Surrey Place Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed enhanced barrier precautions while providing high-contact care to residents in 2 of 3 units reviewed for infection control to prevent the possible spread of infection and communicable diseases.

Inspectors wroteBased on record review and interview, the facility failed to provide the residents with the Notice of Medicare Non-coverage (NOMNC) within the required time frame for 1 of 3 residents reviewed for beneficiary notification (Resident #18).

Inspectors wroteBased on record review and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for 1 of 2 residents reviewed for respiratory services (Resident #14) and 1 of 3 residents reviewed for behavioral health (Resident #31).

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had an accurate Level I Preadmission Screening and Resident Review (PASRR) completed for 2 of 3 residents reviewed for mood and behavior (Residents #27 and #31).

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as per the parameters ordered by physician for 2 of 7 residents reviewed for medication management (Residents #7 and #27).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff cleaned and sanitized the thermometer probe between testing temperatures of different food items.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were accurate for 1 of 6 residents reviewed for medication administration, Resident #36, and for 1 of 3 residents reviewed for accidents, Resident #3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed infection control standards during medication administration for 2 of 5 residents observed, Resident #35 and Resident #7, and during wound care for 1 of 2 residents observed, Resident #32, and failed to ensure staff disinfected the reusable medical equipment to prevent the possible spread of infection and communicable diseases.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident or resident representative received the refund due the resident within 30 days from the resident's date of discharge from the facility for 1 of 3 residents sampled for financial status review, Resident #1.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all residents were free from medical neglect. The facility failed to ensure licensed practical nurses had the appropriate skills and competency to administer intravenous (IV) medication via central line access devices for 1 of 1 residents, Resident #197. The lack of IV certification and validation of competency for IV medication administration can result in an increased risk of infection, damage to veins and the injection sites, an air embolism (a blood vessel blockage cause by one or more bubbles of air or other gas in the circulatory system), phlebitis (inflammation of a vein), and blood clots. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure licensed practical nurses (LPNs) had the appropriate skills and competencies to administer intravenous (IV) medication via central line access devices for 1 of 1 residents, Resident #197. The lack of IV certification and validation of competency for IV medication administration can result in an increased risk of infection, damage to veins and injection sites, an air embolism, phlebitis, and blood clots, causing tissue damage or even be life threatening. The lack of training and verification to assess IV patency (the line is open and not blocked allowing the treatment to flow directly into patients' veins) can increase the spread of infection and can result in the likelihood of increase harm and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility administration failed to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by not assuming full responsibility for the day to day operations of the facility by allowing unqualified facility staff to work outside of their scope of practice, administering IV (intravenous) medications via midline catheters for 1 of 1 residents, Resident #197, without certification of education, training and validation of competency for IV medication infusion to residents who are administered IV medications. IV infusion without IV certification and validation of competency could result in the likelihood of serious harm and/or death for residents who are administered IV medication infusions. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure food is stored, covered, labeled, and discarded in the kitchen and failed to maintain sanitary standards for equipment used to prepare, cook, and serve the residents. (Photographic evidence obtained).

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain equipment to be in a safe and clean operating manner.

Inspectors wroteBased on interview and record review the facility failed to ensure an advanced directive was formulated for 1 of 3 residents, Resident #198.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive person-centered care plan to identify a problem and approach for 1 of 5 residents, Resident #28, reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, record review the facility failed to ensure the residents environment remained free of accident hazards as is possible for 1 of 3 residents, Resident #28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles in 1 of 2 medication carts (East Cart) and unsecured medications observed at resident's bedside, Resident #33. (Photographic evidence obtained).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure assistive adaptive devices for provided for 1 of 1 residents, Resident #145.