Archie Hendricks Senior Skilled Nursing Facility

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement an effective infection control program in accordance with internal policies and procedures, nationally recognized infection control guidelines and regulations when:a. Glucometers (a device used to check the blood sugar) were not cleaned and disinfected after use.b. Staff did not perform hand hygiene before putting on gloves. Failure to implement infection prevention practices may contribute to cross contamination of infection that can jeopardize the health and safety of residents and staff.

Inspectors wroteBased on observation interview, record review, manufacturer's manual review and facility policy review, the facility failed to ensure oxygen (O2) orders were in place for one of three sampled residents (Resident (R)32). In addition, maintain O2 concentrators filters free of dust and nasal cannulas were placed in bags while not in use for two of three sample residents (R32 and R33). This deficient practice had the potential to allow an increased chance of unnecessary respiratory treatment and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services that meet the needs of one of ten residents (Resident [R]5) observed for medication pass when Omeprazole (used to treat heartburn and indigestion) was administered after meal instead of before meal as ordered for R5. These failures could lead to decreased medication effectiveness and potential adverse health outcomes for R5.

Inspectors wroteBased on observations, interview and record review the hospital failed to ensure a Registered Dietitian (RD) or qualified nutrition professional provided frequent oversight of food and nutrition services which resulted in deficient practices related to the competency of foodservice staff for the safe storage of refrigerated foods and ensuring sanitary condition of walk-in refrigerator (Refer to F812). These failures had the potential to lead to foodborne illness in a highly susceptible population of 45 residents who received food from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure food safety standards when 1) there was lack of consistent labeling of preparation date and use-by date for foods capable of foodborne illness 2) storage of food items outside the shelf life and 3) food storage practices that may promote cross contamination as evidence by presence of molds in the walk-in refrigerator. Failure to provide a food production environment that is safe and sanitary may result in foodborne illness, cross contamination of food and equipment and use of expired ingredients that may affect flavor and/or texture of food. Foodborne illness and cross contamination may result in gastrointestinal distress and in severe instances may result in death. The use of expired ingredients may result in a food product that is unpalatable, resulting in decreased meal intake. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 12 sampled residents (R42) was provided assistance in formulating an advance healthcare directive when they expressed a desire to create one. This failure put the resident at risk for not having their wishes for treatment known and had the potential for the resident's decision regarding his healthcare and treatment options not being honored.

Inspectors wroteBased on interview and record review, the facility failed to notify one of three residents (R31) reviewed for hospitalization, or their representatives in writing and send a copy of the notice to the ombudsman of the reason for the transfer. This had the potential for the resident and/or their representative to be unaware of their rights and posed the risk of the ombudsman not being aware of the circumstances should appeals be filed by the resident or their representative regarding the transfer/discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (R31), reviewed for hospitalization, and/or their representative were provided with written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital. This failure had the potential for R31 or their representative to be unaware of their right to request a bed-hold and their right to return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment for two of 12 sampled residents (R23 and R29) accurately reflected the residents' status. *R29's weight loss and anticoagulant use were coded incorrectly. *R23's active diagnosis of depression was not coded in the MDS. These failures had the potential for the residents to not receive an individualized plan of care based on their specific care needs.

Inspectors wroteBased on interview and record review, the facility did not ensure that the resident's drug regimen was free from unnecessary drugs when Midodrine HCL (used to treat low blood pressure) was administered outside the parameters for one of one sampled resident (Resident [R] 41). This failure resulted R41 receiving unnecessary medication that could negatively affect his health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the as needed order for psychotropic medications (drugs that affect brain activities with mental processes and behavior) for one of six residents (R) reviewed for unnecessary medications (R45) had the documented rationale from the physician for the appropriateness of extending the medication beyond 14 days. This failure had the potential for R45 to experience adverse effects or receive unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was below 5%. The medication error rate was 12%. Three medication administration errors were identified out of 25 opportunities during medication administration observation on 09/26/24 as follows: *RN 2 administered a medication to Resident (R) 20 that was ordered to be administered before a meal, but instead, it was administered after R20 had already eaten breakfast. *RN 2 administered two different eye drops to R20 without allowing the required 3-5 minute wait between drops, as outlined in their policy and standard of practice. These failures could lead to decreased medication effectiveness and potential adverse health outcomes for R20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe respiratory care to meet the needs of two of 12 sampled residents (R16 and R28). * The facility failed to ensure the licensed nurses documented the administration of supplemental oxygen to R16 according to the physician's order. In addition, the facility failed to notify R16's physician when he was refusing to wear his CPAP (continuous positive airway pressure, is a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure) according to the physician's order. * The facility failed to ensure R28 was administered oxygen in accordance with the physician's order. These failures posed the risk of the residents not being provided the appropriate respiratory care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 12 sampled residents (R38), who required dialysis (a treatment to rid the body of toxins when the kidneys no longer function), received care and services consistent with professional standards of practice. The facility failed to assess and document care of R38's dialysis access site. This failure posed the risk of not detecting problems such as bleeding or other complications that would require immediate notification of the physician.

Inspectors wroteBased on interview and record review, the facility failed to educate and offer influenza and pneumococcal vaccines the residents were eligible to receive in accordance with the current Centers for Disease Control and Prevention (CDC) guidelines to 3 of 5 residents (R28, R14, and R15) reviewed for immunizations. This failure posed the risk of the residents contracting influenza or pneumonia and its associated complications.

Inspectors wroteBased on interview and record review, the facility failed to offer assistance to formulate an advance directive to one of 12 sampled residents (R38). This failure placed R38 at risk of not having his wishes for treatment known and had the potential for the resident's decision regarding his healthcare and treatment options not being honored.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to complete a thorough investigation for one (Resident (R) 23) reviewed for a facility reported incident of neglect, out of a survey sample of 12 residents. There was no evidence the facility interviewed other current residents regarding the allegation of potential neglect associated with a staff member (Certified Nursing Assistant (CNA) 109). The timeline of the report of the incident does not match the statement from the perpetrator CNA 109.

Inspectors wroteBased on record review, staff interviews, and facility policies and procedures, the facility failed to provide documentation of one resident's (Resident 40) discharge summary at the time of transfer to a hospital. The deficient practice could result in receiving facilities not having the necessary information for continuing care of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive plans of care to reflect the individual care needs of two of 12 sampled residents (R38 and R28). * The facility failed to develop a comprehensive care plan to address R38's dialysis (a treatment to rid the body of toxins when the kidneys no longer function) and care of his dialysis access site. * The facility failed to develop a comprehensive care plan for R28, who was receiving oxygen therapy. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive plan of care for one of 12 sampled residents (R7) was revised to reflect current needs and interventions. R7 sustained an unwitnessed fall in the bathroom on 07/24/23. R7's care plan was not revised to reflect the post fall interventions to apply grab bar covers to optimize grip and to consider support bar options in the bathroom. This failure posed the risk of not providing R7 with individualized person-centered care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident with a pressure injury received necessary monitoring and treatments to promote healing for one of three residents (R40) sampled for closed record review. R40 did not receive thorough weekly wound monitoring, a pressure reducing chair cushion, or changes in wound care after documented changes in wound drainage. R40's sacral wound increased 317% in area, developed malodorous drainage and increased pain requiring transfer to a hospital on 8/4/23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure one of 12 sampled residents (R7) was free from accident hazards. The facility failed to ensure the post fall interventions were in place for R7, who sustained a fall on 7/24/23, creating a risk for further falls and injuries.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that one resident's pain from an unstageable pressure ulcer was managed according to the standards of practice and the resident's goal and preferences for 1 of 3 closed record sampled residents (Resident 40).

Inspectors wroteBased on interview and record review, the facility failed to ensure that trauma survivors receive trauma-informed, culturally competent care accounting for residents' experiences and preferences to avoid triggers leading to re-traumatization for one resident (Resident (R) R19) of 12 residents in the sample.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Consultant Pharmacist's medication recommendation was addressed for one of five residents (R38) reviewed for unnecessary medications. The facility failed to ensure the Consultant Pharmacist's recommendation for R38 was acted upon by the physician. This failure had the potential for R38 to receive unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 12 sampled residents (R25) was free from significant medication errors. R25 was not administered the extended-release medications according to the physician's order. The medications were crushed and dissolved in water and were administered via GT (gastrostomy tube, a tube inserted through the abdomen into the stomach used to administer nutritional formula and medications). This failure could cause in rapid release and absorption of the medications that could result in a potentially life-threatening fatal dose.

Inspectors wroteBased on observation, record review, interviews, and review of facility policy and procedure, the facility failed to ensure infection control practices were maintained during observation of medication administration for one of three residents (Resident 34). The deficient practice puts residents at risk for illness from infection.