Self Skilled Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Self Skilled Nursing & Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Mar 18, 2021

  Based on observation, review of facility policy and cleaning schedules, and interview it was determined the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety. Sanitation concerns were identified in all areas of the kitchen and had the potential to affect 47 of 47 residents who received meals from the kitchen. Findings include: Review of a facility policy titled General Sanitation of Kitchen (dated 2019) revealed food and nutrition services staff would maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. Procedures included: (1) Cleaning and sanitation tasks for the kitchen would be outlined in a written cleaning schedule. […]

• No harm, potential for more than minimal, patternF565Mar 18, 2021

  Based on interview, record review, and facility policy review, the facility failed to act promptly upon the grievances of the resident group regarding food complaints for 15 out of 47 total residents. Interview with the Resident Council on 3/17/21 revealed their food concerns expressed in the 11/6/2020 meeting had not been addressed. Findings include: Review of the facility's policy titled Resident and Family Grievances, dated 3/15/21, revealed the Social Services Director has been designated as the Grievance Official who is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; issuing written grievance decisions to the resident; and coordinating with state and federal… […]

• No harm, potential for more than minimal, patternF584Mar 18, 2021

  Based on observation, interview, and facility policy review, the facility failed to provide necessary housekeeping services to maintain a clean environment and maintenance services necessary to maintain good repair of equipment. Observations on 3/16/21, 3/17/21 and 3/18/21 revealed the heating/air-conditioning (AC) unit vents in two (2) rooms (rooms #127 and #135) had buildup of dust/debris. The exhaust vents in six (6) bathrooms (rooms #111, #113, #125, #127, #130 and #135) had buildup of dust/debris on the Hill Hall and Back Door Hall units. In addition, the bathroom in room [ROOM NUMBER] was observed to contain a metal trash can that was completely covered with rust. […]

• No harm, potential for more than minimal, patternF761Mar 18, 2021

  Based on observation, interview, and facility policy review, the facility failed to properly date and ensure expired medications were removed from the supply in two (2) of four (4) medication carts (medication cart #1 and #2). In addition, the facility failed to ensure expired medical supplies were removed from the supply, properly date medications and dispose of expired medications in two (2) of three (3) medication rooms. Findings include: Review of the facility's policy titled Medication Storage in the Facility, dated August 2018, revealed: Procedures. H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of accordingly to procedures for medication disposal. D. […]

• No harm, potential for more than minimal, patternF880Mar 18, 2021

  Based on observation, interview, record review and facility policy review, the facility failed to ensure standard precautions were followed regarding performing hand hygiene and wearing personal protective equipment (PPE) appropriately to prevent the transmission of communicable disease and infection for eight (8) out of 16 sampled residents (Resident #10, #16, #20, #28, #33, #36, #39 and #198). Observation on 3/16/21 revealed Certified Nurse Aide (CNA) #6 did not wash his/her hands after doffing gloves. Observation on 3/17/2021 revealed Housekeeper (HK) #14 walked down the front Hall without wearing the face mask appropriately. […]