Benefis Senior Services - Grandview

Inspectors wroteBased on interview and record review, the facility failed to identify, assess, measure, document, monitor, and obtain physician orders promptly for the treatment and care of an avoidable pressure ulcer, including failing to develop and implement a baseline care plan for pressure ulcer prevention. The pressure ulcer developed within ten days of the resident's admission to the facility and worsened to a Stage IV, causing the resident pain. She did not want to be repositioned and voiced not wanting to live. The resident was placed in Hospice for end-of-life care and services for 1 (#27) of 5 residents sampled for pressure injuries. This deficient practice increased the risk of negative outcomes of the admission identification process of pressure injuries and residents at risk of developing pressure injuries. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain informed consent to include an explanation of the risks, benefits, and alternatives before the administration of psychotropic medications for 1 (#36) of 18 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to report investigative findings to the State Survey Agency within the required timeframe of 5-working days for 1 (#6) of 18 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for a resident that included the minimum necessary information needed to provide person-centered care for 1 (#39) of 18 sampled residents. This deficient practice increased the risk of the resident not receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to adhere to accepted infection control standards, including proper hand hygiene and glove use, during a medication pass for 2 (#s 33 and 39) of 18 sampled residents. This deficient practice increased the likelihood of the transmission of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff member C followed proper infection control practices while performing blood glucose monitoring with a portable handheld glucometer between residents for 2 (#s 1 and 3); and failed to perform hand hygiene before donning clean gloves prior to blood glucose monitoring for 1 (#3) of 2 sampled residents for blood glucose monitoring. These deficient practices increased the risk of transmission of bloodborne pathogens between residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan which included the minimum necessary instructions needed to provide effective and person-centered care of the resident for 3 (#s 3, 17, and 21) of 17 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the oxygen rate of delivery was included in the provider's oxygen orders for 4 (#s 3, 17, 78, and 129); failed to ensure a form of documentation was in place for when oxygen tubing was last changed for 5 (#s 3, 17, 21, 78, and 129); and failed to ensure proper infection control practices were adhered to for a respiratory nebulizer mask/mouthpiece for 1 (#17) of 17 sampled residents. These deficient practices had the potential to affect the correct rate of oxygen delivery and increase the risk for infections in residents with prescribed oxygen.

Inspectors wroteBased on interview and record review, the facility failed to provide the required SNF Beneficiary Notification, Form CMS-10055 to 1 (#111) of 3 sampled residents who received Medicare Part A skilled services.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medications, prescribed on an as needed basis, were limited to 14 days unless the resident's medical record included documented rationale for continued use for 2 (#3 and #6) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative, in writing, of the facility's bed hold policy when transferring a resident to the hospital for 1 (#3) of 17 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a person-centered comprehensive care plan to include the use of oxygen therapy for 2 (#s 3 and 17); and failed to include an increased risk of aspiration for a resident admitted to the hospital and returned after an event of food aspiration for 1 (#3) of 17 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update resident care plans to include actual falls and updated fall interventions for 2 (#s 4 and 180) of 17 sampled residents. The failures placed the residents at risk for recurrent falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff member H adhered to sanitary hygiene practices, by wearing a beard net/covering while preparing residents' food trays in the kitchen area. This failure increased the risk of hair getting in food for any resident the employee was preparing food for, or from the area the employee was working in, when not wearing protective hair coverings.

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were answered in an appropriate timeframe for 3 (#s 5, 6, and 10) of 4 sampled residents concerning call lights; and the facility failed to prevent falls for 1 resident (#5) requiring help after pushing the call light. This had the potential to result in more falls in the facility with those residents requiring help and pushing the call light button for assistance.

Inspectors wroteBased on interviews and record review, the facility failed to provide a safe and orderly discharge from the facility, to home, for 1 (#1) of 3 sampled residents, and the resident had not met his goals prior to the discharge, he had a wound/fistula, multiple medications, and needed ongoing rehabilitation services. The failure increased the risk of a poor outcome and safety concerns for the resident due to his inability to care for himself as needed.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper food preparation and storage in the kitchen and in the cottages. This deficiency had the potential to affect all residents who received services from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assessed and found safe to self-administer their medications prior to doing so, and the facility failed to document the assessments or get a physician order allowing the self medication administration in the electronic health records's for 3 (#s 153, 158, and 168) of 19 sampled residents. Findings Include: 1. During an observation on 6/17/24 at 4:50 p.m., staff member O set resident #158's medications on her bedside table. The medication cup contained a calcium chloride and two hydrocodone/tylenol tablets. The resident was noted to have some physical deformities of her hands. The nurse exited the room and did not watch or encourage the resident to take the medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services which met professional standards of practice, by allowing residents without assessments and physician orders to self-administer medications, and they were left unattended with medications, for 3 (#s 153, 158, and 168) of 19 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5%. The observed error rate was 40.7%. The errors involved the staff member administering the medication was not staying with the resident to ensure the medications were taken for 3 (#s 153, 158, and 168) of 11 residents sampled for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used appropriate hand hygiene during meal distribution. This practice caused the potential to contaminate food and could effect all residents receiving food from the dietary department.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission, for 2 (#s 165 and 171) of 19 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was updated to reflect a resident's current care requirements for 1 (#169) of 19 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to properly monitor a resident with difficulty swallowing during medication pass for 1 (#168) of 19 sampled residents.

Inspectors wroteBased on observation and record review, the facility failed to provide pharmaceutical services to ensure safe administration of a Schedule II controlled substance for 1 (#158) of 11 residents sampled for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to assess or provide immunization, education, or obtain a declination, for 6 (#s 153, 157, 158, 160, 168, and 173) of 6 sampled residents for immunizations.