Autumn Care of Saluda

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of pressure ulcers for 1 of 2 residents reviewed for pressure ulcers (Resident #2).

Inspectors wroteBased on record review, observation and staff interviews, the facility failed to complete quarterly smoking risk assessments (assessment of a resident to determine if they are safe to smoke where a score between 0-9 indicates a resident was a safe smoker) for 1 of 2 residents reviewed for smoking (Resident #54).

Inspectors wroteBased on observation, record review and staff and Nurse Practitioner (NP) interviews, the facility failed to effectively supervise a cognitively impaired resident when the resident was able to exit the facility unsupervised and without staff knowledge for 1 of 3 residents reviewed for supervisions to prevent accidents (Resident #1).

Inspectors wroteBased on record review, observations, and interviews with residents and staff, the facility failed to protect the resident's right to be free from misappropriation of controlled narcotic pain medications for 3 of 4 residents reviewed for misappropriation of property (Resident #46, #1, and #18).

Inspectors wroteBased on observations and staff interviews, the facility failed to discard potentially hazardous food with signs of spoilage in 1 of 1 walk-in refrigerators, date food items available for residents in 1 of 1 kitchen refrigerators and discard damaged canned goods available for use. This practice had the potential to affect food served to residents.

Inspectors wroteBased on record review, staff, Nurse Practitioner (NP), and Medical Doctor (MD) interviews, the facility failed to notify the physician of a fall when they reported a change in condition to the physician for a severely cognitively impaired resident on blood thinner. In addition, the physician was not notified when there was a delay in a STAT (immediately without delay) x-ray order of the left hip for a resident with a decrease in range of motion in her left hip and pain. The STAT x-ray order was ordered on [DATE] at 12:48 PM and not obtained until [DATE] that showed an acute fracture of the left hip at the intertrochanteric region (the area near the hip joint). On [DATE] Resident #1 underwent surgery to repair the left hip fracture. On [DATE] Resident #1 was discharged from the hospital to hospice care and Resident #1 expired on [DATE]. [...]

Inspectors wroteBased on observation, record review, and staff, Nurse Practitioner, and Medical Doctor interviews, the facility failed to protect a resident's right to be free from neglect when staff disregarded Resident #1's plan of care and transferred the resident without the use of a total mechanical lift and two-person assistance. During the first transfer Resident #1 was assisted to the floor. The following day ([DATE]) the Nurse Practitioner was asked to assess Resident #1 due to her left foot dragging on the floor and x-ray results revealed an acute fracture of the left hip. On [DATE] Resident #1 underwent surgery to repair the left hip fracture. On [DATE] Resident #1 was discharged from the hospital to hospice care and Resident #1 expired on [DATE].

Inspectors wroteBased on record review and Medical Doctor (MD), Nurse Practitioner (NP) and staff interviews, the facility failed to assess Resident #1 by a nurse after a fall and prior to getting her off the floor. Additionally, the facility failed to ensure a STAT (immediate) order for x-ray was executed resulting in delayed care. On 4/24/24 Nurse Aide (NA) #1 transferred Resident #1 from her bed to the sit to stand lift and transported Resident #1 to the shower room. During a transfer in the shower room from the toilet to the sit-to-stand lift Resident #1's foot slipped and NA #1 had to lower Resident #1 to the floor. NA #1 called for assistance from NA #2. NA #1 and NA #2 did not notify the Nurse that Resident #1 had fallen. An assessment for injury was not completed by a Nurse prior to Resident #1 being moved. On 4/25/24 the NP placed a STAT order for left hip x-ray at 2:00 PM. [...]

Inspectors wroteBased on observation, record review, and staff, Nurse Practitioner, and Medical Doctor interviews, the facility failed to safely transfer a resident from the toilet to the shower chair when one staff member used the sit to stand mechanical lift instead of the total mechanical lift resulting in the resident falling to the floor for 1 of 3 sampled residents reviewed for accidents (Resident #1). On [DATE] Nurse Aide (NA) #1 transferred Resident #1 independently using a sit to stand mechanical lift. Resident #1's care plan indicated the resident required use of a total mechanical lift with 2-person assistance. During the transfer from the toilet to the sit to stand mechanical lift, Resident #1's foot slipped, and NA #1 had to lower Resident #1 to the floor. NA #1 requested help from NA #2 and they both assisted Resident #1 off the floor without using a mechanical lift. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to ensure all nursing staff, including agency staff, received orientation to include the location of resident care guides or the [NAME] (nurse aide guide that contains individualized care information) and verify competencies including resident transfers and total and sit to stand lifts prior to providing care for the residents in the facility. On [DATE] Nurse Aide (NA) #1 transferred Resident #1 independently using a sit to stand mechanical lift. Resident #1's care plan indicated the resident required use of a total mechanical lift with 2-person assistance. During the transfer from the toilet to the sit to stand mechanical lift, Resident #1's foot slipped, and NA #1 had to lower Resident #1 to the floor. NA #1 requested help from NA #2 and they both assisted Resident #1 off the floor without using a mechanical lift. [...]

Inspectors wroteBased on record review and interviews with staff, Nurse Practitioner (NP), Director of Nursing (DON) and Administrator, the facility failed to protect the resident's right (Resident #1) to be free of abuse when Resident #2's family member (facility Housekeeper) pulled Resident #2's TV remote from Resident #1's hands. Resident #1 sustained a fracture of his left index finger that required no surgical intervention. This deficient practice occurred for 1 of 1 resident reviewed for abuse. Findings Included: Resident #1 was admitted to the facility on [DATE] with diagnoses including stroke, paralysis of the right side and legal blindness. Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] coded Resident #1 as severely cognitively impaired with no behaviors noted. [...]

Inspectors wroteBased on a lunch meal tray line observation, record review, and staff interviews the facility failed to serve correct portions of food according to the planned menus. This failure had the potential to affect 61 residents receiving a regular diet texture and 6 residents receiving a pureed diet texture.

Inspectors wroteBased on observations and staff interviews the facility failed to maintain a clean floor and walls and label and date food and beverage items in 1 of 1 walk-in cooler; maintain a clean floor, cover food, and store food items off the floor for 1 of 1 walk-in freezer; date food items, store food off the floor, and remove expired food in 1 of 1 dry goods storage room; maintain clean stove, oven, shelves, and floor in 1 of 1 kitchen; cover, label, and date open beverage and food items, discard food with signs of spoilage, and maintain a clean reach-in cooler for 1 of 1 reach-in cooler; cover, label, and date food items and maintain a clean reach-in freezer for 1 of 1 reach-in freezer; restrain facial hair during food preparation; maintain 1 of 1 garbage disposal in working order; and ensure food items were labeled and dated in 1 of 2 nourishment rooms (A/B hall).

Inspectors wroteBased on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey completed on 05/12/22. This was for one repeat deficiency originally cited in the area of food procurement-store/prepare/serve that was subsequently recited on the current recertification and complaint investigation survey of 11/01/23. 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 Assessment and Assurance Program.

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated dietary and staffing concerns voiced by residents during Resident Council meetings for 7 of 9 months reviewed (February 2023, April 2023, May 2023, June 2023, July 2023, September 2023, and October 2023).

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications for 1 of 4 sampled residents observed with medications at bedside (Resident #64).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of Preadmission Screening and Resident Review (PASRR) and wandering behavior for 3 of 22 sampled residents reviewed (Residents #10, #26 and #83).

Inspectors wrote2. Resident #9 was admitted to the facility 02/11/20 with diagnoses including heart failure and quadriplegia (paralysis that affects all four limbs). The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively intact. Review of Resident #9's physician orders revealed no current order for the use of zinc oxide cream. During observations on 10/29/23 at 12:42 PM, 10/20/23 at 8:27 AM, 10/31/23 at 8:46 AM, and 11/01/23 at 8:14 AM, in clear view on top of a shelf in Resident #9's room was a 15-ounce container of medicated cream with the active ingredient 25% zinc oxide. An interview with Resident #9 on 10/29/23 at 12:43 PM revealed the zinc cream was applied by staff but had not been applied for a while. An observation and interview were conducted on 11/01/23 at 4:22 PM with the Director of Nursing (DON). [...]