Springside Rehabilitation and Skilled Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication pass error rate of less than five percent (%) for one Resident (#39), of four applicable residents, out of 29 medication pass opportunities. The medication error rate was observed to be 6.9%. Specifically, 1. For Resident #39, the Resident was administered Memantine (a medication used to treat memory loss) capsule and Depakote Sprinkles (a medication used for seizures and various psychiatric symptoms) capsule by opening the capsules and crushing the inside sprinkle capsules placing the Resident at risk of having less efficacy of the prescribed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections for one Resident (#112), of one applicable Resident reviewed with an intravenous access site, out of a total of 21 sampled Residents. Specifically, for Resident #112, the facility failed to ensure hand hygiene was performed as indicated after removal of gloves to prevent potential cross-contamination during an intravenous (IV) medication administration.

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that staff assessed and offered COVID-19 vaccination as recommended by the Centers for Disease Control and Prevention (CDC) for three Residents (#13, #45, and #53) out of a total sample of five residents. Specifically, for Residents #13, #45, #53 the facility failed to offer a second dose of the current COVID-19 2023 - 2024 vaccination as recommended to by the CDC when a person is over the age of 65.

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to ensure that the accuracy and safety of administered routine medications and pharmaceutical services were provided to meet the needs of each facility resident for one Resident (#30) out of a total sample of 18 residents, and one medication cart (Unit A-side one) out of four medication carts observed. Specifically, the facility staff failed to ensure that expired Insulin (a hormone used to control high blood sugar) medications for Resident #30 was removed from the Unit A- side one medication cart, so that they could not be administered to the Resident thus increasing his/her risk for high blood sugar levels (hyperglycemia) due to the decreased effectiveness of the expired medication.

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that the Physician documented the rationale for disagreeing with the Consultant Pharmacist recommendation from the Monthly Medication Review for one Resident (#34) out of a total sample of 18 residents. Specifically, for Resident #34, the Physician failed to document why he/she disagreed with the Consultant Pharmacist medication recommendation to change the Vitamin D3 (D3 - fat-soluble vitamin that helps the body to absorb calcium and phosphorus) medication to a monthly dose from a daily/weekly dose.

Inspectors wroteBased on interview, record and policy review, the facility failed to provide a medication regimen that was free from unnecessary medications for one Resident (#296) out of a total sample of 18 residents. Specifically, the facility staff failed to ensure that a Physician's order for Torsemide (a potent loop diuretic [water pills that act on the kidneys to increase the flow of urine] medication used to treat fluid retention) medication was accurately transcribed resulting in Resident #296 receiving extra doses of medication and putting him/her at risk for dehydration, electrolyte imbalance, hypotension (low blood pressure) and sudden cardiac arrhythmias (irregular heartbeats).

Inspectors wroteBased on record review and interview, the facility failed to ensure that routine dental services were provided for one Resident (#18) out of a total sample of 18 residents. Specifically, the facility staff failed to assist Resident #18 in arranging for and obtaining routine dental services when the Resident consented to receive dental services while residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure that complete and accurate information was maintained for one Resident (#18) out of a total sample of 18 residents. Specifically, the facility staff failed to document urinary output each shift per the Physician orders for a Resident with urinary retention (condition that occurs when a person is unable to empty their bladder completely or partially of urine) placing him/her at an increased risk of further retention, urinary tract infections, and compromised bladder and kidney function.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2) who had moderate cognitive impairment, but could make his/her needs known, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when at 5:00 A.M. on 09/02/23 and witnessed by Nurse #1, Certified Nurse Aide (CNA) #1 directed profanities at Resident #2 and unplugged his/her television (TV) after threatening to do so, if he/she would not be quiet.

Inspectors wroteBased on record review and interview, the facility and its staff failed to provide a designated person that met regulatory requirements, to serve as the Director of Food and Nutrition Services when a full-time Dietitian was not employed.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff obtained labs timely for a possible urinary tract infection (UTI), resulting in a delay of treatment of an active infection for one Resident (#43), out of a sample of 20 residents. Findings Include: Review of the facility policy titled Urinary Tract Infection (UTI) Protocol, reviewed 9/22, indicated the following: -Start resident on UTI Protocol in PCC (the electronic medical record-EMR that the facility utilized) if showing signs of potential UTI such as (elevated temperature, dysuria (pain/difficulty when urinating), frequency, etc). -Nurse to assess resident daily - monitor for improvement or worsening of symptoms, can assist in identifying when or if a urine sample should be obtained for testing. Resident #43 was admitted to the facility in April 2021 with a diagnosis of Urinary Retention. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure its staff afforded dignity and privacy for one Resident (#34), out of a sample of 20 residents. Specifically, posted personal information related to the Resident's care and condition was viewable from his/her bedroom doorway.

Inspectors wroteBased on observation, interview and policy/procedure review the facility and its staff failed to maintain a safe, clean, comfortable, and homelike environment for one Resident (#74) out of 20 total residents sampled. Specifically, the facility staff failed to: 1. clean soiled walls, curtains and floors of the resident's room, 2. address infestation of fruit flies, and 3. provide repairs where needed.

Inspectors wroteBased on interview and record review the facility failed to ensure its staff completed a Comprehensive Minimum Data Set (MDS) Assessment within the required 14 days of admission to the facility for one Resident (#18), out of a sample of 20 residents.

Inspectors wroteBased on observation, policy review, record review, and interview, the facility failed to ensure staff provided care consistent with professional standards and facility policy, related to replacing and dating oxygen tubing and providing oxygen humidification as ordered by the Physician for one Resident (#86), out of a total sample of 20 residents. Specifically, the facility staff failed to: a) change oxygen tubing as ordered to prevent possible airway infection, and b) monitor and maintain humidification bottles to prevent airway dryness and infection.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff maintained medical records that were accurate for three Residents (#86, #18, and #39) out of a sample of 20 residents. Specifically, the facility staff failed: 1. For Resident #86, documented oxygen tubing changes and oxygen humidification maintenance. 2. For Resident #18, recorded meal percentages (the amount of each meal eaten) as requested by the dietitian. 3. For Resident #39, documented catheter (tubing inserted into the bladder that allows urine to be drained) care and urine output every shift.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff maintained a record that contained a plan of care including what individualized services Hospice will provide for one Resident (#47), out of a total sample of 20 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff provided access to a call light/bell (a button tethered to the wall in a resident's room, indicating in the hallway and at the nurses station that a resident required assistance) for two Resident's (#72 and #141), out of a total sample of 20 residents. Specifically, the call light/bell was not located within easy reach for the residents to summon assistance when needed.