Allure of Zion

Inspectors wroteBased on interview and record review the facility failed to ensure mail is delivered promptly for 1 of 2 residents (R1) reviewed for a resident's right to mail delivery.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure shower water temperatures were at a comfortable temperature for 4 of 4 residents (R7, R8, R9 and R10) reviewed for clean, comfortable and homelike in the sample of 16.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure scheduled nebulizer medications were administered as ordered (R1) and failed to ensure medications were administered at the scheduled time (R7, R8, R15, R16) for 5 of 6 residents reviewed for medication administration in the sample of 16.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident finger nails were cleaned and trimmed for residents needing assistance with activities of daily living (ADLs) for 2 of 3 residents (R6 and R10) reviewed for ADLs in the sample of 16.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received an ordered pain medication in a timely manner for 1 of 3 residents (R2) reviewed for pain the sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident valuables were protected from misappropriation for 2 of 5 residents (R1, R2) reviewed for abuse in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse for 1 of 5 residents (R4) reviewed for abuse in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to ensure psychotropic medication ordered as needed had a duration/stop date for 1 of 3 residents (R3) reviewed for psychotropic medications in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to monitor dementia residents with wandering behaviors. The facility failed to immediately intervene and redirect dementia residents exhibiting wandering and dementia related behaviors. These failures apply to 2 of 3 residents (R1, R2) reviewed for dementia care in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinence care to a resident (R1) that is dependent on staff for incontinence care. This applies to 1 of 3 residents reviewed for ADL's (Activities of Daily Living) in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall prevention measures were in place, failed to ensure skin tear prevention measures were in place. These failures apply to 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure glove changes were performed during incontinence care for a resident with a history of ESBL (Extended-spectrum beta-lactamase) in the urine. This applies to 1 of 3 residents (R1) reviewed for incontinence care in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to supervise a resident at high risk for falls for one of six residents (R1) reviewed for safety/supervision in the sample of six. This failure resulted in R1 experiencing a fall and rib fracture that resulted in R1 transferring to the local hospital.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered by the physician for one of six residents (R1) reviewed for medications in the sample of six.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of misappropriation of money for 4 of 4 residents (R1-R4) reviewed for misappropriation of property in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to implement their Abuse Policy regarding reporting and investigating an alleged misappropriation of money for 1 of 4 residents (R4) reviewed for misappropriation of property in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to ensure that an alleged misappropriation of resident money was reported immediately to the State Survey Agency for 1 of 4 residents (R4) reviewed for misappropriation of property in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to initiate an investigation of an alleged misappropriation of money 1 of 4 residents (R4) reviewed for misappropriation of property in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure low air loss mattresses were provided for 2 of 3 residents (R2 and R3) with Stage 4 sacral pressure ulcers reviewed for pressure ulcers in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) for 1 of 3 residents (R1) reviewed for infection control in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure a residents-controlled medication was misappropriated. This applies to 1 of 10 residents (R1) reviewed for controlled medications in the sample of 10.

Inspectors wroteBased on interview and record review the facility failed to ensure the accurate reconciliation of a controlled substance. This applies to 1 of 10 residents (R1) reviewed for controlled substances in the sample of 10.

Inspectors wroteBased on interview and record review the facility failed to carry out a physician order for an Infectious Disease consultation for 1 of 3 residents (R2) reviewed for Quality of Care in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was notified in writing of a facility-initiated room change and failed to ensure the resident was shown the new room and introduced to her new roommate before the room change for 1 of 3 residents (R1) reviewed for room changes in the sample of 9.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with wandering and aggressive behaviors was supervised and not allowed to enter other resident rooms for 1 of 1 resident (R2) reviewed for safety and supervision in the sample of 9.

Inspectors wroteBased on interview, and record review the facility failed to ensure transfer paperwork was sent to the hospital/emergency room for the correct resident for 1 of 3 residents (R2) reviewed for transfers in the sample of 3.

Inspectors wrote2) R56's electronic face sheet printed on 7/11/24 showed R56 has diagnoses including but not limited to dementia with behaviors, sciatica, bipolar disorder, osteoarthritis, pressure ulcer of left hip-unstageable, and non-pressure chronic ulcer of left buttock. R56's facility assessment dated [DATE] showed R56 has no cognitive impairment and has no pressure injuries. R56's care plan dated 6/19/24 showed, The resident has pressure ulcer or potential for pressure ulcer development related I have 2 wounds and am being seen by the wound doctor/nurse. (SITE 6) unstageable (due to necrosis) of the left hip. 6/21/24 this is now a stage 4 .Follow facility policies/protocols for the prevention/treatment of skin breakdown. Monitor/document/report PRN (as needed) any changes in skin status: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform weekly weights as ordered by a physician for 1 of 7 residents (R58) reviewed for nutrition in the sample of 24. This failure resulted in R58 experiencing a significant weight loss of 7.96% within a 3-month period before it was identified by facility staff and R58 was referred to the facility dietician.

Inspectors wroteBased on observation, interview, and record review the facility failed to store medications according to their policy and failed to ensure medication refrigerator temperatures were maintained. These failures have the potential to affect all residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure a MRR (Medication Regimen Review) was being completed by a licensed pharmacist on a monthly basis. This applies to 5 of 5 residents (R8, R26, R41, R56, and R61) reviewed for MRR's in the sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to obtain physician's orders for a resident (R67) code status for 1 of 1 resident reviewed for advanced directives in the sample of 24.

Inspectors wroteBased on interview and record review the facility failed to ensure a PASRR (Preadmission Screening and Resident Review) level 2 was completed on residents with serious mental illness. This applies to 2 of 2 residents (R66 and R41) reviewed for PASRR in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide thorough incontinence care for a dependent resident. This applies to 1 of 2 residents (R37) reviewed for activities of daily living in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall prevention measures were in place for 2 of 11 resident's (R3, R30) reviewed for safety & supervision in the sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen was administered at the physician prescribed rate and failed to handle oxygen tubing in a manner to prevent cross contamination for 1 of 1 resident (R36) reviewed for oxygen in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate isolation precautions for a resident (R56) with a wound and peripherally inserted central catheter (PICC) lined, failed to perform hand hygiene before and after catheter care for a resident (R248), and failed to wear personal protective equipment for a resident (R248) on enhanced barrier precautions. These failures apply to 2 of 7 residents reviewed for infection control in the sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to transfer a resident according to the resident's care plan. This failure applies to 1 of 5 residents (R1) reviewed for falls in the sample.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement dressing change orders for a resident admitted with an open wound. This applies to 1 of 4 residents (R501) reviewed for pressure/treatment interventions in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have pressure relieving devices in place and failed to perform ordered treatments for a resident with pressure injuries for one of three residents (R1) reviewed for pressure injuries in the sample of eight. This failure contributed to R1's worsening pressure injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall prevention interventions were in place and failed to supervise a resident with a history of falls for one of three residents (R1) reviewed for safety/supervision in the sample of eight. This failure resulted in R1 experiencing a fall that required a local emergency room transfer and sutures to her head.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADL) assistance for residents requiring extensive assistance for two of three residents (R6, R5) reviewed for ADLs in the sample of eight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician ordered treatments were in place to non-pressure wounds for two of three residents (R3, R1) reviewed for non-pressure wounds in the sample of eight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform incontinence care in a manner to prevent urinary tract infections for one of three residents (R6) reviewed for incontinence care in the sample of eight.

Inspectors wroteBased on interview and record review, the facility failed to provide a physician ordered antibiotic for one of three residents (R1) reviewed for medications in the sample of eight.

Inspectors wroteBased on interview and record review the facility failed to clarify a resident's pain management orders with the primary care physician prior to administering additional opiate pain medications and failed to discontinue a residents pain patch. These failures resulted in R2 experiencing a mental status change, lethargy, and required emergent hospitalization for suspected opiate overdose. This applies to 1 of 6 residents (R2) reviewed for pain management in the sample of 13. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 8/10/23, when V20 (Registered Nurse/RN) failed to clarify R2's Morphine (pain medication) plan of care prescription from a pain consultant with her primary care physician prior to carrying out the order. R2 received 11 doses of morphine 15 milligrams (mg.) every 6 hours from 8/11/23 until 8/14/23. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from physical and verbal abuse. This failure resulted in R3 and R5 suffering mental anguish and psychosocial harm. This applies to 2 of 8 residents (R3, R5) reviewed for abuse in the sample of 13.

Inspectors wroteBased on interview and record review the facility failed to follow its abuse policy to ensure staff received abuse training. This failure has the potential to affect all 77 residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall interventions were implemented for a resident (R4) with history of falls for 1 of 7 residents (R4) reviewed for falls in the sample of 13.

Inspectors wroteBased on interview and record review the facility failed to ensure pain medication was administered to a resident experiencing pain after a fall. This failure resulted in (R45) experiencing uncontrolled pain for 4 hours. This applies to 1 of 18 residents (R45) reviewed for pain in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to attempt gradual dose reductions for psychotropic medications and failed to ensure their was a duration ordered for as needed anti-anxiety medications for 4 of 5 residents (R7, R35, R43 and R68) reviewed for unnecessary medications in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to provide nail care and shaving assistance to residents who need extensive assistance with activities of daily living (ADLs) for 3 of 18 residents (R17, R25 and R67) reviewed for ADLs in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a wound dressing was in place as prescribed by the physician. This applies to 1 of 4 residents (R66) reviewed for pressure ulcers in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with limited range of motion and a contracture, received Passive Range of Motion (PROM) and splint application for 1 of 2 residents (R25) reviewed for Range of Motion in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label the enteral feeding administration set (formula receptacle and tubing) and syringe for 1 of 3 residents (R64) reviewed for tube feeding in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was monitored during medication administration for 1 of 18 residents (R280) reviewed for medication administration in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adaptive eating utensils were provided for 1 of 18 residents (R36) reviewed for assistive devices in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure to have an Infection Control Preventionist on staff which affects all 76 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure pharmacy recomendations were forwarded to the facilty in a timely manner, failed to notify the physician of irregularities of medication regimen in a timely manner and failed to develop a policy that included a timeframe for the different steps in the review process for 4 of 7 residents (R7, R16, R74 and R76) reviewed for Medication Regimen Review (MRR) in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure a physician assessed a resident every 14 days for the continued need for an as needed (PRN) anti-psychotic medication and failed to have a duration/stop date for a resident on a PRN anti-anxiety medication for 4 of 7 residents (R7, R16, R74 and R76) reviewed for psychotropic medications in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nail care was provided for 2 of 18 residents reviewed for activities of daily living in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with a contracture had a brace for 1 of 4 residents (R41) reviewed for contractures in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to use a gait belt to safely transfer a resident and failed to ensure a resident was able to safely wash their hands for 2 of 18 residents (R4 and R56) reviewed for safety in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide thorough incontinence care for 1 of 2 residents (R11) reviewed for incontinence care in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a nutritional supplement was given to a resident who had a significant weight loss for 1 of 4 residents (R4) reviewed for weight loss in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to serve a mechanical soft diet to a resident as ordered for 1 of 18 residents (R3) reviewed for diets in the sample of 18.