Amaya Springs Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan (detailed plan with information about a resident's treatment, goal, and interventions) related to a resident's nail care for one of two residents (Resident 2), reviewed for care plan. As a result, the lack of a resident centered care plan with specific interventions had the potential to result in delayed care, miscommunication among caregivers, and a decreased physical well-being of the residents. Cross Reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine nail care to one of two residents (Resident 2), reviewed for Activities of Daily Living (ADL, activities related to personal care/ hygiene) for dependent residents. As a result, Resident 2's toenails were long and curved and Resident 2 was at risk for skin injury and infection. Cross Reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications had proper storage and labeling when:1. An injectable medication (heparin, anticoagulant) comingled with oral medications.2. Discontinued medications of residents were not disposed of accordingly.3. A resident's medication was left at bedside (Resident 38). These failures had the potential for medications to be incorrectly administered, decrease medication potency (medication strength) that could compromise the therapeutic effectiveness of stored medications and prevent misappropriation of the medications.

Inspectors wroteBased on interview and record review, the facility failed to provide documentation to verify performance evaluation had been completed for two certified nursing assistants (CNAs). These failures had the potential to affect clients' well-being, should the staff be unable to perform duties effectively, efficiently, and competently.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's behavior was managed effectively, for one of one sampled resident (Resident 39). As a result, Resident 39's yelling and screaming was constant and disruptive to other residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control procedures were followed when a Licensed Nurse (LN)13 did not wear a gown for Resident 6 with enhanced barrier precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with medical devices]), while passing medication (med/s) during med pass observation. This failure had the potential for cross contamination and spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to provide influenza vaccines (prevents the seasonal flu, a contagious respiratory illness) and pneumococcal (an immunization protecting against streptococcus pneumoniae bacteria, which causes severe infections) for two of five residents (Resident 6 and 39), reviewed for vaccinations. As a result, Residents 6 and 39 were at risks of acquiring flu and pneumonia.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's medical record were clear and complete when licensed nurses (LN) did not consistently sign the Medication Administration Record (MAR) when the tube feeding (TF) formula was administered, and a TF order did not have a rate (the speed of the TF delivered to the stomach) order for 1 of 3 sampled residents (Resident 4). As a result, Resident 4's medical record was incomplete, which compromised the ability to track and verify the amount of TF formula administered.

Inspectors wroteBased on observation, interview and record review the facility failed to follow its animal policy and infection control protocols by allowing a cat to roam in and out of the facility unsupervised without documented flea and tick treatment, proper registration, or adherence to resident preferences. As a result, the facility failed to maintain a sanitary environment placing residents at risk of infection, allergic reactions, and environmental contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain a physician order to provide services in accordance with standards of care when admission orders for one resident, (Resident 1), did not include blood glucose monitoring (a process of regularly measuring the amount of sugar in the blood) before each meal and before bed. This failure had the potential for Resident 1 ' s blood glucose level to be undetected and untreated.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of discharge to one of three sampled discharged residents (8). As a result, Resident 8 was not fully informed regarding his discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of the facility's bed hold policy at the time of discharge to one of three sampled discharged residents (8). As a result, Resident 8 was not fully informed of his bed hold rights.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a resident's low blood sugar readings, and did not monitor fluid intake and output for two of 12 sampled residents (1, 29). As a result, Resident 1 did not receive treatment for low blood sugar, and the facility could not determine if Resident 29 had proper fluid intake and adequate output, which may have lead to the late detection of fluid abnormalities in the body.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that opened dressings in the refrigerator were labeled with an open date and that the freezer's foods were stored per the facility's policy and procedure. These failures placed residents at risk of acquiring foodborne illness and may have caused the texture of the food in the freezer to become less palatable.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed when: (1) The nebulizer (a small machine that turns liquid medicine into a mist that gets inhaled into the lungs), mask, and cup (contains liquid medicine for the nebulizer) were not cleaned and bagged after each use, per the facility's policy, and (2) The water waste management program was not implemented. These deficient practices placed residents at risk for infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Control Preventionist (ICP) completed the specialized infection and prevention training. This failure could result in the ICP not being knowledgeable or qualified to perform the duties to prevent the spread of infection.

Inspectors wroteBased on interview and record review the facility failed to fully prepare three of four sampled residents, (1, 2, 4) for discharge in accordance with the facility discharge policy.

Inspectors wroteBased on observation, interview and record review the facility failed to provide supervised and assisted ambulation to one of one sampled Residents, (1), at high risk for falls. This failure resulted in Resident 1 experiencing an unwitnessed fall that resulted in a broken bone in her left ankle.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide resident safety for 1 resident (Resident 1) when Resident 1 eloped (leaving the facility unsafely or unescorted) from the facility ' s exit door which was equipped with an audible alarm. As a result, Resident 1 had a successful elopement and there was the potential risk for the elopement of other residents.

Inspectors wroteBased on interview and record review, the facility failed to properly prevent COVID-19 (a respiratory infection) when three sampled residents (10, 13, 24) and six unsampled residents (161, 17, 31, 37, 42, 49) were not offered vaccines when they were due.

Inspectors wroteBased on observation, interview and record review, the facility did not deliver mail to four of four Confidential Residents (CR 1, CR2, CR3, CR4) on Saturdays. This deficient practice did not ensure the resident's right to receive and send mail was met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to give a complete and accurate Notice of Medicare Non-Coverage (NOMNOC) for one of three sampled residents (100) reviewed for beneficiary notification. As a result, Resident 100 did not receive adequate information to make an appeal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safeguard and accurately identify a resident's medical record for one of 12 sampled residents (156). This failure had the potential for residents' private medical information to be visible to unauthorized persons.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a baseline care plan for three of 12 residents (160, 102, 153). This deficient practice did not ensure provision of effective and person-centered care for these residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for three of 12 sampled residents (160, 102, 153). Failure to develop a comprehensive care plan had the potential for residents to not receive accurate medical needs and appropriate treatment goals.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate and complete physician discharge summary on three of three sampled residents reviewed for closed records (52, 53, 54). Failure to keep a physician discharge summary had the potential for residents to not receive a safe transition between care settings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safeguard a gated fence that led to the parking lot. As a result, Resident 152 eloped from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an oxygen nasal cannula (device used to deliver oxygen to a person) was changed on one of one sampled resident (154) reviewed for oxygen use. Failure to change an oxygen cannula had the potential for residents to be placed at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system for receiving, reviewing and recording irregularities identified by the pharmacist during the MRR Medication Regimen Review). This deficient practice did not ensure the irregularities identified by the pharmacist was acted upon.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure; 1. A medication cart was locked and, 2. A medication with an unknown expiration date was disposed of. Failure to lock a medication cart had the potential for drug diversion, and failure to dispose a medication with an unknown expiration date had the potential for all residents to receive an ineffective and expired medication.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain proper infection control practices based on current standards when a staff opened and walked through a barrier that separated a Covid-19 red zone (an area where people with infectious respiratory disease are placed) and a green zone (an area where there was no infection). This failure had the potential to spread infection throughout the facility affecting residents' quality of life and care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the corridor had firmly secured handrails on each side. This deficient practice had the potential for harm to all residents.