Stratford Villa Post-Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure for two out of four residents (Resident 1 and 2), that their rights were protected, when facility did not verify the informed consents were obtained from the responsible party, and informed consent were not in Resident 1 and 2's medical records. These failures resulted in violating the residents' right to be informed with their medical treatment. Cross reference to F 684Findings:A review of Resident 1's admission Record (AR) indicated Resident 1 was admitted on [DATE] with diagnoses that included Parkinson's Disease without dyskinesia, without mention of fluctuations. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure for two out of four residents (Residents 1 and 2), Residents 1 and 2 receive treatments according to their needs. Residents 1 and 2 were treated with brain mapping/neurofeedback treatment (a biofeedback, which teaches self-control of brain functions to subjects by measuring brain waves and providing a feedback signal. Neurofeedback usually provides audio and/or video feedback), without after treatment plan and care provided. These failures had potential to affect Residents 1 and 2's health and safety due to lack of care coordination. Cross reference to F 578Findings:1. During a review of Resident 1's admission Record (AR), indicated Resident 1 was admitted on [DATE], with diagnoses that included Parkinson's Disease without dyskinesia, without mention of fluctuations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one out of four residents (Resident 1), that Resident 1 was in a room with Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities), EBP was not followed during nursing care. This failure had the potential to spread infection when prevention was not consistently practiced.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure state requirements were met for a full-time registered dietitian or the person designated to serve as the director of food and nutrition services was hired on staff on a full-time basis (35+hours/week). This failure had the potential for food and nutrition services staff to be inadequately trained and supervised to carry out food and nutrition services for 26 out of 26 residents.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when: 1. Hand washing sink was located right next to coffee machine and beverage dispenser. 2. Multiple food items opened with no use-by dates; bag of permecian gravy opened 3/5/24, bag of chicken gravy mix opened 3/2/24, carton of lactose free milk opened 3/12/24, cartoon of pineapple juice opened 3/10/24. There were five pounds of Monterey jack cheese opened 3/11/24, and a plastic container of apple sauce, dated 3/10/24. 3. Three-compartment sink was not operated according to instructions. 4. Ice machine had brownish whitish hard sticky substance on the right area on the outside difficult to wipe off. 5. Three kitchen air vents and one fly trap by the outside door with excessive blackish dust. 6. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe medication storage when the following medications were found in medication cart one: 1. Resident 22 did not have an accurate medication card label for Colchicine that matched the order the physician had prescribed. (Colchicine is a medication used to prevent or treat gout attacks. Gout is a disease that causes severe pain, swelling, redness and tenderness in joints). 2. Three and one-half loose pills were not in a labeled container. This failure had the potential for medication error and contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and contain refuse properly when the dumpster was not closed. This failure had the potential of harborage and feeding of pests.

Inspectors wroteBased on interview and record review, the facility failed to follow a written hospice (end-of-life) agreement that included joint responsibilities to develop and implement plan of care for one sampled resident (Resident 23) was admitted into the hospice program, when Resident 23 and Resident 23's representative (FM 1) were not included or participated in the development and implementation of Resident 23's hospice plan of care (POC). This failure had the potential to result in negative outcomes and lack of communication of a person-centered care needs for residents.

Inspectors wroteBased on observation, interview, and record review, for one of four sampled residents (Resident 1), the facility failed to ensure staff provide immediate life-saving measures (cardiopulmonary resuscitation [CPR] - rescue breathing and or chest compressions when the heart stops) when Resident 1 was found in bed without vital signs (Vs, temperature, pulse, respirations, blood pressure ). Resident 1 was a full code (desired all medical emergency interventions when breathing and or heart stops). Licensed Vocational Nurse (LVN) 2 declared Resident 1 expired (dead) and did not initiate CPR or call emergency personnel (9-1-1). This failure of LVN 2 to provide CPR and call emergency personnel was determined to constitute an Immediate Jeopardy (IJ). [...]

Inspectors wroteBased on interviews and record review, the facility failed to perform a proficient neurological assessment (a series of questions and or motor tests in the event of a sudden change in condition to detect neurological changes: level of consciousness, orientation, movement of arms and legs, pupil size and reaction to light) for one (Resident 1). Staff did not maintain monitoring according to professional standards to detect early changes that required emergent medical treatment after Resident 1 sustained an unwitnessed fall. This failure resulted in not identifying a change in Resident 1 ' s neurological status. Resident 1 died in the facility the following day after the unwitnessed fall.

Inspectors wroteBased on interview and record, the facility's Quality Assessment Performance Improvement (QAPI) committee failed to identify an adverse event (untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof, including near misses) and the root cause resulting in the death of one (Resident 1) of three sampled residents. Resident 1 was a full code (all emergency interventions in the event breathing and or heart stops). Staff failed to provide emergency medical treatment when Resident 1 was found unresponsive because nursing staff mistakenly thought Resident 1 had a Do Not Resuscitate (DNR) order. This failure resulted in the QAPI committee not taking steps to review the circumstances of Resident 1's death and monitor their system for code status verification to correct the issue.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices when: 1. The walk-in refrigerator had four trays of previously frozen raw meat in the refrigerator for more than three days; the raw meat was not labeled with a use by date. 2. The reach-in refrigerator had undated and unlabeled individually packaged liquids and a bowl of cooked oatmeal. 3. Two dietary personnel did not perform hand hygiene and or glove changes during food handling. 4. The ice machine interior had a pink substance on the ice chute surface, and the exterior surface of the ice bin had a white residue along the bin seams. These failures had the potential to result in food contamination and foodborne illnesses.

Inspectors wroteBased on record review and interview, the facility failed to monitor and document the fluid intake of one (Resident 19) of one resident that required dialysis (a treatment for kidney failure to remove waste products and excess fluids by external filtration of blood). The failure to monitor Resident 19's fluid intake for 29 of 90 shifts had the potential to result in Resident 19 consuming more fluids than ordered by the physician causing fluid overload with resultant problems of swollen extremities and difficulty breathing.

Inspectors wroteBased on record review and interview, the facility failed to ensure one (Resident 22) of one resident receiving anticoagulation medication (medication to prevent blood clot formation, commonly known as blood thinner) was free from unnecessary medication when staff did not monitor the side effects of Resident 22's use of apixaban (medication used to thin blood). This failure had the potential to result in Resident 22 developing adverse side effects such as bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary environment for two of five sampled residents (Resident 14, Resident 16) when staff failed to: 1. perform hand hygiene between glove changes when administering medication to Resident 14, and 2. clean the oxygen mask and tubing for Resident 16. This failure had the potential for infection of Resident 14 and Resident 16.

Inspectors wroteBased on observation, interview and facility document review, the facility failed to label and store food under sanitary conditions when: 1. Five containers of strawberries had white fur on them. Three bananas had black and yellow skin. 2. One loaf of open large wheat bread was without a date. 3. Five small white bowls, two medium bowls two scoops with green handles were stacked and placed in the cabinet with water sitting in them. 4. Registered Dietician (RD) came into the kitchen and did not immediately wash her hands and completely cover her hair. These failures had the potential to cause food contamination and food borne illness in residents.