Azria Health Prairie Ridge

Inspectors wroteBased on observation, clinical record review, facility policy review and staff interview, the facility failed to provide incontinence care for Resident #10 (1 of 3 residents reviewed for incontinence care) after an episode of urinary incontinence and before dressing the resident in clean clothing. The facility reported a census of 53 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to accurately assess and implement a physician order to prevent the worsening of a moisture associated skin damage (MASD) wound for 1 of 2 resident (Resident #18) with a history of MASD. The facility reported a census of 57 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to maintain a clean, odor free, comfortable and homelike environment in 31 of 32 resident rooms, 2 of 2 shower rooms, and 2 of 3 hallways throughout the facility. The facility reported a census of 57 residents.

Inspectors wroteBased on employee record review, facility policy review, and staff interviews, the facility failed to complete a thorough background check for 1 of 5 employees reviewed for background checks. The facility reported a census of 57 residents.

Inspectors wroteBased on observation, facility policy review, resident and staff interview, the facility failed to maintain a safe and homelike environment by ensuring the metal guard was in place over the heating elements of a baseboard heater in the dining room and front sitting room located inside the main entrance of the facility and failed to ensure a the replacement of the molding trim at the base of a window in the dining room. The facility reported a census of 57 residents.

Inspectors wroteBased on observation, record review, staff interviews, and the facility policy, the facility failed to ensure ongoing, personalized interventions for residents to address alcohol consumption by residents at the facility and to address alcohol being shared between residents at the facility for 4 of 4 residents reviewed (Resident #2, Resident #3, Resident #13, and Resident #19) for alcohol use; failed to keep a medication secured in a medication cart resulting in a resident accessing a topical pain relief medication with possible ingestion of the medication per facility staff for 1 of 4 residents reviewed for inadequate nursing supervision (Resident #10); and failed to conduct a smoking evaluation during admission for 1 of 4 residents reviewed for smoking (Resident #12). The facility reported a census of 57 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, resident and staff interview, the facility to ensure staff served food at a palatable temperature to residents who requested a room tray for 1 of 1 meal service observations. The facility reported a census of 57 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to serve food based on resident preference for 1 out of 1 meals services observed (Residents #1, Resident #5 and Resident #7). The facility reported a census of 57.

Inspectors wroteBased on resident interviews, record review, staff interviews, and the facility policy, the facility failed to respect resident rights by not allowing residents to go out and smoke during the designated times for 3 of 4 residents reviewed for smoking (Resident #3, Resident #12 and Resident #13). The facility reported a census of 57 residents.

Inspectors wroteBased on observation, facility policy review, resident and staff interviews, the facility failed to follow up after a report of food purchased by a resident was missing for 1 of 4 residents (Resident #12) reviewed for personal possessions. The facility reported a census of 57 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to ensure staff consistently used and re-ordered the appropriate size bariatric incontinence brief for resident comfort, and to ensure a bathroom faucet and closet were accessible for 2 of 4 residents (Resident #18 and Resident #3) reviewed for accommodations. The facility reported a census of 57 residents.

Inspectors wroteBased on clinical record review, facility policy review and staff interviews, the facility failed to notify a family of a missed medication in a timely manner for 1 of 1 resident (Resident #12) reviewed for family notification. The facility reported a census of 57 residents.

Inspectors wroteBased on observations, record review, staff interviews, and the facility policy, the facility failed to keep urinary catheter tubing and collection bags off of the floor in an effort to prevent an urinary tract infection for 2 of 2 residents (Resident #3 and Resident #14) reviewed with a urinary catheter; and failed to start an antibiotic in a timely manner to treat an urinary tract infection for 1 of 2 residents (Resident #3) reviewed for urinary tract infections. The facility reported a census of 57 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, and staff interview, the facility failed to ensure nursing staff locked an unattended medication treatment cart for 1 of 2 observations for medication storage. The facility reported a census of 57 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to serve a meal to meet the physician ordered dietary needs for 2 (Residents #9 and #16) out of 42 residents reviewed for diet orders during a breakfast service. The facility reported a census of 57.

Inspectors wroteBased on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure nursing staff followed enhanced barrier precautions to prevent the spread of multi-drug resistant organisms to residents during when personal care and wound care provided for 1 of 1 resident (Resident #18) reviewed for infection control. The facility reported a census of 57.

Inspectors wroteBased on record review, staff interviews, and the facility policy, the facility failed to thorough document transfers to the hospital (Resident #2 and Resident #13); failed to provide the resident and/or the resident's representative a transfer notice, in writing, for 2 of 2 residents reviewed for hospitalization (Resident #1, Resident #11). The transfer notice also failed to include the resident appeal rights, the Ombudsman contact information, and the contact information for those agencies responsible for the protection of residents with intellectual, developmental, mental and related disabilities. This failure impacted all residents transferred to the hospital. The facility failed to notify the Ombudsman after resident sent to the hospital (Resident #10) for 5 of 5 residents reviewed for transfers.

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews the facility failed to ensure that residents remained free from resident to resident altercations for 1 of 9 resident records reviewed (Resident #2). The facility reported a census of 62 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews the facility failed to ensure that residents are free from financial exploitation for 1 of 9 residents (Resident #3) reviewed. The facility reported a census of 62 residents.

Inspectors wroteBased on clinical record review, staff, resident and family interviews, the facility failed to make an attempt to meet resident needs prior to issuing emergency discharges for 2 of 2 residents (Resident #1 and Resident #5) reviewed. After a resident to resident altercation the facility issued emergency discharges to Resident #1 and Resident #5 upon their transfer to the hospital for an evaluation. The facility reported census was 57.

Inspectors wroteBased on observation, facility policy review, and staff interviews, the facility failed to store, prepare and handle food in a sanitary manner in an effort to prevent cross contamination and food borne illness during 2 of 2 kitchen observations. The facility reported a census of 53 residents.

Inspectors wroteBased on staff and residents interviews, record review, and the facility policy, the facility failed to treat residents in a dignified manner for 3 of 3 residents (Resident #11, Resident #21, and Resident #33) reviewed for dignity. The facility reported a census of 53 residents

Inspectors wroteBased on staff interviews, record review, and the facility policy, the facility failed to notify the physician of a resident's weight loss for two different occurrences for 1 of 3 residents reviewed for nutrition (Resident #7). The facility reported a census of 53 residents. Findings Include: The MDS assessment dated [DATE] revealed Resident #7 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed a loss of 5% or more in the last month or loss of 10% or more in 6 months and on a therapeutic diet. The MDS revealed resident took an diuretic. [...]

Inspectors wroteBased on clinical record review, facility policy review and staff interviews, the facility failed to update Care Plans to reflect two residents had a significant weight loss and one resident no longer received dialysis services for 3 of 18 (Resident #7, Resident #11 and Resident #3) reviewed for Care Plans. The facility reported a census of 53 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, and resident and staff interviews, the facility failed to follow speech therapy recommendations for eating assistance for 1 of 18 residents reviewed for following provider orders (Resident #11). The facility reported a census of 53 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, and resident and staff interviews, the facility failed to provide an intervention in a timely manner for a resident who complained of a rash and associated discomfort for 1 of 18 residents (Resident #21) reviewed for assessment and intervention. The facility reported a census of 53 residents.

Inspectors wroteBased on observation, clinical record review, and staff interview, the facility failed to implement a restorative nursing program per guidance from therapy for 1 of 1 resident (Resident #25) reviewed for positioning and mobility. The facility reported a census of 53 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent when three medication errors were observed from twenty-seven opportunities for 3 of 6 residents reviewed for medication administration (Resident #28, Resident #33, Resident #36). This deficient practice resulted in facility medication error rate of 11.11%. The facility reported a census of 53 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Warfarin and Apixaban, anticoagulant medications, sliding scale insulin, and narcotic pain medication were administered per physician order for four of four residents reviewed for significant medication errors (Resident #20, Resident #36, Resident #55 and #62). The facility reported a census of 53 residents.

Inspectors wroteBased on clinical record review, and staff interviews, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments completed timely for 5 of 19 residents reviewed for completion of comprehensive assessments (Resident #9, Resident #18, Resident #26, Resident #29, and Resident #34). The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to ensure annual Minimum Data Set (MDS) assessments completed timely for 2 of 19 residents reviewed for completion of comprehensive assessments (Resident #18, Resident #26). The facility reported a census of 55 residents.

Inspectors wroteBased on the clinical record review, staff interviews, and the facility policy review, the facility failed to resubmit a PASRR (Preadmission Screening and Resident Review) with new mental health diagnoses and psychotropic medications added to the plan of care for 1 of 2 residents reviewed for PASRR (Resident #20). The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to administer a pneumococcal vaccine to 1 of 5 residents reviewed for pneumococcal vaccines (Resident #8). The facility reported a census of 55 residents.

Inspectors wroteBased on observation, resident and staff interviews, the facility failed to maintain a clean environment free of hazards. Observations found resident rooms poorly cleaned, leaving debris and trash under beds for multiple days and hallways cluttered with equipment and wheelchairs.

Inspectors wroteBased on observation, infection control policy, clinical record review and staff interview, the facility failed to use enhanced barrier precautions and consistent hand hygiene practices between resident contact. The facility reported census was 48.

Inspectors wroteBased on record review, staff interviews, and the facility policy the facility failed to complete the quarterly Minimum Data Set (MDS) assessment in a timely manner for 4 of 15 residents reviewed for quarterly MDS assessments (Resident #4, #22, #35, #46). The facility reported a census of 48.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed rails, use of foot pedals during transport, and documentation of behaviors, anxiety, and major depressive disorder were addressed on the Care Plan for four of fifteen residents reviewed for Care Plans (Resident #7, Resident #11, Resident #22, Resident #30). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to serve food that was warm and palatable for three of twenty four residents reviewed (Resident #23, Resident #30, Resident #103). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, resident and staff interviews, clinical record review, the facility failed to ensure the dignity of two of three reviewed (Residents #3 and #7). The facility reported a census of 47 residents.

Inspectors wroteBased on observation, interviews, record review, and the facility policy, the facility failed to have the call light within reach for a resident while in bed for 1 of 1 residents reviewed for call lights (Resident #35). The facility reported a census of 48.

Inspectors wrote00. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Diabetes Disorder, Gastrostomy and Anxiety Disorder. It also identified Resident #7 required substantial assistance with showers/baths, dressing, putting on footwear and turning from side to side. It did not identify the resident with a feeding tube and identified she was on a therapeutic diet. Observations of the resident during the survey from 11/27/23 through 11/30/23 revealed the resident's bed with two ¼ side rails up. In an interview on 11/29/23 at 10:19 AM, Resident #7 reported she purchased her own bed as it had an air mattress and the side rails came with it, but none of the staff had provided any kind of education on safety issues on it. [...]

Inspectors wroteBased on record review and staff interview, and facility policy the facility failed to document the resident's Advance Directives for two of two residents reviewed (Residents #103 and #203). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician notification occurred for heart rate per parameters included the resident's Care Plan for one of one residents reviewed for physician notification (Resident #4). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to provide a homelike environment by cleaning and removing stains and dried food on a resident's recliner for 1 of 2 residents reviewed for cleanliness of the building (Resident #22). The facility reported a census of 48.

Inspectors wroteBased on observation, interviews, record review, and the facility policy review, the facility failed to ensure residents free from chemical restraints when narcotics pain medication was administered for management of resident's behavior for 1 of 5 residents reviewed for unnecessary medications (Resident #15). The facility reported a census of 48.

Inspectors wroteBased on record review, interviews, and the facility policy review, the facility failed to provide the required documentation needed for transfers to the hospital for 1 of 3 residents reviewed for hospitalizations (Resident #22). The facility reported a census of 48.

Inspectors wroteBased on record review, interviews, and the facility policy, the facility failed to consistently notify the ombudsman of a resident's transfer to the hospital for 1 of 3 residents reviewed for hospitalization (Resident #22). The facility reported a census of 48.

Inspectors wroteBased on record review, staff interviews, and the facility policy the facility failed to complete the Annual Minimum Data Set (MDS) assessment within a timely manner for 3 of 15 residents reviewed for annual MDS assessments (Resident #15, #22, #35). The facility reported a census of 48.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure timely completion of a Significant change Minimum Data Set (MDS) assessment for one of one resident reviewed for significant change assessments (Resident #14). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, interview, clincial record review, and facility policy review the facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessment to address use of bed rails, gastrostomy tube, and weight loss for two of fifteen residents reviewed for MDS accuracy (Resident #7, Resident #11). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to address the problem of an open wound on the initial care plan for one of one residents admitted within the last 30 days. (Resident #103). The facility reported a census of 48 residents.

Inspectors wroteBased on record review, resident and staff interview, the facility failed to update the Care Plans for two of fifteen residents reviewed after returning from the hospital (Residents #7 and #22). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to follow physician orders and administer blood pressure medications per accepted standard of practice for 3 of 15 residents reviewed (Residents #7, #11, and #30) The facility reported a census of 48 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure through assessment prior to a resident's hospitalization, failed to ensure throrough assessment post a documented episode of choking, and failed to ensure the dressing to a non-pressure skin wound changed as ordered for three of four residents reviewed for assessment/intervention (Resident #7, Resident #14, Resident #103). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was able to access appropriate and timely vision care by an outside provider. The resident's vision had declined over the last nine months. (Resident #23) The facility reported a census of 48 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate falls, determine root cause analysis, and ensure pre-existing interventions were implemented for fall prevention, and failed to ensure foot pedals utilized when a resident pushed in their wheelchair for two of five residents reviewed for accidents (Resident #11, Resident #30). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consistent completion of assessments prior to dialysis for one of one resident reviewed for dialysis (Resident #37). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure informed consent completed for use of side rails and ensure assessments completed for use of side rails for two of two residents reviewed for side rails (Resident #7, Resident #11). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately document receipt of hospice services and completion of a wound treatment for two of two residents reviewed for records (Resident #18, Resident #103). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to ensure proper infection control techniques for one of three residents observed during medication pass (Resident #6), during the drainage of a GT (gastric tube) drainage bag for one of one residents observed with a GT drainage bag (Resident #7) and during wound care for one of one residents observed (Resident #103). The facility reported a census of 48 residents.

Inspectors wroteBased on Immunization Registry Information System (IRIS) review, staff interview, and facility policy review, the facility failed to ensure pneumococcal vaccines offered timely for two of five residents reviewed for immunizations (Resident #4, Resident #11). The facility reported a census of 48 residents.

Inspectors wroteBased on Information Registry Information System (IRIS) review, staff interview, and facility policy review, the facility failed to ensure a resident was offered COVID-19 vaccination(s) timely for one of five residents reviewed for immunizations (Resident #18). The facility reported a census of 48 residents.