Eventide Prairie Commons Care Center

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)Licensure Reference Number 175 NAC 12-006.09(I)(i)(1)Licensure Reference Number 175 NAC 12-006.09(I)(i)(3)Based on observation, record review, and interview the facility failed to provide and implement interventions to protect residents from sunburn injury for 1of 3 residents (Resident 1). This caused Resident 1 to experience sunburn injury requiring treatment. The facility census was 27.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure resident code status for life saving measures were accurate for all residents. This affected 2 (Resident 1 and Resident 18) of 23 sampled residents. The facility census was 23. [NAME] at Prairie Commons was notified on [DATE] at 1:43 PM of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] at 5:20 PM, as confirmed by surveyor onsite verification.

Inspectors wroteLicensure Reference Number 175 NA 12-006.10(D) Based on record reviews, observations and interviews, the facility failed to ensure medication error rates were not 5% or greater (27 opportunities with 10 errors resulted in an error rate of 37.04%). This affected 3 (Residents 1, 5, and 123) of 4 residents sampled. The facility census was 23.

Inspectors wroteLicensure Reference Number 175 NAC 1-005.06(D) Based on observation, record review, and interview; the facility failed to ensure staff performed hand hygiene to prevent the potential for cross contamination while assisting residents who were eating meals in the dining room. This had the potential to affect 9 (Residents 1, 2, 3, 6, 10, 11, 12, 13, and 123) of 9 sampled residents. The facility census was 23.

Inspectors wroteBased on record review and interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice-SNFABN Form CMS 10055 ( a notice issued to a resident and/or responsible party to inform them that Medicare will no longer pay for their services) and Notice of Medicare Non-Coverage-NOMNC Form CMS 10123 (a notice required to be provided by the facility to beneficiaries (residents) that are receiving nursing services paid for by Medicare Part A explaining that skilled nursing services will no longer be paid for by Medicare and informing the residents of the right to appeal) for discharge from Medicare Part A to 2 (Residents 5 and 125) of 3 residents sampled which resulted in the potential to prevent Resident 5 and 125 from filing an appeal of the discharge from Medicare Part A covered services. The facility census was 23.

Inspectors wroteLicensure Reference Number 175NAC 12-006.09(H)(iii)(2) Based on observation, record review, and interview the facility failed to ensure documentation that resident wounds were evaluated and monitored at least weekly as required for 1 of 1 residents reviewed (Resident 16). This prevented staff from determining if the wound condition was healing or worsening. The facility census was 23.

Inspectors wroteLicensure Reference Number 175NAC 12-006.09(H)(i)(3) Based on observation, record review, and interview, the facility failed to answer call lights timely for 1 (Resident 1), of 8 sampled residents and failed to ensure residents received routine bathing for 1 (Resident 1), of 8 sampled residents. The facility census was 32.

Inspectors wroteLicensure Reference Number 175NAC 12-006.10D Based on observation, record review, and interview, the facility failed to follow provider orders for medication administration for 1 (Resident 1) of 2 sampled residents, and failed to ensure proper labeling and priming of an insulin pen for 1 resident (Resident 1) of 1 sampled resident. The facility census was 32.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11A1 Based on record review, observation and interviews; the facility failed to use recipes during meal preparation of all foods to ensure the nutritional adequacy of dishes served. This affected all residents that ate food prepared by the facility kitchen. Current census was 18.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on record review, observation and interviews; the facility failed to ensure that foods were maintained at the required temperatures to prevent food borne illnesses on the steam table during meal service and failed to remove and destroy foods that were in the refrigerator longer than 7 days. This had the ability to affect all 18 residents who ate food served by the facility kitchen. Current census was 18.

Inspectors wroteBased on record review and interview the facility failed to obtain the advanced directive for the residents wishes in regards to code status [a resident's choice for cardiopulmonary resuscitation (a lifesaving attempt combination of rescue breathing and chest compressions when someone's heart has stopped) or do not resuscitate (DNR) (a type of advance directive in which a person states that health care providers should not perform cardiopulmonary resuscitation (restarting the heart) if his or her heart or breathing stops)] and obtain a signed physician order for DNR for 1 resident (Resident 61) and failed to obtain a signed physician order for DNR for 1 resident (Resident 68). The facility census was 18.

Inspectors wroteLicensure Reference Number 175NAC 12-006.12E5; Licensure Reference Number 175 NAC 12-006.12E1b Based on observation, interview, and record review the facility failed to store medications administered by different routes separately for 1 resident, (Resident 67) of 7 sampled residents; failed to administer eye drops following current professional standards of care for 1 resident, (Resident 63) of 7 sampled residents; and failed to ensure accountability of a controlled substance for 1 resident (Resident 7) of 7 sampled residents. The facility census was 18.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05 (4) Based on interview and record review, the facility failed to provide bathing preferences for 1 (Resident 71) of 2 sampled residents. The facility census was 18. Record review of Resident 71's admission Record dated 05/01/2024 revealed that Resident 71 admitted to the facility on [DATE]. Record review of Resident 71's Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 04/22/2024 revealed a Brief Interview for Mental Status (BIMS-a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) of 10, which indicated the resident was mildly impaired. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D3(5) Based on interview and record review; the facility failed to ensure routine bowel movements for 1 (Resident 2), of 2 sampled residents. The facility stated census of 18. Review of a facility policy titled Maintaining Bowel and Bladder Function dated 09/21/2023 revealed the Bowel Care Medication regimen will be implemented for all patients unless otherwise directed by the patient's provider to prevent or manage constipation. Review of a facility document labeled Bowel Care Protocol and dated 04/30/2024 revealed Resident 2 had gone five days without a bowel movement. The document also stated: A. on day three of no bowel movement - Milk of Magnesia 30 milliliters by mouth one time. B. on day four of now bowel movement - Bisacodyl 10 milligram suppository one time. C. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09D7b Based on observation, interview, and record review; the facility failed to update and or change interventions to prevent falls for 1 resident (Resident 2), out of 2 sampled residents. The facility census was 18.

Inspectors wroteLicsensure Reference Number 175 NAC 12-006.09D Based on record review, observation and interviews, the facility failed to ensure that medications used together will not lead to adverse consequences, and that all medications had adequate indications for use with an appropriate diagnosis code. This affected 1 (Resident 3) of 5 sampled residents. Census was 18.