Wayne Countryview Care and Rehabilitation

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)Based on observations, record review, and interviews; the facility failed to reassess and to put interventions in place to prevent potential elopement for 1 (Resident 33) and failed to prevent the potential for burns related to hot water temperatures in resident handwashing sinks. Six out of 35 facility resident rooms had water temperatures that exceeded 120 degrees. The sample size was 20 and the facility census was 41.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(G)(ii)(iii)Based on record review and interviews, the facility failed to complete a comprehensive discharge summary including a recapitulation of care and reconciliation of medications for 1(Resident 43) and failed to notify the State Ombudsman of discharges for 2 (Resident's 43 and 45) of 4 sampled residents.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09(H)(i)(3) Based on observations, record review, and interview; the facility failed to provide timely eating assistance for Residents 33 and 19. The sample size was 2 and the census was 41.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09(J)(i) Based on observations, record review, and interview; the facility failed to implement weight loss interventions for Resident 33. The sample size was 4 and the facility census was 41.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17Based on observations, record review, and interview; the facility failed to perform hand hygiene at appropriate intervals and to utilize the required Personal Protective Equipment (PPE) when providing management/care of Resident 39's catheter. The sample size was 2 and the facility census was 41.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(ii)(3) Based on record review and interview: the facility failed to employ a qualified Dietary Manager (DM). This had the potential to affect food service provided to all residents who were served food from the kitchen. The total sample size was 26 and the facility census was 34.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on observations, record review and interview; the facility failed to maintain the kitchen in a clean and sanitary manner and failed to maintain food temperatures to prevent the potential for food borne illness. This had the potential to effect all residents who ate food from the kitchen. The facility census was 34.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(B)(C)(D) Based on observation, interview, and record review; the facility failed to implement the required Personal Protective Equipment (PPE- items such as gowns, gloves, face shield that are worn to protect care givers during the provision of care and to protect other residents from being exposed to potential harmful communicable disease/s) during the provision of care for Residents 12 and 235, failed to implement a mitigation plan to prevent potential water borne illness, failed to place a protective barrier for medications taken to resident care areas and then returned to the medication cart after use for Resident 21, failed to complete hand hygiene during the administration of medications and the delivery of room trays, and failed to store oxygen equipment in a manner to prevent potential cross-contamination for Resident 85.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.19(A) Based on observation and interview; the facility failed to ensure a clean, comfortable, and homelike environment. The facility census was 34.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.19 Based on observations, record review and interviews: the facility failed to maintain a pest free environment in Resident 235's Room and the facility kitchen. The total sample size was 26 and the facility census was 34.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.10(A)(i) Based on observations, record review and interview; the facility staff failed to evaluate Resident 85 for the ability to self-administer medications and to ensure security of medications. The total sample size was 26 and the facility census 34.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09(H)(i)(1) Based on observations, record review and interview; the facility failed to provide toileting assistance and incontinence management for Resident 13 who required assistance with activities of daily living. The facility census was 34 and the sample size was 2.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on observations, interview, and record review; the facility failed to follow Resident 85's physician order regarding a fluid restriction. The sample size was 1 and the facility census was 34.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review and interview; the facility failed to monitor a dialysis (a method used to treat kidney disease by clearing metabolic waste products, toxins, and excess fluid from the blood) access site for 1 (Resident 85) of 1 resident. The facility staff identified a census of 34.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.12(D)(vi) Based on observation, record review, and interview; the facility failed to ensure insulin pens were dated when opened for Residents 5 and 21. The sample size was 5 and the facility census was 34.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility failed to notify Resident 2's physician for an ongoing weight loss. The sample size was 3 residents. The facility census was 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.06B Based on record review and interview; the facility failed to address food grievances to prevent sustained further resident concerns. The sample size was 16 and the facility census was 40. Review of the facility policy titled Grievances last revised 6/6/22 revealed the following: -the Grievance Official (GO) evaluated and investigated the concerns and would take immediate action to resolve the concern and prevent further potential violations of resident rights, -the Grievance Official or designee would respond to the individual expressing concern within 3 working days of the initial concern, and -the Grievance Official would take appropriate corrective action and contact all parties with the outcome. Review of the facility form titled Grievances revealed the following food concerns: January 2023: - 1/5/23: [...]

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.04 Based on interview and record review; the facility failed to have staff who were trained and certified in Cardiopulmonary Resuscitation (CPR-emergency procedures performed if a person stops breathing or their heart stops) for transportation of residents identified as having a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive) status. This had the potential to affect 3 (Residents 19, 33 and 2) sampled residents identified as having a full code. The facility census was 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11D Based on observation, record review, and interview; the facility failed to serve food at palatable temperatures. The sample size was 16 and the facility census was 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17 Based on observation, record review, and interview the facility failed to ensure hand hygiene was completed to prevent the potential spread of infection for Residents 9,12,23, and 25, test Resident 17 when signs and symptoms of COVID-19 were present and failed to wear the appropriate Personal Protective Equipment (PPE) during care for Resident 9. The sample size was 14 and the facility census was 40.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7(a) (b) Based on observation, interview and record review; the facility failed to implement interventions for the prevention of ongoing falls for Resident 26. The sample size was 5 and the facility census was 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-005.09D8b Based on observations, interview and record review; the facility failed to provide/implement interventions to prevent weight loss for 1 (Resident 26) of 1 sampled resident. The facility census was 40.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to attempt a gradual dose reduction of Resident 12's antipsychotic (medication used to treat a psychotic disorder) medication or have a documented contraindication, and failed to ensure Resident 34's as needed antianxiety medication was limited to 14 days or had renewed orders. The sample size was 5 and the facility census was 40.