Exira Care Center

Inspectors wroteBased on observations, resident interviews, family interviews, staff interviews, and policy review, the facility failed to respond to resident call lights within 15 minutes for 4 of 4 residents (#1, #2, #5, #6). The facility also assigned an uncertified nursing aide to direct resident care alone, used agency staff to orientate a newly hired Certified Nurse Aide, and failed to respond timely to a request for assistance in a locked memory-care unit. The facility reported a census of 35 residents.

Inspectors wroteBased on observations, clinical record review, staff interview, and policy review, the facility failed to maintain dignity for 2 of 3 residents (#6, #7) by leaving a resident's blood-stained sheets on his bed for 4 1/2 hours (#6) and by reaching across the front of a resident's face to pick up a clothing protector off the table (#7). The facility reported a census of 35 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to provide baths for 2 of 3 residents (#1, #3) who required bathing assistance. The facility reported a census of 35 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to appropriately complete assessments for 3 of 3 residents (#1, #6, #7) who fell at the facility. The facility reported a census of 35 residents.

Inspectors wroteBased on observation, record review, staff interviews, and policy review, the facility failed to use a gait belt while transferring a resident who required assistance with mobility for 2 of 3 residents (#3, #4) and failed to lock a wheelchair while transferring a resident without a gait belt for 1 of 3 residents (#4). The facility reported a census of 35 residents.

Inspectors wroteBased on observations, clinic record review, resident and staff interviews, and policy review, the facility failed to maintain competent staff by allowing a Training Nurse Aide (TNA - uncertified nurse aide) to incorrectly transfer two (2) residents (#3, #4), incorrectly apply a leg immobilizer on a resident with a broken leg (#2), and assign a Certified Nurse Aide (CNA) without evidence of dementia training to provide care for dementia residents. The facility reported a census of 35 residents.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to perform hand hygiene while assisting with meals for 2 of 3 residents (#3, #6) who were dependent with eating. The facility reported a census of 35 residents.

Inspectors wroteBased on observation, staff interviews and clinical record review the facility failed to adequately supervise residents in the locked Chronic Confusion or Dementing Illness (CCDI) unit for 1 of 6 residents. The facility reported a census of 44 residents.

Inspectors wroteBased on observation, staff interviews and clinical record review the facility failed to provide adequate urinary catheter care for 2 of 2 residents reviewed. Resident #1 had chronic urinary tract infections and staff failed to monitor his output as ordered. Resident #28 had an order to not insert more than 10 milliliters (ml) of fluid in the catheter balloon. Staff failed to transcribe the specific order and administered fluid according to the catheter package. The facility reported a census of 44 residents.

Inspectors wroteBased on clinical record review, document review, resident interview, and staff interviews the facility failed to consistently monitor meal intakes for residents for sufficient nutrition to maintain proper weight for 1 of 2 residents reviewed (Resident #6). The facility reported a census of 44 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to accurately document resident medication administration for 2 of 13 residents (Resident #1 and #2). The paper Medication Administration Record (MAR) for Residents #1 and #2 showed many days blanks, indicating that the medications had not been given. The facility reported a census of 44 residents.

Inspectors wroteBased on observations, clinical record review, facility document review, staff and resident interviews, and facility policy review the facility failed to supervise a cognitively impaired resident. Staff were unaware Resident #1 left the building on 10/31/24. Staff last saw Resident #1 at approximately 12:45 PM. The door alarm sounded at 1:01 PM, staff responded, took approximately 5 steps outside, did not see anyone, walked back in the facility, disarmed the door alarm and went back to work. At 1:30 PM a different staff member came into the back-parking lot, saw a car backed up against the curb and was blocking the parking lot. Staff realized it was Resident #1 in the driver's seat with the car running and the doors locked. [...]

Inspectors wroteBased on observations, clinical record review, and staff interviews the facility failed to ensure 1 of 3 resident's (Resident #1) Minimum Data Set (MDS) assessments were accurately completed. The facility reported a census of 38 residents.

Inspectors wroteBased on observations, clinical record review, and staff interviews the facility failed to ensure 2 of 3 residents' (Resident #1 and #3) care plans included interventions for staff to follow should these residents exhibit wandering/eloping behaviors. Resident #1's care plan failed to include that she had eloped from the building on 10/31/24 and was found in a staff member's car. The facility reported a census of 38 residents.

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to ensure staff followed physician orders to treat an infection and prevent subsequent hospitalization for 1 of 3 residents reviewed (Resident #1).

Inspectors wroteBased on interviews, observations, and review of facility policies the facility failed to ensure procedures were developed to ensure water was available when normal water supply was lost. This failure had the potential to affect all 36 residents.

Inspectors wroteBased on observations, review of the facility policy, review of menus, and interview with staff, the facility failed to provide a diabetic diet for three of three residents (Resident (R) 14, R25, and R20) with physician orders for a diabetic diet.

Inspectors wroteBased on observation, record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one resident out of 12 sampled residents (Resident (R) 4) had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly can lead to inaccurate federal reimbursements, an inaccurate assessment, and care planning of the resident.

Inspectors wroteBased on interview and document review, the facility failed to develop a person-centered Comprehensive Care plan for one of 12 sampled residents (Resident (R) 31). On admission R31's assessment reflected them as high-risk for falls and the Care Plan did not address person-centered interventions for falls. This deficient practice may result in interventions not identified to prevent resident falls.

Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to update the Care Plan Focus related to a resident's fall risk with new interventions to prevent falls after a resident fell for one of 12 sampled residents (Resident (R)31). This deficient practice placed the resident at greater risk of future falls and injury.

Inspectors wroteBased on observation and interview, the facility failed to post the most recent survey results and the previous three years of surveys including annual surveys, complaint surveys, infection control surveys, and life safety code surveys in a readily accessible location. This has the potential to affect all 36 residents.