Concordia at Spiritrust Sprenkle Drive

Inspectors wroteBased on review of facility policy, record review, and staff interview, it was determined that the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one of five residents reviewed (Resident 8).

Inspectors wroteBased on staff interview and available documentation review, it was determined that the facility administration failed to ensure care policies were reviewed and approved by the administration and Medical Director yearly.

Inspectors wroteBased on review of Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) staffing data report and staff interview, it was determined that the facility failed to electronically submit direct care staffing information for one of one quarters reviewed (FY Quarter 3 - April 1, 2024, to June 30, 2024).

Inspectors wroteBased on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that five residents have the right to a dignified dining experience during meal service in one of one dining rooms observed (Residents 9, 17, 24, 35, and 64).

Inspectors wroteBased on observation, clinical record review, policy review, and resident and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered plan of care for four of 19 residents reviewed (Residents 44, 48, 57, and 64). Findings Include: A review of the facility's policy, titled Comprehensive Care Planning Standard, revised November 15, 2017, read Each .center will develop a comprehensive care plan for each resident that includes their strengths, measurable objectives and timetables. Goal is to meet a resident's medical, nursing (physical/symptom control), mental, intellectual, emotional, social, spiritual, psychosocial and cultural needs that are identified during baseline care planning and in the comprehensive assessment. Care Plans are formatted in the 'I Care Plan' format to ensure resident centered/resident directed living. [...]

Inspectors wroteBased on observations, select facility meal ticket review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, during meal service, for five of 20 residents in one of one dining rooms observed (Resident's 3, 11, 27, 37, 45).

Inspectors wroteBased on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure a resident with limited range of motion receives the appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of one resident reviewed for range of motion services (Resident 57). Findings Include: A review of Resident 57's clinical record revealed diagnoses that included muscle weakness, abnormality of gait (a person's manner of walking), and mobility (the ability to move or be moved freely and easily). A review of the facility's policy, titled Restorative Program Standard, revised July 23, 2015, described its purpose: [...]

Inspectors wroteBased on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen and one of one nourishment area.

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to accurately assess the dental status of one of two residents reviewed for dental services (Resident 64).

Inspectors wroteBased on observations, clinical record review, and resident representative and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of 19 residents reviewed (Resident 61).

Inspectors wroteBased on facility policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to provide nutritional supplements as ordered by the physician for one of six residents observed during medication administration observations (Resident 4), and failed to to notify the physician of a significant weight change for one of five residents reviewed for nutrition (Resident 54).

Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents who are trauma survivors receive 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 of 18 Residents reviewed (Resident 12).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of four residents on transmission-based precautions (Residents 61).

Inspectors wroteBased on facility policy review, clinical record review, review of facility investigation documentation, and resident and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect, which resulted in actual harm, as evidenced by a 4.5 cm (centimeter) x 4 cm skin tear (a wound that occurs when the skin separates from itself, usually due to trauma or friction) for one of five residents reviewed (Resident 1).

Inspectors wroteBased on facility policy review, clinical record review, review of facility investigation documentation, and resident and staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a 4.5 cm (centimeter) x 4 cm skin tear (a wound that occurs when the skin separates from itself, usually due to trauma or friction) for one of five residents reviewed (Resident 1). Findings Include: Review of facility policy, titled Limited Lift Environment Standard, most recently dated August 7, 2015, revealed Resident Transfer- Responsibilities: When a mechanical lift is used, two (2) team members are required. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 22 residents reviewed (Resident 12). Findings Include: Review of Resident 12's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and atrial fibrillation (A-fib- irregular heart rhythm). Review of Resident 12's annual MDS assessment (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), dated August 4, 2023, revealed that section C- Cognitive Patterns, and section D- Mood, were marked with dashes (-), meaning not assessed. [...]

Inspectors wroteBased on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for two of 22 residents reviewed (Residents 1 and 77). Findings Include: Review of Resident 1's clinical record documented diagnoses that included anxiety (a feeling of worry, nervousness, or unease), depression (feelings of severe despondency and dejection), dysphagia (difficulty swallowing), and dementia (a condition characterized by progressive loss of intellectual functioning, and impairment of memory and abstract thinking). During an interview with Resident 1 on January 2, 2024, at 10:01 AM, it was revealed he wears dentures, his gums were sore at that time, and would like to see a dentist for his sore gums. Resident stated that when he bites down, it causes pain in his lower gum. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, it was determined that the facility failed to ensure that the comprehensive care plan was revised to include changes in the resident's status and plan of care for one of 19 residents reviewed (Resident 26).

Inspectors wroteBased on review of the facility's Dental Services policy, observations, staff and resident interviews, and record review, it was determined that the facility failed to provide routine and emergency dental services for one of 22 residents reviewed (Resident 1).