University Post-Acute Rehab

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans (a summary of a person's health conditions, specific care needs, and current treatments) were developed for three of 19 sampled residents (Resident 14, Resident 17, and Resident 27) when: 1. Resident 14 had no anticoagulant (a medicine that help prevent blood clots) monitoring care plan; 2. Resident 17 had no bed alarm and wheelchair alarm (pads that contains sensors that trigger an alarm when they detect a change in pressure) monitoring care plan; and, 3. Resident 27 had no bed alarm monitoring care plan. These failures had the potential to result in inaccurate and inadequate care being provided to Resident 14, 17, and 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% (percent, unit of measure) for two of three sampled residents (Resident 302 and Resident 40). 1. For Resident 302, a Licensed Nurse (LN) did not administer resident's lidocaine patch (medication patch used to treat pain) 5 % as it was prescribed by the doctor. 2. For Resident 40, an LN did not administer resident's finasteride (hazardous medication used to treat an enlarged prostrate) 5 mg (milligram, unit of measure) as prescribed by the doctor. These failure resulted in a medication error rate of 6.45 % with two errors occurring out of 31 opportunities during the observation of medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored correctly, when: 1. The medication refrigerator temperature was out of range in the medication room which put medication requiring specific temperature at risk of degradation, 2. Resident 36's opened inhaler (used to administer medication by breathing in) in the medication cart 1 was not dated when opened, which put Resident 36 at risk of receiving ineffective expired or outdated medication, 3. An opened, undated multidose container of glucose test strip was found in medication cart 1, which had the potential risk of using expired, or inaccurate glucose test strips to monitor resident's blood glucose levels. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide alternative meal options of similar protein/calorie value to the meal entrée when grilled cheese sandwich or cheese quesadilla were provided in place of the entree. This failure had the potential of leading to protein/calorie malnutrition for those choosing these alternatives for census of 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety when: 1. Sanitation was compromised by rust-colored stains under the hand wash sink, and there were unpainted patches on several walls in kitchen and dry storage, 2. Food items were found with incomplete labeling, 3. Expired foods were found in the reach-in refrigerator, 4. A wet steam table pan was found stored wet, 5. Dumpster lid was propped open on two difference occasions, and 6. Tuna salad made from room temperature tuna was not monitored and cool-down to 41 degrees F (Fahrenheit, a unit of measure). These failures had the potential to lead to the growth of microorganisms (bacteria, virus, or fungus) and foodborne illness for the 50 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control policies for three sampled residents (Resident 12, Resident 24, and Resident 38) out of a census of 50 when: 1. Staff did not wear a gown when providing high contact care to one resident (Resident 12) on Enhanced Barrier Precautions (an infection control strategy used in healthcare settings to prevent the spread of multi-drug resistance organisms) nor did staff wash hands or change gloves between residents' care (Resident 12 and Resident 38); and, 2. Resident 24's oxygen tubing was not labeled with a start date. These failures had the increased potential to spread of infection for the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards for one of 19 sampled residents (Resident 8) when Resident 8's oxygen order was not implemented according to physician orders. This failure had the potential to result in respiratory failure (low oxygen levels in the blood and difficulty breathing) for Resident 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for one of 50 residents when two controlled drug record forms (count sheet forms for medication that may be abused or cause addiction) were not accurately completed for Resident 12. This failure had the potential in diversion of the Resident's 12 controlled medications and increased risk of medication error.

Inspectors wroteBased on interview and record review, the facility failed to safely administer medications according to professional standards of care for one of three sampled residents (Resident 1), when staff at day program administered Resident 1's noon medications twice. This failure increased Resident 1's potential to develop adverse effects from medications.

Inspectors wroteBased on observation, interview and documentation review, the facility failed to discard expired medications and medications with no expiration dates, for a census of 58 when, expired medications were mixed with non-expired medications, available for use, in the medication storage room. This failure increased the potential for medication errors and placed the residents at risk for ineffective drug therapy.

Inspectors wroteBased on observation, interview and documentation review, the facility failed to resolve one of 16 sampled residents (Resident 38's) grievance when the resident's co-pay for replacement of lost hearing aids was not reimbursed in a timely manner. This failure resulted in Resident 38's family member wondering if and when the co-pay was to be reimbursed by the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of quality of care for one of 16 sampled residents (Resident 35) when a pain medication and a renal nutritional supplement were not administered as ordered by the physician. This failure placed Resident 35 at risk for ineffective pain control and for nutritional imbalance.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a communication board for one of 16 sampled residents (Resident 20) who had expressive aphasia (loss of ability to express speech). This failure resulted in Resident 20 being frustrated and impeded the resident's communication with others.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow guidelines for Enhanced Barrier Precaution (EBP, an infection control intervention to reduce transmission of multi-drug resistant organisms) that require the use of gowns and gloves during direct care activities for two of 16 sampled residents, Resident 9 and Resident 5, when: 1. Licensed Nurse 3 (LN 3) did not wear the full required Personal Protective Equipment (PPE) before entering Resident 9's room to change his wound dressing of his right foot; and 2. Certified Nursing Assistant 1(CNA 1) did not wear the full required PPE while changing Resident 5's undergarments. This deficient practice had the potential for the spread of multi-drug resistant organisms (MDRO's, bacteria that resist treatment with more than one antibiotic) among residents, staff and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) of two sampled residents was free from abuse when Resident 2 threw water at her. This failure decreased the facility's potential to protect Resident 1's right to be free from harm.

Inspectors wroteBased on interviews, clinical record review, and facility documents review, the facility failed to ensure one of three residents (Resident 1) was treated with dignity and respect when Restorative Nursing Aide (RNA) 1 was rough when providing care to Resident 1 and stated to Resident 1 to stop whining and stop fussing. This failure resulted in Resident 1 to have pain and not feel human and not allowed to cry.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to implement policies and procedures for ensuring the reporting of an allegation of abuse when Resident 1 complained of being inappropriately touched on her left breast by a male occupational therapist (OT 2- a health care worker who helps individuals resume daily tasks such as dressing). This failure resulted in the facility not meeting the mandated reporting requirement of an alleged abuse and prevented the facility from immediate investigation of the allegation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection prevention and control guidelines were maintained for a census of 41, when: 1. Several urinals for three residents were not labeled or dated; 2. Licensed Nurse (LN) did not sanitize blood pressure cuff before use, and did not wear gloves when providing care to resident; 3. Drinks were found in the laundry room; and 4. Nasal cannula was found on the floor. These failures had the potential to result in transmission of infection in a vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive assessments were performed in accordance with regulatory time frames for three of 18 sampled residents (Resident 90, Resident 141 and Resident 193), when the admission Minimum Data Set (MDS, an assessment tool) assessments were not completed. This failure had the potential to result in residents not meeting their highest practicable mental, physical and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a plan of care for two of 18 sampled residents (Resident 90 and Resident 23) when: 1. Communication care plan was not developed for Resident 90; and 2. Chair alarm care plan was not developed for Resident 23. These failures had the potential to result in residents not attaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely handle and store medications for a census of 41, when an expired IV (intravenous, administered through the vein) medication eKit (emergency kit) was found expired in the medication room, and another IV medication eKit was found not locked, outside the medication storage room. This failure had the potential to result in medications and drugs being accessed by unauthorized personnel for drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and secure labeling and storage of medications and biologicals (vaccines or drugs) for a census of 41, when expired medications and expired IV (intravenous, administered through the vein) medication eKit (emergency kit) were found in the medication storage room. This failure had the potential to result in expired medications being administered and causing a negative effect on the health and well-being of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident needs were accommodated for two of 18 sampled residents (Resident 5 and Resident 10) when: 1. Call light was not within reach for Resident 5; and 2. A haircut was not provided for Resident 10. These failures had the potential to result in increased risks for unmet needs of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident assessments were performed in accordance with regulatory time frames for two of 18 sampled residents (Resident 5 and Resident 2), when the quarterly Minimum Data Set (MDS, an assessment tool) assessments were not completed. This failure had the potential to result in resident's care needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the summary of the baseline care plan (BCP) to one of 18 sampled residents (Resident 90). This failure resulted in Resident 90 and family not having clear information and understanding of the resident's initial goals, discharge plans, medications, and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary environment to help prevent the transmission of diseases and infections, when the dietary staff had hair not completely covered by a hair net. This failure had the potential to result in transmission of food borne illness.