Center at Centerplace, LLC, the

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value and was palatable in taste, texture and temperature. Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and temperature.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to prevent the development and transmission of diseases and infection on two of two units. Specifically, the facility failed to:-Ensure staff wore the appropriate personal protective equipment (PPE) while providing care to Resident #4; and,-Ensure staff properly cleaned shared vital signs equipment between residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for one (#1) of three residents reviewed for grievances out of 29 sample residents. Specifically, the facility failed to report, document and follow-up on a grievance reported by Resident #1 concerning a lost personal item.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#6) of two residents reviewed for accident hazards out of 29 sample residents. Specifically, the facility failed to provide adequate supervision for Resident #6, who had previous falls, while showering.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#37) of two residents who required respiratory care received the care consistent with professional standards of practice out of 29 sample residents. Specifically the facility failed to:-Ensure a physician's order was in place for a bilevel positive airway pressure (BiPAP) machine (a type of non-invasive ventilation that helps people breathe by providing pressurized air through a mask or nasal plugs) for Resident #37 to use during the day; and,-Ensure a care plan was in place to clean, sanitize and store Resident #37's BiPAP mask.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure one (#15) of two residents reviewed for dialysis care out of 29 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to implement recommendations from the dialysis center for Resident #15 to be on a therapeutic diet and a fluid restriction.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free from any significant medication errors for two (#4 and #30) of five residents reviewed for medication errors out of 31 sample residents. Specifically, the facility failed to follow the physician's order parameters for Resident #4 and Resident #30's blood pressure medications.

Inspectors wroteBased on observations and interviews, the facility failed to provide proper storage for medical supplies and supplements for two of three medication carts and two of two medication storage rooms. Specifically, the facility failed to:-Discard expired insulin;-Discard expired testing supplies; and,-Discard expired supplements.

Inspectors wroteBased on record review and interviews, the facility failed to ensure each resident had the right to formulate an advanced directive for one (#1) out of three residents reviewed out of three sample residents. s out of three sample residents. Resident #1 was admitted on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia (lungs struggle to get enough oxygen into the blood), interstitial pulmonary disease (a condition that causes inflammation and scarring in the lungs), pulmonary hypertension (high blood pressure in the arteries connecting the heart to the lungs), chronic obstructive pulmonary disease with acute exacerbation (sudden worsening of respiratory symptoms like shortness of breath and coughing), and pneumonia (a lung infection). [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#5) of five residents received the highest practicable treatment and care in accordance with professional standards of practice of five sample residents. Specifically, the facility failed to ensure:-All prescribed medications which were ordered upon Resident #5's admission, including medications to treat infections, were administered as ordered and when available; and,-Notify the physician when Resident #5 medications were not administered as ordered.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received treatment and care consistent with professional standards of practice. This affected five (#1, #2, #5, #6 and #7) of six residents out of eight total sample residents. RESIDENT #1 Resident #1 was admitted to the facility from the hospital on [DATE]. His diagnoses included long-term use of anticoagulants (blood thinner). Orders included the anticoagulant Lovenox by injection, started 10/10/24 and discontinued 11/7/24, and Apixaban (Eliquis) an oral anticoagulant for deep vein thrombosis, started 11/7/24, discontinued 11/13/24, and ordered again on 11/13/24 to 11/28/24. A review of the treatment administration record (TAR) revealed the November orders, starting 10/16/24, read in part, Anti-coagulation medication monitoring: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of care by not sending a resident to the hospital when indicated that rose to the level of immediate jeopardy and created a situation where a serious adverse outcome occurred and caused harm.

Inspectors wroteBased on record review and interviews, the facility failed to honor resident choices for one (#7) of three residents reviewed out of eight sample residents. Specifically, the facility failed to provide Resident #7 a shower schedule based on her preferences.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure a process was in place which enabled staff to identify residents who were on enhanced barrier precautions (EBP) when a sign was not posted outside the residents' rooms; -Ensure staff donned (put on) appropriate personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP); -Ensure staff followed appropriate infection control procedures while administering a medication intravenously; and, -Ensure staff donned appropriate PPE and performed hand hygiene during medication administration.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to maintain accurate minimum data set (MDS) assessment for one (#18) of five residents out of 22 sample residents. Specifically, the facility failed to accurately complete the minimum data set (MDS) assessment and submit a timely assessment for Resident #18.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#12 and #138) of five residents who required respiratory care received the care consistent with professional standards of practice out of 22 sample residents. Specifically, the facility failed to: -Ensure a physician's order was in place to include the appropriate care of a continuous positive airway pressure (CPAP) machine for Resident #12 and Resident #138; -Implement a routine cleaning schedule for the care of Resident #12 and Resident #138's CPAP machines; -Ensure the distilled water was used in Resident #138's CPAP machine instead of tap water; and, -Ensure a care plan was in place and implemented for Resident #12 and Resident #138's CPAP machines to include route of administration, oxygen supplementation, storage, cleaning and machine settings.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free from significant medication errors for one (#89) of 11 residents reviewed for medication errors out of 22 sample residents. Specifically, the facility failed to ensure Resident #89 was administered blood pressure medications according to the physician's order.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that self-administration of medications was clinically appropriate for two (#54 and #49) of 12 residents out of 31 sample residents. Specifically, the facility failed to: -Ensure Resident #54 and Resident #49 were assessed for the appropriateness and safety of self-administration of medications; -Ensure Resident #54 and Resident #49 had physician's orders to self-administer medications; and, -Ensure Resident #54 had a physician's order for the medication being self-administered.

Inspectors wroteBased on record review, observations and interviews the facility failed to develop and implement a comprehensive centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for two (#8 and #16) of 12 out of 31 sample residents. Specifically, the facility did not ensure care plans and interventions were developed for: -Resident #8's antidiabetic medications that included hypo/hyper glycemic protocols; and, -Resident #16's post-traumatic stress syndrome (PTSD) with triggers (something that causes flashbacks to occur).

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who required dialysis received dialysis services consistent with professional standards of practice for one (#11) of two residents out of 31 sample residents. Specifically, the facility failed to: -Ensure Resident #11's comprehensive care plan included a care plan for dialysis; -Consistently and accurately monitor pre and post dialysis weights for Resident #11; and, -Ensure communication forms between the facility and the dialysis center were completed consistently and accurately for Resident #11.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#16) of three out of 31 sample residents. Specifically, the facility failed to identify Resident #16's post traumatic stress disorder (PTSD) and identify triggers which may retraumatize him.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were as free from unnecessary psychotropic medications as possible for one (#11) of four residents out of 31 sample residents. Specifically, the facility failed to: -Obtain consent for the use of a hypnotic medication for Resident #11; -Ensure behavior monitoring was occurring for the use of an anxiolytic (antianxiety) medication for Resident #11; -Ensure hours of sleep were consistently documented for Resident #11 who was on a hypnotic (sleep) medication; and, -Document resident specific care plan approaches to include medication specific target behaviors and non-pharmacological interventions for Resident #11's psychotropic medications.