Spalding Post Acute LLC

Inspectors wroteBased on observations, staff interviews, record review and review of the facility's policies titled Handwashing/Hand Hygiene, and Infection Prevention and Control Program, the facility failed to implement infection control protocol for two residents (R) (R34 and R82) of 14 residents observed for infection control. Specifically, nurse did not sanitize hands between glove change and nurse placed a tablet in her bare hand. The deficient practice increased the risk of cross contamination and the spread of infection to residents and staff.

Inspectors wroteBased on observations, resident and staff interviews, record review and review of the facility's policy titled Medication: Self Administration and Bedside Medication Storage, the facility failed to remove one inhaler from the bedside of one resident (R) (R94) of 54 sampled residents. This deficient practice increased the risk of clinical complications.

Inspectors wroteBased on resident and staff interviews, review of facility documentation, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to ensure three residents (R) (R158, R140, and R59) of four residents reviewed were free from abuse. Specifically, R158 experienced physical abuse from a Certified Nursing Assistant (CNA) and R140 and R59 experienced emotional abuse by another resident. The deficient practice had the potential to affect resident psychosocial health and safety.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Abuse, Neglect and Misappropriation, the facility failed to ensure three of three residents (R) (R94, R89 and R37) were free from misappropriation of medication when narcotic medications were signed out and not administered. This deficient practice increased the risk of adverse clinical outcomes.

Inspectors wroteBased on observations, record reviews, staff interviews, and review of the facility policy titled, Falls Management and Minimum Data Set (MDS)/Care Plans the facility failed to implement the care plan interventions to keep one resident (R) (R125) from a sample of 12 residents, free from avoidable falls. The deficient practice increased the risk of falls with injury.

Inspectors wroteBased on record review, staff interviews and review of the facility's policies titled Minimum Data Set (MDS)/ Care Plans and Advance Directives, the facility failed to update the care plan for Advance Directives of Do Not Resuscitate (DNR) for one resident (R) (R94) of 54 residents reviewed for advance directives. This deficient practice had the potential to cause staff to initiate cardiopulmonary resuscitation (CPR) and all other necessary, life-sustaining treatments for cardiac and/or respiratory arrestFindings include:Review of the facility's policy titled Minimum Data Set (MDS)/ Care Plans reviewed [DATE] documented Policy Statement: Each resident will have an individualized interdisciplinary plan of care in place. The Comprehensive Care Plan will be reviewed and revised on a quarterly basis. Procedure: 2. [...]

Inspectors wroteBased on observations, record reviews, staff interviews, and review of the facility policy titled Accidents/Incidents, and Falls Management, the facility failed to provide supervision for the prevention of falls for one resident (R) (R125) from a sample of five residents reviewed for falls and accidents. The deficient practice increased the risk of avoidable falls and injury.

Inspectors wroteBased on observation, staff interviews and review of the facility's policies titled Storage of Medications, and Medication Administration, the facility failed to record an open date on one bottle of blood sugar strips in one medication cart and failed to lock one medication cart from the six medication carts reviewed for medication storage. This deficient practice had the potential to cause inaccurate blood sugar readings for the residents and unauthorized access of the medication cart with increased risk of diversion.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Patient/Resident Trust Funds, the facility failed to maintain a Surety Bond in an adequate amount to cover the resident trust fund account balance for six of six months reviewed. This deficient practice had the potential to adversely affect the finances of 84 residents with trust fund accounts managed by the facility.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Storage of Medication, the facility failed to ensure there were no expired medications in two of two medication storage rooms. The deficient practice had the potential to place residents at risk of receiving expired medications.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Catheter Care, and Quality of Life-Dignity, the facility failed to promote, maintain, and protect residents' dignity for one of five residents (R) (R475) with an indwelling urinary catheter. This failure had the potential to diminish R475's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled Self-Administration of Medications by Patients/Residents, the facility failed to ensure that one of 51 sampled residents (R) (R55) was assessed for safe medication self-administration before allowing medications to be stored at the bedside. This deficient practice had the potential to place R55 at risk of self-administering medications in an unsafe manner.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Abuse, Neglect, and Misappropriations, the facility failed to ensure pre-employment screenings, specifically a background check for one employee and a background check and fingerprints for one employee, were obtained for two of 10 staff reviewed. This deficient practice had the potential to place residents residing in the facility at risk of abuse, neglect, and exploitation from staff. The facility census was 126 residents.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Care Planning-Interdisciplinary Team, the facility failed to ensure that one of five residents (R) (R475) with an indwelling urinary catheter had a person-centered comprehensive care plan for the use of the indwelling urinary catheter. This deficient practice had the potential to place R475 at risk of not receiving treatment and/or care according to their needs.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure that one of five residents (R) (R475) with an indwelling urinary catheter had a qualifying medical diagnosis for the use of an indwelling urinary catheter. The deficient practice had the potential to place R475 at risk of avoidable urinary tract complications.

Inspectors wroteBased on observations, staff interviews, record reviews, and a review of the facility's policy titled Medication Administration, the facility failed to ensure a medication error rate of less than five percent. There were three errors with 29 opportunities for two of four residents (R) (R43 and R74) observed during medication administration. The medication error rate was 10.34 percent. These failures had the potential to place R43 and R74 at risk of medical complications and decreased therapeutic effects of medications.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policies titled Hand Hygiene and Infection Prevention and Control Policy, the facility failed to ensure infection control processes were followed during resident care for three residents (R). Specifically, during a fingerstick blood sugar (FSBS) test for one of 36 R requiring a FSBS (R8), during wound care for one of 20 R receiving wound care (R6), and for one of eight R receiving tube feeding (R91). The deficient practices had the potential to place R8, R6, and R91 at risk of avoidable exposure to infections.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Transfer and Discharge Including AMA [against medical advice], the facility failed to ensure the Ombudsman was notified for six of six residents (R) (R5, R1, R2, R7, R8, and R11) reviewed for discharge from the facility.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled, Glucometer Disinfection, and Infection Prevention and Control, the facility failed to ensure the infection control process was followed by two of three nurses observed using a glucometer (a device used to measure blood glucose) to check resident's blood sugar levels. The deficient practices had the potential to increase the potential for cross-contamination and spread of infection.

Inspectors wroteBased on resident interviews, staff interviews, review of the facility policy titled, Patient/Resident Trust Funds, and review of the facility-provided document titled, Resident Fund Accounts, the facility failed to provide resident trust fund account quarterly statements for three of 100 residents (R) with trust fund accounts managed by the facility (R4, R6, and R9). This deficient practice had the potential to affect all residents who had a trust fund account with the facility.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility policies titled, Grievances Policy, Missing Items (Including Misappropriation of Property), and Resident Council Meetings, the facility failed to make a prompt effort to file a grievance for two of 25 sampled residents (R) (R7 and R9) who verbally reported grievances. This deficient practice had the potential to place residents at risk of not having their grievances resolved in a timely manner.

Inspectors wroteBased on observation and staff interviews the facility failed to ensure the kitchen was maintained in a clean and sanitary condition. The deficient practice had the potential to affect 122 of 136 residents receiving an oral diet.

Inspectors wroteBased on interviews, record reviews, and the document Rules and Regulations for Criminal Background Checks the facility failed to consistently require new hires to go through a criminal background check before beginning employment. This deficient practice affected 5 out of 10 new employees. The census was 137.

Inspectors wroteBased on staff interviews, record reviews, and the facility policy titled Controlled Substance Administration and Accountability the facility failed to maintain accurate records on controlled substances on four of six medication carts (Magnolia Hall, [NAME] Lane Hall, Pine Circle Hall, and Cedar Street Hall).

Inspectors wroteBased on observations, staff interviews, and facility policy titled Handwashing/Hand Hygiene Cleaning and Disinfection pt Resident - Care Items and Equipment, and Tracheostomy Care, the facility failed to maintain proper infection control practices by not performing hand hygiene between residents during meal pass on one hall of six, one resident (R) (R122) during tracheostomy care, and not properly labeling and storing of resident- care items on two of six halls. The facility census was 139.

Inspectors wroteBased on observations, and staff interviews, the facility failed to maintain a clean and homelike environment as evidenced by the presence of dusty fans in resident rooms in two of six halls. This failure had the potential to place residents at risk for use of unsanitary and unsafe equipment and a potential for diminished quality of life. The facility census was 139.

Inspectors wroteBased on observations, staff interviews, record review, and a review of the facility policy titled Reporting Reasonable Suspicion of a Crime, the facility failed to report an alleged violation of misappropriation of property, specifically the medication Morphine for one of 39 residents (R) (R286) sampled, to the State Agency (SA).

Inspectors wroteBased on observations, resident and staff interviews, record review, and a review of the facility's policy titled, Activities of Daily Living the facility failed to ensure two of 137 residents (R) (R42 and R127) were given showers as scheduled. This failure had the potential to impact residents' quality of life and decrease functional status.

Inspectors wroteBased on observations, staff interviews, record review, and a review of the facility policy titled, Enteral feeding process, the facility failed to label and date nutritional enteral feedings and failed to follow physician orders to Label each component with date and initials every night shift for two of fourteen residents (R) (R120 and R132). This failure had the potential for tube feeding to exceed the expiration date and time while administering an incorrect formula.

Inspectors wroteBased on observations, staff interviews, record review, and a review of the facility policy Oxygen Safety, the facility failed to provide necessary respiratory care consistent with professional standards of practice by not ensuring the oxygen equipment gauge was set on the prescribed flow rate for two of four residents (R) (R122 and R93) receiving oxygen therapy. This deficient practice has the potential to cause respiratory distress for the residents. The sample size was 39.

Inspectors wroteBased on observations, staff interviews and a review of the facility policy titled Storage of Medications, the facility failed to secure drugs and biologicals in a safe, secure manner for one of six medication cart and one of one treatment cart. This failure placed residents, staff and visitors at risk for having unauthorized access to resident's medications. The facility census was 139.