Centerville Post Acute

Inspectors wroteBased on record review, staff interview, and transportation interview, the facility failed to properly discharge a resident. This affected one (Resident #117) out of three reviewed for discharge. The facility census was 111.

Inspectors wroteBased on observations, record review, and resident and staff interview, the facility failed to ensure a clean and sanitary environment. This had the potential to affect all 92 residents residing in the facility.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to assess residents with new diagnoses and medications to treat serious mental illness for eligibility for Level II pre-admission screening and resident review (PASARR) services. The affected four (#19, #34, #55, And #63) of five residents sampled for PASARR. The facility census was 96.

Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility failed to ensure a resident was being transported in a wheelchair in a dignified manner. This affected one (#34) of four residents sampled for dignity. The facility census was 96.

Inspectors wroteBased on record review, staff interviews; resident interviews, and policy review, the facility failed to ensure quarterly care conferences were conducted with residents and resident representatives. This affected three (#16, #41, and #73) of three residents sampled for care planning. The facility census was 96.

Inspectors wroteBased on medical record review, observation, staff interview, and family interview, the facility failed to ensure gastrostomy tube dressings were changed as ordered. This affected one (#301) residents of four residents reviewed for wound care. The facility census was 96.

Inspectors wroteBased on medical record review, observation, staff interview, resident interview, and review of policies, the facility failed to accurately assess a wound and timely initiate a treatment for new skin area. This affected one (#41) residents of four residents reviewed for wound care. The facility census was 96.

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to investigate a resident elopement. This affected one (#22) of one resident reviewed for elopement. The facility census was 96.

Inspectors wroteBased on observation, staff and resident interviews, and policy review, the facility failed to provide mechanically alter diet as ordered. This affected one (23) of the two residents reviewed for food texture. The facility identified seven residents on a pureed diet. The facility census was 96.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record reviews, review of Self-Reported Incident (SRI), staff and guardian interviews and review of facility policy, the facility failed to ensure resident was free from abuse. This affected one (#102) out of the three residents reviewed for abuse. The facility census was 110.

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to provide assistance with activities of daily living by not offering a resident showers. This affected one (#10) of three residents reviewed for personal hygiene. The facility census was 96.

Inspectors wroteBased on record review, observations and staff and resident interviews, the facility failed to accurately assess, monitor and/or document resident with bruising. This affected two ( #10 and #11) of three residents reviewed for skin breakdown. The facility census was 96.

Inspectors wroteBased on record review, observations, staff interviews and review of facility policy, the facility failed to ensure fall interventions were implemented per the residents care plan. This affected two (#10 and #12) of three residents reviewed for falls. The facility census was 96.

Inspectors wroteBased on observation, staff and resident interview, and policy review, the facility failed to ensure staff wore Personal Protective Equipment (PPE) appropriately. This had the potential to affect all 88 residents who reside in the facility. The facility census was 88. Findings Included: 1. Observation on 06/13/22 at 12:24 P.M. with Registered Nurse (RN) #31 who worked on the skilled hall, came out of Resident #326 room wearing a yellow procedure gown, and gloves. RN #31 had an N95 mask and a face shield on. RN #31 walked from room [ROOM NUMBER] to room [ROOM NUMBER] to retrieve a straw for Resident #326. RN #31 walked back to Resident #326's room after retrieving a straw from medication cart located in the hall. At no time was RN #31 observed removing her yellow protective gown or gloves. [...]

Inspectors wrote2. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included displacement of gastrointestinal prosthetic devices/implants/grafts, nontraumatic intracerebral hemorrhage, acute respiratory failure with hypoxia, hyperlipidemia, hemiplegia and hemipresis affecting the right side. Review of the MDS five day assessment dated [DATE]. Resident #31 had a Brief Interview for Mental Status (BIMS) score of eight indicating he had moderate cognitive impairment. He needed extensive assistance of two staff for bed mobility, transfer, toilet use, and personal hygiene. He did not walk. He required extensive assist of one staff for eating. He was totally dependent on one staff for bathing. He had functional limitation in range of motion on one side in the upper and lower extremity. Observation on 06/14/22 at 8:59 A.M. Resident #31 was lying in bed. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure physician orders for oxygen therapy were implemented. This affected one resident (#30) of three residents reviewed for oxygen. In addition, the facility failed to obtain physician orders for oxygen use. This affected one resident (#73) of three residents reviewed for oxygen. The facility census was 88. Findings Included: 1. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE]. Diagnosis included pulmonary hypertension, Covid-19 on 06/07/22, major depressive disorder, dementia, mild cognitively impaired, and cardiomyopathy. Review of the minimum data set (MDS) quarterly assessment dated [DATE] revealed the Brief Interview of Mental Status was not completed. Resident #30 was alert and not able to answer questions in the interview. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notices of Non-Coverage (SNFABN). This affected two (Resident #230 and #231) of three residents review for Beneficiary Notices. The facility census was 88.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to initiate a baseline and/or comprehensive care plan related to a seizure risk. This affected one (Resident #72) of five residents reviewed for unnecessary medications during the investigation stage of the annual survey. The facility census was 88.

Inspectors wroteBased on observation, record review, staff interview, and review of facility policy, the facility failed to provide proper positioning for a resident requiring total assistance. The affected one (Resident #25) of two residents reviewed for positioning, during the annual survey. The facility census was 88.

Inspectors wroteBased on medical record review, staff and family interviews, and review of facility policy, the facility failed to obtain and provide medication timely. This affected one (Resident #72) of five residents reviewed for unnecessary medication during the annual survey. The facility census was 88. Findings including: Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Herpes Viral Encephalitis (virus causing swelling in the brain), difficulty waking, urinary tract infection, hypertension, and dementia without behaviors. Review of the admission Minimum Data Set (MDS) assessment, dated 06/06/19, revealed Resident #72 was severely cognitively impaired with disorganized thinking behavior continuously present. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to timely act upon recommendations made by the facility pharmacist. This affected one (Resident #54) of five residents reviewed for unnecessary medication during the annual survey. The facility census was 88.