Ascension Living Via Christi Village McLean

Inspectors wroteThe facility reported a census of 32 residents, with 12 residents sampled for advanced directives (a written document, which indicates the medical decisions for health care professionals when the person could not make their own decisions). Based on observation, interview and record review, the facility failed to ensure one resident's advanced directives were thoroughly completed when Resident (R)34 had a do not resuscitate (DNR- or no code, a legal document or order that means the person does not desire resuscitative measures) which was only signed by two licensed nurses as a verbal order and lacked a physician signature rendering it invalid. This placed the resident at risk for an impaired right to have advance directives honored.

Inspectors wroteThe facility reported a census of 32 residents. The sample included 12 residents. Based on interview and record review, the facility failed to ensure the correct and complete Beneficiary Protection Notification forms were issued to one of three residents reviewed, Resident (R) 27. This placed the resident at risk for uninformed decisions.

Inspectors wroteThe facility reported a census of 32 residents. The sample included 12 residents, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 34's as-needed antianxiety (a class of medications that calm and relax people) medication had a 14-day stop date, or a specified duration, and physician rationale for the extended duration. This deficient practice placed the affected resident at risk for adverse effects associated with the use of psychotropic (alters mood or thoughts) medications.

Inspectors wroteThe facility had a census of 32 residents. The sample included 12 residents, with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide a written bed hold policy and failed to issue a written notification as soon as practicable for transfers of Resident (R) 39. This placed the resident at risk for impaired rights related to returning to the facility.

Inspectors wroteThe facility had a census of 32 residents. The sample included 12 residents. Based on observations, interviews, and record review, the facility failed to provide services to meet professional standards of care when staff signed a treatment order as completed but did not complete the treatment for Resident (R) 15. This placed the resident at risk for delayed healing and infection.

Inspectors wroteThe facility reported a census of 32 residents. The sample included 12 residents with one dependent resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to provide ADL care including grooming of facial hair for Resident (R) 9. This placed the resident at risk for impaired dignity and poor hygiene.

Inspectors wroteThe facility reported a census of 32 residents; the sample included 12 with five residents reviewed for unnecessary medications and related monitoring. Based on observation, interview, and record review revealed the facility failed to monitor and respond to Resident (R)14 and R36 for lack of bowel movements. This placed the residents at risk for complications including constipation and bowel obstruction.

Inspectors wroteThe facility reported a census of 32 residents. The sample included 12 residents. Based on interviews, observation and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to a Resident (R) 42 with a peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart). The facility further failed to ensure adequate hand hygiene during personal care for R3 when staff failed to complete proper hand hygiene. The facility failed to store respiratory equipment in a sanitary manner for R6. These deficient practices had the potential to spread infections to the residents in the facility.

Inspectors wrote- Review of Resident (R)10's electronic medical record (EMR) revealed diagnoses which included: morbid obesity (a serious health condition resulting from an abnormally high body mass) and schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She required extensive assistance of two staff for transfers. Her balance was not steady, and she was only able to stabilize with staff assistance. She had no falls since her prior assessment. The Falls Care Area Assessment (CAA), dated 12/09/22, documented the resident was at a high risk for falls. The Quarterly MDS, dated 09/07/23, documented the resident had a BIMS score of 15, indicating intact cognition. [...]

Inspectors wroteThe facility reported a census of 35 residents. Based on observation, record review and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria.

Inspectors wroteThe facility reported a census of 35 residents. Based on observation, interview and record review, the facility failed to maintain an effective infection control program with the failure to ensure sanitary storage of clean linen in the beauty shop, lack of housekeeping staff knowledge of cleaning products for clostridium difficile (a spore producing highly transmissible bacteria), use of expired sanitizing wipes, and unsanitary catheter care for resident (R)33.

Inspectors wroteThe facility reported a census of 35 residents. Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff regarding the parameter of the kitchen floor containing trash and debris.

Inspectors wroteThe facility reported a census of 35 residents. Based on observation and interview, the facility failed to ensure the beauty shop exhaust ventilation remained in good working order for the residents of the facility.

Inspectors wroteThe facility reported a census of 35 residents with 15 selected for review which included six residents observed for medication administration. Based on observation, interview and record review, the facility failed to ensure appropriate storage of one Resident (R)19's inhaler of the six residents observed.