The Rehabilitation Center at the Palazzo

Inspectors wroteBased on the clinical record review, facility documentation, and staff interviews, the facility failed to notify the Office of the State Long-Term Care Ombudsman (OSLTCO) of one resident's transfer (Resident #1). The deficient practice had the potential to limit the Ombudsman's ability to advocate for residents' rights and ensure safe, appropriate transitions of care.

Inspectors wroteBased on personnel file review, interviews, and policy review, the facility failed to complete a yearly performance review for 1 of 2 sampled Certified Nursing Assistants (CNA/Staff #12). The deficient practice could result in insufficient and inadequate care for residents.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to ensure that medications were dated when opened. The deficient practice could result in reduced drug effectiveness and adverse reactions.

Inspectors wroteBased on resident and staff interviews, review of the clinical record, facility documentation, and policy, the facility failed to ensure that a code status was accurate and consistent in the medical record for one resident, # 10 of sixty-nine residents. The deficient practice could result in the resident not receiving care consistent with the signed advance directive. Based on resident and staff interviews, review of the clinical record, facility documentation, and policy, the facility failed to ensure that a code status was accurate and consistent in the medical record for one resident, # 10 of sixty-nine residents. The deficient practice could result in the resident not receiving care consistent with the signed advance directive.

Inspectors wroteBased on clinical record reviews, staff interviews, and facility policies, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level I was processed for determination of need for PASRR level II for one resident (# 42). The deficient practice could result in residents not receiving the appropriate services they need.

Inspectors wroteThe facility failed to ensure appropriate infection control measures were implemented and followed for one resident (# 44) related to tube feeding. The deficient practice could result in a spread of preventable illness to residents and staff.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to provide continence and shower care according to professional standards for one resident (#102). The deficient practice could result in skin breakdown. Findings Include:-Resident (#102) was admitted to the facility on [DATE] with diagnoses that included a urinary tract infection, multiple sclerosis, and anxiety disorder. The hospital summary dated September 15, 2022 included that the resident had an open area on buttocks with measurements: length: 4 mm, width 3 mm, and depth 0. A wound care weekly observation dated September 16, 2022 revealed left buttock with moisture associated skin damage (MASD). Measurements were length 4 mm, width 3 mm and depth 0. [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure weekly skin assessments were provided for one resident (#21) of three sampled residents, as ordered by the physician and failed to ensure that physician orders for one resident (# 28) for diagnostic testing were addressed in a timely manner following an unwitnessed fall. The deficient practice could lead to an injury being missed and a delay in care being provided to the resident and result in skin impairments developing or worsening without staff intervention.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of misappropriation for one resident (#38) was reported to the State Agency within the required time frame of twenty-four hours.

Inspectors wroteBased on clinical record review, interviews, and review of policies, the facility failed to ensure one resident (#4), was free from significant medication errors, related to the resident receiving medications ordered for another resident. The deficient practice could result in complications and adverse medication side effects.

Inspectors wroteBased on clinical record review, staff interviews, and facility policies and procedures, the facility failed to ensure the clinical record for one resident (#4) contained the required notification/documentation to the receiving provider. The deficient practice could result in the receiving provider not being informed of the resident's status.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to ensure that one resident's (#33) care planned interventions were reassessed for effectiveness and revised as needed. Resident #22 was admitted on [DATE] with diagnoses that included major depressive disorder and claustrophobia. A physician order dated December 22, 2022 directed for the resident's behavior to be monitored every shift in relation to the medication Sertraline for depression as evidenced by flat affect and self-isolation. It also indicated to monitor anti-depressant side effects every shift. Review of the admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. The assessment did not indicate that the resident was receiving psychological therapy. [...]

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#201) was provided services consistent with professional standards of practice. The deficient practice could result in unmanaged pain for residents.

Inspectors wroteBased on observations, clinical record review, staff interviews and policy reviews, the facility failed to ensure that services were provided to treat and follow-up a resident's (#33) diagnosed mental health condition. The census was 49. The deficient practice could result in residents not receiving individualized person-centered care and treatment, in order to reach their highest practicable well-being.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident's (#11) drug regimen was being monitored and the PRN (as needed) psychotropic medications had a limited duration. The facility census is 49. The deficient practice could result in residents receiving psychotropic medications that may not be necessary.

Inspectors wroteBased on observation, staff interviews, facility documentation and policy and procedures, the facility failed to maintain infection prevention and control during catheter care for one resident (#26). The deficient practice could result in transmission of infection.

Inspectors wroteBased on clinical record reviews, staff and resident interviews, and review of facility policy, the facility failed to ensure two residents (#17 & #39) received medications according to professional standards of practice. The sample size was 5 residents. The deficient practice could result in residents experiencing negative impact from not receiving ordered medications.

Inspectors wroteBased on clinical record review, staff interviews, facility document, and review of policies and procedures, the facility failed to ensure one resident (#94) consistently received the necessary services to maintain good hygiene. The sample size was 2 residents. The deficient practice could result in skin breakdown, odors and negative psychosocial impact.

Inspectors wroteBased on clinical record reviews, staff interviews, and facility policy and procedures, the facility failed to provide incontinence care on a regular basis for one resident (#145) and failed to provide appropriate care/services to maintain or improve continence for one resident #146. The sample size was 3 residents. The deficient practice could impact the dignity and independence along with the skin integrity of residents.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one resident (#18) was administered medications according to the parameters as ordered by the physician. The sample size was 5 residents. The deficient practice could result in residents receiving unnecessary drugs.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure lab results for one sampled resident (#94) were obtained and reported as ordered by the physician related to diabetic management. The deficient practice could result in uncontrolled blood sugar changes with adverse effects to the resident.

Inspectors wroteBased on concerns identified during the survey, the Facility Assessment, staff interviews, and policy review, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure a plan of action was developed and implemented that corrected identified quality care concerns related to infection control surveillance and antibiotic stewardship. The deficient practice could result in other quality concerns not being corrected.

Inspectors wroteBased on observations, staff interviews, facility documentation, and policy and procedure review, the facility failed to consistently implement an ongoing system of surveillance for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, and failed to handle potentially soiled linens using safe and sanitary techniques. The deficient practice could result in trends not being identified and the spread of infection.

Inspectors wroteBased on staff interviews, facility documentation, and policy and procedure review, the facility failed to develop and implement a facility-wide system to monitor the use of antibiotics. The deficient practice could result in the facility not ensuring residents who require an antibiotic are prescribed the appropriate antibiotic and could result in adverse effects from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on personnel file reviews, staff interviews, facility document, and facility policy and procedures, the facility failed to provide evidence that 3 out of 10 staff (#16, #34, and #19) were provided training on abuse, neglect, exploitation, misappropriation of resident property and dementia management. The deficient practice could result in staff not knowing how to protect residents from abuse and residents with dementia not receiving the services and care needed.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to provide one resident (#194) and the resident's representative a written notice of transfer/discharge for transfers to the hospital. The sample size was 2 residents. The deficient practice could result in residents and representatives not being provided a written notice of transfers or being informed of their discharge transfer rights, and advocacy information.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to provide evidence of a Level 1 PASRR (Preadmission Screening and Resident Review) screening for one sampled resident (#4). The deficient practice could result in residents not receiving services needed.

Inspectors wroteBased on observation, staff interviews, facility documentation, and policy reviews, the facility failed to ensure the dishwasher sanitation was consistently monitored. The deficient practice could increase the risk of foodborne illness.

Inspectors wroteBased on clinical record reviews, facility documentation, staff interviews, and review of facility policy, the facility failed to ensure advance directive information was accurate for two residents (#18 and #32). The sample size was 2 residents. The deficient practice could result in the resident's wishes not being honored.