The Peaks Health & Rehabilitation

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to ensure expired food items in the kitchen were discarded, food items were dated and stored correctly. The deficient practice could result in possible food-borne illnesses and unwanted pests.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to properly monitor and supervise the whereabouts of one resident (#28). The sample size was 12 and the universe was 43. The deficient practice could result in physical, mental, and/or psychosocial harm.

Inspectors wroteBased on observation, staff interviews, and review of facility policy and procedure, the facility failed to ensure that one medication cart was locked when unattended. The deficient practice could result in residents, visitors, or other staff members having unrestricted access to medications.

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy, the facility failed to ensure an allegation of abuse was reported to mandated entities within 2 hours for one resident (#5). The deficient practice could lead to an allegation of abuse not being investigated by all mandated entities timely, resulting in possible ongoing abuse to a resident.-

Inspectors wroteBased on staff interview, review of facility documentation, and policy, the facility failed to ensure that facility documents regarding grievances, reportables and resident council meeting minutes were available. The deficient practice could result in documentation regarding residents' issues and concerns pertaining to life and safety not being readily available.

Inspectors wroteBased on observations, staff interviews, and review of facility policy, the facility failed to ensure that care and services met professional standards of practice regarding medication administration for one of six sampled residents (#3). The deficient practice could result in residents not receiving the appropriate medication and for additional errors in medication administration.

Inspectors wroteBased on observations, staff interviews, record review, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for one resident (#3). The medication error rate was 21.43%. Six medication administration errors were identified out of 28 opportunities during medication administration observation. The deficient practice could result in further medication errors.

Inspectors wrote-During a medication room observation conducted with a Registered Nurse (RN/staff #6), on November 6, 2024 at 12:39 p.m., there were two Semglee insulin glargine pens in Ekit #1 in the fridge with an expiration date of June 2024; and, Moderna covid-19 vaccines in a black locked box in the fridge had a sticker on the box indicating the expiration date to be June 30, 2023. During the medication room observation with RN (staff #6) conducted on November 6, 2024 at 12:39 p.m., the following supplies were found having exceeded their expiration date: -Autoshield duo cap for insulin pen in Ekit #1 from fridge with an expiration date of February 2023; -Statlock intravenous kit with an expiration date of December 28, 2023; -Entraflo safety spike plus pump set with enfit with an expiration date of June 28, 2023; -Powerloc port access kit with an expiration date of October 31, 2024; [...]

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure one sampled resident (#5) was assessed for medication self-administration. The deficient practice could result in resident not taking or able to take the medication needed for treatment.

Inspectors wroteBased on observation, interviews, review of clinical record, facility documentation, and facility policy, the facility failed to ensure policies were implemented regarding investigating and timely reporting of allegations of abuse for 3 sampled residents (#13, #19, and #29). The deficient practice could lead to allegations of abuse not being investigated timely, and could lead to continued harm to residents.

Inspectors wroteBased on observation, interviews, review of clinical record, facility documentation, and facility policy, the facility failed to ensure alleged violations of abuse were reported to proper authorities within prescribed timeframes for 3 residents (#13, #19, and #29). The deficient practice could lead to allegations of abuse not being investigated timely, and could lead to continued harm to residents.

Inspectors wroteBased on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated, and to prevent further abuse from occurring during the investigation for two residents (#19 and #29). The deficient practice could lead to allegations of abuse not being investigated thoroughly, and residents not being protected from further abuse and retaliation.

Inspectors wroteBased on observation, clinical record review, staff interview, and policies and procedures, the facility failed to ensure a comprehensive person-centered care plan with interventions was developed and implemented related to dialysis care and assessment for one resident (#22); and, oxygen use for one resident (#29). The deficient practice could result in staff not being aware of changes in interventions and asessments.

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that a care plan was revised after each fall for two sampled residents (#18 and #22). The deficient practice could result in resident not getting the appropriate care they need.

Inspectors wroteBased on observation, staff interviews, and review of facility policy, the facility failed to ensure that one medication was disposed of in accordance with professional standards of practice, the deficient practice could result in medications not being disposed of properly. The sample was 28 medication administrations observed.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, the facility failed to ensure that one sampled resident (#342) did not receive a pneumococcal vaccine. The deficient practice could result in residents not receiving vaccines.

Inspectors wroteBased on review of employee personnel file, staff interviews and policy review, the facility failed to ensure personnel records for 2 staff (#4 and #101) included documentation of orientation and in-service education as required by policies and procedure. The deficient practice could result in incompetent care of residents. The facility census was 32 and the sample was 12.