Cumberland Trace Health & Living Community

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy for wound management to ensure a resident, (Resident C) received effective and appropriate treatments to prevent a non-pressure wound from becoming infected which resulted in actual harm when Resident C's wound became infected and required a hospital re-admission with a hip replacement exchange of the femoral head and liner [the plastic or metal part that sits inside the socket] for 1 of 1 residents reviewed for non-pressure wounds.

Inspectors wroteA. Based on observation, interview, and record review, the facility failed to prevent the potential for accidents for a resident (Resident 60) who had a history of falls with injury, by ensuring appropriate interventions were in place after she moved to a new room which resulted in actual harm, after she rolled out of bed and sustained an arm fracture for 1 of 9 residents reviewed for accidents; and failed to implement new interventions to prevent the potential for accidents for 2 of 9 residents reviewed for accidents (Residents 30 and 64). B. Based on observation, interview, and record review, the facility failed to prevent the potential for accidents when medications were found at bedside for residents without orders or assessments to self-administer their medications for 4 of 9 residents reviewed for accidents (Residents 41, 49, 22 and 2).

Inspectors wroteBased on observation and interview, the facility failed to date and label medications for 3 of 4 medication carts reviewed and 1 of 2 medication storage rooms reviewed.

Inspectors wroteBased on record review and interview, the facility failed to implement an advanced directive (code status) order for 1of 1 residents reviewed for advanced directives.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accurately assess 2 of 29 residents (Residents 53 and 15) reviewed for accurate Minimum Data Set (MDS) assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a care plan for history of Urinary Tract Infections (UTI) for a Resident (Resident 22) and for advanced directives for a resident (Resident 216) for 2 of 29 residents reviewed for care plan implementation.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a Peripherally Inserted Central Catheter (PICC) line was dressed properly to prevent infection for 1 of 1 residents (Resident 22) reviewed for PICC line dressings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (Resident 83) was treated with respect and dignity for 1 of 6 residents who attended and complained during an Indiana Health Department (IDOH) Resident Council meeting. This deficient practice resulted in psychosocial harm when the facility failed to provide interventions for her ongoing roommate concerns causing Resident 83 to be afraid to continue complaining about the situation, she began to lose sleep, had bad dreams, isolated herself in her room, became more tearful, and required an increase in her medication. (Residents 83 and 30).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a call device was within reach for 1 of 1 random observation for call lights (Resident 36).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely assessment and treatment of a resident's new open areas on the skin for 1 of 4 residents reviewed for pressure ulcer treatments and services (Resident 93).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders for oxygen administration and storage of oxygen equipment provided to 2 of 2 residents reviewed for oxygen administration (Residents 70 and 261).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure person-centered, individualized dementia care services were provided for a resident who desired outdoor activities which resulted in an increase of exit seeking behaviors and eventual elopement off a secured memory care unit for 1 of 6 residents reviewed for dementia care (Resident E); and the facility failed to ensure individualized dementia activities were implemented for 6 of 6 male residents who resided on the memory care unit (Resident E, 63, 13, 29, 56, and 22).

Inspectors wroteBased on record review and interview, the facility failed to ensure an advance directive was documented accurately in the medical record for 1 of 1 residents reviewed for advanced directives (Resident 88).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hot water temperatures were kept within required temperature ranges for 2 of 17 resident rooms in the dementia unit sampled for hot water temperatures.

Inspectors wroteBased on record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was coded to reflect serious mental illness for 2 of 3 residents (Residents 59 and 60) reviewed for Preadmission Screening and Resident Review (PASRR).

Inspectors wroteBased on observation, interview, and record review, the facility failed to document and follow up on non-pressure skin impairments and failed to address new onset acute pain promptly resulting in a change of condition for a resident for 1 of 3 residents reviewed for Urinary Tract Infections (UTIs). (Resident F)

Inspectors wroteA. Based on observation, interview, and record review, the facility failed to prevent the potential for accidents when two residents, who were both at risk for wandering and elopement, were able to exit the secured memory care unit without staff knowledge or supervision for 2 of 8 residents reviewed for accidents (Residents F and E). B. Based on interview and record review, the facility failed to prevent the potential for accidents by not identifying specific risk factors and implementing person-centered interventions for a resident for 1 of 8 residents reviewed for accidents (Resident 84).

Inspectors wroteBased on observation, record review and interview the facility failed to ensure a narcotic medication was properly destroyed and kept in a safe double locked condition, inside the medication cart, after it was identified for destruction, for 1 of 1 random observations of medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand washing was completed correctly and wrapped utensils were not contaminated during lunch services for 10 of 17 resident served on the memory care unit.