Self Skilled Nursing & Rehab

Inspectors wroteBased on observation, review of facility policy and cleaning schedules, and interview it was determined the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety. Sanitation concerns were identified in all areas of the kitchen and had the potential to affect 47 of 47 residents who received meals from the kitchen.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to act promptly upon the grievances of the resident group regarding food complaints for 15 out of 47 total residents. Interview with the Resident Council on 3/17/21 revealed their food concerns expressed in the 11/6/2020 meeting had not been addressed.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to provide necessary housekeeping services to maintain a clean environment and maintenance services necessary to maintain good repair of equipment. Observations on 3/16/21, 3/17/21 and 3/18/21 revealed the heating/air-conditioning (AC) unit vents in two (2) rooms (rooms #127 and #135) had buildup of dust/debris. The exhaust vents in six (6) bathrooms (rooms #111, #113, #125, #127, #130 and #135) had buildup of dust/debris on the Hill Hall and Back Door Hall units. In addition, the bathroom in room [ROOM NUMBER] was observed to contain a metal trash can that was completely covered with rust. Observations on 3/17/21 and 3/18/21, revealed a thick black buildup on the secured unit floors in three (3) resident rooms (rooms #4, #7, and #9), the bathroom next to room [ROOM NUMBER] and in the sitting room.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to properly date and ensure expired medications were removed from the supply in two (2) of four (4) medication carts (medication cart #1 and #2). In addition, the facility failed to ensure expired medical supplies were removed from the supply, properly date medications and dispose of expired medications in two (2) of three (3) medication rooms.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure standard precautions were followed regarding performing hand hygiene and wearing personal protective equipment (PPE) appropriately to prevent the transmission of communicable disease and infection for eight (8) out of 16 sampled residents (Resident #10, #16, #20, #28, #33, #36, #39 and #198). Observation on 3/16/21 revealed Certified Nurse Aide (CNA) #6 did not wash his/her hands after doffing gloves. Observation on 3/17/2021 revealed Housekeeper (HK) #14 walked down the front Hall without wearing the face mask appropriately. Observations on 3/16/21 revealed CNAs #9 and #13 didn't wash their hands or change their gloves between residents when delivering the meal trays during lunch.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide the resident and the resident representative a notice in writing of the transfer to an acute care hospital for three (3) out of four (4) sampled residents who were discharged from the facility (Resident #4, Resident #13, and Resident #19).

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure a bed-hold notice was given to the resident and the resident representative prior to the transfer to an acute care hospital for four (4) of 16 sampled residents (Resident #4, #13, #19, and #46).

Inspectors wroteBased on observation, interview, record review and facility policy review, it was determined the facility failed to ensure a person-centered, comprehensive care plan was implemented for one (1) of 16 sampled residents. Resident #37 was not provided assistance with positioning in bed per the assessment requirement and care planned intervention.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure one (1) of 16 sampled residents received services in accordance with professional services and the person-centered care plan. Resident #37 did not receive the assessed treatment and care to address positioning needs when in bed.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure the staff labeled and dated the oxygen tubing when changed for one (1) of 16 sampled residents (Resident #33).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to perform a gradual dose reduction [(GDR) - a periodic attempt to taper a medication in order to use the lowest effective dose or to discontinue the medication] and document the clinical rationale as to why an attempt would be contraindicated (likely to cause harm) for one (1) of 16 sampled residents (Resident #10). Resident #10 was receiving Risperdal (an antipsychotic medication) for Unspecified Dementia with Behavioral Disturbance, however, a GDR attempt had not been performed since 1/14/2020.

Inspectors wroteBased on observations, interviews, and review of facility policies titled, Food Storage and Cleaning Instructions: Hoods and Filters, the facility failed to ensure: 1) vents over the stove were free of grease and dust like substance; 2) biscuits in the freezer were sealed tightly and; 3) eggs in the reach in refrigerator were sealed and had an opened and use by date on the bag. This had the potential to affect 81 of 81 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Cleaning Instructions: Hoods and Filters with a date of 2013, revealed Policy: Stove and filters will be cleaned according to the cleaning schedule, or at least monthly. On 2/4/2019 at 3:55 p.m., the surveyor observed the vents over the stove were dirty. [...]

Inspectors wroteBased on observation, interview and a review of a facility policy titled, Garbage and Refuse, the facility failed to ensure the dumpster door was closed on 2/4/2018. This affected 1 of 2 facility dumpster's.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the beauty shops within the facility were clean and free of dust like substance in the fan and the supply carts, free of hair in the hair rollers and the floors were not dirty. This was observed on 2/5/19 and had the potential to affect 29 of 29 residents who received services from the beauty shops. This deficient practice was cited as a result of the investigation of complaint AL 00035908. Findings Include: On 2/05/19 at 8:38 AM, the surveyor observed the beautician open the beauty shop. The surveyor asked her name and how many days a week the beauty shop was open. Employee Identifier (EI) #5, Beautician, replied three or four times a week. EI #5 was asked what did she do for residents. EI #5 replied, hair cuts, perms, wash and roll hair, hair sets and styled. [...]

Inspectors wroteBased on record review, interview and review of a facility policy titled, Charting and Documentation Guidelines, the facility failed to ensure information regarding antibiotic therapy and Urinary Tract Infection were documented in Progress Notes Record for Resident Identifier (RI) #13 and RI #128. This affected 2 of 2 sampled residents identified receiving antibiotic treatment for UTI's.

Inspectors wroteBased on observation, record review, interview and review of a facility policy titled Dressings -Clean, the facility failed to ensure licensed staff did not clean Resident Identifier (RI) # 52's wound then place the soiled 4 x 4's gauze on the over bedtable. This was observed on 2/5/19 and affected one of one resident's observed for wound care. Findings Include: A review of an undated facility policy titled Dressings - Clean, revealed . PROCESS: . 3. A disposable cloth (paper towel is adequate) is placed on the overbed table to establish a clean field; .10. Cleanse the wound as ordered; . RI #52 was admitted to facility on 4/3/18 and readmitted on [DATE] with a diagnosis of pressure ulcer of sacral region, stage 4. A review of RI #52's February 2019 Physician Orders revealed . Start Date: [...]

Inspectors wroteBased on interviews and an observation of a breakfast meal tested on [DATE], the facility failed to serve food at palatably warm temperatures. This had the potential to affect all 94 residents for whom meals were prepared and served at the time of this survey. Findings Include: During the initial tour on 03/06/18 between 3:00 PM and 6:00 PM, four of 36 residents questioned about food palatability commented the morning coffee was lukewarm, the food was not always hot, and breakfast foods were cold. A Resident Council Meeting was held on 03/07/18, with ten residents in attendance. All residents reported the food was served cold and was not appetizing. On 03/07/18 at 7:49 AM, the surveyor requested a breakfast tray to determine the temperature and palatability of foods and beverages served. [...]

Inspectors wroteBased on observation, review of the facility's policies regarding Manual Dishwashing and Personal Refrigerators and Food Storage and interviews with staff, the facility failed to: 1) discard commercially-prepared chicken salad after the date of expiration; 2) maintain the solution used to sanitize food preparation counters at the recommended concentration; and 3) discard expired Ensure pudding and yogurt in one of three nursing station refrigerators checked on 03/08/18. These concerns had the potential to affect all 94 residents for whom meals were prepared and served or snacks provided at the time of this survey. Findings Include: 1) On 03/06/18 at 2:15 PM, during the initial kitchen tour, a five-pound container (80% consumed) of commercially prepared chicken salad was stored in the reach-in refrigerator with an expiration date of 2/25/18 (nine days prior). [...]

Inspectors wroteBased on observation, interview, record review and review of a facility policy, Oxygen Administration, the facility failed to ensure Resident Identifier (RI) #26 received oxygen as ordered. This was observed on 3/7/18 and affected one of four residents observed for oxygen use. Findings Include: A review of an undated facility policy titled, Oxygen Administration revealed: .STANDARD: Oxygen should be administered under orders of the attending physician, .PROCESS: 1. Obtain physician's orders for the rate of flow and route . 8. Check oxygen flowmeter for correct liter flow . RI #26 was admitted to the facility on [DATE] with diagnoses to include Chronic Pulmonary Edema and Unspecified Systolic (congestive) Heart Failure. A review of RI #26's March 2018 Physicians Orders revealed: .Treatment Apply oxygen at 2 L/min (Liters per minute) NC (nasal cannula) continuous - QS (every shift) . [...]

Inspectors wroteBased on observation and interview the facility failed to ensure a Certified Nursing Assistant (CNA) did not perform incontinent care and catheter care for Resident Identifier (RI) #18 and then touch clean pads and a clean brief with the same soiled gloves. This was observed on 3/7/18 and affected one of one residents observed for incontinent care and catheter care. Findings Include: RI #18 was admitted to the facility on [DATE], with a diagnosis of Dementia without Behavioral Disturbance. On 3/7/18 at 10:00 a.m., Employee Identifier (EI) #4 (a CNA) was observed performing catheter care for RI #18. EI #4 cleaned the front of the perineal area and the catheter, then with the same gloves picked up a clean pad and opened it. EI #4 picked up another clean pad and opened it and placed it on top of the first pad. EI #4 picked up a clean brief and opened it and placed it on top of both pads. [...]