Savannas Park Health and Rehabilitation Center

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure resident rights for 1of 3 sampled residents, as evidenced by the failure to assess Resident #20 for self-administration of medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to respond to a resident's request to remove food allergies from the meal ticket for 1 of 8 sampled residents reviewed regarding choices, Resident #34.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide a safe, clean comfortable homelike environment for 3 of 4 units.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a PRN (as needed) antipsychotic medication was addressed in a timely manner for 2 of 7 sampled residents, as evidenced by the Lorazepam (antipsychotic) prescribed to Resident #96 and Resident #85 did not have a discontinue date or documented rationale by the doctor to extend the order.1. Review of the record revealed Resident #96 was admitted to the facility on [DATE]. The annual comprehensive assessment dated [DATE], documented that the resident had a Brief Interview for Mental Status Score of 10 on a 0 to15 scale, indicating moderate cognitive impairment. The resident had a documented medical diagnosis history of anxiety disorder and mood disorder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely and appropriate care and services for 5 of 34 sampled residents as evidenced by the failure to clarify multiple physician orders and appropriately treat a rash for Resident #8; failure to ensure timely initiation of an antibiotic for Resident #96, who had an infected wound; failure to ensure medications were not provided by mouth for Resident #3, who had orders for nothing by mouth; failure to ensure treatment for a skin cancer wound for Resident #61; and failure to follow physician ordered blood pressure medication parameters for Resident #6.

Inspectors wroteBased on facility policy, observations, record reviews, and interviews, the facility failed to provide care and services to prevent further decrease in range of motion for 1 of 3 sampled residents as evidenced by not applying the splints on Resident #25.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to follow physician orders for nutritional support via a feeding tube for 2 of 2 sampled residents, Residents #3 and #5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen orders and cleanliness of oxygen equipment for 1 of 3 sampled residents, Resident #5, who lacked any order for oxygen, failure of staff to change an oxygen nasal cannula that had been on the floor, and failure to ensure a clean oxygen canister filter.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that it was free of medication errors for 2 of 4 sampled residents, as evidenced by a medication error rate of 14.81% with 27 opportunities due to failure to ensure that Resident #22 received medications prescribed to him and was available for him, failure to ensure Resident #86 received medications prescribed to him and was available and failure to follow physician orders for a narcotic prescribed to Resident #86.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the laboratory test was completed as ordered for 1 of 5 sampled resident records reviewed, Resident #5.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control standards for 4 of X34 sampled residents as evidenced by the failure to ensure timely contact precautions for Resident #33 who had symptoms of C-diff (Clostridium difficile, a highly contagious infection characterized by diarrhea); failure to collect a stool sample timely to ensure timely treatment for C-diff for Resident #51; failure to follow contact precautions during the medication pass observation for Residents #51 and #22; and failure to follow Enhanced Barrier Precautions (EBP) for Resident #129.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to store, prepare and serve foods in a sanitary manner in accordance with professional standards for food safety. The census at the time of the survey was 117 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the approved menu for meals, for French Dip on a Roll, that was to be served for lunch on 04/30/24 from the Main Kitchen and the satellite kitchen on the Oasis Unit (400 unit). This regular menu could potentially affect 113 residents, including residents receiving the puree diet, of the 117 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services per residents' request and choice for 2 of 2 sampled residents, as evidenced by failure to ensure showers as per preference and schedule for Resident #56, and failed to provide meals in the dining room per residents' request for Resident #56 and #78.

Inspectors wroteBased on observation and interview, the facility failed to ensure it provided a safe, clean comfortable homelike environment, as evidenced by damaged and dirty equipment, peeling paint, bathroom issues, and stained walls and doors.

Inspectors wroteBased on observations, interviews, policy and record reviews, the facility failed to follow policies and procedures to ensure a safe smoking environment for residents that choose to smoke for 3 of 3 residents reviewed for smoking, Residents #60, 110 and 112.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide nutrition via enteral means as ordered by physicians for 1 of 1 sampled resident, Resident #108, reviewed for tube feeding.

Inspectors wroteBased on observations interviews and record reviews, the facility failed have nurse staffing information posted daily and failed to update the nursing staff information, including names of staff providing care to the residents and residents' census on 2 of 3 units.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare and provide meals in a manner to conserve the nutritive value of pureed vegetables.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide foods per residents' religious preferences for 1 of 4 sampled residents reviewed for food concerns, Resident #108.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide assistive devices to enable residents to improve or maintain their ability to eat or drink independently for 1 of 28 sampled residents, Resident #267.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure staff limited the use of cell phones while on duty and providing care to 9 of 22 sampled residents (Residents #27, #15, #6, #89, #29, and #300); staff did not communicate in a foreign language while providing care to 9 of 22 sampled residents (Residents #27, #15, #6, #89, #29, and #300); and four of 22 sampled residents (Resident #204, #92, #47, #58) were treated in a dignified manner related to dining in 1 of 3 dining rooms (200 unit).

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure reasonable accommodation of needs for 2 of 21 sampled residents, as evidenced by: Resident #24 lacked a call bell system that she could physically utilize to get staff assistance; and Resident #80 lacked an appropriately sized bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide requested beautician services to 1 of 1 sampled resident (Resident #7).