Clearvista Lake Health Campus

Inspectors wroteBased on interview and record review, the facility failed to assess, monitor, and complete a timely Interdisciplinary Team (IDT) review of a resident's skin condition, per facility policy, for 1 of 3 residents reviewed for assistance with transfers. (Resident D)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure monitoring of the dishwasher sanitation and maintain clean kitchen flooring. This had a potential to effect 44 of 44 residents that reside in the skilled facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a self medication assessment was completed timely for 2 of 2 residents randomly observed for self medication (Residents 4 and 14)

Inspectors wroteBased on interview and record review the facility failed to ensure a safe method of transfer for 1 of 2 residents reviewed for falls. (Resident 1)

Inspectors wroteBased on interview and record review, the facility failed to timely notify a physician of a resident with pain, timely receive scheduled pain medications from the pharmacy, and to assess pain level, location of pain, and non-pharmacological interventions attempted prior to administering prn medications for 2 of 2 residents reviewed for pain. (Residents 26 and 63)

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply TED hose (stockings that help prevent blood clots and swelling in the legs) as ordered for 1 of 1 resident reviewed for edema and to hold blood pressure medication, as ordered by the physician, for 2 of 5 residents reviewed for unnecessary medications. (Resident 3, Resident 9, and Resident 13)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's pain was assessed for severity of her pain for 1 of 3 residents reviewed for catheter. (Resident 25)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication and/or supply storage rooms did not contain expired supplies for 1 of 2 medication rooms observed and 1 of 2 central supply rooms observed.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were complete and accurate with behavior monitoring and documentation of urine characteristics after insertion of a Foley catheter for 2 of 5 residents reviewed for unnecessary medications and 1 of 3 residents reviewed for catheters. (Residents' 11, 25, and 26)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control was maintained with hand hygiene during Foley catheter care for 1 of 3 residents reviewed for catheters. (Resident 3)

Inspectors wroteBased in observation, interview, and record review, the facility failed to ensure resident rooms were in good repair for 2 of 3 resident rooms reviewed for environment (Resident 15 and 29).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable, homelike environment for 1 of 37 residents in the facility. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's wound was maintained free of contamination by ants for 1 of 3 residents reviewed for wounds. (Resident B)

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a wound treatment order was placed timely for 1 of 3 residents reviewed for wound care. (Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by touching the tip of a medication tube with a bare finger, not performing hand hygiene with glove use, and not wearing proper personal protective equipment (PPE) when providing incontinence care to a resident in enhanced barrier precautions (EBP) (an infection control strategy to reduce the spread of multi-drug resistant organisms during high-contact care activities) for 1 of 3 residents reviewed for wounds. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was provided timely care and/or services in accordance with professional standards of practice for a resident who experienced an unwitnessed fall within the facility for 1 of 3 residents reviewed for falls. (Resident M)

Inspectors wroteBased on interview and record review, the facility failed to ensure a gait belt was utilized for transferring a resident who lost their balance and fell onto the bathroom floor for 1 of 3 residents reviewed for accidents. (Resident B)

Inspectors wroteBased on observation, interview and record review, the facility failed to timely assist in arranging emergency dental services for a resident with an abscessed tooth resulting in a delay of dental services for the abscessed tooth which was painful and infected 1 of 1 Resident reviewed for Dental (Resident 2).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prime an insulin flex pen prior to administering insulin for 1 of 5 residents observed during administration of medications, ensure monitoring of bowel and bladder outputs for 1 of 2 residents reviewed for hospitalization and 1 of 1 residents reviewed for constipation, and to administer antibiotics, as ordered by a physician, for 1 of 1 resident reviewed for dental (Residents' 2, 9, 35 and 142)

Inspectors wroteBased on observation, interview, and record review the facility failed to serve pureed food at appropriate temperatures with the potential to affect 7 of 37 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to have the interdisciplinary team determine and document self administration of medications was clinically appropriate for 1 of 5 residents observed during medication administrations. (Resident 190)

Inspectors wroteBased on interview and record review, the facility failed to inform a resident of a room change, prior to it being initiating, for 1 of 1 resident reviewed for abuse (Resident 10).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments completed regarding Dental concerns for 1 of 1 resident reviewed for dental, Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident reviewed for MDS Accuracy, assistance with eating for 1 of 2 residents reviewed for Activities of Daily Living and Discharge MDS accuracy for 1 of 1 resident reviewed for discharge (Resident 2, 9, 18 and 38)

Inspectors wroteBased on interview and record review, the facility failed to prepare a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, a reconciliation of all pre and post discharge medications, and a discharge plan of care for 1 of 1 resident reviewed for discharge. (Resident 38)

Inspectors wroteBased on observation, interview and record review, the facility failed to provide showers for 1 of 2 residents reviewed for Activities of Daily Living. (Resident 140)

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care planned fall intervention and to include therapy recommendations to the care plan for 1 of 1 resident reviewed for accidents. (Resident 29)

Inspectors wroteBased on interview and record review, the facility failed to coordinate a resident's medication administration times with their dialysis schedule and complete post dialysis assessments, as ordered, for 1 of 1 resident reviewed for dialysis. (Resident 14)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control was maintained during medication administration for 1 of 5 residents observed during medication administration and failed to ensure urinary catheter tubing and drainage bags were not touching the floor for 1 of 1 resident reviewed for urinary catheter. (Resident 2 and 35)