Waterside Health & Rehab Center

Inspectors wroteBased on observation, family interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide a necessary assistive device to prevent and protect a resident from fall related injuries (transfer the resident from a dialysis chair to a Geri-chair with a locking device to obtain optimal safety) which resulted in cervical-5 fracture which required a period of intubation and ventilation which constituted harm for one (1) of seven (7) residents (Resident #1), in the survey sample.

Inspectors wroteBased on observations, resident interview, and staff interview, the facility staff failed to maintain a clean comfortable homelike environment for 1 of 50 residents (Resident #273), in the survey sample.

Inspectors wroteBased on interview, record review, document review and facility policy review, the facility failed to protect seven out of seven residents (Resident (R) 71, R2, R64, R324, R225, R63, R56) reviewed for abuse, specifically the misappropriation of resident's property out of a total sample of 50 residents. This failure has the potential for misappropriation of property for other residents.

Inspectors wroteBased on staff interviews, clinical record review and facility documentation review, the facility staff failed to send a copy of the Resident's Care Plan to include their goals for 1 of 50 residents (Resident #324) after being transferred and admitted to the hospital on [DATE].

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to provide evidence that one of two residents (Resident (R) 102) reviewed for hospital transfers, out of a total sample of 50 residents, documentation that the resident and/or the resident representative were provided a written notice of transfer when the residents were transferred to the hospital.

Inspectors wroteBased on staff interviews, facility documentation review and clinical record review the facility staff failed send a copy of the Bed-Hold policy upon discharge/transfer for 1 of 50 resident's (Resident #324) that was transferred to the local hospital on [DATE].

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure a resident received a comprehensive Minimum Data Set (MDS) assessment not less than once every 12 months, within 366 days for 1 of 50 residents (Resident #41), in the survey sample.

Inspectors wroteBased on information gleamed during the closed record review and staff interview the facility staff failed to complete a Death in Facility tracking record for Resident #47. Resident #47 was originally admitted to the facility [DATE] after an acute care hospital stay. The current diagnoses included chronic respiratory failure, a seizure disorder, mini stroke and diabetes. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #47's cognitive abilities for daily decision making were intact. The closed record was categorized as hospitalization. A review of the discharge MDS revealed it was coded discharged return not anticipated. During the review of the clinical record a nurse's note date [DATE] at 4:50 a.m. [...]

Inspectors wroteBased on staff interview, and a clinical record review the facility's staff failed to develop a person-centered comprehensive care plan to include a seizure disorder for 1 of 50 residents (Resident #27), in the survey sample.

Inspectors wroteBased on staff interviews, clinical record review and facility documentation review, the facility staff failed to revise the resident's person-centered care plan to include the application and removal of a right leg immobilize for 1 of 50 residents (Resident #75), in the survey sample.

Inspectors wroteBased on observation, staff interview, and clinical record review the facility's staff failed to ensure appropriate care and services were provided to prevent/reduce complications while utilizing an indwelling catheter for 1 of 50 residents (Resident #27), in the survey sample.

Inspectors wroteBased on observations, staff interview, and clinical record review, the facility staff failed to ensure staff reviewed the risks and benefits of bed rail use with the Resident and/or Resident Representative prior to installation, provide documentation that the facility staff attempted alternatives or that they obtained consent for the use of bed rails prior to use for 1 of 50 residents (Resident #27), in the survey sample.

Inspectors wroteBased on observations, resident interview, and staff interview, the facility staff failed to maintain an effective pest control program so that the facility was free of gnats which was voiced by 1 of 50 residents (Resident #273), in the survey sample.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to notify a representative of the Office of the State Long-Term Care Ombudsman of discharges to the hospital for 6 residents (Residents #63, #27, #71, #61, #37 and #62) of 43 residents in the survey sample. This deficiency is cited as Past Non-Compliance.

Inspectors wroteBased on observation, staff interviews, and review of the facility's policy, the facility staff failed to ensure food was stored under sanitary conditions.

Inspectors wroteBased on observation and staff interviews the facility staff failed to protect resident from public view during care for 1 resident (Resident #2), of 43 residents in the survey sample. The facility staff failed to ensure Resident #2's privacy was maintained during tracheostomy care.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policies by failing to submit to the appropriate state agencies, a five day follow up investigation to a FRI (facility reported incident) that was reported on 1/7/19, for one of 43 residents in the survey sample, Resident #84.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that facility staff failed to submit the results of an investigation within 5 working days of an allegation of neglect reported on 1/7/19 to the appropriate state agencies for one of 43 residents in the survey sample, Resident #84.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that facility staff failed to send the required documentation to include care plan goals upon transfer to the hospital, for 3 of 43 residents in the survey sample, Residents # 61, #71, #63.

Inspectors wroteBased on clinical record review, staff interview and facility documentation the facility staff failed to ensure 1 of 43 residents (Resident #54) in the survey sample received a complete and accurate assessment.

Inspectors wroteBased on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to develop a care plan for the prevention of pressure ulcers/injury for 1 of 43 residents (Resident #30) in the survey sample.

Inspectors wroteBased on observation, staff interview, resident interview and clinical record review the facility staff failed to revise the comprehensive care plan to reflect the resident's current weight bearing status for 1 of 43 residents in the survey sample, Resident #49.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide fingernail care to a dependent resident for one of 43 residents in the survey sample, Resident #52.

Inspectors wroteBased on observations, clinical record review, staff interviews and facility documentation review, the facility staff failed to develop and implement preventative measures to prevent the formation of a new pressure ulcer to an at risk resident prior to identification at an advanced stage, for 1 or 43 residents (R#30) in the survey sample. Resident #30's sacral/coccyx pressure ulcer was first identified on 12/6/19 by the nursing staff as an unstageable pressure ulcer.

Inspectors wroteBased on observation, staff interviews and clinical record review the facility staff failed to ensure 1 of 43 residents (Resident #35) in the survey sample, who were unable to carry out activities of daily living, received the necessary services to maintain toenail care.

Inspectors wroteBased on observation and staff interview, the facility staff failed to a system in place to control, account for, and periodically reconcile, the controlled medication Ativan.

Inspectors wroteBased on record review, staff interview and facility policy review, the facility staff failed to ensure 1 (Resident #335's) of 43 residents in the survey sample's medical records were readily accessible.

Inspectors wroteBased on observation, staff interviews, closed record review, and in the course of a complaint investigation, the facility staff failed to ensure 2 residents (Resident #477 and #14) of 61 residents in the survey sample was free from accidents. Resident #477 sustained harm after the application of a hot compress resulted in second degree burns and the facility staff failed to ensure the Resident #14's mobility wheel chair was in safe operating condition. 1. Resident #477 sustained second degree burns after a hot compress was applied to his left hand. (A second degree burn is described according to the University of Rochester Medical Center as: the epidermis or top layer of skin appears red, and blistered and my be painful and swollen). 2. For Resident #14, the wheel chair had torn arms, a torn seat, and a torn back rest.

Inspectors wroteBased on observation, staff interview, facility document review, and closed record review the facility staff failed for one (Resident #477) of 61 residents in the survey sample, to assess, prevent, and treat a penile injury caused by an indwelling catheter which resulted in a 2 cm (centimeter) split to the meatus (opening) of Resident #477's penis resulting in harm. For Resident #477, the facility staff failed to prevent an indwelling Foley catheter related injury.

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to maintain an active facility wide Infection Prevention and Control Program (IPCP) and failed to ensure infection control measures to prevent the potential transmission of infection while performing a blood glucose test on 1 resident of 61 residents in the survey sample (Resident #26) The finding's included; 1. On 6-25-18 at approximately 5:00 p.m., During the end of day debriefing, the Administrator was asked who surveyors should speak with, the next morning in regard to the facility infection control program. The Administrator stated the Director of Nursing (DON) who was no longer employed at the facility had previously been in charge of it, however, since she was no longer there, the new interim DON would be responsible. [...]

Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to maintain an active antibiotic stewardship program. The finding's include; On 6-25-18 at approximately 5:00 p.m., During the end of day debriefing, the Administrator was asked who surveyors should speak with, the next morning in regard to the facility infection control program. The Administrator stated the Director of Nursing (DON) who was no longer employed at the facility had previously been in charge of it, however, since she was no longer there, the new interim DON would be responsible. On 6-26-18 at 10:00 a.m., the Registered Nurse (RN-2) south unit manager and the Corporate Infection Preventionist (Other 3) RN came into the conference room and stated they would be in charge of infection control, not the DON. RN-2 and Other 3 were interviewed in the conference room by surveyors. [...]

Inspectors wroteBased on medical record review, staff interviews and facility document review the facility staff failed to revise care plans for 5 of the 61 Resident's in the Survey Sample, Residents' #125, #28, #11, #5, and #72. 1. The facility staff failed to revise Resident #125's care plan on 5/21/18 to include the initial physician order for the antipsychotic medication Quetiapine 50 mg (milligram) tablet one time daily. 2. For Resident #28 care plan was not revised to include new wounds and pain from shingles. 3. For Resident #11 care plan has not been updated to accurately reflect Residents current communication abilities. 4. For Resident #5 care plan was not revised to include pain assessments or interventions. 5. For Resident #72 the facility staff failed to revise the care plan for wounds and treatments. The Findings Included: 1. [...]

Inspectors wroteBased on a complaint investigation, observations, clinical record review, staff and resident interview, the facility staff failed to ensure 1 of 61 residents (Resident #107) in the survey sample were seen by a physician, nurse practitioner or physician assistant every 60 days with 10 day grace period. Resident #107 was not seen every 60 days with 10 day grace period by the physician, nurse practitioner or physician assistant per mandate. Specifically, there was a 5 month gap between physician visits from 9/14/17 to 2/13/18.

Inspectors wroteBased on observations, clinical record review, staff and resident interview, and facility documentation review, the facility failed to ensure sufficient staff was in place to provide nursing and related services to maintain the highest practicable physical, mental and psychosocial well-being for 4 of 61 residents (Resident #124, #23, #118 and #5) in the survey sample. 1. Resident #124 was not provided timely incontinence care due to insufficient staffing on the 3 pm-11 p.m. shift on 6/25/18. She was left soiled and cold for 2.5 hours before she was able to receive incontinence care. 2. Resident #23 was not provided timely incontinence care due to insufficient staff on the 3 p.m.-11p.m. shift on 6/25/18. She was left up in her wheel chair soiled for 5.5 hours. The next shift (11 p.m.-7 a.m.) placed her in bed and provided incontinence care at 12:20 p.m. 3. [...]

Inspectors wroteBased on Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure medications were available for administration for two Residents (Resident #72, & #5) of the 61 residents in the survey sample. 1. For Resident #72 the facility staff failed to administer Magnesium Citrate as requested and ordered on 6-14-18. 2. The facility failed to provide Resident #5, with twelve consecutive doses of a scheduled narcotic pain medication.

Inspectors wroteBased on observation, resident interview, family interview, staff interview, and clinical record review the facility staff failed to ensure 1 Resident (Resident #5) in a survey sample of 61 to be free of significant med error. For Resident # 5 facility staff failed to follow physicians order to administer Oxycodone 5 mg. (narcotic pain medication) as scheduled.

Inspectors wroteBased on clinical record review, staff interview, resident interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed for 2 (Resident #176 and #118) of 61 residents in the survey sample to notify the physician and/or resident's family of a change of conditions 1. For Resident #176, the facility staff failed to notify the resident's family of a fall. 2. For Resident #118, the facility staff failed to notify the physician and/or designee of missed Physical Therapy (PT) appointments.

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, the facility staff failed to ensure the Privacy of Residents related to leaving a team assignment face up on 1 medication cart of 10 med carts (Cart 2 Unit 2)

Inspectors wroteBased on resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 2 of 61 residents in the survey sample, Resident #42 and 91. 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #42's transferred and admitted to the hospital on [DATE]. 2. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #91 transferred and admitted to the hospital on [DATE].

Inspectors wroteBased on staff interviews, clinical record review and facility documentation review the facility staff failed send or provide a copy of the Bed-Hold Policy for 1 resident (Resident #42) of 61 residents in the survey sample, after being transferred to the hospital on 5/19/18. The facility staff failed to provide the resident #42 or the resident's representative with a written copy of the bed hold policy.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to assure one resident (Resident #1) of 61 residents in the survey sample, was assessed at least quarterly utilizing the Minimum Data Set (MDS). For Resident #1, the facility staff failed to complete a quarterly MDS assessment within the required 92 days.

Inspectors wroteBased on clinical record review, staff interviews and facility documentation review, the facility staff failed to accurately reflect, via the required Minimum Data Set (MDS) assessment, the resident's status for 1 of 61 residents (Resident #18) in the survey sample. The facility staff failed to accurately assess the resident's sacral pressure upon re-admission to the facility on [DATE].

Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to develop and implement a comprehensive person centered care plan for two Residents (Residents #95, & #72) of the 61 residents in the survey sample. 1. Resident #95's care plan did not include person centered interventions for weight loss. 2. For Resident #72 the facility staff failed to care plan the Resident for constipation.

Inspectors wroteBased on observation, staff interview, and closed record review the facility staff failed to meet professional standards of quality for 2 (Residents #477 and #95) of 61 residents in the survey sample. 1. The facility staff failed to meet professional standards of quality when an LPN (Licensed Professional Nurse) delegated the application of a hot compress to a CNA (certified nursing assistant) which resulted in second degree burns on Resident #477's hand. 2. The facility staff failed implement a physician's order to increase Pro-stat from once per day to three times per day for Resident #95; and provided the wrong diet to the Resident on 6-19-18 for the lunch meal.

Inspectors wroteBased on record review, and family and staff interview, the facility staff failed to provide one resident (Resident #103) with physician ordered oxygen in the survey sample of 61 residents.

Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to meet the nutritional needs of one resident (Resident #95) of the 61 residents in the survey sample. For Resident #95, the facility staff failed to provide the ordered diet on 6-19-18, failed to provide the Pro-stat supplement as ordered, provide ongoing nutritional assessments, and failed to revise the care plan with feeding needs, during a significant weight loss.

Inspectors wroteBased on record review, family and staff interview the facility staff failed to provide one resident (Resident #103) with Respiratory care in accordance with professional standards of practice and the person centered care plan, in the survey sample of 61 residents.

Inspectors wroteBased on staff interview, and clinical record review the facility staff failed to provide pain management for 1 resident (Resident # 5) in the survey sample of 61 Residents. For Resident # 5 facility staff failed to provide pain management according to physician's orders.

Inspectors wroteBased on record review and staff interview the facility staff failed to provide on communication with the dialysis facility for one resident (Resident #110) in the survey sample of 61 residents.

Inspectors wroteBased on a information obtained during a complaint investigation, resident, staff and family interviews, and review of the clinical record, the facility staff failed to ensure residents who displays or has a history of a mental disorder and trauma receives the care and services necessary to reach and maintain the highest level of mental and psychosocial functioning for 1 of 61 residents (Resident #118), in the survey sample. The facility staff failed to acknowledge, assess, develop and implement a person centered plan for the underlying cause of displayed expressions of distress exhibited by Resident #118 on 6/5/18 and 6/12/18, and to ensure Resident #118 received appropriate, individualized treatment, services and assistance to meet her needs during community physical therapy appointments; which resulted in a decline in her psychosocial well-being.

Inspectors wroteBased on record review and staff interview, the facility staff failed to attempt gradual dose reductions of psychoactive medications for two residents (Resident #63 and 118) in the survey sample of 61 resident. 1. For Resident #63, the facility staff failed to attempt gradual dose reductions or document why gradual dose reductions are not indicated for ordered doses of Seroquel. 2. For Resident #118, the facility staff failed to attempt gradual dose reductions or document why gradual dose reductions were not indicated for ordered doses of Seroquel and Duloxetine; and to not prescribe as needed Xanax for greater than 14 days without documenting the rationale and duration of use in the medical record.

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, clinical record review, the facility staff failed to ensure Insulin was stored correctly with both an open and a correct expiration date on 1 of 10 medication carts (Unit 4 Cart 2, and failed to ensure one PPD (purified protein derivative-tuberculosis skin test) vial was stored correctly with both an open and expiration date on 1 of 3 medication storage rooms (South 1 Medication Storage Room) and failed to ensure one treatment cart was secure by LPN #7 after leaving her keys in the treatment cart lock when not in direct supervision of the nurse.