Town & Country

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the documentation were accurate for one of four sampled residents (Resident 1). The skilled nursing documentation showed speech was clear for Resident 1 who was assessed based on MDS to have unclear speech- slurred or mumbled words. This failure posed a risk for the resident to not receive the appropriate care as the resident's record was inaccurate.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed. * Meat thawing process was not followed; * Expired food was not discarded; * Meal preparation equipment was not air dried; * The food preparation sink did not have backflow prevention; * Food preparation equipment was not clean; and * Cutting boards were stained and heavily marred. These failures posed the risk for food-borne illnesses in highly susceptible resident population of 82 facility residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete for 10 of 10 final sampled residents (Residents 1, 3, 7, 8, 10, 11, 29, 37, 43, and 58) reviewed for bed rails use. * The facility failed to ensure the entrapment assessment of bed rails were accurate and complete for Residents 1, 3, 7, 8, 10, 11, 29, 37, 43, and 58. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 45) reviewed for unnecessary medications was free from unnecessary psychotropic medications. * Resident 45's medical record did not include the prescriber's clinical rationale for the continued use of the PRN (as needed) psychotropic medication. This failure had the potential for the resident to experience adverse effects for the use of the psychotropic medication.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to report an allegation of physical abuse to local law enforcement for one of three final sampled residents (Resident 32) investigated for abuse. * The facility failed to notify the law enforcement of Resident 32's allegation of a CNA being too rough with him. This failure had the potential to delay local law enforcement interventions related to the abuse allegation.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the abuse investigation protocol was followed for one of three final sampled residents (Resident 46) investigated for abuse. * Family Member 1 reported CNA 2 allegedly hit Resident 46. The facility failed to ensure CNA 2 was removed from the facility during the investigation of the abuse allegation. The failure had the potential to negatively impact Resident 46's well-being.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to provide the services to attain or maintain the highest practicable well-being for one nonsampled resident (Resident 52). * Resident 52 was prescribed two medications to manage the BP. The facility failed to ensure a physician's order was obtained to monitor Resident 52's BP. This failure had the potential to negatively affect the resident's health condition and well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the appropriate care and services for one of one final sampled resident (Resident 29) reviewed for the use of the indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the urinary bladder to collect and drain urine). * The facility failed to accurately monitor the fluid intake and output of Resident 29 related to the urinary catheter use as per the physician's order. The monitoring of Resident 29's urine output documented in the MAR (Medication Administration Record) did not match the CNAs documentation. In addition, the calculation of the daily total of Resident 29's urine output was inaccurate and in turn, the weekly calculation of Resident 29's urine output was also inaccurate. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the physician's orders were clear and concise for one final sampled resident (Resident 32) investigated for intravenous care. * The facility failed to ensure Resident 32's physician's orders related to IV (Intravenous) care clearly indicated the IV access type as a PICC (Peripherally Inserted Central Catheter). This failure had the potential for the staff to not provide appropriate care for the resident's PICC line.

Inspectors wroteBased on observations, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of two final sampled residents (Residents 11 and 29) reviewed for respiratory care. * The facility failed to ensure Resident 11 and 29's nebulizer masks were properly cleaned after each use and stored when not in use. This failure had the potential for cross-contamination and increased risks of infection for Residents 11 and 29.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four final sampled residents reviewed for side rail use (Resident 11) remained free from the accident hazards associated with the use of elevated bed rails. * The facility failed to ensure the assessments, physician's order, care plan, and consent were completed and obtained for Resident 11's use of bed rails. These failures had the potential to put the resident at risk for entrapment and serious injuries.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 32) reviewed for unnecessary medications was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 32's physician's orders were appropriate and properly clarified. This failure resulted in the prescriber's orders not being transcribed correctly in the resident's medical record and could have potentially lead to missed medication.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and disposal of the drugs and biologicals. * The facility failed to ensure safe storage of the medications when LVN 9 left medications on Resident 3's bedside table during medication administration observation. * The facility failed to ensure the bubble packs containing the gabapentin (anticonvulsant) tablets for Resident 3 and zolpidem (sedative medication) tablets for Resident 21 remained intact and free from tears inside Medication Cart B. * The facility failed to ensure safe storage of the medications when LVN 3 left medications on Resident 15's bedside table during the medication administration observation. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide only food in a form designed to meet the individual needs for one of 11 residents (Resident 45) receiving soft and bite sized diet (food that are soft, tender and moist throughout but with no separate thin liquid). *Resident 45 was served breakfast with Cheerios cereal added to the resident's meal tray. This failure had the potential to result in difficulty in swallowing, chewing, decrease in food and nutrient intake, resulting in possible unintended (not planned) weight loss and choking (when food gets stuck in the airway, blocking the flow of air to the lungs).

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the food preferences were honored for one nonsampled resident (Resident 17) who received food prepared in the kitchen. * The facility served pork to Resident 17 during lunch when there was a physician's order for no pork, and resident's religious preference for no pork. This failure had the potential to negatively impact the resident's food intake and well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the residents had the ability to store and reheat food brought from outside the facility. * There was no microwave or refrigerator available to use for the residents' food brought from outside the facility to be stored or reheat. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections for one final sampled resident (Resident 7) and one nonsampled resident (Resident 96) reviewed for infection control. * The facility failed to ensure CNA 1 performed proper hand hygiene after providing incontinence and indwelling urinary catheter care to Resident 7. * The facility failed to ensure COTA 1 wore a gown when transferring Resident 96, who was on the EBP from the wheelchair to bed. These failures had the potential for cross-contamination and spread of infectious organisms throughout the facility.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain essential equipment in safe operating condition. * The facility failed to ensure two of two glucometers (a device which measures the amount of sugar in the blood) currently used and stored in Medication Carts A and B were properly calibrated. This posed the risk for inaccurate blood glucose test results used to determine the residents' insulin doses which could lead to inappropriate treatments and negatively affect the well-being of the residents.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the call light system (a communication system which are utilized by the residents to call for staff assistance) for two of two nurses stations (Nurse Stations A and B) were fully functional. * The facility failed to ensure the call light system panel console had an audible sound heard from Nurse Stations A and B. These failures had the potential for the residents in the facility not to receive assistance from the staff in a timely manner.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the residents' rights to make choices about daily routines were honored for two of three final sampled residents (Residents 45 and 66) reviewed for choices. * The facility staff entered Residents 45 and 66's room during early morning hours while the residents were sleeping. The staff turned on the residents' room lights and moved their wheelchairs in the room without informing the residents. This failure had the potential to not to accommodate the residents choice.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive person-centered plan of care to reflect the individual care needs for one of 18 final sampled residents (Resident 11). * The facility failed to ensure the comprehensive person-centered care plan for the use of bed rails was in place for Resident 11. This failure had the potential to cause inconsistent, inappropriate, and inadequate plans of care for Resident 11.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was revised for one of 18 final sampled residents (Resident 10). * The facility failed to ensure Resident 10's comprehensive care plan was revised to reflect when the physician's order for the apixaban (used to treat and prevent blood clots) medication was resumed. This failure placed the resident at risk of not being provided with the appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food item served for two nonsampled residents (Residents 33 and 96) was palatable. * Residents 33 and 96 were served with dry shrimp scampi. This posed the risk of Residents 33 and 96 for decreased meal intake, which may contribute to inadequate nutrition and negatively impact their well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan for one of three sampled residents (Resident 1) was initiated upon admission. * The facility failed to ensure Resident 1's baseline care plan included the necessary information to properly care for the resident with ileostomy (a surgery that lets stool pass from your body without going through your colon or anus) and the necessary nutritional interventions to maintain or prevent weight loss of the resident. This failure had the potential for Resident 1 to not receive the necessary resident-centered care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the care plan was developed for one of three sampled residents (Resident 1) who had a change in condition. * The facility failed to develop a care plan when Resident 1 had nausea, vomiting, poor meal intake, and weight loss. This failure had the potential for Resident 1 to not receive the necessary care and services.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained the highest practicable physical well-being. The facility failed to to notify Resident 1's physician regarding the discharge instructions from the acute care hospital to provide specific fluid amount and type to the resident, and to monitor the resident's intake and output. In addition, the facility failed to notify the physician regarding the resident's weight loss of 17 pounds timely. This failure posed the risk for Resident 1 to not receive the necessary care and services timely to maintain the resident's highest physical well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to ensure the CNAs followed the EBP to wear not only gloves but also a gown when providing resident care. This failure posed the risk for the transmission of disease-causing microorganisms.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure the ice machine was properly cleaned. * The facility failed to ensure the ice scoopers were properly stored. * The facility failed to ensure the food items were discarded on or before the best by date. * The facility failed to ensure the food preparation utensils and equipment were in good, sanitary, and cleanable working conditions. * The facility failed to ensure the kitchen staff wore hair and beard restraint. * The facility failed to ensure the blender was free of water prior to use. * The facility failed to ensure the water liners were covered during transportation in the hallway. * The facility failed to ensure the kitchen staff performed hand hygiene. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to ensure the contact and droplet precautions were practiced for Resident 569. * The facility failed to ensure the infection control was maintained in the laundry room. * The facility failed to show consistent and accurate documentation of its testing protocols for Legionella and other opportunistic pathogens in building water systems. These failures had the potential risk for transmission of communicable diseases or organisms to residents in the facility.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the essential kitchen equipment were in safe operating condition. * The facility failed to ensure two of two ice machines were properly cleaned as per the ice machine cleaning instruction. This failure had the potential for ice served from the kitchen to be unsanitary.

Inspectors wrote15. On 9/10/24 at 0911 hours, a concurrent observation and interview was conducted with Resident 37. Resident 37 was observed sitting in his wheelchair next his bed, with bilateral side rails elevated. Resident 37 stated he used the side rails to help turning himself in bed and getting out of bed. On 09/11/24 at 0806 hours, a concurrent observation and interview was conducted with Resident 37. Resident 37 stated the bilateral side rails were elevated all the time. Medical record review for Resident 37 was initiated on 9/10/24. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's H&P examination dated 7/28/24, showed Resident 37 had the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 18 final sampled residents (Resident 43) reviewed for side rail use and unnecessary medication was provided the right to self-determination regarding the use of psychotropic medication (medications affecting brain activity) and side rails. * The facility failed to obtain the informed consent for side rail from Resident 43's responsible party when Resident 43 was deemed to not have the capacity to make medical decisions. In addition, the facility failed to ensure the informed consent was obtained from the responsible party and signed by the physician before administering alprazolam (antianxiety) medication for Resident 43. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain and maintain a copy of the advance directives (a legal document stating a person's wishes about receiving medical care if the person is no longer able to make medical decisions) for six of 18 final sampled residents (Residents 8, 37, 43, 44, 320, and 669). * The facility failed to obtain a copy of advance directives for Residents 8, 37, 43, and 669. * The facility failed to obtain a copy of advance directives for Residents 44 and 320. In addition, the facility failed to ensure the POLSTs for Residents 44 and 320 were completed. These failures had the potential for the residents' decisions regarding their healthcare and treatment options to not be honored.

Inspectors wroteBased on observation, interview, medical record review and facility document review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of one final sampled resident reviewed for activities (Resident 43). * The facility failed to provide activities for Resident 43 to meet the resident's identified interests. The facility only provided activity program to Resident 43 on 8/8, 8/9, and 8/18/24 since his admission on [DATE]. This failure had the potential for the resident to experience feelings of social isolation and frustration.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to provide services to attain or maintain the highest practicable well-being for two of 18 final sampled residents (Residents 37 and 52) and one nonsampled resident (Resident 621). * LVN 3 failed to follow the physician's order to give furosemide (medication to treat fluid retention) 30 minutes before spironolactone-hydrochlorothiazide (medication to treat high blood pressure and fluid retention) to Resident 621. * Resident 37's physician's order was not followed when the physician was not notified of Resident 37's weight changes. * The licensed nurse failed to document the resident's BP when administered the as needed BP medication to evaluate the effectiveness of medication. These failures had the potential to compromise the health and safety of these residents.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation and disposal of medications. * The facility failed to ensure the removed controlled medications for Resident 31 was documented in the controlled drug record. * The facility failed to ensure the discontinued controlled medication for Resident 670 was removed from the current medication supply in Medication Cart B. These failures had the potential for drug diversion of the controlled medications, and potential for medication errors.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure two of two final sampled residents (Residents 2 and 56) reviewed for unnecessary medications were free from unnecessary drugs. * The facility failed to ensure Resident 2's losartan potassium (medication used to lower high blood pressure) was administered as per the physician's ordered parameter. * The facility failed to ensure Resident 56's midodrine hydrochloride (medication used to treat low blood pressure) was administered as per the physician's ordered parameter. These failures had the potential for Residents 2 and 56 to receive unnecessary medications and develop significant side effects arising from errors in administration.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents reviewed for unnecessary medication (Resident 43) was free from unnecessary psychotropic drugs. * The facility failed to ensure the side effects were monitored for Resident 43 related to the use of alprazolam (antianxiety medication). This failure posed the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the orally administered medications were stored separate from externally used medications. * The facility failed to ensure disinfectant wipes were stored separately from medications and treatment supplies. * The facility failed to ensure the medication bottle was kept clean and free of sticky residue. These failure posed the risk for cross-contamination of the medications.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the pureed recipes were followed for three of 77 residents who received pureed food from the kitchen. * The facility failed to ensure the puree recipes for biscuit and rice were followed. This failure had a potential for not providing nutritional meals to meet the residents' needs.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure four of 75 residents (Residents 17, 26, 39, and 65) who received food from the kitchen were palatable. * The facility failed to ensure Residents 17, 26, 39, and 65 received palatable green beans during dining observation. This failure had a potential for the residents not consuming the food and may experience weight loss.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the facility's P&P titled Use of Food Brought Into the Facility was updated to address the use and storage of foods brought to the residents by the family or visitors. In addition, the facility failed to ensure the visitors were educated on safe food handling of outside food. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consume food brought from outside sources.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the Director of Activities did not use her personal cell phone to take pictures of the residents during activities. This failure had the potential to negatively affect the dignity of the residents and violate privacy.

Inspectors wroteBased on interview, medical record review, facility document review and facility P&P review, the facility failed to remove a staff (CNA 1) from resident care areas pending an alleged violation of abuse for one of two sampled residents (Resident 1) as per the facility's P&P. This failure had the potential to expose Resident 1 to abuse.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide an environment free from accident hazards for one of 17 final sampled residents (Resident 10). * The facility failed to ensure safe smoking practice for Resident 10 who smoked in the facility. Resident 10 had her smoking materials in her possession when her care plan for safe smoking included the intervention for the activity staff to keep her lighter and the facility's smoking policy showed the smoking materials were to be maintained by staff. This failure posed the risk of fire and injury to the residents and staff in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for the use of a GT for one of 17 final sampled residents (Resident 37). * The facility failed to ensure Resident 37 received the accurate amount of enteral feeding as ordered by the physician. In addition, the facility failed to accurately document Resident 37's amount of enteral feeding and water flushed via enteral pump. These failures had the potential for not meeting the resident's nutritional and hydration needs.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the respiratory care needs to two of 17 final sampled residents (Residents 30 and 44). * The facility failed to ensure Resident 44's oxygen therapy titration (adjusting oxygen level) based on her oxygen saturation level (percentage of oxygen in the blood with normal levels of 95% and higher) was monitored and documented in the medical record. * The facility failed to ensure Resident 30's oxygen was administered as ordered by the physician. These failures had the potential to put the residents at risk for adverse effects of the improper care and administration of oxygen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the licensed nurses had the specific competencies and skill sets needed to care for the residents. * The facility failed to ensure a program was in place to check the competencies and skill sets of the licensed nurses at the facility upon hiring and ongoing basis. The DSD/IP 1, IP 2, LVNs 1, and 4 failed to demonstrate how to obtain the history of the volume of feeding and water flush via the enteral pump for Resident 37. This failure had the potential to put the residents at risk for care not provided in a safe and competent manner.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure safe medication storage was observed in two of eight medication carts (Treatment Cart 1 and IV Cart 1). * An expired central line (catheter that is placed into a large vein) dressing kit was observed in IV (intravenous) Cart 1. * An expired tube of Remedy cream (moisture barrier cream) was observed in Treatment Cart 1. These failures had the potential for the residents to be exposed to the expired medications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the proper infection control measures were implemented as evidenced by: * LVN 1 did not perform hand hygiene when preparing Resident 207's medications. * The facility failed to ensure aseptic technique was observed during the preparation of Resident 207's heparin (medication to prevent the formation of the blood clot) medication. LVN 1 did not disinfect the self-sealing rubber topper of the medication vial with an antimicrobial swab each time she attempted to withdraw the heparin medication. LVN 1 used the same needle and syringe multiple times to withdraw the medication from the heparin vial. These failures had the potential to result in the transmission of infection for the resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the risks and benefits of influenza vaccination were reviewed with the resident for one of 17 final sampled residents (Resident 52) when Resident 52 refused the influenza vaccine. This failure had the potential for the resident not being informed of the benefits and risks of influenza vaccination to make an informed decision.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure four of seven residents interviewed (Residents 15, 36, 207, and 208) knew how to contact the state long-term care ombudsman (an official who investigates, reports and help settle complaints). This posed the risk of residents not knowing how to contact the ombudsman should the residents require the ombudsman's services.

Inspectors wroteBased on interview and medical record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 17 final sampled residents (Resident 205). *The facility failed to develop a care plan to address Resident 205's use of continuous oxygen. This failure had the potential to negatively impact the care needed for the residents.