily living (ADL's). The facility staff failed to ensure Resident #62 was offered and received scheduled twice-weekly showers to maintain good personal hygiene.

Inspectors wroteBased on resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to communicate ongoing assessments for Resident #73 for the monitoring of complications after dialysis treatment. The facility staff failed to ensure ongoing communication and assessments with the dialysis center for Resident #73 who attended an outpatient dialysis three days per week every Tuesday, Thursday and Saturday.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of the facility's policy the facility staff failed to acquire medications needed to meet each resident's needs for 1 of 42 residents (Resident #44), in the survey sample. The facility's staff failed to obtain Nystatin ointment (an antifungal) ordered for Resident #44 on 4/22/19.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that facility staff failed to follow infection control practices for three of 42 residents in the survey sample, Resident # 229, #71, and #58; and the facility staff failed to ensure they followed infection control practices to prevent the possible transmission of infection and disease on 2 of 2 facility nursing units. 1. For Resident #229, facility staff failed to wear the appropriate PPE (Personal Protective Equipment) while she was on contact precautions on 4/28/19 and had the wrong precaution sign on the resident's door. 2. For Resident #71, facility staff failed to wear the appropriate PPE while she was on droplet precautions on 4/29/19 and had the wrong precaution sign on the resident's door. 3. [...]

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, clinical record review, the facility staff failed to notify pertinent individuals of a change in condition for 1 of 42 Residents (Resident #30), in a survey sample. The facility staff failed to notify the physician and Responsible Party of Resident #30's open areas on the right lower extremity.

Inspectors wroteBased on clinical record review, staff interviews and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 1 of 3 residents (Resident #68) in the survey sample. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #68. Resident #68 was discharged from skilled services who remained in the facility with Medicare days remaining.

Inspectors wroteBased on observation during wound care and staff interviews the facility staff failed to assure privacy was maintained during the provision of care for 1 of 42 residents (Resident #67), in the survey sample. The facility staff failed to pull the privacy curtain to obscure Resident #67 from view while providing wound care and failed to wait for a response after knocking on the door before entering.

Inspectors wroteBased on staff interviews, clinical record review and facility documentation the facility staff develop a comprehensive personal centered care plan for 1 of 42 residents (Resident #6) in the survey sample. The facility staff failed to develop a person-centered care plan to include the diagnosis of depression with the use of a psychoactive medication (*Zoloft).

Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation the facility staff failed for one (Resident #109) of 14 residents in the survey sample, to follow professional standards of care for medication administration. The facility staff failed to administer medication to Resident #109 per physician's order on 06/17/2019 and failed to document attempts to acquire the medication.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure there was Registered Nurse (RN) coverage for 8 hours, 7 days a week. The facility staff failed to ensure there was RN coverage for 8 hours on 3/2/19.

Inspectors wroteBased on clinical record review and staff interviews the facility staff failed to ensure that the medication irregularities identified by the Pharmacist during the Drug Regimen Review were acted upon for 1 of 42 residents (Resident #47) in the survey sample. The facility staff failed to ensure medication irregularities identified by the Pharmacist during the Drug Regimen Review were acted upon for Resident #47.

Inspectors wroteBased on observation and inspection of 1 of 2 medication rooms (Unit II), the facility staff failed to ensure provision of a separately locked, permanently affixed compartment for the storage of controlled drugs or drugs subject to abuse.

Inspectors wroteBased on staff interview, facility documentation review, the facility staff failed to ensure the Quality Assessment and Assurance (QAA) committee met at least quarterly and the required members attended. The facility staff failed to consistently have the required members at each quarterly Quality Assessment and Assurance Committee (QAA) meeting and failed to meet on a quarterly basis for one year.

Inspectors wroteBased on resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 3 of 42 residents (Resident #73, 32, and 70) after being transferred to the hospital. 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #73's discharge and admission to the hospital on [DATE]. 2. For Resident #32, facility staff failed to evidence that the Office of the State Long-Term Care Ombudsmen received written notification that the resident was sent to the hospital on 2/9/19. 3. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #70's discharges to the hospital/emergency room on 6/1/18, 6/3/18, 10/5/18 and on 12/21/18.