Signature Healthcare at Jackson Manor Rehab and We

Inspectors wroteBased on record review, interview, facility document, policy review, and review of the Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare & Medicaid Services (CMS) system within 14 days after the assessments were completed for three (Resident (R)12, R34, and R47) of three sampled residents reviewed for resident assessments.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three (Resident (R) 107, R21, and R53) of 15 sampled residents. MDS data was not coded accurately, in accordance with instructions from the Resident Assessment Instrument (RAI) User Manual, related to fall history, antipsychotic use, and/or discharge status.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an environment that was free from verbal abuse involving one (1) of eighteen (18) sampled residents (Resident #7). On 08/02/2023, Resident #8 entered Resident #7 room and cursed at Resident #7.

Inspectors wroteBased on observation, interview, record review, and facility policy review it was determined the facility failed to have sufficient staffing to provide for the care needs of the residents in the facility. Resident #10 and Resident #15 had incontinence episodes while waiting on staff to help them to the bathroom. Resident #30 and Resident #20 did not receive assistance with shaving due to insufficient staff and were observed to have several days' growth of beard.

Inspectors wroteBased on observation, interview and facility policy review it was determined the facility failed to ensure food was stored under sanitary conditions (covered, labeled and dated) for 12 residents who receive thickened liquids. In addition, observation, on 09/22/2020 at 9:50 AM, revealed unlabeled and undated food and food products being stored in the refrigerator for use.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to develop a comprehensive care plan for one (1) resident (Resident #15) and failed to implement the care plan for one (1) of fifteen (15) sampled residents (Resident #10). Resident #15 had an admission assessment with a reference date of 07/14/2020 that assessed the resident to be occasionally incontinent of urine. The facility failed to develop a care plan to address the resident's toileting needs. Resident #10's care plan stated for the resident to be checked for incontinence episodes every two (2) hours; however, the facility failed to implement Resident #10's care plan and the resident had to wait extended amounts of time for incontinence care.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents at risk for elopement received supervision to prevent accidents for one (1) of fifteen (15) sampled residents (Resident #11). Resident #11 was assessed at risk for elopement and displayed wandering behaviors; however, the facility failed to ensure the resident's picture and identifying information were in the Elopement Book per the resident's plan of care and facility policy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident who was continent of bladder received assistance to maintain continence for one (1) of fifteen (15) sampled residents (Resident #15). Resident #15 was assessed by the facility on the admission Minimum Data Set to be occasionally incontinent of bladder (resident was incontinent less than seven times during the seven-day look back period). The facility failed to provide care and services to ensure the resident received assistance with toileting. Interview with Resident #15 revealed the resident was now having more incontinence episodes because staff were not toileting the resident when needed.

Inspectors wroteBased on observation, interview, and facility policy review it was determined the facility failed to ensure the facility was free of a medication error rate of 5% or greater. Observations during medication administration on 09/24/2020 revealed the nurse made two (2) medication errors out of thirty-one (31) opportunities for a medication administration error rate of 6.45%. The Findings Include: Review of the facility policy titled Medication Administration General Guidelines, dated September 2018, revealed medications were to be administered as prescribed and in accordance with manufacturers' specifications and good nursing principles and practices. The policy further stated medications were to be administered in accordance with written order of the prescriber. [...]

Inspectors wroteBased on observation, interview, record review, review of facility policy and review of Centers for Disease Control (CDC) guidance, it was determined the facility failed to prevent the possible spread of COVID-19 for two (2), Resident #186 and Resident #187, of forty-two (42) sampled resident's. Resident's #186 and #187 were new admits to the facility and were not placed in isolation per the facility policy and per CDC guidance.

Inspectors wroteBased on observation, interview, and review of facility policy, it was determined the facility failed to ensure sufficient staff was available to provide nursing and related services to maintain the highest practicable physical, mental, and psychosocial well-being. Observation during meal service on 03/26/19 revealed not enough staff were available to deliver meal trays timely during the lunch meal. The group interview revealed residents stated call lights were not answered timely. In addition, interview with Resident #44 on 03/26/19 at 11:34 AM, revealed the resident had to wait up to thirty (30) minutes for staff to replace his/her colostomy bag.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to employ sufficient dietary staff with the appropriate competencies and skill sets to safely and effectively carry out the functions of food and nutrition service for forty-two (42) residents who received meals at the facility. Observation and interview revealed there was not enough dietary staff to serve food to residents timely. In addition, the recipe was not followed for the pureed ranch chicken sandwich; the temperature of the potato salad was not taken, and the potato salad was not properly cooled on 03/26/19.

Inspectors wroteBased on observation, interview, and review of the facility policy, it was determined the facility failed to ensure food was palatable and at a safe and appetizing temperature. Three (3) of twenty-nine (29) sampled residents and seven (7) residents who attended the Resident Council Meeting stated foods served at the facility did not taste good and the food was often served cold. A test tray of the meal served to forty-two (42) facility residents on 03/26/19 revealed the Ranch Chicken Sandwich and Potato Salad were not palatable and were not within a palatable temperature as defined by the facility's policy.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to distribute and serve food under sanitary conditions during the lunch and supper meal service on 03/26/19 and the lunch meal service on 03/27/19 for forty-two (42) residents who received nutrition from the Kitchen. The facility failed to cool the potato salad and hold the food at a safe temperature, and failed to clean the juice machine, and a heavy buildup of dust was observed on the machine. Further, observation revealed the Regional [NAME] President (RVP) entered the Kitchen on three (3) occasions while tray line service was in progress to retrieve a prepared food tray with no beard restraint in place. In addition, staff removed a meal tray from the dining room meal cart, brought the tray inside the Kitchen, and placed it on the meal cart that was being loaded with residents' food.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an effective infection prevention and control program to provide a safe and sanitary environment to prevent the transmission and development of infection. Observation of wound care for Resident #17 revealed the resident was in Contact Isolation due to an infection of the resident's pressure sore. The facility failed to ensure staff took measures to prevent the spread of the infection. Further observation revealed a nurse took wound cleanser in Resident #17's room, utilized the cleanser to clean the resident's wound, and took the cleanser out of the room and stored it in a treatment cart that contained other residents' treatment items. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to protect the right to a dignified existence for one (1) of two (2) residents (Resident #44). Interview with Resident #44 on 03/26/19 at 11:34 AM, revealed the facility failed to maintain the resident's colostomy bag (a small pouch used to collect stool) to prevent leakage of stool, resulting in the resident feeling bad.