University Nursing & Rehab Center

Inspectors wroteBased on observations, staff interview, and review of the facility's policy titled DATING AND LABELING POLICY, the facility failed to ensure that food items were properly labeled, dated, and discarded in accordance with facility policy to prevent potential foodborne illness. This deficient practice had the potenitial to affect all 98 residents receiving an oral diet.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled Self-Administration of Medications, the facility failed to offer and assess a resident for administering her own calcium and medicated mouthwash for one of 49 sampled residents (R) (R48). This deficient practice had the potential to cause the resident to leave medication at her bedside until she was ready to take it and could endanger other residents who wander and are confused.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's poliies titled Care Plans-Baseline, the facility failed to provide an updated baseline care plan for one of 49 residents sampled (R) (R8). This deficient practice had the potential to cause a lapse in care for Foley catheter care, JP (Jackson Pratt) drain, and surgical incision care.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure a physician's order was obtained for oxygen therapy administration for one resident of 13 residents (R) (R19) reviewed who were receiving oxygen therapy. This deficient practice had the potential to affect resident safety by administering oxygen without a current physician order.

Inspectors wroteBased on record review, resident representative interview, staff interviews, and review of the facility policy titled Infection Prevention and Control Program, the facility failed to ensure one of five residents (R) (R10) reviewed for immunizations were provided education regarding influenza and pneumococcal immunizations and failed to ensure documentation related to vaccine administration, refusal, contraindication, consent, and/or declination for sampled residents reviewed for influenza and pneumococcal immunizations. The deficient practice had the potential to place the 98 residents at increased risk of vaccine-preventable illnesses, including influenza and pneumococcal disease.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Infection Prevention and Control Program, the facility failed to ensure residents were timely offered the COVID-19 vaccine, educated regarding the risks and benefits of the COVID-19 vaccine, and failed to ensure documentation related to COVID-19 vaccine administration, refusal, contraindication, and/or consent for one of five sampled residents (R) (R9) reviewed for COVID-19 immunizations. This deficient practice had the potential to place R9 at increased risk of medical complications related to COVID-19.

Inspectors wroteBased on observations, interviews, and cleaning schedule review, the facility failed to maintain the cleanliness of the kitchen creating the potential for contaminated food to be served to 97 of 102 residents that received an oral diet.

Inspectors wroteBased on observations and interviews, the facility failed to provide necessary maintenance to five of 49 rooms creating an unsafe, uncomfortable, and unhomelike environment for eight of eight residents (Resident (R) 11, R48, R71, R43, R49, R64, R19, and R25) reviewed for the environment of 29 sample residents. This failure had the potential to affect the residents' homelike environment.

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy titled, Nail Care, the facility failed to ensure nail care was provided for two of three residents (Residents (R) 85 and R8) reviewed for activities of daily living (ADL). This failure had the potential to cause R85 and R8 to have unmet care needs.

Inspectors wroteBased on observations, record review, staff and resident interviews, and review of the facility policies titled, Infection Prevention and Control Program and Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to maintain proper infection control and prevention in 11 of 46 resident rooms (17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) related to storage of resident personal care items. In addition, the facility failed to adhere to and to serve food to residents in isolation using transmission-based precautions (TBP). The deficient practice had the potential to affect all facility residents by exposing them to infection. The facility census was 90.

Inspectors wroteBased on observations, record review, staff and resident interviews, and review of the facility policies titled, Infection Prevention and Control Program and Antibiotic Stewardship, the facility failed to establish an infection prevention and control program that included an Antibiotic Stewardship Program with included antibiotic use protocols and a system to monitor antibiotic use for four of 27 sampled residents (R) (R77, R38, R58, and R83). This deficient practice had the potential to affect all residents that receive antibiotics. The facility census was 90.

Inspectors wroteBased on staff interviews, record review, and review of policy and procedures titled Transfer or Discharge, preparing a Resident for, and Bed-Holds and Returns, the facility failed to provide one resident (R) (R290) a discharge summary, three residents (R38, R4, and R291) and/or their representative a notice of transfer or discharge and the reason for the move in writing. Additionally, the facility failed to send a copy of the notice to the representative of the office of the State Long Term Care Ombudsman for four of 52 residents sampled (R290, R38, R4, and R291).

Inspectors wroteBased on observation, staff interviews, record reviews, review of the manufacturer's package insert, and review of the facility policy titled, Administering Medications, the facility failed to ensure that one of three residents (R) (R61) received the correct dosage of medication as prescribed by the physician. The deficient practice had the potential to result in medication not being given in accordance with the physician's orders and had the potential to affect the residents' clinical conditions.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled, Resident Rights and Protected Health Information (PHI), Management and Protection of the facility failed to ensure privacy of clinical information for one resident (R) (R9), specifically by posting signage containing clinical information in R9 room and failed to ensure confidentiality of electronic medical records was maintained for seven residents, specifically by allowing the electronic medical record screen to be visible in a hallway. The sample size was 51 residents.

Inspectors wroteBased on staff interviews, record reviews, and review of the facility's policy titled, Transfer or Discharge, Preparing a Resident for, the facility failed to document preparation and orientation to ensure a safe and orderly discharge from the facility for one of 52 Residents (R) (R290) reviewed for discharges.

Inspectors wroteBased on staff interviews, record reviews, and review of the facility's policy titled, Bed-Holds and Returns, the facility failed to notify residents of the bed-hold policy during which the resident was permitted to return and resume residence in the nursing facility for two residents (R) out of 52 Residents (R4 and R38) reviewed for discharges.

Inspectors wroteBased on observation, interviews, record review, and review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to implement the comprehensive-person centered care-plan for one of 52 Residents (R) (R59), related to dental services.

Inspectors wroteBased on staff interviews, record reviews, and review of the facility's policy titled, Transfer or Discharge, Preparing a Resident for, the facility failed to complete a discharge summary that includes a recapitulation of the residents stay, reconciliation of medications, and a post discharge plan of care developed for one out of 52 Residents (R) (R87) reviewed for discharges.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policy titled, Referrals, Social Services, the facility failed to ensure one out of 52 Residents (R) (R24) received proper treatment and assistive devices to maintain vision and hearing abilities. Specifically, the facility failed to arrange appointments for vision or hearing services to meet the residents' needs.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of facility's policy titled, Oxygen Administration, the facility failed to ensure that two of 11 Residents (R) (R17 and R70) were administered oxygen therapy in accordance with the physician orders. In addition, the facility failed to ensure that all necessary administration equipment and supplies were in use for one of 11 residents (R70) reviewed with oxygen orders.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Referrals, Social Services, the facility failed to provide timely assistance for one of 52 Residents (R) R59 sampled for dental appointments.

Inspectors wroteBased on observation, staff interviews, record reviews, and reviews of the facility policy titled, Administering Medications, the facility failed to ensure the medication error rate was less than five percent. Four medication errors of 26 opportunities for three residents (R) (R28, R31 and R61) were observed during a medication pass. The medication error rate was 15.38 %. The deficient practice had the potential to result in medication not being given in accordance with the physician's orders and had the potential to affect the residents' clinical conditions.

Inspectors wroteBased on resident interview, staff interviews, record review, and review of the policy titled Referrals, Social Services, the facility failed to ensure one of 52 residents(R) (R59) was referred to an oral surgeon as recommended by physician in a timely manner. The deficient practice had the potential for R59 to have a delay in needed oral surgery as recommended by the facility contracted dentist.