Richland Post Acute

Inspectors wroteBased on interview and record review, the facility failed to identify a change in condition for 1 of 3 residents (Resident 1) reviewed for assessments. The failure to perform an assessment disallowed an opportunity to adequately evaluate the resident's medical condition, which potentially caused a delay in treatment.

Inspectors wroteBased on observation interview and record review the facility failed to maintain a dignified dining experience for 2 of 7 residents (Residents 25 and 215) reviewed for dignity during dining. The facility did not provide timely meals to Residents 25 and 215 who waited for their meals after the other residents had been served. This failure placed residents at risk for decreased dignity and overall, wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASRR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) accuracy and have the required Level 2 referral sent if residents had a positive Level 1 PASRR as required for 3 of 6 residents (Resident 27, 19 and 47) reviewed for PASRR. This failure placed the residents at risk for inappropriate long term care placement and not receiving necessary mental health care and services.

Inspectors wroteBased on interview and record review the facility failed to develop a baseline care plan (BCP) within 48 hours of admission to the facility for 7 of 17 residents (Resident 19, 310, 47, 165, 213, 27, and 221) reviewed for BCP. The facility failed to document resident specific goals, physician orders, dietary orders, therapy services, and social service needs to include Preadmission Screening and Resident Review (PASRR a federally mandated process that ensures residents admitted to a nursing home were properly assessed for their mental health needs and appropriate placement). Additionally, a written summary of the BCP had not been provided to the residents and or their representatives, that included the components of the BCP. This failed practice placed residents at risk for unmet care needs and potential complications in their health status.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and/or implement comprehensive resident centered care plans for 3 of 6 residents (Residents 21, 27 and 47) reviewed for care planning. This failure placed residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration agreement (a legal document that required the use of a third party to resolve a dispute) in its entirety, including the right to cancel the agreement within 30 calendar days, in a manner and language that the resident understood for 3 of 4 residents (Resident 30, 40, and 52) reviewed for binding arbitration. This failure placed the residents at risk for losing legal protection, lack of understanding of the legal document, and the right to a jury or court hearing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary respiratory care and services consistent with professional standards of practice for 1 of 1 resident (Resident 165), reviewed for respiratory care with tracheostomy tubes (a mechanical device inserted into a surgically created opening made in the neck, known as a tracheostomy, which assists with breathing), by failing to ensure; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medications were properly disposed of for 1 of 1 medication rooms (Medication Room) reviewed for medication storage. This failure placed the residents at risk for receiving expired, ineffective, and/or compromised medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure influenza and pneumococcal immunizations were offered and risks and benefits of the immunizations were provided to 2 of 5 residents (Resident 30 and 42) reviewed for immunization and infection control. This failure placed the residents at risk for illness, lack of knowledge to make medical decisions, and spread of communicable diseases.

Inspectors wroteBased on interview and record review the facility failed to ensure implementation and maintenance of an effective training program for new or existing staff, prior to staff independently providing services to residents and annually, related to; A) effective communications, resident's rights/facility's responsibilities, abuse/neglect and dementia management regarding abuse prevention, infection prevention/control, and compliance/ethics program trainings for 1 of 3 staff (Staff Q) reviewed for training requirements and, B) Quality Assurance and Performance Improvement (QAPI, a process to maintain and improve safety/quality of residents in a nursing home) training for 3 of 3 staff (Staff Q, O, and P) reviewed for training requirements. This failure placed residents at increased risk for unmet care needs and inadequate care from unqualified staff.

Inspectors wroteBased on interviews and record review, the facility failed to report an incident of neglect regarding a fall to the State agency as required, involving 1 of 3 residents (Resident 1), reviewed for falls. This failed practice placed residents at risk for harm and diminished protection and oversight from the State agency.

Inspectors wroteBased on interviews and record review, the facility failed to supervise to ensure staff provided care according to the resident's plan of care and facility policy to prevent falls for 1 of 3 residents (Resident 1), reviewed for falls. This failed practice resulted in potential injuries to Resident 1 when they fell to the floor. Failure to follow residents' plans of care placed residents at risk for injury, falls, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective discharge planning process that addressed the resident's goals and needs, that involved the resident and the interdisciplinary team [(IDT) a group of healthcare professionals from different disciplines to help residents receive the care they need] for 2 of 4 residents (Resident 1 and 2) reviewed for discharge planning process. The failure to develop and implement a discharge plan consistent with the resident's needs and expressed discharge goals, placed the resident at risk for decreased self-worth and dissatisfaction with their living situation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the prevention, development, and worsening of a facility-acquired pressure injury (PI) for 1 of 4 residents (Resident 23) reviewed for PIs. The facility did not consistently provide ordered wound treatments, perform/document skin assessments, or obtain/implement Durable Medical Equipment (DME, medically necessary equipment used by people with a medical condition, disability, or injury) as ordered. Resident 23 experienced harm when they developed an avoidable PI that was not present upon admission. This failure placed Resident 23 at risk for further wound complication and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities are not inappropriately placed in nursing homes for long term care) were correct on admission and had required level II referral if residents had a positive level I PASARR, for 4 of 5 residents (Residents 43, 5, 23, and 34 ) reviewed for PASARR. This failure placed the residents at risk of not receiving the mental health care and services appropriate for their needs.

Inspectors wroteBased on interview and record review the facility failed to develop a baseline care plan (BCP) within 48 hours of admission that included resident specific initial goals and treatment plans, nor provide a summary of the required information from the BCP to the resident for 3 of 6 residents (Residents 7, 58, and 52) reviewed for baseline care plans. This failure placed the residents at risk for a lack of knowledge regarding the initial plan for delivery of care/services and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) for 3 of 5 residents (23, 34 and 35) reviewed for unnecessary medications. The facility failed to ensure residents had an appropriate diagnosis for use of psychotropic medications, had person-centered behaviors being monitored to reflect adequate need for the medications or implement non-pharmacological interventions to attempt prior to administering psychotropic medications. Additionally, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS, to assess for the presence and severity of abnormal movements of the face, limbs, and body) prior to beginning the psychotropic medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure protection of residents from their Alleged Perpetrator (AP), after allegations of abuse/neglect were reported to the facility for 1 of 6 residents (Resident 51) reviewed for abuse/neglect. This failure placed all residents at an increased risk for unidentified abuse and/or further abuse, and unmet psychosocial care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report allegations of abuse and/or neglect to the State Agency for 2 of 6 residents (Residents 27 and 52) reviewed for abuse/neglect. This failure placed the residents at risk for unidentified and ongoing abuse/neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a thorough investigation into an allegation of abuse and/or neglect and prevent an elopement for 2 of 5 residents (Resident 27 and 52) reviewed for abuse/neglect. This failure placed the residents at risk for unidentified and/or continued abuse, recurrent elopements, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement comprehensive resident centered care plans for 2 of 6 residents (Residents 34 and 51) reviewed for unnecessary medications and skin conditions. This failed practice put residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services for 1 of 2 residents (Residents 51), reviewed for skin care when they did not obtain a skin treatment order for an on-going rash for Resident 51. This failure placed the residents at risk for further skin irritation, discomfort, and pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the adequate supervision and safety monitoring for 1 of 1 resident (Resident 52) reviewed for elopements (the potential danger when a resident, often deemed impaired to make sound decisions, leaves the facility premises or safe area unauthorized, posing immediate threats to their health or safety). This failure placed the resident at risk for serious injury related to an inaccurate risk assessment for elopement.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen orders were obtained, the resident's respiratory status was monitored, or the maintaining of respiratory equipment was completed for 2 of 3 residents (Residents 58 and 5) reviewed for respiratory care. were provided such care, consistent with professional standards of practice. This failed practice placed these residents at risk for unmet respiratory needs and potential negative outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dialysis (a process that removes your blood from your body, filters out toxins in a machine, and then sends your filtered blood back into your body) care and services were consistent with professional standards of practice for 1 of 1 resident (Resident 23) reviewed for dialysis care. The facility failed to administer morning medications consistently, to include insulin (a medication that helps regulate blood sugar levels) and monitoring blood sugar levels (a procedure that required a stick to the fingertip with a lancet, and a drop of blood placed on the tip of a test strip that is inserted into a machine to determine what the blood sugar level is) to the resident prior to leaving for dialysis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were trauma survivors received trauma-informed care in accordance with professional standards of practice by not assessing or monitoring past experiences of Post Traumatic Stress Disorder [(PTSD) an anxiety disorder that develops in some people who have experienced a shocking, scary, or dangerous event) for 1 of 2 residents (Resident 13) reviewed for mood and behavior. This failure placed residents at risk for unidentified triggers and re-traumatization.

Inspectors wroteBased on interview and record review, the facility failed to ensure recommendations from the Pharmacist's monthly medication review (MMR) were reviewed and appropriately completed by the medical provider for 1 of 5 residents (Resident 23) reviewed for unnecessary medications. This failed practice put the resident at risk for receiving duplicate therapy (more than one, same class of medication used for the same indication) of depression (a persistent feeling of sadness and loss of interest) medications that were unnecessary and a negative medical reaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1) the labeling of several small containers of syrup on three trays located in dry 1 of 1 dry storage rooms in the kitchen, and 2) the resident's nutritional refrigerator was kept in a sanitary manner and undated /expired foods were discarded for 1 of 1 nutritional refrigerators in the facility. These failures placed residents at risk for consuming contaminated, expired foods, and food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement components of their infection prevention and control precautions for, 1) hand hygiene and glove change for 2 of 6 residents (Resident 3 and 23) reviewed during daily resident cares and wound care treatment, and 2) Legionella (a bacteria that can cause a severe respiratory disease) testing protocols and procedures when control measures (actions or steps taken) were not met to reduce the risk of growth/spread of pathogens (bacteria, virus or other microorganisms that can cause diseases) in water for 1 of 1 water management program (WMP) reviewed for infection control. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases.

Inspectors wroteBased on observation and interview the facility failed to provide a functional, comfortable and sanitary environment for 1 of 1 laundry rooms (LR1) reviewed for environmental conditions. This failure placed staff and residents at an increased risk for infections related to unsanitary surfaces.

Inspectors wroteBased on interviews and record review, the facility failed to ensure hemodialysis (a machine that filters wastes, salts and fluids from the blood when the kidneys no longer were working properly) care and services were consistent with professional standards of practice for 1 of 2 residents (Resident 1) reviewed for dialysis care. The facility failed to remove the pressure dressing applied to the A/V fistula (arteriovenous fistula - surgically created connection between vein and artery to allow direct access to the bloodstream for dialysis) following dialysis treatment, failed to consistently monitor the resident's condition following dialysis and to ensure facility policies and procedures were implemented. This failed practice placed Resident 1 at risk for complications and adverse medical conditions.

Inspectors wroteBased on interviews and record review the facility failed to timely and thoroughly evaluate and monitor a change of condition for 1 of 3 residents (Resident 1) reviewed for changes in condition. Failure to assess and monitor Resident 1 in a timely manner following a significant change of condition placed the resident at risk for a delay in medical treatment.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage dumpster area was maintained in a manner to prevent the harborage (shelter) of pests during 4 of 4 observations made on three days of the survey. This failure placed the facility at risk for an unsanitary environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 1 kitchen was maintained in a sanitary manner for prevention of cross contamination. The dishwasher was not maintained and repaired as needed, perishable (food that will go bad quickly) food labeling was inconsistent, expired food was observed in the refrigerator, and a staff beverage was located with clean dishware. These failures placed all residents that ate food from the kitchen at risk for food borne illnesses and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure standard infection prevention and control precautions were implemented for 2 of 2 residents (Residents 18 and 163) observed during wound care dressing changes. Additionally, hand hygiene was not performed during personal care (cleaning the private areas of a resident) by 2 of 2 staff (Staff G and Staff H) observed for hand hygiene. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a right calf rash was identified, the cause determined, and monitoring occurred in 1 of 1 Residents (Resident 55) reviewed for non-pressure related skin conditions. This failure placed the resident at risk for a delay in identification and treatment of new skin impairments, a delay in preventative measures put in place to prevent worsening, discomfort, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 5 residents (Resident 23) reviewed for accidents, was assessed for safe, independent use of a smoking device, after the resident's roommate reported to staff that Resident 23 had been using a vape pen (an electronic cigarette device that simulates tobacco smoking) in their room. This failure placed the residents at risk for preventable accidents and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 4 residents (Resident 215) who utilized adaptive eating equipment was provided with the necessary adaptive equipment for eating as ordered by Staff S, Occupational Therapist (OT). Resident 215 was not provided with a plate guard (a curved assistive device that helps to keep food from falling off of the plate) for two of three meals observed. This failure placed the resident at risk for increased dependence for eating and the potential for decreased food consumption.