Upland Rehabilitation and Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living services were provided for one of three residents (Resident 1) in accordance with facility policy when, Resident 1 was not provided with a restorative nursing assistance (RNA) exercise for walking. This failure had the potential to cause a decline in a clinically compromised resident (Resident 1) health and ability to walk.

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards for food safety when employees' food was found inside 1 of 3 residents' refrigerators (Station 1 RR). This failure had the potential to expose 50 highly susceptible residents from Station 1, who were on an oral diet, to cross-contaminated (the transfer of harmful substances or disease- causing microorganisms) food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of three sampled residents (Resident 398) with dignity when Certified Nurse Assistant 3 (CNA 3) was standing over the resident while assisting during lunch. This deficient practice had the potential to negatively impact the self-esteem and self-worth of Resident 398.

Inspectors wroteBased on interview and record review, the facility failed to honor the right to formulate an Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) for five of 37 sampled residents (Residents 50, 147, 153, 175, and 497) when: 1. The Advance Directives Checklist forms did not indicate whether Residents 50, 147, and 153 were provided an opportunity to formulate an Advance Directive. 2. Resident 175's Advance Directives Checklist form was not followed up to ensure their responsible party was given the opportunity to complete an Advance Directive on behalf of the resident. 3. There was no documented evidence indicating Resident 497 was provided with written information to formulate an Advance Directive. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation in the medical record demonstrated the rationale for extending the pro re nata (PRN- as needed) psychotropic (any drug that affects brain activities associated with mental processes and behaviors) anxiety medication for one of five residents (Resident 146). This failure had the potential to increase the risk of clinically significant physical dependence and/or negative clinical outcomes for Resident 146.

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes) before discharge for one of four sampled residents (Resident 70). This deficient practice had the potential to leave Resident 70 unprotected from improper discharge and deny them access to an advocate for their options and rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure the individualized care plans (the plans showing specific interventions to provide effective and person-centered care to meet a resident's needs) were developed and implemented for three of 37 final sampled residents (Residents 19, 45, and 151) when: 1. Resident 19 did not have a care plan developed for the use of apixaban (a medication used to prevent and treat blood clots). 2. Resident 45 did not have a care plan developed for dental care. 3. Resident 151's care plan intervention to monitor for bruising associated with anticoagulant (medication to prevent blood clot formation) therapy was not implemented. These failures created the risk of health complications and reduced safety from unmonitored conditions for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate grooming services to one of three sampled dependent residents (Resident 47), when Resident 47 was observed with untrimmed and dirty fingernails on the right hand. This had the potential for skin problems and infection around the nail bed for Resident 47.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for 1 of 37 final sampled residents (Resident 4), when Resident 4's wound was not assessed consistently in accordance with the facility's Policy and Procedure (P&P). This failure had the potential to delay identification of wound deterioration for Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care services for 1 of 37 final sampled residents (Resident 89) when the facility failed to ensure the filter of the Continuous Positive Airway Pressure machine (CPAP- a machine that uses air pressure delivered through tubing and a mask over the mouth or nose to keep the airway open) was replaced in accordance with the manufacturer's guidelines. This failure could potentially result in nasal irritation and/or illness for Resident 89.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision of care and services for dialysis (a treatment to cleanse the blood of waste and extra fluids through a machine when the kidney(s) have failed) when a bandage was left on the dialysis site for more than four hours for one of two sampled residents (Resident 49). This had the potential to prevent appropriate monitoring for complications including potential for infection and malfunction of Resident 49's dialysis access site .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the side rail (also called bedrail) assessment was accurate and side rail use was indicated to meet the needs of one of 37 final sampled residents (Resident 66), who was unable to use the side rails due to functional limitations in both upper extremities. This failure had the potential for injury related to improper use of side rails for Resident 66.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe and effective pharmaceutical services when an order was not clarified before a medication was held for one of five residents (Resident 112). This failure had the potential to result in preventable medication errors resulting from incomplete or unclear orders for Resident 112.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored at an appropriate temperature range, in accordance with drug manufacturers' requirements, in one of three medication rooms (Station 2 Med Room). This failure had the potential for residents to be given deteriorated (reduced quality) medications which could result in suboptimal treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurate documentation for one of 37 final sampled residents (Resident 151), when Restorative Nursing Assistant (RNA) services were not documented. This failure had the potential for Resident 151's care needs to go unmet due to inaccurate information in the record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control and prevention measures when: 1. One single-dose container of acetic acid (solution to prevent blockage in tubes connected to the resident's body) was not discarded after being opened. This failure had the potential for cross contamination (unintentional transfer of germs) to residents or residents to be treated with deteriorated treatments which could negatively impact their clinical condition. 2. One non-laundry staff entered the restricted clean area of the laundry department and obtained items from a linen cart. This failure had the potential for cross contamination and spread of infection which could adversely affect the health and wellbeing of residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents, (Resident 1) received treatment and care in accordance with professional standards of practice, when: 1. A Certified Nursing Assistant (CNA 1) left Resident 1 in bed naked and uncovered with the curtain halfway open. 2. A CNA (CNA 2) took a long time in attending to Resident 1 for a change. These failures had the potential to cause Resident 1 a psychological effect for maintaining respect and dignity.

Inspectors wroteBased on record review and interview, the facility failed to provide a resident and or representative a copy of medical records following a written request for 1 of 3 residents reviewed for resident rights (Resident 1). This failure could potentially violate Resident 1 (R1) rights to access her medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat a resident in a dignified manner with respect and value for one of three sampled residents (Resident 2) when a staff entered Resident 2 ' s room and removed her oxygen tubing (a plastic tube that carries oxygen from a tank or machine to a person, connecting to a nasal cannula [a tube that goes in the nose] or mask) without requesting permission from Resident 2 on August 19, 2024. This failure compromised Resident 2 ' s dignity, violated her right to respect, and affected her well-being and ability to make choices, which had the potential to cause psychosocial harm (mental distress and suffering) and lead to feelings of upset.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper care was provided to prevent a pressure ulcer/injury (injury to skin/tissue from prolonged pressure on the skin) for one of three sampled residents (Resident 1). This failure placed a clinically compromised Residents (Resident 1) health and safety at risk, when a facility acquired unstageable pressure ulcer to coccyx left buttocks (lower back/spine) developed while in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure reasonable accommodation of resident needs and preferences was provided when one resident of four sampled residents (Resident 1) was not provided a bedside commode and not assisted to the bathroom for toileting. This failure had the potential to cause Resident 1 a psychological effect for maintaining respect and dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy and procedure to ensure call lights were answered in timely manner to provide care and services for two of three sampled residents (Resident 1 and 2). This failure had the potential to place a clinically compromised Residents (Resident 1 and 2) safety at risk. When residents were left soiled, and their activities of daily living were not met in timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary practices were maintained in the kitchen when: 1. Three (3) of three (3) ice machines had a black unknown substance in the ice chute (area between where ice is formed and where it enters the ice bin) which put 133 residents, who used or ingested ice from this machine, at risk for foodborne illness (illness acquired from ingesting contaminated food). 2. Three (3) sinks in the kitchen and one of three (3) ice machines (ice machine 1) did not have an air gap (which had the potential for back flow from the sewer to enter the ice machine and the sinks). These failures had the potential for food-borne illness (food poisoning) to a population of 133 immuno-compromised (having an impaired ability to fight disease) residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's change of condition was assessed, monitored, and documented in accordance with the facility's policy and procedure for one resident (Resident 76) reviewed for change of condition. This failure had the potential to result in an unidentified complication and/or worsening condition due to a delay in assessment and treatment, placing Resident 76 at risk for further injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for one of three residents (Resident 73) reviewed for accidents when Resident 73's bed had an 11-inch gap between the mattress and the footboard. This failure place Resident 73 at risk for entrapment, falls, and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 80) reviewed for tube feeding (enteral feeding- liquid nutrition administered via a feeding tube inserted into the stomach) receieved enteral nutrition services inaccordance with the facility's policy and procedure. This failure had the potential to impact Resident 80's health as a result of receiving less enteral nutrition than was recommended by the RD which may have resulted in sub-optimal (less than ideal) nutritional status for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. A Certified Nursing Assistant (CNA 1) did not perform COVID-19 (a highly contagious illness caused by a virus) screening upon entry into the facility on May 4, 2022, in accordance with the facility's policy and procedure. 2. A Licensed Vocational Nurse (LVN 2) did not perform hand hygiene or hand washing during a wound care treatment for Resident 150. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasites) to a highly vulnerable population of 179.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program when: 1. One live spider was observed in Resident 57's room. This failure resulted in Resident 57's dissatisfaction in the condition of his room, which could negatively impact his psychological wellbeing. 2. Three live spiders were observed in the conference room. This failure had the potential to result residents, staff, and visitors to be bitten by a spider, placing their health and safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary storage practices in the kitchen when 24 plastic water pitchers, 28 plastic water cups and 54 small plastic water trays which are used at resident bedsides were found stacked wet and ready for use. This failure had the potential to lead to harmful bacterial growth and cross contamination that could lead to waterborne illness for a medically compromised population of 130 residents who received drinking pitchers, cups and trays from the kitchen. According to the FDA Food Code 2017, Items must be allowed to drain and air-dry before stacked and stored. Stacking wet items, such as pans, prevents them from drying and may allow an environment where microorganisms can begin to grow.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safeguard residents property when the staff did not complete an inventory list to include all jewelry for one of one sampled Resident (Resident 36) when her initial and updated personal Inventory lists only included one gold and silver watch. This failure had the potential for Resident 36's personnel belongings to be unaccounted for, lost or stolen.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 35 sampled residents' (Resident 75) PASRR (Preadmission Screening and Resident Review (PASRR- is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Form was filled out correctly for the diagnosis of dementia. This failure had the potential to result in an inappropriate level of care for Resident 75.