Winship Green Center for Health & Rehab, LLC

Inspectors wroteBased on record review and interviews, the facility failed to have as needed medication readily available for resident use in a timely manner and failed to follow physician orders related to medication administration for 2 of 4 residents reviewed for medications (Resident #1 and #12).

Inspectors wroteBased on observations and interviews, the facility failed to ensure the confidentiality of protected health information for 10 of 67 residents during 1 of 1 day of survey (Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure written bed hold and transfer/discharge notices were provided to the resident or their legal representative for a facility-initiated transfer/discharge for 1 of 3 sampled residents who were transferred/discharged to an acute care facility (Residents #1).

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of a significant change in condition for 1 of 3 residents reviewed for a significant change in condition. (Resident #1)

Inspectors wroteBased on record review and interviews, the facility failed to provide evidence that the Resident Representative was informed of a physician order for an antipsychotic medication, informed of the side effects of that medication and given the opportunity to agree or disagree with the use of medication for 1 of 3 sampled residents reviewed for unnecessary medications (#1).

Inspectors wroteBased on interviews, the facility failed to deliver resident mail in a timely manner to 2 out of 4 residents who receive mail in the facility. ( #48 and #63)

Inspectors wroteBased on record review and interviews the facility failed to provide/obtain residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 8 of 23 residents reviewed for advanced directives ( #10, #35, #46, #67, #37, #9, #63 and #23).

Inspectors wroteBased on observations and interviews, the facility failed to adequately maintain maintenance services necessary to maintain the facility in good repair and sanitary condition for the ceiling air vents and surrounding ceiling tiles, all unit shower rooms, and bathrooms in rooms [ROOM NUMBER] on the [NAME] Unit.

Inspectors wroteBased on interviews and record review, and policy review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) meeting, which included the participation of the resident and resident's representative, after each Minimum Data Set (MDS) 3.0 assessments, for 6 of 6 residents whose care plans were reviewed (#16, #10, #13, #26, #23, #31).

Inspectors wroteBased on observations, interviews, record review, and facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, failed to ensure foods were dated/ labeled and stored appropriately for 2 of 3 survey days (kitchen and Pemaquid dining room), failed to ensure that the freezers and refrigerator's temperatures were monitored appropriately. This has the potential to affect all residents that eat food prepared by kitchen staff.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that a call bell was accessible to 1 of 24 sampled residents observed for 2 of 3 days of survey (#10).

Inspectors wroteBased on record reviews and interviews, the facility failed to update/implement goals and interventions in the area of depression for 1 of 4 residents reviewed ( #10), In addition facility failed to ensure care plan was updated/implemented on the areas of elopement, and diabetes for 1 of 4 care plans reviewed ( #13).

Inspectors wroteBased on record review, policy review, observations and interviews, the facility failed to provide residents with a continuous resident centered activities program for 1 of 1 resident reviewed for activity participation ( #10).

Inspectors wroteBased on observation and interview, the facility failed to ensure that the resident's safety when the residents wander guard was expired for 1 of 1 resident reviewed for elopement (#13). In addition, the facility failed to a blocked fire door on 1 of 3 units ([NAME] Unit), on 2 of 3 survey days.

Inspectors wroteBased on record review and interviews, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 2 of 190 days reviewed for RN coverage.

Inspectors wroteBased on observation, interview, and facility policy, the facility failed to ensure an outdated vaccine was removed from the supply available for use in medication refrigerator in 1 of 1 medication storage rooms reviewed for 1 of 4 days of survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that the resident's record contained accurate information (#13).

Inspectors wroteBased on interviews and observations, the facility failed to ensure a resident's wheelchair was clean on 2 of 3 survey days (#13).

Inspectors wroteBased on record review and interview, the facility failed to readmit 1 of 1 Resident (#1) back to the facility following a hospital emergency department/hospital visit.

Inspectors wroteBased on observations and interviews, facility failed to adequately date and properly dispose of open medications according to manufacturer specifications and failed to ensure expired medications were removed from the supply available for use on 2 of 3 units observed (Passport and [NAME]).

Inspectors wroteBased on observations and interview, the facility failed to ensure that the kitchen was maintained in a clean and sanitary manner for 2 of 4 kitchen tours. In addition, the facility failed to ensure the main dining room refrigerator temperatures were maintained at 41 degrees for 1 of 4 days of survey.

Inspectors wroteBased on record review, observations and interview the facility failed to provided care in accordance with professional standards of practice, based on the comprehensive person-centered care plan, and the residents' choices for 1 of 3 residents reviewed for positioning (Resident #27).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a Restorative Nursing Program (RNP) was provided in accordance with the Physical Therapist (PT) recommendations for 1 of 3 sampled residents reviewed for rehabilitation (#27).

Inspectors wroteBased on observation, record review and interview, the facility failed to obtain physician orders for oxygen therapy for 1 of 5 residents reviewed for respiratory care (#161) .

Inspectors wroteBased on observation and interview, the facility failed to maintain the dignity of 1 of 3 residents (Resident #14) reviewed for dignity related to urinary collection bags during 2 of 4 days of survey (4/2/23 and 4/4/23).

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services, necessary to maintain in good repair and sanitary condition, for 2 of 2 environmental tours.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide interventions outlined in the resident's care plan for 2 of 29 sampled residents. (#43, #203).

Inspectors wroteBased on observations and interviews, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 4 medication carts (Pemaquid) and failed to store medication according to manufacturer specifications for Acidophilous in 3 of 4 medication carts observed (Passport and Pemaquid).

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for (1) fan, two light switches and the dish wash room floor for 1 of 3 days of survey.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate documentation for 2 of 29 sampled residents (#5 and #32).