Autumn Care of Cornelius

Inspectors wroteBased on observations, record review, and dietary staff, Registered Dietitian (RD), and Regional Registered Dietitian interviews, the facility failed to provide food items as specified by the approved menu. This practice had the potential to affect 11 residents receiving a regular diet and 2 residents receiving a puree diet (consisting of foods with a pudding-like texture) on 1 of 4 units (700/800 hall).

Inspectors wroteBased on observations, record reviews, staff and resident interview, the facility failed to reassess for the ability to self-administer medications for a resident who was self-administering a medication for 1 of 1 resident reviewed for self-administering medications (Resident #10).

Inspectors wroteBased on record review and Law Enforcement Detective and staff interviews, the facility failed to assure residents' property was safeguarded and staff did not misappropriate the residents' property for personal gain. Nurse Aide #1 used Resident #118's credit card to make unauthorized purchases totaling $757.73 without Resident #118's permission or knowledge and Housekeeper #1 used Resident #119's credit card to make an unauthorized purchase totaling $152.13 without Resident #119's permission or knowledge for 2 of 3 residents reviewed for misappropriation of resident property (Resident #118 and Resident #119).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to ensure Nurse #7 suctioned a resident's tracheostomy (a surgical opening in the neck to allow breathing) using sterile technique (a way of providing care that attempts to eliminate germs to prevent infection) for 1 of 1 resident reviewed for tracheostomy care (Resident #1).

Inspectors wroteBased on record review and interviews, the facility failed to ensure accurate accounting for the receipt of nine (9) tablets of controlled medications. This was for 1 of 1 facility emergency-controlled medication storage areas.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 25 opportunities, resulting in a medication error rate of 12% for 3 of 5 residents observed during the medication administration (Resident #79, Resident #84 and Resident #26).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to secure 3 bottles of medicated powder observed in a resident's room for 1 of 1 resident reviewed for medication storage (Resident #19).

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to honor a resident's food preferences for 1 of 1 resident reviewed for food preferences (Resident #88).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure staff implemented their infection control policy for hand hygiene when a nurse aide failed to remove dirty gloves and perform hand hygiene during incontinence care for Resident #1. This deficient practice was identified for 1 of 7 staff members observed for infection control practices (Nurse Aide #4).

Inspectors wroteBased on record review, and Responsible Party and staff interviews, the facility failed to refund the balance of an expired resident's personal fund account within thirty days to the individual or probate jurisdiction administering the resident's estate (Resident #107) and failed to refund Social Security checks received after a resident transferred to another nursing facility (Resident #104) for 2 of 2 residents reviewed for personal funds.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to prevent urinary catheter bags from touching the floor for 2 of 3 residents (Resident #11 and Resident #17) reviewed for urinary catheters.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure a controlled substance medication ordered for a resident was safely stored and secured using a double lock feature for 1 of 4 medication storage refrigerators observed (Resident #65). A controlled substance has an accepted medical use, a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. The facility also failed to date an open vial of insulin on 1 of 2 medication carts reviewed (300/400 hall medication cart) and failed to date a vial of Tuberculin Serum (used to conduct tuberculosis screening) and failed discard the Tuberculin serum after 30 days in 2 of 4 medication rooms reviewed 300/400 hall medication cart and 500/600 hall medication cart).

Inspectors wroteBased on test tray observations, resident, and staff interviews the facility failed to serve food that was palatable in taste for 7 of 7 residents reviewed for food (Resident #25, Resident #26, Resident #30, Resident #47, Resident #77, Resident #124, and Resident #126). This practice had the potential to affect other residents.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 06/04/21. This failure was for two deficiencies that were originally cited in the areas of Resident Assessment (F636) and Pharmacy Services (F761) that were subsequently recited on the current recertification and complaint investigation survey of 05/02/24. The repeat deficiencies during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program.

Inspectors wroteBased on observations, record review, staff and Resident interviews the facility failed to assess the resident for the ability to self-administer medications for 1 of 1 resident (Resident #25) reviewed for self-administration of medication.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete Care Area Assessments (CAAs) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 5 sampled residents (Residents #67 and #32).

Inspectors wroteBased on observation, record review and interviews the facility failed to develop a care plan that included an area of focus for a urinary catheter for 1 of 3 residents (Resident #17) reviewed for urinary catheters.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure the area around the dumpster was free of trash and debris for 1 of 2 dumpster reviewed.

Inspectors wroteBased on record review, observations, and interviews with staff the facility 1) failed to implement their policy and procedures for Hand Hygiene when Nurse Aide #2 did not perform hand hygiene before donning gloves and after possible contact with body fluids before touching other surfaces in the room for 1 of 1 resident reviewed for incontinence care (Resident #49), 2) failed to store soiled linens off the floor for 1 of 1 laundry room, 3) failed to follow the Droplet Precautions signage posted by the door of a resident's room when 1 of 1 staff (Activity Assistant #1) did not don a gown while feeding a resident for 1 of 4 residents on droplet/contact precautions (Resident #98).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to honor a resident choice to get out of bed everyday for 1 of 3 residents reviewed for choices (Resident #44).

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to thoroughly investigate alleged abuse and protect residents from further abuse and failed to implement their abuse policy and procedure in the area of reporting to the State Survey Agency when they received an allegation of staff to resident abuse for 1 of 3 residents (Resident #57) reviewed for abuse.

Inspectors wrote2. Review of document titled Preadmission Screening Resident Review (Pasrr) dated 06/07/22 indicated that Resident #9 was determined to be Level 2 Pasrr. Resident #9 was admitted to the facility on [DATE] with diagnoses that included paranoid personality disorder and traumatic brain injury. Review of the admission comprehensive Minimum Data Set (MDS) dated [DATE] indicated that Resident #9 did not have a Level 2 Pasrr and was completed by the MDS Coordinator. The MDS Coordinator was interviewed on 01/06/23 at 12:31 PM. The MDS Coordinator confirmed she had completed the admission comprehensive MDS dated [DATE] for Resident #9 and confirmed he had a Level 2 Pasrr in place. She stated it was probably an accident, I meant to click yes and accidentally clicked no. The MDS Coordinator stated she would correct the mistake immediately. [...]

Inspectors wroteBased on record review and interviews with staff the facility failed to clarify a physician's order for pain medication to include the frequency of administration between doses for 1 of 5 residents reviewed for pain (Resident #96).

Inspectors wroteBased on record review, staff, and family interviews the facility failed to fully complete and ensure the accuracy of a recapitulation of stay for 1 of 3 residents reviewed for discharge (Resident #143).

Inspectors wroteBased on record review and interviews with staff the facility failed to obtain a physician's order for use of a continuous positive airway pressure (CPAP) machine for a resident admitted with a diagnosis of moderate obstructive sleep apnea (sleep-related breathing disorder) for 1 of 2 residents reviewed for oxygen (Resident #251).

Inspectors wroteBased on observations, record review, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey of 06/04/21 and the focused infection control and complaint survey of 7/23/2020. This was for two deficiencies that were originally cited in June and July 2020 in the area of respiratory care and infection control and prevention and was subsequently recited on the current recertification survey of 01/07/23. The continued failure of the facility during two federal surveys of record shows a pattern of the facility ' s inability to sustain an effective Quality Assurance Program. The Findings Included: This tag is cross referred to: [...]