Ross Memorial Health Care Ctr

Inspectors wroteBased on interviews, record review, and review of the facility policies titled, Notification of Change and Resident's Right Regarding Treatment and Advanced Directive, the facility failed to obtain consent/permission from the responsible party (RP) to change insurance provider for one of 51 sampled residents (R) (R7).

Inspectors wroteBased on staff and resident interviews, record review, and review of the facility's policies titled Abuse, Neglect, Exploitation and Fall Prevention, the facility failed to ensure that injuries of unknown source were reported timely to the State Survey Agency (SSA) for one sampled resident (R) (R41).

Inspectors wroteBased on observation, resident and staff interviews, record review, and review of the facility policy titled, Care Planning-Resident Participation, the facility failed to implement the care plan for one of 51 sampled residents (R) (R26) related to oxygen (O2) administration and Bi-pap (bilevel positive airway pressure device). Specifically, the resident returned from the hospital with new orders for O2 which were not addressed in the new five-day care plan.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Safe and Homelike Environment, the facility failed to maintain a safe, clean, comfortable, homelike environment by not making needed repairs in three of five hallways (100 hallway, 400 hallway, and 600 hallway) observed in the facility. There were seven resident rooms needing repair on the 100 hallway (room [ROOM NUMBER], 102, 105, 110, 111, 114, 116, and 118), two resident rooms on the 400 hallway (room [ROOM NUMBER] and 403), and one resident room on the 600 hallway (room [ROOM NUMBER]). Additionally, the therapy room had gouged areas in the door exposing rough wood, the main dining room had cracked and loose tiles, and the Beauty Salon's shampoo chair for the residents to sit in to have their hair done was missing one front leg and was being held up by a brick.

Inspectors wroteBased on staff interviews and document review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for the resident population during day-to-day operations and emergencies.

Inspectors wroteBased on document review, policy review, and interviews, the facility failed to designate at least one qualified individual as the infection preventionist (IPs) responsible for the facility's infection prevention and control program (IPCP). The failed practice had the potential to affect all residents who resided in the facility. As of 6/28/22, the facility census was 82.

Inspectors wroteBased on record review and interviews, the facility failed to perform routine and outbreak COVID-19 testing for all staff and residents as per guidelines from the Centers for Medicare and Medicaid Services (CMS) QSO-20-38-NH. Specifically, the facility failed to: - Identify an outbreak of COVID-9 in the facility after a resident tested positive to ensure broad-based outbreak testing or contact tracing was immediately conducted for residents and staff; and - Perform routine COVID-19 testing per current guidelines when the facility was in a county with a high community transmission rate. This had the potential to affect all staff and residents in the facility. As of 6/28/22, the facility census was 82 and there were 98 employees.

Inspectors wroteBased on interviews, document review, and policy review, the facility failed to develop and implement policies and procedures to ensure each resident and staff member was offered the COVID-19 vaccination and provided with education regarding the benefits, risks, and potential side effects associated with the vaccine prior to such offering. Additionally, the facility failed to maintain thorough medical record and personnel documentation reflecting such education and offerings or the vaccination status of each resident and staff member. This had the potential to affect 82 residents and 98 staff.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for two of three residents (R) (R#7 and R#37) reviewed for beneficiary protection notification review.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to have an effective infection control program and failed to implement measures to prevent the potential spread of COVID-19 throughout the facility, in accordance with guidance from the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS). Specifically, the facility failed to: - Ensure visitors entering the facility were screened for signs and symptoms of COVID-19 prior to entering the facility. - Ensure proper personal protective equipment (PPE) was used during an outbreak of COVID-19. - Ensure there was proper social distancing during communal activities and dining. This had the potential to affect all residents and staff in the facility. As of 6/28/22, the facility census was 82 and there were 98 staff members.

Inspectors wroteBased on interviews and facility document and policy review, the facility failed to inform residents, resident representatives, and/or families of confirmed COVID-19 cases in the facility, along with mitigating actions, in a timely manner. This had the potential to affect all residents in the facility. The facility census was 82.

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to ensure all facility staff, including contract staff, were vaccinated for COVID-19 or had an exemption in place. Specifically, the facility's vaccination rate was 98.5%. The facility also failed to have policies and procedures in place for the COVID-19 vaccine. This had the potential to affect 82 residents and 98 staff.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure assessments were completed to determine residents' ability to self-administer medications safely and accurately for two of two residents (R) (R#59 and R#38) reviewed for medication self-administration.

Inspectors wroteBased on interviews, document review, and review of the facility policy, the facility failed to ensure allegations of abuse were reported to the facility Administrator and the State Survey Agency for one of two sampled residents (R) (R#4) reviewed for abuse and for one of one staff member (Licensed Practical Nurse BBB) reported as having abusive behaviors towards unidentified residents.

Inspectors wroteBased on interviews, document review, and review of the facility policy, the facility failed to ensure allegations of abuse were thoroughly investigated for one of two sampled residents (R) (R#4) reviewed for abuse and for one of one staff member (Licensed Practical Nurse [LPN] BBB) reported as having abusive behaviors towards unidentified residents.

Inspectors wroteBased on interviews and record review, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASRR) for two of two sampled residents (R) (R#11 and R#23) reviewed for PASRR.

Inspectors wroteBased on record review and interviews, the facility failed to provide care according to professional nursing standards for two of four sampled residents (R) (R#133 and R#287) reviewed for falls. Specifically, the facility failed to assess R#133 and R#287 for neurological changes after the residents experienced unwitnessed falls.

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy, the facility failed to monitor and maintain hot water at a safe temperature for six of 68 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]).