Caring House

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide adequate supervision and follow its elopement policy for 1 of 1 resident (R1) reviewed for supervision. This failure resulted in R1 remaining alone outdoors for approximately 4 hours in extreme heat conditions (100 Fahrenheit (F) - 111 F, with a heat index of up to 114 F). (Heat index is defined as a measurement that combines air temperature and relative humidity to determine how hot the air actually feels to the human body.) The deficient practice placed the resident at risk for heat exhaustion, heat stroke, and/or death and resulted in a situation of immediate jeopardy. [...]

Inspectors wroteBased on observation, interviews, and review of records, the facility failed to protect one resident's (R4) right to be free from physical abuse by another resident (R3) for one resident-to-resident altercation reviewed when R3 hit R4. The deficient practice resulted in a violation of R4's right to be free from resident-to resident abuse.

Inspectors wroteBased on interviews, records, and review of the RAI (Resident Assessment Instrument) manual, the facility failed to ensure that the MDS (Minimum Data Set) assessment accurately reflected the status of 1 out of 2 residents reviewed for falls (R12) and failed to reflect the PASARR (Preadmission Screening and Resident Review) status for 1 out of 2 residents reviewed for PASARR requirements (R8). Specifically, R12's MDS did not reflect a fall with major injury and R8's MDS did not reflect her PASARR Level II status for 3 consecutive years. The deficient practice may result in residents not receiving care appropriate to their individual needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR) screenings were coordinated and/or referred for Level II evaluations as required for newly evident Serious Mental Illness (SMI) diagnoses for two of two residents (Resident (R) 9 and R12) reviewed for PASARR requirements out of a total sample of 19 residents. The deficient practice may result in residents with Mental Disorders (MD) and/or Intellectual Disabilities (ID) not receiving specialized services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services to meet the needs of Resident (R) 2, one of five residents reviewed for unnecessary meds, when Staff held R2's long acting insulin 3 times in July unnecessarily, without an order or notifying the physician. This had the potential to cause R2 to experience hyperglycemia (elevated blood sugar). Hyperglycemia can lead to various short-term and long-term complications. Short-term effects include ketoacidosis (A complication of diabetes in which acids build up in the blood to levels that can be life-threatening), dehydration, and confusion. Long-term complications include diabetic retinopathy, nephropathy, neuropathy, cardiovascular disease, and increased risk of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 19 residents sampled (R35), was able to call for assistance when their call bell was not within reach and R35 was not capable of retrieving and using it. As a result, R35 was not able to call for help until the surveyor alerted the staff. This had the potential for R35's needs to be unmet. FindingsReview of the admission Record revealed the facility admitted R35 most recently on 04/12/2023 with a primary diagnosis of acute posthemorrhagic anemia (a condition where the body experiences a sudden and significant drop in red blood cells and hemoglobin due to a rapid loss of blood). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident (R) 38, one of three residents reviewed for beneficiary notices was provided a written Notice of Medicare Non-Coverage (NOMNC), and Advanced Beneficiary Notice of Non-coverage (ABN) when the facility identified R38's Part A benefit last covered day was due to end. This had the potential for R38 and/or their representative to be unaware of their appeal rights or how to activate an appeal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident [R] 1) received adequate assistance during transfer when transfer equipment was not utilized based on resident's plan of care. The deficient practice resulted R1 experienced right knee and left shoulder pain after the assisted fall during transfer on 05/07/24 at 10:52 AM.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident-centered care and treatment were provided in accordance with professional standards of practice and resident's comprehensive care plan when facility staff failed to ensure 1 of 5 sampled residents (R)(R78) reviewed for pressure injuries/skin conditions had documented evidence of weekly wound measurements to ensure the wound was objectively monitored and evaluated. In addition, R78 was observed with incorrect weight settings on their pressure relieving low air loss mattresses (LAL). These failures increased the resident's risks for pressure injuries, delayed care and less than optimal treatment.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure the residents environment was free of accident hazards for one (Resident (R)36) of three residents reviewed for accidents when staff failed to gather all necessary equipment prior to preparing the resident for a transfer from the bed to the wheelchair which resulted in R36 standing up on her own without the assistance of the CNA.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 1 sampled resident (R) 42 reviewed for bladder incontinence was comprehensively assessed for the type of urinary incontinence to ensure the development of individualized interventions to restore or maintain continence to the extent possible. This failure increased the resident's risk for ongoing and increased urinary incontinence.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure 1 of 1 resident (R24) observed for thickened liquids received liquids in the appropriate honey thick form as prescribed by a physician. This failed practice increased the resident's risk for aspiration.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to mail delivery on Saturdays. Four of 4 residents (R24, R18, R8 and R51) who receive mail and attended Resident Council stated that they did not receive mail on Saturdays. This failure had the potential to affect all residents who received mail and denied the residents timely access to their mail over the weekend, and placed residents at risk for diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that transfer/discharge notices provided to residents (R) and their responsible parties (RP) included information on their right to appeal including the name and contact information of the entity(ies) and information on how to obtain an appeal form for 3 of 3 sampled residents (R71, R61, R65) reviewed for hospitalizations. These failures did not afford residents and/or their RPs the opportunity to make informed decisions about transfers or discharges and prohibited access to an advocate who could inform residents and their RPs of their options and rights.

Inspectors wroteBased on observation, interview and record review the facility did not assure that staff followed infection prevention and control protocols for three of 18 sampled residents (R), when staff did not 1. sanitize their hands during and after the provision of incontinence care for two residents (R) (R38 and R15) and 2. did not sanitize surfaces and wound care equipment with Environmental Protection Agency (EPA) registered sanitizer after the provision of wound treatment for resident (R65). This deficient practice had the potential for staff to cross contaminate surfaces and spread contagious infections to other residents, staff or the public.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that one of one resident (R) R17 sampled for urinary catheters received appropriate treatment and services based on standards of practice when the facility failed to ensure that the urinary collection bag was kept in a dignity bag and did not touch the floor. This failure was a breach in infection control and had the potential to lead to a urinary tract infection.