Tanglewood Nursing & Rehabilitation

Inspectors wroteThe facility identified a census of 46 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to maintain safe and comfortable temperature levels for residents in the facility. On 11/22/24, Administrative Staff B received reports that one of the halls was cold. Administrative Staff B arranged for a maintenance company to assess the problem and a part was required for repair. The part was set to come in on 11/26/24. The facility supplied extra blankets and residents wore their coats inside but reported being extremely cold and experiencing physical discomfort over the weekend and on 11/25/24. [...]

Inspectors wroteThe facility had a census of 49 residents. The sample included 13 residents of which seven were reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure fall prevention interventions, including a floor mat, were utilized for Resident (R) 45. R45 subsequently had a fall, which resulted in a right femur non-displaced femoral (thigh bone) neck fracture. The facility further failed to ensure R17's WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) was in place and functioning. These deficient practices placed the resident at risk of accidents and related injuries.

Inspectors wroteThe facility had a census of 49 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week. This placed all residents who reside at the facility at risk of decreased quality of care.

Inspectors wroteThe facility identified a census of 49 residents. The facility had one main kitchen and one main dining area. Based on observation, record review, and interview the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs.

Inspectors wroteThe facility identified a census of 49 residents. The facility had one main kitchen. Based on observation and interview, the facility failed to ensure staff stored food items in accordance with the professional standards for food service safety. This placed residents at risk of foodborne illness and cross-contamination (the transfer of harmful substances to food).

Inspectors wroteThe facility had a census of 49 residents. Based on interviews and record review, the facility failed to submit complete and accurate staffing information through Payroll-Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate staffing.

Inspectors wroteThe facility had a census of 49 residents. The sample had 13 residents, with four reviewed for bathing. Based on observation record review, and interview, the facility failed to provide consistent bathing for fResident (R) 17, R24, R44, and R45. This placed the residents at risk for poor hygiene and related complications.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure accurate reconciliation of controlled medications (substances that have an accepted medical use, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) was completed. This placed residents at risk of medication misappropriation and diversion.

Inspectors wroteThe facility had a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R) 45's indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid), R7's gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) care, and R43's wound care. The facility failed to ensure R33's eye medication was administered using adequate infection control standards and failed to ensure R7's oxygen equipment was changed and stored in a sanitary manner. This placed the residents at risk for infectious processes.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 13 residents with three sampled residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R) 7's transfer or discharge was documented in the resident ' s medical record and appropriate information was communicated to the receiving healthcare institution or provider. This placed R7 at risk for delayed treatment and impaired continuity of care.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 13 residents with three sampled residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notification of transfer to Resident (R) 33 and R44 or their representatives for their facility-initiated transfers. This deficient practice had the risk of miscommunication between the facility and resident/family and impaired rights for R33 and R44.

Inspectors wroteThe facility had a census of 49 residents. The sample included 13 residents of which three residents were reviewed for transfer and/or discharge. Based on record review and interview, the facility failed to provide Resident (R) 33 and R44 with the appropriate bed hold policy as required. This placed the residents at risk of being uninformed of bed-hold requirements.

Inspectors wroteThe facility had a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to accurately assess and document that Resident (R) 30 had a terminal condition on the Minimum Data Set (MDS) assessment. This placed the resident at risk for an inaccurate care plan and unmet care needs.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 13 residents with two residents reviewed for treatment of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to ensure Resident (R) 7 received appropriate prompt treatment to promote healing and prevent worsening of a Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcers. The facility also failed to ensure R43 had nutritional measures and a pressure reducing device for her wheelchair in place. This placed R7 and R43 at risk for delayed healing and or increased risk for pressure ulcers.

Inspectors wroteThe facility had a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 45 with sanitary indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) care. This placed the resident at risk for urinary tract infections (UTI-an infection in any part of the urinary system) and other catheter-related complications.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 13 residents with one resident reviewed for enteral feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube) management. Based on observation, record review, and interview the facility failed to ensure that Resident (R) 7 had a flush order for pre and post-bolus (a method of tube feeding that involves giving a patient a large amount of liquid formula through a feeding tube all at once) via gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). This placed R7 at risk of G-tube complications and adverse reactions including dehydration (not enough fluids) and fluid overload.

Inspectors wroteThe facility had a census of 49 residents. The sample included 13 residents, with three reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 30 had physician orders for oxygen therapy and failed to provide direction to staff for the cleaning, storage, and dispensing of oxygen. The facility failed to ensure R7 had a physician's order for his oxygen and further failed to store R7's and R45's respiratory equipment in a sanitary manner. This placed the residents at risk for increased respiratory infections and other related complications.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 13 residents with Resident (R) 19 reviewed for pain management. Based on observation, record review, and interview, the facility failed to ensure R19 had her physician ordered Norco (a combination pain medication of opioid pain reliever hydrocodone and non-opioid pain reliever acetaminophen) medication available for administration as scheduled for pain management, which resulted in R19 missing a scheduled dialysis (a procedure where impurities or wastes are removed from the blood) appointment. This placed R19 at risk of complications related to unmanaged pain.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 13 residents with one resident reviewed for dialysis for dialysis (a procedure where impurities or wastes were removed from the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services regarding Resident (R) 19's health status with each procedure. This deficient practice placed R19 at risk for complications related to dialysis.

Inspectors wroteThe facility had a census of 49 residents. The sample included 13 residents, with six reviewed for behaviors. Based on observation, record review, and interview, the facility failed to immediately involve the physician and provide supportive mental health services to attain Resident (R) 30's highest practicable mental and psychosocial well-being after he made statements of self-harm. This placed the resident at risk for unmet mental health care needs and related complications.

Inspectors wroteThe facility had a census of 49 residents. The sample included 13 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported that staff failed to follow the physician's orders to administer insulin (medications used to help reduce the amount of sugar present in the blood) to Resident (R) 44. This placed the resident at risk for physical decline and an ineffective medication regimen.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 13 residents with six sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 19's as-needed antihypertensive (a class of medication used to treat high blood pressure) medication hydralazine was given per physician-ordered parameters. The facility failed to ensure R44's insulin (a hormone that lowers the level of glucose in the blood) was administered as directed. This placed these residents at risk of medication-related complications and possible adverse reactions.

Inspectors wroteThe facility had a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to hold food at a safe temperature for Resident (R) 36's room tray. This placed the resident at risk for foodborne illness.

Inspectors wroteThe facility had a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 37 received thickened liquids per his orders. This placed R37 at risk of complications of aspiration (inhaling liquid or food into the lungs).

Inspectors wroteThe facility identified a census of 49 residents. The facility identified one main kitchen. Based on observation, record review, and interview, the facility failed to ensure the kitchen ' s stand-up freezer and plate warmer were in safe operating condition.

Inspectors wroteThe facility identified a census of 43 residents. The sample included five residents. Based on record review and interviews, the facility failed to ensure Resident (R) 1 received care consistent with the standards of practice when staff failed to notify and obtain physician involvement regarding R1's multiple medication refusals including medications used to control seizures (violent involuntary series of contractions of a group of muscles). R1 refused all morning doses for his twice-daily Keppra (medication used to treat seizures) from [DATE] through [DATE]. R1's clinical record lacked evidence the staff reported the refusals to the physician for medical evaluation. On [DATE] at 04:02 PM, R1 sat in the dining room, talking to staff, when his legs began to shake and extend outward. [...]

Inspectors wroteThe facility had a census of 44 residents. Based on observation, record review, and interview, the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week placing all residents who reside in the facility at risk of lack of assessments and inappropriate care.

Inspectors wroteThe facility had a census of 44 residents. The sample included 14 residents with no COVID (an acute respiratory illness capable of producing severe respiratory complications) positive residents identified. Based on observation, record review and interview the facility respond to the high county transmission rates for COVID when the facility failed to ensure facility vendors wore masks in the facility to protect and prevent COVID transmission for the 44 residents residing in the facility.

Inspectors wroteThe facility had a census of 44 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to follow-up or resolve resident grievances, placing the residents at risk for unresolved concerns leading to decreased quality of life.

Inspectors wroteThe facility had a census of 44 residents. The sample included 14 residents, with eight reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services as care planned for four sampled residents, Resident (R) 27, R29, R2, and R22. This placed the residents at risk for poor hygiene.

Inspectors wroteThe facility had a census of 44 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to ensure a consistent reconciliation of narcotic medications between shifts. This deficient practice placed created the risk for misappropriation and/or drug diversion.

Inspectors wroteThe facility had a census of 44 residents. The sample included 14 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect for one sampled resident, Resident (R) 18, who was unnecessarily exposed. This placed the resident at risk for undignified care and services.

Inspectors wroteThe facility had a census of 44 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to honor Resident (R) 8's preference to receive two showers a week. This deficient practice placed R8 at risk for decreased self-determination and impaired psychosocial well-being.

Inspectors wroteThe facility had a census of 44 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed keep Resident (R) 23's protected health information (PHI) private on a medication cart parked in the hallway next to the nurse's station, placing the affected resident at risk for impaired privacy. Finds included: - On 04/10/23 at 07:29 AM observation revealed a medication cart parked across from the nurse's station with a laptop computer sitting on the top; there were no staff present. The laptop computer screen had R23's PHI on the screen visible to all who passed by the medication cart. The information visualized included R23's date of birth , allergy information, code status, and medications. On 04/10/23 at 07:32 AM Certified Medication Aide (CMA) R approached the cart and reported the laptop screen should not have been visible. [...]

Inspectors wroteThe facility had a census of 44 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to report to the state agency a resident-to-resident altercation between two sampled residents, R29 and R22. This placed the resident's at risk for further injury and unidentified abuse or mistreatment.

Inspectors wroteThe facility had a census of 44 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to investigate a fall for Resident (R) 17, who fell during transport to dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions), and the facility failed to investigate a resident-to-resident altercation between two sampled residents, R29 and R22. This placed the resident's at risk for further injury and unidentified abuse or mistreatment.

Inspectors wrote- The Electronic Medical Record (EMR) for R26 documented diagnoses of edema, hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness but without complete paralysis) following a cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels that supply it) affecting left dominant side, dysphagia (difficulty swallowing), apraxia (inability to perform particular purposive actions, as a result of brain damage), seizures (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and hypertension (high blood pressure). [...]

Inspectors wroteThe facility had a census of 44 residents. The sample included 14 residents, with one reviewed for edema (swelling). Based on observation, record review, and interview, the facility failed to apply the standards of practice as related to dependent edema when staff failed to elevate Resident (R)26's legs to decrease the edema in her legs. This placed the resident at risk for complications related to edema.

Inspectors wrote- The Electronic Medical Record (EMR) for R17 documented diagnoses of hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness but without complete paralysis) following a cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels that supply it) affecting left dominant side, dysphagia (difficulty swallowing), end stage renal disease (kidney failure), diabetes mellitus type 2 (the body either doesn't; produce enough insulin or it resists insulin), and abnormal posture (abnormal positions of the body). R17's Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R17 had severely impaired cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, personal hygiene; R17 did not ambulate. [...]

Inspectors wroteThe facility had a census of 44 residents. The sample included 14 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain physician ordered blood sugars for one sampled resident, Resident (R) 17, who received insulin (medication used to treat high blood glucose). This placed the resident at risk for complications related to high or low blood sugars.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 14 residents with eight residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to ensure that bathing was provided for eight residents who required partial or complete assistance from staff for bathing. This deficient practice placed resident (R)8, R30, R43, R22, R37, R17, R40 and R94 at risk for potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices and impaired psychosocial well-being.

Inspectors wroteThe facility had a census of 45 residents with one kitchen and one dining room. Based on observation, interviews, and record review, the facility failed to ensure sanitary equipment cleaning and food storage. This deficient practice placed residents at risk for food borne illnesses and food safety concerns. Findings Include: - During the initial inspection of the kitchen on 12/06/21 at 07:20 AM the facility's ice machine cleaning and maintenance log indicated that the last documented cleaning occurred on 09/18/2021. The machine had some brown stains on the opening area. An inspection of the freezer located inside the cooking area revealed two opened whipped topping piping bags setting directly on the bottom of the upper freezer unit. The bags were dated 12/06/2021 and contained 1/3 of the whipped topping inside them. [...]

Inspectors wroteThe facility identified a census of 45 residents. The sample included 14 residents, with three residents reviewed for discharge. Based on record review and interviews, the facility failed to document a recapitulation of the facility stay upon discharge from the facility for Resident (R) 45. This placed R45 at risk for impaired continuum of care.

Inspectors wroteThe facility reported a census of 45 residents. The sample included 14 with one reviewed for accidents. Based on observations, interviews, and record reviews, the facility failed to assess and remove hazards in the resident's environment resulting in a fall. This deficient practice placed the resident at increased risk for future injuries related to accidents and /or hazards.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 14 residents, with one resident reviewed for hemodialysis (procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to retain communication sheets which included information from the dialysis provider for Resident (R) 40, which had the potential for unwarranted and unidentified physical complications related to dialysis.