Allure of Peru

Inspectors wroteBased on interview and record review the facility failed to set up a resident's dialysis treatment and transportation to dialysis upon discharge for 1 of 3 residents (R1) reviewed for discharge planning in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that controlled substances were reconciled and stored appropriately. This has the potential to affect all 82 residents residing in the facility. The facility's Medication Storage policy, undated, documents to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperatures, light, ventilation, moisture control, segregation, and security. This form also documents that schedule II drugs and back-up stock of schedule III, IV, and V medications are stored under double-lock and key. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure interventions were in place to prevent misappropriation of a medication for one of three residents (R1) reviewed for misappropriation of property in a sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident at risk for falls who was placed in the bathroom had access to a call light for safety. This applies to 1 of 5 residents (R1) in the sample of 5 reviewed for safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the privacy of residents' health information for two (R12 and R174) of 18 residents reviewed for confidentiality/privacy in a sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to ensure fingernail care was added to a resident's Care plan for one (R40) of 18 residents reviewed for Care plans in a sample of 31.

Inspectors wroteBased on observation, interview and record review the facility failed to perform nail care for two residents (R19) and (R40) of 18 reviewed for assistance with daily living in a total sample of 31. Findings Include: The facility's undated Nail Care policy documents Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: 3. Routine cleaning and inspection of nails will be provided during ADL (Activities of Daily Living) care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises. 5. The Resident's plan of care will identify: a. The frequency of nail care to be provided. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure glove change during pressure ulcer treatment for one (R27) of seven residents reviewed for pressure ulcers in a sample of 31.

Inspectors wroteBased on interview and record review the facility failed to document behaviors to justify the use of psychotropic medications for two residents (R6 and R46) and failed to attempt nonpharmacologic interventions for one resident (R46) of five residents reviewed for unnecessary medications in a total sample of thirty one. Findings Include: The Facility's undated Use of Psychotropic Medications policy documents It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to physician orders and pharmacy medication instructions for two (R12 and R48) of six residents reviewed during Medication Administration in a sample of 31. There were two errors out of 26 medication opportunities observed resulting in a 7.69% medication error rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep residents' medications securely stored for two (R12 and R174) of seven residents reviewed for medication storage during medication administration in a sample of 31.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accuracy of resident medical records for two (R40 and R48) of 18 residents reviewed for medical records in a sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to report potential allegations of theft to the local law enforcement for two (R1 and R2) of four residents reviewed for misappropriation of property in a sample of four.

Inspectors wroteBased on observation, interview, and record review the facility failed to utilize PPE (Personal Protective Equipment), failed to perform hand hygiene during medication pass, failed to initiate enhanced barrier precautions and failed to sanitize equipment after usage in an enhanced barrier precaution room for six residents (R2, R12, R32, R58, R14 and R281) of 24 reviewed for infection control. This has the potential to affect 79 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a resident with a mirror to allow for self grooming for one (R66) of one resident reviewed for Accommodations of Need in a sample of 35.

Inspectors wroteBased on interview and record review the facility failed to implement a person centered baseline care plan for two residents (R281 and R283) of five reviewed for baseline care plans in a sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an order was placed and a resident was wearing a recommended assistive device for one (R62) of one resident reviewed for Limited Range of Motion in a sample of 35.

Inspectors wroteBased on interview and record review the facility failed to ensure psychotropic medication ordered PRN (as needed) was limited to 14 days for one (R39) of three residents reviewed for Unnecessary Medications in a sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications as ordered by the physician for two residents (R58 and R72) on the sample of 7 residents reviewed for medication pass. This failure resulted in two medication errors out of twenty- five opportunities for error, for an 8% medication error rate.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered by the physician for one resident (R72) of seven residents reviewed for medication administration, in a sample of 35. The undated facility policy, Intravenous Therapy directs staff, The facility will adhere to accepted standards of practice regarding infusion practices. Review and verify practitioner's order for infusion solution or medication, dose, frequency and route of administration. R72's current Physician Order Sheet, dated May 2024 includes the following diagnoses: Osteomyelitis Of Vertebra, Thoracic Region; Methicillin Resistant Staphylococcus Aureus Infection; Type 2 Diabetes Mellitus. This same sheet includes the following medications: Vancomycin HCl ((Hydrochloride)Intravenous Solution 2500 mg intravenously in the morning. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pureed bread was provided for residents' lunch for three (R19, R38, and R60) of three residents reviewed for Pureed Diets in a sample of 35.

Inspectors wroteBased on record review and interview, the facility failed to prevent a safe and secure transfer for one of three (R1) residents reviewed for safe transfers in a sample of three. This failure resulted in R1 falling on 11/15/2023 and receiving a Displaced oblique distal diaphyseal fracture of the left femur. Findings Include: R1's V7/ Physician Assistant History and Physical, dated 11/15/2023, documents the following,(R1's) left leg shortened and internally rotated. Motor limited due to pain. R1's Trauma Level 2 History and Physical, dated 11/15/2023, from V8/ Orthopedic Surgeon documents, [AGE] year-old female Caucasian patient who was brought into the trauma bay, who fell from her wheelchair while being transferred in vehicle. (R1) was found to have a distal left femur fracture. Patient presents with left leg internally rotated, very tender. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to recognize the immediate need for transferring a Covid-19 positive resident to the hospital for necessary medical treatment for one (R26) of four residents reviewed for hospitalization in the sample of 29. This failure resulted in delay of treatment resulting in R26 expiring in the emergency room.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to wear hair nets, while in the kitchen, during meal service. This failure has the potential to affect all 80 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond to resident call devices promptly for two (R35 and R59) of 18 residents reviewed for call devices in a sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to issue the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) Form CMS-10055 (Centers for Medicare and Medicaid Services) to two (R32, R36) of three residents reviewed for Beneficiary Protection Notification in the sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to notify the Long Term Care Ombudsman of residents' transfer/discharge to the hospital for three (R37, R46, R69) of four residents reviewed for emergency hospital transfer in the sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of the bed hold policy for two (R37, R69) of four residents reviewed for emergent transfer in the sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident oxygen humidifiers were changed as ordered and full while in use for one (R59) of two residents reviewed for oxygen in a sample of 29.

Inspectors wroteBased on interview, observation and record review, the facility failed to obtain a physician's order for the implementation of dialysis and failed to ensure a resident's dialysis needs were addressed fully in a care plan for one of one resident (R12) reviewed for dialysis in the sample of 29. Findings Include: R12's current Physician Order Sheet, dated April 2022 documents that R12 was admitted to the facility on [DATE] with the following diagnoses: End Stage Renal Disease, Chronic Kidney Disease, Acute Kidney Failure and Dependence on Renal Dialysis. Also included are the following physician orders: Monitor port to RT upper chest for any signs and symptoms of infection; Weekly weights. No physician orders for the implementation of Hemodialysis is noted. R12's Care Plan, dated 9/11/2019 includes the following focus area: (R12) is on dialysis (hemo) related to renal failure. [...]