Cura of Monticello

Inspectors wroteBased on record review and interview, the facility failed to ensure residents' comprehensive care plans were updated to include Enhanced Barrier Precautions (EBP) interventions for 3 of 3 residents reviewed (R11, R14, and R28) who met criteria for EBP. Furthermore, based on observation, interview and document review, the facility failed to ensure resident care plans and TASK sheets contained information for 1 of 1 resident (R1) in the sample who received oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided care in a manner that promoted dignity and respect by failing to offer and perform routine grooming services, specifically shaving, for 2 of 2 residents (R14 and R28) reviewed for personal hygiene. In addition, the facility failed to ensure a catheter bag containing urine was concealed from public view for 1 of 1 residents (R20) reviewed with a catheter.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was assessed, as scheduled, for the ability to safely self-administer a prescribed nebulizer treatment for 1 of 1 resident reviewed (R14). Specifically, the facility failed to complete required assessments to determine the resident's continued ability to self-administer nebulizer treatments in accordance with facility policy and professional standards of practice. This deficient practice resulted in the potential for improper medication administration, missed or ineffective treatments, and respiratory compromise.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was informed of the medications being administered at the time of administration in accordance with the resident's expressed preferences and right to make informed choices for 1 of 1 resident (R11) reviewed. Specifically, the facility failed to verbally identify medications prior to administration for a resident who was blind and had requested to be informed of all medications received.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's representative was notified after a fall for 1 of 1 resident (R11) reviewed for notification of change.

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate reporting of an alleged violation involving resident neglect for 1 of 1 incident reviewed involving (R11). Specifically, the facility reported inaccurate information related to a resident fall with injury, which did not accurately reflect the circumstances and outcome of the accident. This deficient practice resulted in the potential for delayed or inappropriate oversight, failure to ensure resident protection, and noncompliance with federal reporting requirements.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Office of the Ombudsman for Long-Term Care was notified of a resident's transfer to the hospital and subsequent discharge from the facility for 2 of 2 residents (R70 and R72) reviewed as a closed record.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Brief Interview for Mental Status (BIMS) assessment was completed and accurately coded for a quarterly and/or admission Minimum Data Set (MDS) assessment for 2 of 2 residents reviewed (R28 and R20). In addition, the facility failed to ensure a physical restraint assessment was completed for 1 of 1 resident reviewed (R8) for accuracy of assessment. R28 R28's quarterly MDS dated [DATE], identified cognition was coded as not assessed. R28 required assistance with activities of daily living (ADLs). [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure weekly skin assessments were completed as scheduled for 1 of 1 residents (R14) reviewed for completion of skin assessments. Furthermore, based on observation, interview and document review, the facility failed to ensure residents care plans were implemented for 1 of 1 resident (R41) in the sample who received occupational therapy orders for positioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident was provided adequate supervision and assistive devices to prevent avoidable accidents for 1 of 4 residents reviewed (R11) for accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided in accordance with professional standards of practice for 3 of 5 residents (R4, R14, and R1) reviewed for oxygen services.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure the facility was monitoring dialysis access site for 1 of 2 residents (R40) reviewed for dialysis. R40's annual Minimum Data Set (MDS) dated [DATE], identified R40 was cognitively intact and was independent with activities of daily living (ADLs) with exception of needing assistance with toileting and showering needs. R40 had diagnoses which included end stage 4 renal disease (kidney failure), dependance on hemodialysis (artificial blood filtration to remove waste and excess fluids), chronic pain, osteoarthritis and hypertension. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed enhanced barrier precautions (EBP) during resident care for 1 of 1 resident (R14) observed. In addition, the facility failed to discontinue isolation precautions that were no longer clinically indicated for 2 of 3 residents (R11 and R14) reviewed for infection control.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents wheelchairs were kept clean for 1 of 1 resident (R41) in the sample whose wheelchair (WC) was stained with food debris.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure survey results were placed in a prominent place and contained or directed where to obtain the last three years of survey results. This had the potential to affect all 64 residents residing in the facility, along with family, visitors and staff.

Inspectors wroteBased on observation, interview and document review, that facility failed to comprehensively assess and implement interventions for 1 of 2 residents (R26) reviewed for pressure ulcers. R26 developed pressure ulcers after splint placement for ankle fracture resulting in actual harm when the facility did not clarify orders for monitoring or when to remove the splint.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively investigate a fall for 1 of 3 residents (R26), who had a fall while being transferred.

Inspectors wroteBased on observation, interview and document review, the facility failed to assess the resident and determine safety for 1 of 1 resdients (R1) reviewed for self-administration of medications (SAM).