Inspection Reports for Acclaim Rehabilitation and Care Center

The initial survey found the facility failed to provide a sanitary environment by not properly disposing of garbage and refuse, with dumpsters uncovered and surrounding areas littered. The follow-up survey found the deficiency was not corrected as dumpsters remained uncovered, but corrective actions were underway including ordering covers and improving waste management practices.

Deficiencies were cited related to failure to notify resident representatives in writing for emergency transfers, incomplete and untimely Minimum Data Set (MDS) assessments, medication administration errors, food safety violations, life safety code violations including means of egress and sprinkler system maintenance, and staffing deficiencies. The facility was found not in compliance with several federal and state regulations.

The facility was found deficient in timely notification to resident representatives for emergency hospital transfers, delayed submission of MDS assessments for 6 residents, medication administration documentation errors for 8 residents, poor kitchen sanitation and hygiene practices, and failure to implement smoking policies that ensure smoke-free air in designated areas.

The facility failed to develop and implement smoking policies in accordance with state law, allowing indoor smoking in a designated smoking room where windows could not be opened and ashtrays lacked self-closing lids. Residents were observed smoking inside the room, and the facility acknowledged ongoing indoor smoking since April 2022.

The complaint investigation substantiated physical abuse between residents R19 and R83, as well as between R26 and R74. The facility substantiated the incidents as abuse. Both pairs of residents engaged in physical altercations involving hitting and verbal aggression. The facility implemented interventions including separation, emotional support, psych consultations, family and MD notifications, neurological checks, and trauma assessments. Residents declined room changes and some psychological counseling. No further altercations were reported after interventions.

The facility failed to protect residents from physical abuse by other residents, with documented incidents involving residents R19, R83, R26, and R74. Investigations revealed physical altercations, verbal aggression, and inadequate prevention of abuse, despite interventions such as separation, supervision, and psychological evaluations.

The facility failed to ensure privacy for residents due to broken privacy curtains, failed to protect residents from physical abuse by other residents, and failed to assist a resident in obtaining dentures despite documented needs. The facility substantiated abuse incidents and took corrective actions including psych consultations and supervision.

The complaint survey found the facility was not in compliance with accuracy of assessments requirements. The deficiency was substantiated based on observation, interview, and record review of Resident #2's MDS assessments.

The facility failed to accurately assess and encode a resident (Resident #2) in the Minimum Data Set (MDS) assessments, specifically in Section M related to skin conditions and coding accuracy. The inaccuracy was confirmed through observation, interviews, and record reviews.

The facility was found not in compliance with 42 CFR §483.80 infection control regulations, specifically failing to ensure that all staff and visitors were properly screened for COVID-19 signs and symptoms according to facility policy and CDC guidelines. Seven of fifteen employees and seven of twenty visitors were not fully screened prior to entry.

The facility was found not in substantial compliance with federal regulations, with deficiencies noted in resident privacy during medication administration and physical examination, accident hazards and supervision, pharmacy services including narcotic inventory discrepancies, and infection prevention and control practices.

The facility was found to be noncompliant with several Life Safety Code requirements including smokeproof enclosures, fire alarm system maintenance, corridor wall construction, and corridor door integrity. Deficiencies included a faulty door in an exit enclosure, fire alarm panel trouble condition, missing doors and partitions in corridor walls, and doors with missing hardware or improper latching.

The facility was found deficient in providing full visual privacy during medication administration and physical examinations, ensuring a safe environment to prevent falls, maintaining accurate controlled medication inventories, and implementing proper infection prevention and control measures including appropriate PPE use.