Rockport Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure plastic cups were clean. 2. The facility failed to ensure all items in the freezer were tightly sealed. 3. The facility failed to ensure a worn spatula was discarded. 4. The facility failed to ensure there were no personal items in the refrigerator. 5. The facility failed to ensure the ice machine was clean and not leaking. These failures could place residents who received meals and/or snacks from the kitchen at risk for food contamination and food-borne illness.

Inspectors wroteBased on interviews and record review the facility failed to ensure the residents right to be informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 1 of 7 residents (Resident #53) reviewed for resident rights in that: Resident #53 was prescribed and administered aripiprazole (an antipsychotic) without prior consent based on information of the benefits, risks, and options available. This failure could affect the right to self-determination of all facility residents who receive medication by allowing them to receive medication without their prior knowledge or consent, or that of their responsible party or emergency contacts.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the resident's medical symptoms for 1 (Resident #53) of 7 residents reviewed for unnecessary medications. The facility failed to have an adequate indication for the use of the medication aripiprazole (an antipsychotic) for Resident #53 before administering the medication with a black box warning. This failure could put residents at risk of harm from adverse reactions or harmful side effects.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchens observed. The facility failed to provide each resident with properly prepared food that had the most nutritional value and follow their therapeutic diets.2. The facility failed to provide tasty food served to Residents #1, #12, and #79, and other anonymous complaints made during the resident council meeting who complained the food served did not taste good. This deficient practice could place residents at risk for poor food intake, weight loss, not having their nutritional needs met, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was developed and implemented within a timely manner for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 (Resident #1) out of 5 residents reviewed for care plans. The facility failed to update or revise Resident #1's care plan to reflect Resident #1's verbal and combative behavior of resistant to care or refusal of care. This failure could place resident at risk for receiving inadequate care and services.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed and 1 of 1 resident refrigerator/freezer reviewed for storage, preparation and sanitation. -The facility failed to ensure plastic dishes were clean on the clean rack in the kitchen. -The facility failed to ensure staff personal food items were kept out of the resident's refrigerator and freezer in the activities area. -The facility failed to ensure food items in the resident's refrigerator and freezer were labeled and dated. -The facility failed to ensure food items in the resident's refrigerator and freezer were not expired. -These failures could place residents at risk for complications from food contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from abuse for one (Resident #1) of two residents reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse. On 01/25/25, Resident #2 hit Resident #1 in the stomach with a closed fist as she was walking past her. This failure could place residents at risk for abuse and psychological harm.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for 1 resident (Resident #2) of 5 residents whose care plans were reviewed for timing and revision. The facility failed to include heightened monitoring strategies to Resident #2 ' s care plan after she hit another resident on 01/25/25. This failure could place residents at risk of not receiving appropriate care to meet their current needs.

Inspectors wroteBased on observation and interviews, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 2 medication rooms (Medication room [ROOM NUMBER]). The facility failed to keep Medication room [ROOM NUMBER] free from the employee personal food items on 01/28/25 as there were sunflower seeds, coke, and a tumbler cup in the room. This deficient practice could place residents at risk of receiving medications contaminated by food and drinks.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #178) of 4 residents reviewed for infection control in that: 1. The facility failed to ensure that Resident #178 had EBP (Enhanced Barrier Precautions) signage and PPE (Personal Protective Equipment) available for staff providing care to Resident #178 on 1/27/25 and 1/28/25 due to Resident #178 having an indwelling urinary catheter.

Inspectors wroteBased on interview and record review the facility failed to immediately consult with the resident's physician when there was a significant change or a need to alter treatment, for one resident (Resident #1) of three residents reviewed for notification of changes. The facility failed to consult with Resident #1's physician when Resident #1 held her groin, indicating pain, yelling ow ow ow on 07/06/2024. On 07/06/2024 there was indication of groin pain, which was different from 07/05/2024's left and right knee pain. These failures could affect residents who experience a change in condition that require immediate pain assessment and assistance.

Inspectors wroteBased on interviews and record review the facility failed to notify the resident, resident's representative, and ombudsman of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood before transferring or discharging the resident for 1 of 4 residents (Resident #2) reviewed for transfer and discharge. Resident #2's responsible party and the ombudsman were not notified in writing of the effective date of transfer or discharge for Resident #2, the reason for the transfer/discharge, the location to which the resident would be transferred, or the right of appeal. Resident #2 was discharged on 5/21/2024 to an emergency room hospital for a psychological evaluation. This deficient practice could affect residents who are transferred or discharged from the facility at risk of having their discharge rights violated.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' physical, mental, and psychosocial needs, for 1 resident (Resident #3) of 4 residents reviewed for care plans. The facility did not care plan Resident #3's refusal of care nor his aggressive behaviors. These failures could place residents at risk for not receiving necessary care and services.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 3 of 16 residents (Resident #38, Resident # 41, Resident #63) reviewed for resident rights . The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #38 prior to administering Ativan, a sedative used to treat anxiety (excessive worry and tension that disrupts daily life and lasts 6 months or longer). [...]

Inspectors wrote[NAME], [NAME] Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #7 and #48) of 5 residents reviewed for infection control. CNA A failed to wash her hands and change her gloves after they became contaminated during incontinent care while assisting Resident #7. CNA D and NA G failed to wash their hands and change their gloves after they became contaminated during incontinent care while assisting Resident #48. This failure could place resident's risk for cross contamination and the spread of infection.