Donalson Care Center

Inspectors wroteBased on facility policy review, medical record review, observations, and interview, the facility failed to ensure medical information was not visible for 2 residents (Resident #34 and Resident #57) of 83 residents observed for dignity.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASRR) to include a new mental health diagnosis for 2 residents (Resident #59 and #18) of 4 residents reviewed for PASRR.

Inspectors wroteBased on facility policy review, medical record review, and interviews the facility failed to follow physician's orders related to blood pressure medications for 3 residents (Residents #84, #28, and #9) of 10 residents reviewed for blood pressure medications.

Inspectors wroteBased on medical record review, observation, and interview the facility failed to ensure a water flush was infusing as ordered for 1 resident (Resident #20) of 3 residents reviewed for tube feedings.

Inspectors wroteBased on facility policy review, drug manufacturer's information, observation, and interviews, the facility failed to ensure an insulin medication was labeled appropriately to include an open and expiration date in 1 of 4 medication carts observed for medication storage which had the potential to affect 1 resident (Resident #26) of 18 residents reviewed for insulin use.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to maintain an accurate medical record for 1 resident (Resident #56) of 10 residents reviewed for blood pressure medications.

Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to offer hand hygiene assistance to residents prior to meals for 5 residents (Residents #4, #12, #59, #49, and #140), of 5 residents observed on 3 of 4 hallways observed for meal tray distribution and failed to ensure staff donned appropriate Personal Protective Equipment (PPE) for 2 residents (Residents #30 and #27) of 6 residents observed on Enhanced Barrier Precautions (EBP), and failed to perform hand hygiene appropriately during medication administration for 1 resident (Resident #73) of 4 residents observed for medication administration.

Inspectors wroteBased on facility policy review, medical record review, facility documentation review, and interview the facility failed report an allegation of injury of unknown origin timely for 1 resident (Resident #20) of 5 residents reviewed for abuse.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to maintain a sanitary environment for 3 of 5 sample residents (Resident #23, #28, and #48) who required enteral tube feeding.

Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to keep a clean and sanitary privacy curtain for 1 of 78 rooms (room [ROOM NUMBER]) observed.

Inspectors wroteBased on medical record review and interview, the facility failed to accurately assess weights on the Quarterly Minimum Data Set (MDS) assessment for 1 of 38 sample residents (Resident #62) reviewed.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to coordinate the timely completion of a Level II Pre-admission Screening and Resident Review (PASARR) for 1 of 4 sample residents (Resident #80) reviewed.

Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to revise comprehensive care plans for 1 of 38 sample residents (Resident #63) reviewed. Review of the facility's policy titled, Care Plan, dated 9/23/2020, revealed, .The plan should be kept current and flexible to meet the resident's changing problems or needs . Review of the medical record, revealed Resident #63 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Heart and Chronic Kidney Disease with Heart Failure. Review of the Significant Change Minimum Data Set (MDS) dated [DATE], revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. Continued review revealed the resident was assessed to require one-person extensive assistance. [...]

Inspectors wroteBased on facility policy review, medical record review, observation, and interview the facility failed to ensure 1 of 38 sample residents (Resident #56) had clean and groomed fingernails.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to change and date oxygen tubing and humidified water bottle for 1 of 8 sample residents (Resident #63) receiving respiratory therapy.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to provide a sanitary environment to help prevent the development and transmission of infection for 1 of 6 sample residents (Resident #7) who required an indwelling urinary catheter.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to revise the care plan for smoking safely with effective interventions to prevent accidents for 5 of 5 (Resident #22, #102, #30, #88, and #180) sampled residents reviewed for smoking which placed these residents in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Interim Administrator, Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist, Quality and Infection Preventionist Director, and Minimum Data Set (MDS) Coordinator #2, were notified of the IJ on 7/12/19 at 9:32 PM, in the Conference Room. [...]

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure a safe environment that provided supervision to eliminate the risk of elopement and accidents for 9 of 9 (Resident #22, #102, #18, #12, #13, #38, #2, #70, and #377) wandering and smoking residents reviewed and failed to ensure residents were supervised while smoking to prevent accident hazards for 5 of 5 (Resident #22, #30, #88, #102, and #180) smoking residents. The 5 of 5 (Resident #22, #30, #88, #102, and #180) smoking residents also had knowledge and used the exit door key pad codes provided to them by the staff, allowing the residents to exit the building independently without staff supervision, were allowed to smoke unsupervised, and were allowed to keep smoking materials (cigarettes and lighters) on their person. [...]

Inspectors wroteBased on the Interim Administrator's Contract, Director of Nursing Job Description, medical record review, observation, and interview, the Interim Administrator failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of the residents. Administration failed to ensure the residents that smoked had adequate supervision, and failed to provide oversight and training of staff to ensure the security devices for the exit doors were operational and the exit codes to the doors remained secure. The Administration's failure placed Residents #2, #12, #13, #18, #22, #30, #38, #70, #88, #102, #180, and #377 in Immediate Jeopardy when staff did not assess, report, implement, evaluate or monitor for resident safety concerns for smoking and elopements. [...]

Inspectors wroteBased on review of the Medical Director's Agreement Contract, policy review, medical record review, observation, and interview, the Medical Director failed to ensure resident care policies were developed and implemented to use resources effectively and efficiently to attain and maintain the highest practicable functioning of all residents by failing to ensure an effective plan to assure the residents' environment was safe and that vulnerable residents were adequately supervised. The Medical Director failed to identify issues and concerns in the facility related to smoking safety and elopement risk, which resulted in Immediate Jeopardy (IJ) for Resident #2, #12, #13, #18, #22, #30, #38, #70, #88, #102, #180, and #377 when staff failed to assess, report, implement, evaluate or monitor for resident safety concerns related to smoking and elopements. [...]

Inspectors wroteBased on review of the Administrator's job description, review of the Medical Director's job description, review of the Director of Nursing (DON) job description, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program recognized an ongoing concern related to smoking safety, residents with elopement risks that had knowledge of exit door codes and nonfunctioning wanderguard sensors on exit doors. The QAPI committee failed to ensure the facility identified the root cause of the concerns, developed appropriate plans of action, ensured systems and processes were in place and were consistently followed by staff to address quality concerns. [...]

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure accurate and complete medical records for 7 of 56 (Resident #2, #22, #30, #88, #102, #180, and #377) sampled residents reviewed.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments were conducted for residents with wander/elopement alarms for 2 of 7 (Resident #5 and #70) sampled residents reviewed with elopement risk.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to provide care and services for an indwelling urinary catheter for 1 of 1 (Resident #227) sampled residents reviewed for urinary catheters.