Resthaven Nursing & Rehab Center, LLC

Inspectors wroteBased on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: opened food item not labeled with the date; expired foods in the kitchen walk in cooler, and dry storage area;grease splatter and thick layer of debris on the deep fryer cover and cooking oil collection area; andexposed facial hairThis deficient practice had the potential to affect the 103 residents who consumed food from the kitchen.

Inspectors wroteBased on record reviews and interviews, the facility failed to notify the State's Long-Term Care Ombudsman of a discharge in writing for 1 (#110) of 1 (#110) resident reviewed for discharge requirements out of a final sample of 36.

Inspectors wroteBased on record reviews and interview the facility failed to complete a significant change MDS (Minimum Data Set) within 14 days after determining there was a significant change in 2 (#2, #4) of 36 sampled resident's reviewed. The deficient practice had the potential to affect a total census of 105.

Inspectors wroteBased on record review and interview, the provider failed to accurately code a resident's MDS (Minimum Data Set) for use of an antipsychotic medication for 1(#25) out of 36 sampled residents.

Inspectors wroteI. Based on observations, interviews, and policy and procedure reviews, the facility failed to maintain a clean and sanitary kitchen to prevent cross contamination and the likelihood of foodborne illnesses to the 110 residents who ate meals prepared from the facility's kitchen. This deficient practice resulted in an Immediate Jeopardy on 08/18/2024 at 9:15 a.m. when the following was observed during multiple visits in the facility's kitchen: 1. Equipment: a. Excessive food residue on the stove top. b. Black residue under the ice machine's filter. Water dripped down over the black residue. c. Collection receptacle of the oven's grill top with old food, thick black burnt residue, and uncooked pasta. d. Dry food particles and grease on the oven handle. e. Burnt food particles on the stove burners. f. Food splatter on the shelf of the stove. g. Grease on the backsplash of the fryer. h. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to ensure the well-being of residents by failing to provide oversight in the kitchen. This lack of oversight resulted in an Immediate Jeopardy on 08/18/2024 at 9:15 a.m., when the kitchen was observed to have equipment, environment, food storage, preparation practices; and dinnerware storage practices that were unsanitary and unsafe for meal distribution to residents with the high likelihood to cause foodborne illness. S1ADM (Administrator) was notified of the Immediate Jeopardy on 08/18/2024 at 5:51 p.m. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility's kitchen was free from insects. The deficient practice had the potential to affect 110 residents who ate meals from the kitchen. 111 residents resided in the facility.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to develop and implement the resident's plan of care to provide the necessary care and services in accordance with professional standards of practice for 3 (#1, #4, and #5) residents in a final sample of 44 residents by: 1. failing to follow physician's orders for tube feeding for Resident #1; 2. failing to follow physician's orders for applying prevalon heel protector to Resident #4's right foot; 3. failing to ensure that interventions were care planned after Resident #5 sustained a fall.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to ensure that residents who required dialysis received such services consistent with professional standards of practice and the comprehensive person-centered care plan as evidenced by: 1. failing to ensure assessment of the resident's condition before dialysis treatments, and 2. failing maintain an effective communication system between the facility and the dialysis center for 1(#68) of 1(#68) investigated for dialysis care out of 44 sampled residents.

Inspectors wroteBased on record reviews, observations, and interview the facility failed to provide appropriate treatment and services for 1 (#4) of 3 (#1, #4, and #32) residents reviewed for tube feeding by failing to ensure the tube feeding container was appropriately labeled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure respiratory equipment was properly stored when not in use for 2 (#27, #31) of 2 (#27, #31) residents investigated for respiratory care in a final sample of 44 residents.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that nursing staff followed facility policies and procedures for medication administration. This deficient practice is evidenced by a nurse leaving medications at the resident's bedside for 1 (#26) of 44 sampled residents.

Inspectors wroteBased on observations, interviews and policy reviews, the facility's staff failed to follow the facility's policy for storage of medications as evidenced by: 1. Expired medication stored in the refrigerator in Med RoomA; 2. Expired medications stored inside 2 ([NAME], CartB) of 3 ([NAME], CartB, CartC) medication carts inspected; 3. Unlabeled medication stored inside 1 ([NAME]) of 3 ([NAME], CartB, CartC) medication carts inspected. The deficient practice had the potential to affect a total census of 111 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure it employed a qualified social worker on a full-time basis. The facility had 160 licensed beds with a census of 111 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection control and prevention program and implement accepted infection control practices to help prevent and control the spread of an infectious communicable disease, COVID-19 by failing to post proper signage outside the resident's entrance room clearly identifying the type of transmission based precautions and appropriate PPE (Personal Protective Equipment) be used for 1 (#110) of 3 (#27, #82, #110) residents investigated for transmission based precautions (TBP). This deficient practice had the ability to affect 6 residents in the facility that were on transmission based precautions.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents identified with Mental Disorder and/or Intellectual Disability had an accurate (PASARR) Pre-admission Screening and Resident Review Level I and/or Level II for 3 (#44, #52, #82) of 6 (#1, #16, #44, #52, #82, #85) residents reviewed for PASAAR screening. The deficient practice had the potential to effect 102 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a Significant Change in Condition Minimum Data Set (MDS) assessment was completed within the required timeframe after resident discharged from hospice services for 1 (#40) out of 21 sampled residents. This deficient practice had the potential to affect a total census of 102 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the assessment accurately reflected the resident's status by failing to accurately code the Minimum Data Set (MDS) for medications for 1 (#52) of 21 residents reviewed in the initial pool. The deficient practice had the potential to affect a total of 102 residents.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to refer all residents with a newly evident or serious mental disorder, intellectual disability, or a related condition for level II resident review for 2(#82, #85) out of 6 (#1, #16, #44, #52, #82, #85) residents reviewed for Pre-admission Screening and Resident Review (PASARR). The deficient practice had the potential to affect a total census of 102 residents.

Inspectors wroteBased on observation, record review and interviews, the facility failed to implement care plan for 1 (#90) out of 33 sampled residents. The deficient practice had the potential to affect a total census of 102 residents.