Stonebridge Westphalia

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD) (a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents at risk of exposure which could lead to illness. The facility census was 54 with a capacity of 64.1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed:-The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan to meet the medical, nursing, mental and psychosocial needs for three residents (Resident #21, #29, and #48) out of three sampled residents who self-administered medication and kept medication at the bedside. The facility census was 54.1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for three (Resident #9, #10, and #15) out of five sampled residents who required assistance with bathing as scheduled. The facility census was 54. 1. Review of the facility's Bath, Shower/Tub policy, dated February 2018, showed the policy directed staff to document:-The date and time the shower/tub bath was performed;-The name and title of the individual who assisted the resident with the shower/tub bath;-All assessment data obtained during the shower tub/bath;-If the resident refused the shower/tub bath, the reason and the intervention taken;-The signature and title of the person recording the data. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure the resident environment remained free of accident hazards when staff left medication at the bedside of three residents (Resident #21, #29, and #48) of eight sampled residents. The facility census was 54. 1. Review of the facility's Storage of Medication's policy, dated April 2007, showed drugs shall be stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems. Review of the Self-Administration of Medications policy, dated December 2016, showed self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident room, the medications of resident permitted to self-administer will be stored on a central medication cart or in the medication room. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for two residents (Resident #7 and #9) out of three residents sampled. The facility census was 54.1. Review of the facility's policy titled Bed Hold Notice Prior to Transfer, dated October 2017, showed:-In the event of a resident transfer to the hospital or the resident goes on therapeutic leave, the facility will provide written information to the resident and/or the resident representative regarding the bed hold;-The notice will be provided prior to leave, if possible;-In the event the notice is not provided prior to leave due to unforeseen circumstances, the notice will be provided within the requirements for such notices. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to meet professional standards when staff did not complete weekly skin assessments per facility policy, for three residents (Resident #1, #2, and #3) out of three sampled residents. The facility census was 49. 1. Review of the facility's Pressure Injury Prevention and Management Policy, dated October 2018, showed licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/11/24, showed staff assessed the resident as: -Cognitively intact; -Impairment to both upper and lower extremities on both sides; [...]

Inspectors wroteBased on observation, interview, and record review, staff failed to ensure medications were stored in a safe and effective manner, when staff failed to ensure medications were properly labeled and contained in their original package until time of administration on two medication carts. Staff failed to ensure multi-dose medications were dated when opened. Staff failed to discard expired medications in one medication room. Staff failed to store time scheduled controlled medications (drug or other substance that may cause addiction) in a separately locked, permanently affixed compartment. The facility census was 50. 1. Review of the facility's Storage of Medication policy, revised 04/2007, showed drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to perform appropriate hand hygiene, and glove changes during incontinence care for two (Resident #19 and #21) out of two sampled residents. Facility staff failed to perform appropriate hand hygiene, and glove changes during catheter care for one (Resident #4) out of one sampled resident. Facility staff failed to appropriately sanitize a multi-use glucometer (a device for monitoring blood sugars) between use for two residents (Resident #19 and #28) out of four sampled residents to prevent the spread of infection causing contaminants. The facility census was 50. 1. Review of the facility's hand hygiene policy, undated, showed all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide an ongoing program of activities designed to meet three (Resident # 5, #13 and #41) out of 13 sampled residents interest on the weekends. The facility census was 50. 1. Review of the facility's policy titled, Life Enrichment Program, dated 10/21, showed this facility will provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Review showed staff were directed to: -Activities will be designed with the intent to enhance the residents sense of well-being, promote or enhance physical activities, promote or enhance cognition, and promote or enhance emotional health; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the arbitration agreement was explained in a form and manner which correctly describes the arbitration process, or the option to decline the arbitration agreement. The census was 50. 1. Review of the facility's policies showed staff did not provide a policy for Arbitration Agreements. 2. Review of the facility's admission Packet showed a one page Arbitration Agreement did not contain a place to decline arbitration. During an interview on 05/08/24 at 2:12 P.M., the Social Services Director (SSD) said he/she goes over the admission packet with new residents and their family at admission. The SSD said he/she lets them know if they sign, it avoids going to court and cuts on court cost for everyone. The SSD said he/she explains even though they sign and agree to the arbitration, doesn't mean they can't go to court still. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure call lights were within reach for three residents (Resident #6, #37, and #42) out of 13 sampled residents. The facility census was 50. 1. Review of the facility's policy titled, Call Light Accessibility and Response, dated 9/21, showed all staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. All residents will be evaluated on how to call for help by using the resident call system. Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. The call system should be accessible to a resident lying on the floor. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to post, in a form and manner accessible to the residents and resident representative, the required telephone number to the Department of Health and Senior Services (DHSS) hotline (to report allegations of abuse and neglect), or a list of names, addresses, and phone numbers of the State Survey Agency (SSA). The census was 50. 1. Review of the facility's Facility Postings Policy, dated October 2017, showed the facility will post required postings in an area accessible to all staff and residents. The facility posting include a list of names, addresses (mailing and email), and telephone numbers of all pertinent State Agencies and advocacy groups to include but not limited to: -State Survey Agency; -Adult Protective Services. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to transfer three residents (Residents #1, #2 and #3) in a safe manner, when staff did follow the facility's policy and procedures for the mechanical lift, which resulted with one resident (Resident #1) with fracture of facial bones and laceration of the head. The facility census was 50. 1. Review of the mechanical lift owner's manual, dated June 2015, showed staff are to move lift so that it is positioned directly over the individual and utilize leg opening function if required. Attach the straps of the sling to the hooks of the carry bar. Be sure to double check to ensure the straps are properly attached to the carry bar, and the individual is properly positioned in the sling prior to lifting. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility census was 54. 1. Review of the facility's Glove and Hand Washing Procedures policy, dated 2011 and posted in the kitchen, showed the policy directed staff to wash their hands upon entering the kitchen from any other location, after all breaks, between all tasks, before and after handling foods, and after touching any part of the uniform, face, or hair. Review also showed the policy directed staff to turn off the faucet with a paper towel after they wash their hands. Observation on 11/29/22 at 9:47 A.M., showed Dietary Aide (DA) N washed his/her hands at the handwashing sink and then turned the faucet off with his/her wet bare hands. [...]

Inspectors wroteBased on observation, interviews, and record review the facility staff failed to ensure the resident's call lights were answered in a timely manner. The facility's census was 54. 1. Review of the facility's Call light Accessibility and Response policy dated, [DATE], showed staff were directed as follows: -All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light; -Staff will report problems with a call light or the call light system immediately to the supervisor and/or the maintenance director and will provide immediate or alternative solutions until the problem can be remedied; -All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to ensure full time employment of a Director of Nursing (DON) since 9/26/22. The facility census was 54. 1. Review of the facility's Director of Nursing Services policy, revised August 2006, showed the following: - The Nursing services department is managed by the Director of Nursing Services. The Director is a Registered Nurse (RN), licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing; - The Director is employed full-time (40 hours per week). Review of the facility's Director of Nursing job description, undated, showed the following: - Interviews, hires, and trains employees; - Oversees facility in absence of higher-ranking management officials; - Maintains administrative authority, responsibility and accountability for the clinical team; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store and label medication in a safe and effective manor in one of one medication storage rooms and in one of one medication storage carts. The facility census was 54. 1. Review of the facility's Storage of Medications policy dated, [DATE], showed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Observation on [DATE] at 9:03 A.M., showed the 100 and 200 hall medication storage room contained: -Two 90 tablet bottles of 24 hour Loratadine 10 ml, with an expiration date of 11/22; -Two 100 capsule bottles of Vitamin E 90 mg, with an expiration date of 11/22. Observation on [DATE] at 9:25 A.M., showed the 100 hall medication cart contained: -One loose yellow tablet with a L stamped on it; [...]

Inspectors wroteBased on interview and record review, facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against pneumococcal (infection caused by bacteria) pneumonia in accordance with national standards of practice for five (Residents #3, #7, #16, #18 and #25) out of five sampled residents. The facility census was 54. 1. Review of the facility's Pneumococcal Vaccine Program policy, undated showed the following: -The pneumococcal vaccine program as recommended by the Centers for Disease Control and Prevention (CDC) varies for patients by age group. The recommendations were updated in 2016; -In 2016 there are two pneumococcal vaccines available for use in the United States; PCV13 and PPSV23; -Adults [AGE] years old or older who have already received a dose of PPSV23, should also receive a dose of PCV13 a year or more later; 2. Review of the U.S. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of staff and the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility staff also failed to keep the required daily staffing records for eighteen months. The facility census was 54. 1. Review of facility Nurse Staff Posting policy, dated September 2022, showed the following: - Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents; - The nurse staffing sheet will be posted on a daily basis and will contain the following information: - Facility name; - The current date; - Facility's current resident census; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one or more individuals completed specialized training in infection prevention and control (IPC) prior to assuming the role of infection preventionist (IP) for the facility's infection prevention and control program. The census was 54. 1. Review of the facility's Infection Preventionist Policy dated September 2022 showed: -The facility will ensure the Infection Preventionist is qualified by education, training, experience or certification; -The IP must have obtained specialized IPC training beyond initial professional training or education prior to assuming the role and must provide evidence of training through a certificate(s) of completion or equivalent documentation. Review of the Center for Disease Control and Prevention (CDC) training website showed: [...]