Rocky Ridge Manor

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent misappropriation of resident property when one staff member (Business Office Manager (BOM) A) took money from four residents (Resident #1, #2, #3, and #4) without their permission and not for resident use. The facility census was 49. Review of the facility's Guidelines for Maintaining the Resident Trust Fund Account, revised 08/04/22, showed the facility will establish and maintain a system that assures full, complete, and separate accountings of each resident's personal funds entrusted to the facility on the resident's behalf. 1. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to complete and document a full investigation of all allegations of abuse with steps taken to protect residents during the investigation documented when staff failed to fully investigate one allegation of abuse made by one resident (Resident #1) alleging abuse by one staff member (Restorative Nurse Aide (RNA)) E. The facility census was 48. Review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property, undated, showed the following:-Each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse;-All employees who have been alleged to commit abuse will be suspended immediately, pending investigation;-Facility will complete an investigation. 1. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to Administrator and within two hours to the state licensing agency (Department of Health and Senior Services - DHSS) when staff failed to report an allegation of abuse involving one resident (Resident #1) to management and DHSS in a timely fashion. The facility census was 48. Review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property, undated, showed the following:-Each resident will be free from abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were treated in a dignified manner, when one staff member (Social Services Director (SSD)) would not allow one resident (Resident #1) to smoke after the resident displayed behaviors. The facility census was 49. Review of the facility policy titled Resident's Rights, undated, showed the following: -The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility; -The resident has the right to exercise his/her rights as a resident of the facility and as a citizen or resident of the United States; -The resident has the right to be free of interference, coercion, discrimination and reprisal form the facility in exercising his/her rights, and be supported by the facility in the exercise of his/her rights. 1. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency (Department of Health and Senior Services - DHSS) when staff failed to report two allegations of abuse involving one resident (Resident #1) to management and DHSS in a timely fashion. The facility census was 49. Review of the facility policy titled Abuse Prohibition Protocol Manual, revised 11/28/16, showed the following: -Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to complete and document a full investigation of all allegations of abuse with steps taken to protect residents during the investigation documented when staff failed to fully investigate two allegations of abuse made by one resident (Resident) alleging abuse by staff. The facility census was 49. Review of the facility policy titled Abuse Prohibition Protocol Manual, revised 11/28/16, showed the following: -Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property; -All residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation; [...]

Inspectors wroteBased on interview, and record review, the facility failed to protect all residents right to be free from sexual abuse by other residents when staff failed to care plan and implement new interventions when one resident (Resident #1) exhibited sexually abusive behaviors towards two residents (Resident #2, Resident #3) and sexually verbal behaviors toward one resident (Resident #4). The facility census was 49. Review of the facility policy, titled Abuse Prohibition Protocol Manual, revised 11/28/2016, showed the following: -All residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation; -The facility must thoroughly investigate the alleged violation, prevent further abuse while the investigation is in progress, and take appropriate corrective action; [...]

Inspectors wroteBased on interview and record review, the facility failed to report all allegations of resident-to-resident abuse to the State Survey Agency (Department of Health and Senior Services- DHSS) within the required two hours when staff did not report multiple allegations of sexual abuse by one resident (Resident #1) towards other residents to DHSS. The facility census was 49. Review of the facility policy, titled Abuse Prohibition Protocol Manual, revised 11/28/16, showed the following: -Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property; -The Administrator or designee must report to the State Survey agency no later than two hours after the allegation is made if the event involved abuse or resulted in injury. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete performance reviews of every certified nurse aide (CNA) at least once every 12 months when staff failed to document competency evaluation and performance review for two staff (CNA N and CNA M). The facility census was 39. Review showed the facility did not provide a written policy pertaining to nurse aide competency reviews. 1. Review of personnel records showed the following CNAs had been employed for more than one year: -CNA N - Hire date of 12/20/22; Re-hire date of 04/26/23; -CNA M - Hire date of 01/27/23; Re-hire date of 06/28/23; -Staff did not have documentation of a yearly performance review for CNA N and CNA M. During an interview on 09/11/24, at 9:08 A.M., the Director of Nursing (DON) said the facility did scheduled monthly in-services for all staff, with some specific to nursing and the CNAs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of meaningful activities based on residents' interests and abilities when the staff failed to provide a complete activity schedule with a variety of daily activities, failed to complete activities as scheduled, and failed to document steps taken to provide meaningful activities for nine residents (Resident #13, #17, #14, #39, #9, #16, #7,#40, and #16) out of a sample of 20 residents. The facility had a census of 39. Review of the facility policy titled, Activity/Recreational Therapy Manual last reviewed on 03/2012, showed the following: -The purpose was for the facility to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident; [...]

Inspectors wroteBased on observation, record review, and interview, the facility staff failed to ensure the facility was maintained in a sanitary and comfortable fashion when staff failed to keep the outside of the ice machine clean and failed to keep all light fixtures, vents, and ceiling areas clean. The facility census was 39. 1. Review of the facility's policy titled Ice Maker, dated May 2015, showed staff would clean the outside of the machine week. Staff would wash the outside of the ice machine monthly with a soft brush or cloth and dry. Review of the facility's Ice Machine Cleaning Schedule showed the machine was to be cleaned monthly. Staff last documented cleaning the ice machine on 08/31/24. Observations on 09/09/24, beginning at 9:13 A.M., of the ice machine in the kitchen showed the following: -The outside had white and brown buildup along the crevasses of the machine at the top; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of need for one resident (Resident # 39) when staff did not place the resident's call light where it could be accessed by the resident. The facility census was 39. Review of the facility policy titled, Use of Call Light, dated March 2015, showed the following: -Answer all call lights in a prompt, calm, courteous manner; -When providing care to the residents, be sure to position the call light conveniently for the resident's use; -Tell the resident where the call light is and show him/her how to use the light; -Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. 1. Review of Resident #39's face sheet (brief resident profile sheet) showed the following: -admission date of 06/04/24; -Diagnoses included stroke. [...]

Inspectors wroteBased on record review and interview, the facility failed to complete the required Preadmission Screening and Resident Review (PASARR - a two level tool used to screen each resident in a nursing facility for mental disorder or intellectual disability prior to admission) prior to or upon admission to the facility for one resident (Resident #42). The facility census was 39. Review of the facility's admission Packet showed a checklist showing Obtain DA 124C (preadmission screening related to psychological diagnoses). Review showed the facility did not provide a written policy pertaining to PASARRs. 1. Review of Resident #42's face sheet (gives brief profile information) showed the following: -admission date of 05/10/24; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that each resident's written care plan was accurate and up-to-date, when staff failed to care plan hospice services for two residents (Resident #39 and Resident #2). The facility census was 39. 1. Review of Resident #39's face sheet (brief resident profile sheet) showed the following: -admission date of 06/04/24; -Diagnoses included chronic obstructive pulmonary disease (COPD - refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath), stroke, depression, anxiety, and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event); -Resident on hospice services. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to assist all dependent residents with activities of daily living to maintain good grooming when the facility staff failed to perform peri-care for one resident (Resident #41) following an episode of incontinence and toileting. The facility census was 39. 1. Review of Resident #42's face sheet (gives basic profile information about the resident) showed the following: -admission date of 05/14/24; -Diagnoses included metabolic encephalopathy (brain dysfunction that occurs due to a chemical imbalance in the blood) and congestive heart failure (CHF - irregular heart function). Review of the resident's care plan, last updated 08/15/24, showed the following: -Staff to assist with toileting; -Staff to provide changing and peri-care with each incontinent episode to keep skin clean and free from odor and breakdown; [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure staff followed acceptable standards of care when staff did not change gloves or sanitize their hands during care for the indwelling suprapubic catheter (tubing inserted directly into the bladder through the abdomen to drain to an exterior collection bag) of one resident (Resident #20). The facility census was 39. 1. Review of Resident #20's face sheet (gives basic profile information) showed the following: -admitted to the facility on [DATE]; -Diagnoses included bipolar disease (mental disorder causing alternating depressive and manic episodes), generalized anxiety disorder, insomnia, muscle weakness, history of urinary tract infection (UTI), benign prostatic hyperplasia (BPH; [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide care per standards of practice when staff failed to address one resident's (Resident #39) complaints of pain in a timely manner. The facility census was 39. Review of the facility's policy Pain Management Guidelines, dated January 2017, showed the following: -The goal of pain management will be to control pain so it will not interfere with the ability to have restful sleep patterns, perform activities of daily living (ADL's- dressing, grooming, bathing, eating, and toileting), participate in usual activities, or cause problems with mood or behaviors; -A licensed nurse or certified nurse aide (CNA) may assess and communicate degrees of pain to the person administering the pain medications to the residents; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that all residents who were trauma survivors received care per standards of practice when staff did not address the the diagnosis of Post-Traumatic Stress Disorder (PTSD - disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event) in the medication record or in the care plan, to include triggers and interventions, and failed to ensure care staff were aware of the PTSD history, to include triggers and interventions, for one resident (Resident #41). The facility census was 39. Review of the facility assessment, updated 10/25/23, showed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when staff failed to complete appropriate hand hygiene and use PPE appropriately while providing wound care for one resident (Resident #32). Facility staff also failed to complete appropriate hand hygiene while providing indwelling suprapubic catheter (tubing inserted directly into the bladder through the abdomen to drain to an exterior collection bag) care for one resident (Resident #20). The facility census was 39. Review of the facility policy, titled Handwashing, dated 03/2015, showed the following information: -Purpose to reduce transmission of organisms from resident-to-resident, staff-to-resident, and resident-to-staff; -Wash hands with soap and water. [...]

Inspectors wroteBased on interviews and record review, the facility staff failed ensure all allegations of possible abuse were reported timely when staff did not report an allegation of employee to resident abuse involving one resident (Resident #1) immediately to administration and within two hours of staff becoming aware of the allegation to the state survey agency (Department of Health and Senior Services - DHSS). The facility census was 32. Review of the facility policy titled Abuse Prohibition Protocol Manual, revised 11/28/16, showed the following: -Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property; [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that an allegation of possible abuse was immediately investigated with immediate steps taken to protect all residents during the investigation when staff failed to immediately report an allegation of abuse involving one resident (Resident #1) and a staff member. The facility census was 32. Review of the facility policy titled Abuse Prohibition Protocol Manual, revised 11/28/16, showed the following: -Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property. Review of the facility policy titled Reporting, revised 11/2017, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal vaccines (vaccines used to prevent some cases of pneumonia, meningitis (swelling of brain and spinal cord membranes, typically caused by an infection), and sepsis (potentially life-threatening complication of an infection) to four residents (Resident #6, #10, #14, and #38) following the residents' admission to the facility, and staff failed to obtain a consent prior to administering an influenza vaccine for two residents (Resident #5 and #39) The facility census was 42. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, dated 11/30/15, showed the following: -Two pneumococcal vaccines are recommended for adults; [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN-form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two (Residents #9 and #23) of three sampled residents who remained in the facility upon discharge from Medicare Part A services. The facility census was 42. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC-form CMS-10123) is issued when all covered Medicare services end for coverage reasons; [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to consistently document a resident's code status and failed to include the resident's code status in his/her care plan for one resident (Resident #9) in a selected sample of 17 residents. The facility census was 42. Record review of the facility policy titled, DNR Guidelines dated 9/2010, included the following information: -When a resident or legal representative decides to change the code status of the resident, the Social Services Designee will make the changes as soon as the OHDNR (out of the hospital do not resuscitate) form has been signed by the physician. -The Social Services Designee will complete the following: a green paper with Full Code (a person wanted all interventions needed to get his/her heart started. [...]

Inspectors wroteBased on observations, interviews, and record review the facility staff failed to obtain a physician order and provide proper cleaning and maintenance for a Bilevel Positive Airway Pressure (BIPAP - a machine used to help a person breathe) for one resident (Resident #37) out of a selected sample of 17 residents. The facility census was 42. Record review of the facility's BIPAP Administration policy, from the Nursing Guidelines Manual, dated March 2015, included the following: -Purpose to administer positive airway pressure to maintain open airway to the resident with obstructive apnea or respiratory problems breathing, primarily during sleep. -Care and use of BiPAP machine with cleaning mask, head gear, tubing and humidifier same as the CPAP (continuous positive airway pressure) guidelines. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician's orders for side rail usage and failed to complete timely side rail assessments to include bed rail safety checks, and regular inspections/measurements on the potential entrapment zones of the mattress to bed frame for two residents (Resident #2 and Resident #241) in a selected sample of 17 residents. The facility census was 42. Record review of facility records showed the facility did not provide a policy regarding side rail assessment and assessments (measurements) of potential entrapment zones. 1. Record review of Resident #2's face sheet (general resident information form) showed the following information: -admission date of 4/4/16 with readmission date of 4/4/19; [...]