Victorian Post Acute

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure 1 (Resident #10) of 5 residents reviewed for unnecessary medications was free from significant medication errors. Specifically, staff failed to hold (not administer) blood pressure medications when blood pressure or heart rate values were outside of ordered parameters for administration.

Inspectors wroteBased on observation, interview, record review, facility policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore the proper personal protective equipment (PPE) when providing care for 2 (Resident #30 and Resident #19) of 5 residents reviewed for transmission-based precautions.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when Resident 1 continued to have right knee swelling after a fall. This failure resulted in delay of care for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure an appropriate pain management and assessment when a PRN (as needed) medication for pain was not administered when Resident 1 complained of pain. This failure resulted in Resident 1 not receiving appropriate pain management.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. Packaged food items were not sealed close or secured after opening, had no use by dates, and not stored properly 2. A pitcher was stored wet in the pitcher cupboard 3. Kitchen trays and plate covers or domes were not maintained in good condition 4. Food storage containers and equipment found in the kitchen were not kept clean 5. Kitchen staff did not wear a hairnet in the kitchen 6. Cooling procedures of potentially hazardous foods was not followed (PHF, food that requires time/temperature control for safety to limit the growth of pathogenic microorganisms [such as bacterial or viral organisms] that can cause foodborne illness. Examples of PHF include meat, poultry, chicken, seafood, milk, etc.) 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage and refuse were disposed properly when: 1. The dumpster lids for garbage and recycled items were kept open 2. A facility staff did not close the dumpster lid after garbage bags were thrown into the garbage dumpster These failures could result in harborage and feeding of pests in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services were consistent with professional standards of care and the residents' comprehensive, person-centered care plan and preferences for 2 out of 2 residents (Resident 60 and Resident 23) who received hemodialysis [a treatment for advanced kidney failure where a machine filters wastes and water from the blood] at an offsite location when: 1. There was no interdisciplinary team (IDT) recommendation to monitor, document, and ensure nutrition and hydration needs related to provision of meals or snacks, including bagged meals were provided to residents before going to dialysis appointments 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure policies and procedures regarding use and storage of foods brought to residents by family or visitors were implemented when: 1. The temperature inside the refrigerator designated for residents was at 43°F. This temperature was above the acceptable temperature range of 34°F to 38°F as indicated on the food refrigerator temperature log. 2. A food item found inside the refrigerator was not labeled with a resident name and room number. This failure had the potential to cause unsafe food storage, handling, and consumption of foods by residents. This failure could result in the resident not knowing and/or receiving foods brought in by their family or visitor if there was no name and/or identifying information.

Inspectors wroteBased on interview and record review, the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to three residents (Resident 1, Resident 2 and Resident 23). This failure left the residents or their responsible parties without information related to continuing to receive Part A Medicare services, the cost, and their appeal rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written grievance decision was issued to one resident (Resident A). This failure had the potential to not ensure Resident A and/or other residents are appropriately apprised of progress and/or decisions on grievances reported to the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident assessment tool) comprehensive assessment was completed within the required period of within 14 days of admission for two of 19 sampled residents (Resident 21 and Resident 90). Failure to complete a comprehensive resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of Resident 90.

Inspectors wroteBased on interview and record review, the facility failed to complete significant change in status assessment (SCSA, is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of 19 sampled residents (Resident 14) when Resident 14 was discharged from hospice services. This failure could potentially delay the provision of appropriate treatment and services for Resident 14.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident assessment tool) quarterly assessment was completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act of 1987) assessment type for six of 19 sampled residents (Resident 6, 21, 62, 14, 80, and 50). Failure to complete quarterly resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure complete and accurate assessment for one of 19 sampled residents (Resident 36) when coding in Section M of the Minimum Data Set (MDS, a resident assessment tool) did not reflect Resident 36's actual skin condition as of the Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process). The deficient practice resulted in an inaccurate assessment and interventions provided for Resident 36. Additionally, the deficient practice lead to delayed healing and development of a new pressure ulcer/injury (PU/PI - a localized damage to the skin and/or underlying soft tissue usually over a bony prominence, or related to a medical or other device, as a result of intense and/or prolonged pressure or pressure in combination with shear) for Resident 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for one of 19 sampled residents (Resident 21) when physician's treatment orders for Resident 21's healing burn area on right forearm were not implemented. Failure to implement physician's treatment orders could result to delayed wound healing and the potential for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide preventive care and treatment to avoid worsening and development of additional pressure ulcer/injury (PU/PI - a localized damage to the skin and/or underlying soft tissue usually over a bony prominence, or related to a medical or other device, as a result of intense and/or prolonged pressure or pressure in combination with shear) on left medial toe (big toe); and promote healing of existing pressure injuries for one of 4 sampled residents (Resident 36) when: 1. The facility did not ensure complete and accurate wound assessment on admission that includes identification, measurement, and description of wound. Additionally, there was no consistency in wound identification, measurement, and description of wound among nursing and physician/practitioner. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide trauma informed care for one of three residents (Resident 12) when facility did not identify and address symptoms of PTSD (Post -Traumatic Stress Disorder). This failure to identify symptoms had the potential to result in inaccurate and inappropriate provision of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide medically related social services to attain or maintain highest practicable physical, mental, psychosocial well-being for one (Resident 12) of three residents reviewed when social worker (SW) did not address care plan and progress note on diagnoses of PTSD and history of trauma. This failure can result in staff not recognizing the trauma symptoms can trigger re- traumatization.

Inspectors wroteBased on observation, interview, and document review the facility failed to meet the needs of the residents when unauthorized personnel that had access to the station one medication room.

Inspectors wroteBased on observation, interview, and document review the facility failed to maintain a medication error rate less than five percent when three medications errors were observed for twenty-six observed opportunities which would equal a medication error rate of eleven percent.

Inspectors wroteBased on observation, interview, and record review the facility failed to appropriately label and store medications as evidence by: 1. The facility pharmacy dispensed medications that was mislabeled. The labeling indicated incorrect administration instructions that did not correspond to the physician's orders. 2. The facility station two medication refrigerator was too cold for the medications that were stored inside the refrigerator.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain its infection control program when: 1. For Resident 62, the undated urinary drainage bag (collection bag) was stored together with the undated urinal (a bottle for urination) in a black bag touching the floor. 2. Resident 25 and Resident 18's oxygen tubing in use were undated. Failure to implement infection prevention practices may result in cross contamination of infection that may jeopardize the health and safety of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the required 80 square feet per resident in multiple resident bedrooms. This failure had the potential for inadequate, unsafe space for resident care and may impact their quality of life.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe and pest free environment for residents and an effective pest control program, when a rodent was sighted on 4/18/23 in the basement. This failure can result to infection control problem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate pain management for one of three sampled residents (Resident 40), when Resident 40 did not receive pain management in accordance with the care plan and preferences of the resident. This deficient practice resulted in Resident 40 verbalizing ineffective pain assessments and pain regiment including medications and non-pharmacological interventions. Her pain induced suicidal ideations and affected her wellbeing and ability to participate in activities.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide medically related social services to address the psychosocial needs of one of 32 sampled residents (Resident 40). For Resident 40, this deficient practice resulted in verbal and non-verbal indicators of distress (e.g. crying and verbalization of loneliness and hopelessness), and expressions of difficulties coping with passive suicidal ideations, substance use, and the decline in function. In addition, this deficient practice led to delayed psychiatric services and treatment for Resident 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to display the total and actual hours worked by Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs) each shift, and the actual hours worked by the Certified Nursing Assistants (CNAs) each shift. This deficient practice had the potential to misinform residents and visitors on the facility's staffing levels, and the deficient practice had the potential to lead to inadequate RN, LVN, and CNA staffing levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store foods in accordance with accepted professional standards of practice when: 1. Five cartons of Glucerna Therapeutic Nutrition (medical nutritional beverages meant for people with diabetes) were stored beyond expiration date; and 2. One opened container of Parsley Flakes was undated. This deficient practice may put the residents at risk for food borne illnesses, and may affect the appetite of the residents due to loss of potency and flavor of expired seasonings.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the required 80 square feet per resident in multiple resident bedrooms. This failure had the potential for inadequate, unsafe space for resident care, and may impact their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a complete and accurate notice before discharge in writing to the resident and the Office of the State Long-Term Care Ombudsman (Office of the State LTC Ombudsman) for two of two sampled residents (Resident 61 and Resident 81). In addition, the facility did not store the written notice in the medical record of Resident 61 and Resident 81. This deficient practice had the potential to result in an unsafe discharge for Resident 61 and Resident 81.

Inspectors wroteBased on meal plating observation, interview, and record review, the facility failed to accommodate the food preferences of six of 81 residents (Residents 28, 55, 78, 69, 74, and 36) during meal distribution. This failure had the potential for loss of appetite which may lead to decreased food intake and could potentially cause unintentional weight loss to the residents who receive food from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to distribute meals in accordance with the physician ordered therapeutic diet for one of 67 residents (Residents 78) when Resident 78 was plated with a whole cheeseburger sandwich during lunch meal distribution. Failure to follow physician ordered diets may further compromise the medical status of residents which may lead to unnecessary hospitalizations, and in severe instances may result in death.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure an allegation involving abuse was reported to appropriate authorities immediately but not later than 2 hours for 1 of 21 sampled residents (Resident 36). This failure had the potential to compromise protection of residents from abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan that reflect the current needs, treatment, and services for one of 21 sampled residents (Resident 130) when the care plan for at risk for fall was not revised to address an actual fall incident. This failure had the potential to result in provision of inaccurate and inadequate care and services that may prevent Resident 130 from achieving and maintaining her highest practicable quality of life/level of functioning.

Inspectors wroteBased on interview and record review, the facility failed to meet the proper transfer and discharge requirements for one of two sampled resident (Resident 61) when Resident 61 did not receive comprehensive care plan goals, the reason for the discharge written by the physician, all special instructions for ongoing care, and a discharge summary containing the required information, such as the resident's post-discharge plan of care and the reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter). This deficient practice had the potential to result in a discontinuation of necessary care and services for Resident 61.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure specialized rehabilitative service was provided for 1 of 21 sampled residents (Resident 67), when Resident 67 did not receive physical therapy (PT) on 8/13/19. This failure had the potential for residents to not attain, maintain or restore their highest practicable level of physical, mental, functional and psycho-social well-being.