South River Rehabilitation and Wellness Center

Inspectors wroteBased on complaint investigations, medical record reviews, and staff interviews, it was determined that the facility failed to ensure appropriate wound assessment and timely specialist consultation. This was evident for one of one resident (Resident #1) reviewed for pressure ulcers during this Change of Ownership (CHOW) and complaint survey.

Inspectors wroteBased on complaint investigation, a review of resident medical records, and interviews with facility staff, it was determined that the facility failed to monitor residents' nutritional status regarding body weight and failed to timely address significant weight loss. This was evident for one (Resident #1) of two residents reviewed for nutrition during this Change of Ownership (CHOW) and complaint survey.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a resident's comprehensive care plan specified the level of assistance the resident required for bathing and the resident's frequent refusals of showers for 1 (Resident #2) of 3 sampled residents reviewed for activities of daily living.

Inspectors wroteBased on observations and facility staff interviews it was determined that the facility failed to maintain a safe clean comfortable homelike environment for Residents. This finding was found to be evident in review of Resident rooms on station 2 nursing unit of the facility during the annual recertification survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to perform accurate Minimum Data Set (MDS) assessments. This was found to be evident for 3 (#3, #45, and #107) of 18 residents observed for coding accuracy of MDS assessments.

Inspectors wroteBased on observations, staff interviews and surveyor record review it was determined that the facility failed to maintain sanitation practices in the kitchen and in the nursing unit nourishment refrigerator. This finding was found to be evident in review of the kitchen, service area and the nourishment refrigerator on the nursing unit.

Inspectors wroteBased on observation and interviews, it was determined that the staff failed to perform consistent hand hygiene in between resident interactions. This was evident for 2 (Staff #19 and #20) out of 2 staff observed during the medication administration task.

Inspectors wroteBased on facility staff interviews and surveyor record review it was determined that the facility failed to provide notification of room change when a Resident was transferred to another room in the facility. This finding was found to be evident in 1 (Resident #107) out of 10 Residents reviewed for notification of room change.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that physicians and Responsible Party (RP)'s were notified of changes in a resident's condition. This was evident for 1 (Resident #6) of 1 resident reviewed for nutrition.

Inspectors wroteBased on interview, observation, and record review, it was determined that the facility failed to provide treatment and services to maintain hearing abilities. This was evident in 1 (Resident #81) out of 8 residents reviewed for vision and hearing during the recertification survey.

Inspectors wroteBased on observation, medical record review and interviews, it was determined the facility staff failed to clarify and document appropriate care measures to prevent complications from a hand contracture. This was evident for 1 (resident #10) of 1 resident reviewed for mobility.

Inspectors wroteBased on record review and interviews with staff, it was determined that the primary medical provider failed to review the total program of care for 1 (Resident #11) out of 43 residents reviewed during the survey.

Inspectors wroteBased on observation, interview, and record review, it was determined that the pharmacy failed to deliver the correct medication dosages to the facility. This was evident in 1 (Resident #95) out of 6 residents evaluated for accurate dispensing during the medication administration task. Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence.

Inspectors wroteBased on observation, record review and interview, it was determined that the facility failed to ensure that a controlled medication was labeled and stored properly. This was evident for 1 (Resident #95) out of 6 residents observed during the medication administration task. Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence.

Inspectors wroteBased on interview and medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (Resident #9) of 1 resident reviewed for dental services during the survey.

Inspectors wroteBased on Resident and staff interviews, observations and surveyor record review it was determined that the facility failed to ensure that a Resident's food preferences, food intolerances and food allergies were followed. This finding was found to be evident in 1 (Resident #41) out of 8 Residents reviewed for food and nutrition services.

Inspectors wroteBased on observations and facility staff interviews it was determined that the facility failed to ensure that garbage and refuse was maintained in a proper manner. This finding was found to be evident during the review of the outside dumpster area adjacent to the service hall during the annual recertification survey.

Inspectors wroteBased on observations and facility staff interviews it was determined that the facility failed to have call lights accessible for Residents. This finding was found to be evident in 2 (Resident #18 and Resident #75) out of 28 Residents reviewed for accessibility of Resident Call System.

Inspectors wroteBased on observations and staff interviews, it was determined the facility failed to provide a resident with an environment that promotes a dignified existence. This was evident for 1 (Resident #349) of 8 residents reviewed for dignity.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure the call bells were within reach of a resident. This was evident in 1 (Resident #79) of 1 resident reviewed for access to the call system during the recertification survey.

Inspectors wroteBased on record review and interview, it was determined that the facility staff failed: (1.) to provide documentation whether a Resident had an advance directive and/or wished to formulate an advance directive and (2.) to ensure the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) in place. This was found to be evident for 2 (Resident #32 and #23) out of 12 residents reviewed for the MOLST and advance directives.

Inspectors wroteBased on observations and staff interview during facility environmental observations, it was determined that the facility staff (1.) failed to provide housekeeping and maintenance services necessary to maintain a safe homelike interior and (2.) failed to exercise reasonable care for the protection of the resident's property from the wandering residents. This was evident for 1 of 8 rooms and 1 (Resident #67) out of 3 residents observed during the annual survey.

Inspectors wroteBased on record review and interview, it was determined that the facility staff failed to provide a safe resident environment and protect residents from abuse from other residents. This was found to be evident for 2 (Resident #22 [1.] and #113 [2.]) out of 9 residents reviewed for abuse.

Inspectors wroteBased on medical record review, and interviews it was determined the facility failed to provide the Resident and/or Representative with a written notice of the facility's bed hold policy upon transfer to an acute care facility. This was evident for 2 (Resident #54 [1.] and #34 [2.]) of 6 residents reviewed for hospitalization.

Inspectors wroteBased on observation, facility staff interview and medical record review, it was determined that the facility failed to accurately document resident assessments on the MDS (Minimum Data Set) as evidenced by inaccurate coding for residents. This was found to be evident for 2 (Resident #42 [1.] and #79 [2.]) out of 2 residents reviewed for accuracy of MDS assessments.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to initiate a new pre-admission screening and resident review (PASARR) Level I screen after a resident was diagnosed with bipolar disorder while admitted to nursing facility. This was identified for 1 (Resident #49) of 1 resident reviewed for PASARR requirements during an recertification survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to include all initial healthcare information in the baseline care plan. This was found evident of 1 (resident #94) of 5 residents reviewed for care planning.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to develop a comprehensive person-centered care plan. This was found to be evident of 3 (Resident #94 [1.], #77 [2.] & #42 [3.]) of 13 Residents reviewed for care planning.

Inspectors wroteBased on interview and medical record review it was determined that the facility failed to update and revise resident's care plans. This was found to be evident in 1 (Resident #42) out of 3 residents reviewed for care plan timing and revision.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent residents. This was found evident in 2 (Resident #449[1.] & #68[2.]) out of 11 Residents reviewed for Activity of Daily Living (ADL) cares.

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to provide treatments according to a resident's plan of care. This was found evident of 2 (Resident #71 & #94) out of 32 residents reviewed during the survey.

Inspectors wroteBased on resident interview, record review, and staff interview, it was determined that the facility failed to ensure to coordinate vision services for a resident. This was evident for 1 (Resident #77) of 8 residents reviewed for vision.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to protect the resident from a preventable accidents. This was evident for 1 (Resident #104) of 3 residents reviewed for falls.

Inspectors wroteBased on resident observation, staff interview and record review it was determined that the facility failed to provide adequate care and services for a resident that required colostomy care. This was found to be evident in 1 Resident #42 out of 1 Resident reviewed for colostomy care and services.

Inspectors wroteBased on observation, interview and medical record review it was determined that the facility failed to provide respiratory care and services appropriately. This was found to be evident for 1 (Resident #21) out of 1 resident that was reviewed for respiratory care and services.

Inspectors wroteBased on interview, record review and observation, it was determined that the facility staff failed to ensure that pain management of an intrathecal baclofen pump was provided to residents who require such services, consistent with professional standards of practice and monitoring appropriately for effectiveness and/or adverse consequences. This was found to be evident for 1 resident (#22) out of 1 for pain management review.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to have the medical provider thoroughly review and accurately document a resident's updated plan of care after a visit. This was found evident of 1 (Resident #106) out of 32 reviewed during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary drugs. This was evident for 2 (Resident #94 and #106) or 7 residents reviewed for unnecessary medications.

Inspectors wroteBased on interviews and resident records, it was determined that the facility failed to coordinate routine dental services for a resident. It was evident for 1 (Resident #68) of 8 residents reviewed for dental services.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to keep accurate resident records in accordance with professional standards. This was evident of 1 (Resident #54) out of 32 residents reviewed for accuracy of documentation during the survey.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to follow proper infection control practices when handling a resident's waste. This was evident for 1 (Resident #349) of 8 residents reviewed for infection control.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to notify and obtain consent from a resident representative for immunizations. This was evident for 1 (Resident #92) of 5 residents reviewed for immunizations during recertification survey.

Inspectors wroteBased on observations, review of facility pest control records and interviews of facility staff, it was determined the facility failed to ensure an effective pest control program as flying gnats were observed throughout the building. This was found to be evident during the survey.

Inspectors wroteBased on review of the facility investigation, medical records, interviews with facility staff and other pertinent documentation it was determined that the facility failed to 1) notify the physician when it was discovered on 10/14/19, that the side of the tip of Resident #72's penis was discolored (brownish in color) and had a white milky discharge; 2) to document that an assessment was done during the initial findings, which resulted in a delay in treatment, and 3) provide and implement a revised plan of care to meet the resident needs. This was true of 1 (Resident #72) of 45 residents reviewed as part of the annual survey. Based on the findings, on Thursday, October 31st, 2019 at 10:30 AM an Immediate Jeopardy was called related to the quality of care for Resident #72. [...]

Inspectors wroteBased on surveyor observation it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on medical records review, and resident and staff interview it was determined that the facility staff failed to notify the physician that the resident missed their scheduled Nephrologist (Kidney physician) appointment. This was true for 1 of 45 residents (Resident #33) reviewed for notification during the complaint survey.

Inspectors wroteBased on resident and staff interview and review of Facility Reports MD00145732 and MD00146337, it was determined that the facility failed to ensure residents were free from misappropriation of resident property and exploitation. This was evident for 2 of 45 residents (Resident #78 and Resident # 75) reviewed during the survey.

Inspectors wroteBased on medical record review and interviews with the resident family and facility staff it was determined the facility failed to organize and invite the Resident and/or Responsible Party (RP) to a care plan conferences. This was found to be evident for 1 resident (Resident #34) reviewed for care plans during the survey.

Inspectors wroteBased on review of resident medical records, review of facility investigative material, and interview with facility staff, it was determined that the facility failed to ensure that residents going outside were safe to do so without supervision. This was evident for 1 of 3 residents (Resident #189) reviewed for accidents.

Inspectors wroteBased on review of resident medical records and interview with residents and facility staff, it was determined that the facility failed to ensure that residents with as-needed pain medication regimens received pain medication according to physician prescribed parameters. This was evident for 1 of 4 residents (Resident #1) reviewed for Pain Management.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to notify the physician of abnormal laboratory results and failed to fax the results of the laboratory results to the kidney specialist. This was found to be evident for 1 of 45 residents (Resident #33) reviewed during the investigation stage of the survey.

Inspectors wroteBased on medical record review and interview, it was determined that facility staff failed to maintain a medical record in the most accurate form for residents. This was evident for 2 of 45 residents (Resident #65 and #88) reviewed during the survey.