Autumn Care of Altavista

Inspectors wroteBased on observation, staff interview and clinical record review, the facility failed to follow physician orders for one of 24 residents. Resident #20 did not have physician ordered Geri sleeves in place. The Findings Include: Diagnoses for Resident #20 included; Convulsions, diabetes, pathological fracture, ostoarthritis, and Alzheimer's disease. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 5/5/23. Resident #20 was assessed with long and short-term memory problems with severely cognitive impairment with daily decion making. On 5/22/23 at 11:58 AM during an initial observation, Resident #20 was lying in bed with partial lower legs exposed. Resident #20's legs showed several small (dime to quarter size) faint bruising with no open areas. [...]

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to apply a hand splint for one of twenty-four residents in the survey sample (Resident #93).

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to implement interventions for fall/injury prevention for one of twenty-four residents in the survey sample (Resident #93)

Inspectors wroteBased on staff interview and clinical record review, the facility failed to ensure an accurate clinical record for two of 24 residents. Resident #20 and Resident #93 had an inaccurate Treatment Administration Record (TAR). The Findings Include: 1. Nurses inaccurately documented use of an intervention for Resident #93, when it was not being applied. Diagnoses for Resident #20 included; Convulsions, diabetes, pathological fracture, ostoarthritis, and Alzheimer's disease. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 5/5/23. Resident #20 was assessed with long and short-term memory problems with severely cognitive impairment. On 5/22/23, review of Resident #20's clinical record documented an active order that read: Geri sleeves to BLE [bilateral lower extremities] daily . [...]

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to have physician orders for care of a colostomy for one of 27 residents in the survey sample, Resident #28. Resident #28 had no physician orders for colostomy site cleansing and wafer/bag changes for over a month.

Inspectors wroteBased on resident interview, resident council group interview, staff interview, and a test tray observation, the facility staff failed to ensure food served was palatable and attractive in appearance for 8 residents in the survey sample. Resident #57, #83, #11, #55, #23, #15, #34, and #78 complained about the taste and appearance of the food.

Inspectors wroteBased on observations, staff interview, resident interview, and review of facility documents, the facility failed to provide residents the opportunity to select alternate menu items, and substituted menu items without the residents' knowledge; and failed to provide appealing options of similar nutritive value as substitutes, for all residents on a regular diet.

Inspectors wroteBased on observations and staff interview, the facility failed to follow professional standards for food service safety in the main kitchen. The oven, deep fryer, and stove were observed dirty with a build up of dirt and grease.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to follow professional standards of practice for performing quality control (QC) testing for two glucometers on two of two units: East and West. Staff performing the QC did not follow manufacturer directions, which was identified as the standard to follow for performing the QC.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure a safe room environment for one of 27 residents in the survey sample (Resident #64) and failed to provide supervision to prevent accidents for one of 27 residents in the survey sample (Resident #35). A portable oxygen cylinder (3/4 full) was stored unsecured in Resident #64's room. Facility staff failed to provide supervision to prevent multiple falls for Resident #35.

Inspectors wroteBased on clinical record review, resident interview, and staff interview, the facility staff failed for one of 27 residents in the survey sample, Resident # 34, to honor the resident's food preferences, and failed to periodically update the resident's food preferences. Resident # 34 was served a meal that included food for which he had expressed a dislike. The resident's food preferences had not been updated since 2017.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure professional standards of practice by a hospice provider for one of 27 residents in the survey sample, Resident #20. Records of weekly hospice visits for Resident #20 were not provided to the facility as required in the hospice services agreement.

Inspectors wroteBased on a medication pass and pour observation and facility document review, the facility staff failed to follow infection control practices for handwashing on the East and [NAME] units of the facility.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to follow professional standards of care for one of 25 residents in the survey sample. An extended release tablet of potassium chloride was crushed and administered to Resident #42 during a medication pass observation.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to follow physician's orders for a PICC (peripherally inserted central catheter) line dressing change for one of 25 residents in the survey sample, Resident #91; and failed to apply a physician ordered sheep skin arm cushion for one of 25 residents, Resident #307.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to implement interventions for pressure ulcer prevention for one of 25 residents in the survey sample. Resident #104's feet/heels were not elevated in bed as required in her plan of care for pressure ulcer prevention.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure proper wheelchair positioning for one of 25 residents in the survey sample, Resident # 43.

Inspectors wroteBased on observation, facility document review and staff interview, the facility failed to store the controlled medication Lorazepam in a secure manner on one of two nursing units (west unit medication room).

Inspectors wroteBased on resident interview and staff interview, the facility failed to ensure prompt delivery of mail received on Saturday, for all residents in the facility.