Promontory Point Rehabilitation

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an Advance Directive. This was true for 9 of 12 residents (Resident #2, # 3, #17, #29, #37, #52, #60, #61 and #66) whose records were reviewed for advance directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning.

Inspectors wroteBased on observation, policy review, manufacture's manual review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment for 2 of 2 residents (#57 and #66 ) observed for respiratory equipment use and clean/sanitary laundry rooms. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of psychotropic medications for 1 of 1 resident (Resident #60) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medications were prescribed, the expected benefits, and the risks associated with the medications.

Inspectors wroteBased on observation, resident and staff interviews, record review, and policy review it was determined the facility failed to assess whether residents had the ability to self-administer their medications for 1 of 1 resident (Residents #66) reviewed for self-administration of medications. This failure created the potential for adverse effects if medications were self-administered inappropriately by the resident.

Inspectors wroteBased on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure a resident's call light was within reach for 1 of 37 residents (Resident #9) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention.

Inspectors wroteBased on policy review, record review, and staff interviews it was determined the facility failed to ensure transferring information and documentation, notice of bed-hold policy, and notice to the State Long-Term Care Ombudsman for 2 of 12 residents (#37 and #47) and the facility reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if the residents were not treated in a timely manner, allowed to return to the facility, or protected from inappropriate transfers and discharges.

Inspectors wroteBased on observation, staff interviews, and the State Operations Manual, Appendix PP it was determined the facility failed to ensure nurse staffing information was accurate and included scheduled and actual hours. This failed practice had the potential to affect the 37 residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels.

Inspectors wroteBased on observation, interview, and the FDA Food Code, the facility failed to ensure food was appropriately stored, distributed, and labeled. This deficient practice had the potential to affect all residents and staff who received meals prepared in the facility's kitchen. This placed residents and staff at risk for potential contamination of food and adverse health outcomes including food-borne illnesses.

Inspectors wroteBased on observation and staff interview it was determined the facility failed to ensure resident's privacy was maintained during medication administration and medical information was protected. This was true for 1 of 2 medication carts reviewed for privacy and confidentiality. This deficient practice placed residents at risk of embarrassment and loss of control over their personal information.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure professional standards of nursing practice were followed for 1 of 12 residents (Resident #1) reviewed for quality of care. Resident #1 was at risk for adverse outcomes when she did not have a physician's order to provide oxygen as needed. This failed practice had the potential to adversely affect residents whose care and services were not followed according to accepted standards of practice.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and stored appropriately, this was true for 1 of 2 medication storage rooms inspected and 1 of 2 medication carts audited for labeling and storage of medications. This failure created the potential for residents to receive the wrong medication and to receive expired medications with decreased efficacy.

Inspectors wrote3. Resident #7 was admitted on [DATE], with multiple diagnosis including respiratory failure and hypertension. An MDS admission assessment, dated 1/31/24, documented Resident #7 was cognitively intact. Resident #7's record did not include an advanced directive or documentation information about an advanced directive was provided and discussed with her. 4. Resident #182 was admitted to the facility on [DATE], with multiple diagnosis including respiratory failure and sepsis (when your immune system has a dangerous reaction to an infection). A MDS admission assessment, dated 3/1/24, documented Resident #182 was cognitively intact. Resident #182's record did not include an advanced directive or documentation information about an advanced directive was provided and discussed with her. [...]

Inspectors wroteBased on record review, policy review and resident staff interview, it was determined the facility failed to ensure a baseline care plan was reviewed and provided to residents' and their representative. This was true for 5 of 12 residents (#7, #16, #130, #181, and #184) whose records were reviewed. This failure placed residents at risk of not having their goals for care and services met.

Inspectors wroteBased on policy review, observation, and staff interview, it was determined the facility failed to ensure infection control measures were consistently implemented and maintained to provide a safe and sanitary environment. This was true for 2 of 4 residents (#116 and #133) observed for infection control. This failure created the potential for harm by placing residents at risk for cross-contamination and infection.

Inspectors wroteBased on policy review, observation, record review, and, resident and staff interview, it was determined the facility failed to ensure a resident was assessed for safety to self-administer medication. This was true for 1 of 1 resident (Resident # 2) reviewed for self-administration of medications. This failure created the potential for adverse outcomes if Resident #2 received too much or too little of the medication.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure pertinent health information was provided to the receiving hospital. This was true for 1 of 2 residents (Resident #8) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if residents were not treated in a timely manner due to a lack of information provided upon transfer.

Inspectors wroteBased on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure there was an on-going activity program designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident. This was true for 2 of 12 residents (#8 and #180) reviewed for activities. This failure created the potential for harm if residents experienced boredom and lack meaningful activities throughout the day.

Inspectors wroteBased on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' dressing care was provided according to professional standards of nursing practice for 2 of 2 residents (#181 and #182) reviewed for quality of care. This failed practice had the potential to create infection in wounds or to Intravenous line sites.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 1 resident (Resident #181) reviewed for feeding tube use. This created the potential for harm if complications developed from improper tube feeding practice.

Inspectors wroteBased on policy review, observation, record review, and staff interview, it was determined the facility failed to follow physician orders for the maintenance of supplemental oxygen This was true for 3 of 4 residents (#7, #181, and #182) reviewed for supplemental oxygen use. This placed residents at risk for respiratory infections when the supplemental oxygen and nebulizer tubing and humidifier bottle were not dated when changed.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were free from medication errors. This was true for 2 of 2 residents (#11 and #132) whose medication administration were observed. This failure created the potential for harm to residents who receive insulin using an insulin pen to experience low or high blood sugars when they received an incorrect amount of insulin.