Shrewsbury Rehabilitation and Nursing at Southgate

Inspectors wroteBased on observation, and interview, the facility failed to ensure that the facility dumpster area was maintained in a clean and sanitary manner to mitigate the harborage and feeding of pests. Specifically, the facility failed to ensure trash, garbage, and refuse were appropriately disposed of and properly contained within a trash receptable and not thrown on the ground around two dumpsters in a fenced-in dumpster area that was located in proximity to the main facility kitchen.

Inspectors wroteBased on observations, policy review and interviews, the facility failed to maintain accurate records of controlled substances (drugs or chemicals that the government regulates for its manufacturing, possession, and use, that are classified into schedules based on their potential for abuse) for one Control Medication Log (Unit One Side A) out of three Control Medication Logs reviewed. Specifically, for the Unit One Side A Control Medication Log, the facility failed to ensure accurate documentation was maintained relative to the reconciliation of the controlled medication count, when the Control Medication Log was missing licensed nursing documentation that controlled medication reconciliation was completed as required.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that drugs and biologicals were stored in accordance with State and Federal laws for one (Unit One) of two medication storage rooms reviewed. Specifically, the facility failed to ensure a multi-dose vial of medication was discarded upon the expiration date according to manufacturer's guidelines in the Unit One medication storage room.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of urinary retention (bladder does not empty completely or at all), the Facility failed to ensure he/she was provided with quality of care that met professional standards of practice, when he/she did not receive a physician ordered treatment for the monitoring and treatment of his/her urinary retention, placing him/her at risk for the development of complications associated with this condition.

Inspectors wroteBased on record review and interview, the facility failed to complete an accurate comprehensive assessment, according to the required Resident Assessment Instrument (RAI) process in the Minimum Data Set Assessment (MDS), for one Resident (#6) out of a total sample of 18 residents. Specifically, the facility staff failed to assess Resident #6's cognitive and mood status through the required Resident interview process when the Resident had adequate hearing, clear speech, and sometimes made him/herself understood and sometimes understood others.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure professional standards of practice for medication administration for one Resident (#15) out of a total of 18 residents sampled. Specifically, the facility staff failed to administer Ativan (a medication used to treat anxiety [persistent worry and fear about everyday situations]) in accordance with the physician order.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure its staff maintained professional standards of practice to prevent the development and promote healing of pressure ulcers/skin injuries for one Resident (#55) out of a total sample of 18 residents. Specifically, for Resident #55, the facility staff failed to perform a wound treatment as ordered by the physician, placing the Resident at risk for delayed wound healing.

Inspectors wroteBased on observation, interviews, and records reviewed, the facility failed to adequately assess wandering and elopement risk for one Resident (#83) out 18 total sampled residents which increased the Resident's risk for unsafe wandering and elopement. Specifically, facility staff failed to: - Accurately complete Resident #83's admission Assessment for Wandering according to the instructions provided in the facility's admission Wandering Assessment for the Resident. - Assess Resident #83's wandering risk, when the Resident exhibited changes in behavior and demonstrated exit seeking behaviors that were not present when the Resident was admitted to the facility. - Establish a resident-centered plan of care relative to wandering when Resident #83 began exhibiting wandering behaviors and seeking exit from the facility.

Inspectors wroteBased on observation and interview, the facility failed to remove expired medications from one medication cart, out of a sample of three medication carts. Specifically, the facility failed to remove and dispose two bottles of expired Ferrous Gluconate liquid (Iron Supplement), increasing the risk of non-therapeutic benefit when the medication is administered.

Inspectors wroteBased on record review and interview, the facility failed to maintain an accurate medical record for one Resident (#34) out of a total sample of 18 residents. Specifically, the facility failed to accurately document a behavioral incident by Resident #34 putting his/her roommate at risk for potential abuse.

Inspectors wroteBased on interview and records reviewed, the facility failed to accurately complete the Minimum Data Set (MDS) Assessment for one Resident (#83) out of a total sample of 18 residents. Specifically, facility staff failed to accurately code the use of antianxiety (used to treat symptoms of anxiety [feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome] medication on one MDS Assessment for Resident #83.

Inspectors wroteBased on interviews and records reviewed, the facility failed to notify the State mental health authority promptly after a significant change in the mental condition for resident review for one Resident (#83) out of 18 total sampled residents which increased the Resident's risk for not receiving specialized services in a timely manner. Specifically, facility staff failed to notify the State mental health authority of the need for resident review when: - Resident #83 exhibited a new onset of paranoia (unwarranted or delusional belief that one is being persecuted, harassed, or betrayed by others, occurring as part of a mental condition), delusions (unshakable belief in something that is untrue; [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program to prevent the development and transmission of communicable diseases and infections for two Residents (#1 and #3) out of a total sample of three residents and one unit (Station 1) out of three units observed. Specifically, the facility failed to: 1. Ensure the appropriate personal protective equipment (PPE - protective devices, garments, or coverings such as eye protection, gloves, and gowns, that are worn to minimize exposure to hazards that may cause injury or illness) was utilized by staff during an active Covid-19 (a disease caused by the SARS-CoV-2 virus which can be very contagious and spreads quickly) outbreak. 2. Monitor Resident's #1 and #3 for signs and symptoms of Covid-19 during an active outbreak.

Inspectors wroteBased on observation, records reviewed and staff interviews, the facility failed to provide an adequate level of assistance to prevent an avoidable accident for one Resident (#49), out of a total sample of 18 residents. Specifically, the facility staff failed to implement a necessary two-person transfer, resulting in the Resident sustaining a laceration (a deep cut or tear in skin or flesh) requiring hospital transfer and eight sutures (row of stitches holding together the edges of a wound or surgical incision) to the injury. Findings Include: Resident #49 was admitted to the facility in May 2019 with diagnoses including: [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one Resident (#10), out of a total sample of 18 residents, who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition. Specifically, the facility failed to provide Resident #10 with interventions to engage in eating, when he/she was identified to have impaired cognition, terminal prognosis and an eating deficit, in addition to requiring assistance from staff to eat.

Inspectors wroteBased on policy review, record review, observation and interviews, the facility failed to follow infection control guidelines relative to hand hygiene during a wound dressing change treatment for one Resident (#49), in an applicable sample of four residents, and a total sample of 18 residents. Specifically, the facility staff failed to complete required hand hygiene between glove changes during a wound dressing change to Resident #49's right lower leg laceration (a deep cut or tear in skin or flesh), increasing the Resident's risk for wound infection.