Townsend Park Health and Rehabilitation

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policies titled, Hand Hygiene, and Transmission-Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airborne), the facility failed to implement appropriate infection prevention and control practices for one of fourteen sampled residents (R) (R14). Specifically, staff failed to follow Enhanced Barrier Precautions (EBP) during high-contact perineal care for a resident with wounds. This deficient practice had the potential to increase the risk of infection transmission to residents and staff.

Inspectors wroteBased on record review and interviews, the facility failed to ensure five Certified Nurse Aides (CNA) of five CNAs reviewed received their annual performance evaluation. Failing to ensure CNAs received their annual performance evaluations potentially could cause CNAs to not meet the requirements of their job description and potentially lead to poor resident care. Findings Include: Review of the facility's policy titled, dated 2019, .3.1 HR (Human Resources) Conditions of Employment: Standard of Conduct: [...]

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to immediately report an injury of unknown origin for one of 28 sampled residents (Resident (R) 97). This failure decreased the facility's potential to protect R97 from a possible allegation of abuse and ensure a safe environment during the investigation of the cause of injury.

Inspectors wroteBased on observations, staff interview, and reviews of the facility's policy and procedures, the facility failed to ensure that the medication error rate was not five percent or greater, the medication error rate was 7.69 percent.

Inspectors wroteBased on observations, interviews, record review, and review of facility policy, the facility failed to ensure staff adhered to the guidelines for Enhanced Barrier Precautions for two of sixteen residents (Resident (R)44 and R81). Additionally, the staff member failed to sanitize a stand to lift equipment after using it on R44. This failure has the potential cross-contamination.

Inspectors wroteBased on observation, staff interviews, review of the facility's meal schedule, and review of the facility's policy titled, Meal Times, the facility failed to have sufficient dietary staff to assure food was prepared, served, and stored in a sanitary and safe manner. Kitchen cleaning schedules were not implemented due to a lack of sufficient staff to perform these duties, and food preparation, and service equipment was not cleaned and sanitized. Dietary staff failed to cover stored food and discard a stored food item with an expired use by date. Additionally, there was not sufficient dietary staff to ensure resident meals were served as scheduled. The lack of dietary staff had the potential to affect 64 of 64 residents who consumed food that was prepared from the kitchen.

Inspectors wroteBased on observation, staff interviews, and review of the facility's policies titled, Cleaning and Sanitizing and Storage Areas, the facility failed to keep the kitchen's ovens, food preparation pans, manual can opener, shelves, knife rack, storage bin and kitchen carts clean and sanitized and failed to close stored food items and discard a bread product with an expired use by date. This had the potential to affect 64 residents who consumed food that was prepared from the facility's kitchen.

Inspectors wroteBased on staff interview, record review, and review of facility policy titled, Abuse Prohibition, the facility failed to ensure residents were free from physical abuse by another resident for one of one resident (R) 35 reviewed for resident-to-resident altercations and one supplemental resident R57. R35 was the victim of physical abuse perpetrated by R33 on three occasions and R57 was the victim of physical abuse perpetrated by R33 on one occasion. This deficient practice had the potential to affect the safety of all residents in the facility.

Inspectors wroteBased on observation, resident and staff interviews, record review, and review of the facility's policy titled, Dialysis and Nutrition Management, the facility failed to make meal scheduling adjustments for the provision of meals during the mornings for one of two residents (Resident (R) 48) reviewed for dialysis and who left the facility to receive dialysis treatments. The deficient practice had the potential to prevent the maintenance of adequate nutritional status, to the extent possible, to ensure R48 was able to maintain the highest practicable level of well-being.

Inspectors wroteBased on observation, resident and staff interviews, record review, and review of the facility's policy titled, ''Infection Control Recommendations,'' the facility failed to ensure infection control policies were followed for four of 22 sampled residents that included: the storage of a Yankaeur catheter used for suctioning for one resident (R1), the storage of nebulizer masks for two residents (Resident (R) 9 and R39), and the cleaning of a nebulizer mask after medication administration for one resident (R211). These deficient practices had the potential to spread infection. Findings Include: Review of a facility's policy titled, ''Infection Control Recommendations,'' updated June 2018, indicated, ''Nebulizers should be in a bag when not in use . Nebulizers should be rinsed with sterile water or sterile saline and air dried after each treatment . [...]

Inspectors wroteBased on staff interviews, record review, and review of facility policy titled, Abuse Prohibition, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime for resident to resident physical and verbal abuse in accordance with section 1150B of the Social Security Act. The facility failed to report one allegation of physical and verbal abuse to the State Survey Agency (SSA) for one of one resident (Resident (R) 35) reviewed for abuse. These failures had the potential to contribute to further physical and verbal abuse and possible psychosocial harm for R35.

Inspectors wroteBased on observation, resident and staff interviews, record review, and review of the facility's policy titled, ADL [Activities of Daily Living] Plan of Care, the facility failed to ensure residents received showers per the shower schedule for one of three residents (Resident (R) 58) reviewed for ADLs. Specifically, the facility failed to ensure that scheduled showers were completed for R58.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility's policy titled, Weight and Nutrition Management, the facility failed to implement a planned intervention to prevent weight loss for one of four residents (Resident (R) 32) reviewed for nutritional status. The facility failed to serve R32 a nutritional shake with meals as ordered by the resident's physician. The deficient practice had the potential to prevent the maintenance of adequate nutritional status, to the extent possible, to ensure R32 was able to maintain the highest practicable level of well-being.

Inspectors wroteBased on observation, staff interviews, record review, and review of medication guidance titled, Instructions for Use Toujeo® Solostar® (insulin glargine injection) 1.5 mL single-patient-use prefilled pen, the facility failed to ensure proper injection technique was used for one of one sampled residenst (Resident (R) 14) reviewed for insulin during medication administration. This failure had the potential to result in the wrong dose of insulin being administered to the resident.

Inspectors wroteBased on observation, resident and staff interviews, tasting of foods served on a requested test tray, record review, review of Resident Council meeting minutes, and review of the facility's policy titled, Meal Service, the facility failed to serve food that was hot to three of 38 sampled residents (Resident (R) 61, R52, and R47) reviewed for food palatability. This had the potential to affect 64 residents who consumed food that was prepared from the facility's kitchen.