Stonehenge of Richfield

Inspectors wroteBased on interview and record review, for 3 of 15 sampled residents, the facility did not ensure that residents who used psychotropic drugs received a gradual dose reduction, and behavioral interventions unless clinically contraindicated in an effort to discontinue the drugs; additionally the facility did not ensure PRN (as needed) orders for psychotropic drugs were limited to 14 days unless clinically contraindicated. Specifically, there was no rationale after 90 days for continued use of a prn anti-anxiety medication, another resident did not have a rationale for continuation of an anti-depressant and anti-anxiety and another resident did not have a gradual dose reduction that was ordered by the physician implemented. Resident identifiers: 2, 7 and 11.

Inspectors wroteBased on interview, the facility did not employ a full time Director of Food and Nutrition Services with the required qualifications of Certified Dietary Manager, Certified Food Service Manager or with a degree in food service management or 2 or more years of experience as a director of food and nutrition services. Specifically, the facility's Certified Dietary Manager was employed part time and the full-time Dietary Manager was not yet certified to work as a Dietary Manager.

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer, walk-in refrigerator and dry food storage room were open to the air. Additionally, food items in the food storage room were past their use by dates.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Specifically, during medication pass a staff member was observed to place her bare fingers inside the medication cups prior to administering medications to residents. Additionally, during hallway meal pass, drinks, cold cereal and soup were observed to be transported uncovered to residents. Resident identifiers: 10, 11 and 12.

Inspectors wroteBased on interview and record review, it was determined that for 1 out of 15 sampled residents the facility did not send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. Resident identifier:

Inspectors wroteBased on interview and record review, it was determined for 2 of 15 sampled residents, the resident assessment did not accurately reflect the resident's status. Specifically, two residents who were using oxygen had assessments stating they were not using oxygen at the facility. Resident identifiers: 2 and 10.

Inspectors wroteBased on observation, interview and record review, for 1 out of 15 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the resident's nursing needs. Specifically, a care plan was not developed to address the resident's oral hygiene care. Resident identifier: 11.

Inspectors wroteBased on observation, interview and record review, for 1 of 15 sampled residents, the facility did not provide appropriate treatment and services to maintain or improve his ability to carry out the activities of daily living (ADL). Specifically, a resident was observed to have buildup on his teeth and there was no documentation that he was provided oral care routinely. Resident identifier: 11.

Inspectors wroteBased on interview and record review it was determined, for 1 of 17 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible. Specifically, a resident that required two staff members assistance sustained a fall resulting in 6 sutures to her face when one staff member was assisting her.

Inspectors wroteBased on interview and record review, it was determined that the facility did not employ a clinically qualified full-time dietitian or other clinically qualified nutrition professional to serve as the Director of Food and Nutrition Services. Specifically, the facility did not employ a full-time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the Director of Food and Nutrition Services.

Inspectors wroteBased on interview and record review it was determined, for 6 out of 17 sampled residents, that the facility did not ensure that the physician reviewed each residents total program of care, including medications and treatments at each visit; write, sign and date progress notes at each visit; and sign and date all orders with the exception of influenza and pneumococcal vaccine. Specifically, residents Physician Orders for Life Sustaining Treatment (POLST) forms, care plans, death reports and physical therapy (PT) and occupational therapy (OT) evaluation and treatment plans were not signed by the medical director (MD). Resident identifiers: 2, 6, 7, 12, 14, and 64.

Inspectors wroteBased on interview and record review it was determined, for 4 out of 17 sampled residents, that the facility did not maintain medical records on each resident that were complete, accurately documented, readily accessible and systematically organized. Specifically, resident's medical records did not contain the physician notes, assessments, and orders. Resident identifiers: 2, 4, 7, and 12.

Inspectors wroteBased on interview and record review it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, observations were made of staff entering a quarantine room on droplet isolation precautions without donning a N95 mask, staff were observed inside the facility and resident areas without eye protection, and staff were observed wearing their surgical masks down below their nose and mouth. Resident identifier: 2 and 65.

Inspectors wroteBased on observation and interview it was determined, for 1 out of 17 residents, that the facility did not ensure that the Interdisciplinary Team (IDT) had determined that the resident was safe to self administer medications. Specifically, a resident was not evaluated to determine if they were safe to self administer two inhaler medications. Resident identifier 65.

Inspectors wroteBased on interview and record review it was determined, for 2 of 17 sampled residents, that the facility did not immediately consult with the resident's physician and notify when there was a significant change in the resident's status or a need to alter treatment. Specifically, a resident had a fecal impaction that required digital evacuation of the bowel and a resident had increasing complaints of pain after a fall and the physician was not immediately notified. Resident identifier 4 and 12.

Inspectors wroteBased on interview and record review it was determined, for 1 of 17 sampled residents, that the facility did not ensure that the Minimum Data Set (MDS) data was transmitted within 14 days after the resident's assessment was completed. Specifically, a resident was discharged from the facility and the MDS data was not transmitted to the Centers for Medicare and Medicaid Services System for greater than 120 days. Resident identifier 1.

Inspectors wroteBased on observation, interview, and record review it was determined, for 2 of 17 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident went 5 days without a bowel movement with no interventions and a resident suffered a fall and did not get x-rays for 5 days. Resident identifiers: 4 and 12.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 17 sampled residents, that the facility did not ensure that a resident with pressure ulcers (PU) received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, a resident with a Stage II PU was provided wound care treatment without a documented evaluation and order to treat the wound by the wound care specialist. Additionally, the order entered in the medical records for wound care did not specify the type of treatment to be applied to the wound. Resident identifier 2.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 17 sampled residents, that the facility did not ensure that another physician supervised the medical care of residents when their attending physician was unavailable. Specifically, the attending physician did not respond to a resident's change in condition for two days. Resident identifier 4.

Inspectors wroteBased on interview and record review it was determined, for 2 of 17 sampled residents, that the facility did not ensure that psychotropic drugs were not given unless necessary to treat a specific condition diagnosed and documented in the clinical record and residents who used the psychotropic drugs received a gradual dose reduction and behavioral interventions unless clinically contraindicated. Specifically, a resident was prescribed a psychotropic for insomnia without a diagnosed and documented condition, and a resident was prescribed a psychotropic and did not receive a gradual dose reduction. Resident identifiers: 4 and 64.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 5 sampled facility staff, that the facility did not ensure that testing of all facility staff for COVID-19 was completed based on the parameters set forth by the Secretary. Specifically, routine testing of an unvaccinated staff member based on the county positivity rate was not completed for one week out of the four weeks reviewed. Staff identifier: Certified Nurse Assistant (CNA) 5.