Clay Center Presbyterian Manor

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food in a sanitary manner for the 29 residents who received food from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a 14-day stop date or a specified duration with rationale for Resident (R)3's ongoing as needed (PRN) antianxiety (class of medications that calm and relax people) medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a 14-day stop date or a specified duration with rationale for Resident (R)3's ongoing as needed (PRN) antianxiety (class of medications that calm and relax people) medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to store Resident (R)21 and R3's oxygen tubing and nasal cannula in a sanitary manner.

Inspectors wroteThe facility had a census of 29 residents. Based on observation, interview, and record review, the facility failed to submit complete and submit accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents, with three reviewed for skin conditions not pressure-related. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent and treat skin tears and bruises for Resident (R) 19, who received skin tears and bruises during combative outbursts. This placed R19 at risk for further skin injury and pain due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 remained free from preventable accidents when staff failed to ensure R1 was positioned on the bed properly before placing her legs in bed, causing her to roll out of bed. This placed the resident at risk for injury related to preventable accidents. Findings Included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbance, pain, a history of falls, abnormalities of gait and mobility, and hypertension (high blood pressure). [...]

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents, with five reviewed for behaviors. Based on observation, record review, and interview, the facility failed to follow the plan of care and provide appropriate behavioral health care for Resident (R) 19, who had behaviors and was combative with care. This deficient practice resulted in skin tears and bruises and placed R19 at risk for impaired quality of life.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor and provide interventions for bowel management for one sampled resident, Resident (R) 19. This placed the resident at risk for fecal impaction and physical decline.

Inspectors wroteThe facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store and label biologicals as required when staff failed to place an open date on Resident (R) 17's Novolog (rapid-acting medication that works by lowering levels of glucose in the blood) flex pen (a device used to inject insulin). This placed the resident at risk of receiving an expired and ineffective dose of insulin.

Inspectors wroteThe facility had a census of 29 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food in a sanitary condition for 28 residents who resided in the facility and received meals from the facility kitchen, which placed the resident at risk for food borne illness.

Inspectors wroteThe facility had a census of 29 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for two of the 13 residents which had falls. The deficient practice placed the residents at risk of inaccurate care needs for Resident (R) 3 and R19.

Inspectors wroteThe facility had a census of 29 residents. The sample included 13 residents, with eight reviewed for behaviors. Based on observation, record review, and interview, the facility failed to revise one care plan for antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression) for one sampled resident, Resident (R) 9. This placed the resident at risk for inaccurate side effect monitoring.

Inspectors wroteThe facility had a census of 29 residents. The sample included 13 residents, with eight reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide medically- related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one sampled resident, Resident (R) 9, who had behaviors. This placed the resident at risk for further decline of her emotional and mental well-being.

Inspectors wroteThe facility had a census of 29 residents. The sample included 13 residents, with six reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate indication for use for one of six sampled residents, Resident (R) 28's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment in reality testing) medication, Seroquel. This placed the resident at risk for adverse side effects related to antipsychotic use.