Fort Valley Crossing of Journey LLC

Inspectors wroteBased on observations, staff interviews, and facility document review, the facility failed to ensure puree recipes were followed to ensure the correct nutritional value was provided for 10 of 10 residents who received a puree meal. This deficient practice had the potential to place the residents receiving pureed meals at increased risk of weight loss and medical complications.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Refrigerators and Freezers F812, the facility failed to ensure food items were labeled, dated, and not beyond their expiration date. In addition, the facility failed to ensure proper use of the three-compartment sink and to maintain sanitary conditions in the kitchen. These deficient practices had the potential to place 42 of 42 residents receiving an oral diet from the kitchen at increased risk of foodborne illness.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Safe, Clean, Comfortable, Homelike Environment F584, the facility failed to maintain a safe, clean, comfortable, homelike environment for nine out of 28 rooms (Rooms 202, 204, 206, 208, 210, 302, 303, 304, and 306). This deficient practice had the potential to compromise the hygiene and safety of the residents' environment, increasing the risk of infection and negatively impacting the health and well-being of residents.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Baseline Care Plan, the facility failed to develop a baseline care plan for one of 33 sampled residents (R) (R55). This deficient practice had the potential to place R55 at risk of unmet care needs.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to implement the plan of care for one of 33 sampled residents (R) (R19). In addition, the facility failed to develop a comprehensive person-centered care plan for two of 33 sampled residents (R16 and R29). This deficient practice had the potential to place R33, R16, and R29 at increased risk of unmet needs and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, record review and review of the facility's policy titled, Oxygen Administration, the facility failed to administer oxygen (O2) as ordered and clean the outside of the oxygen concentrator for one resident (R) (R19) and failed to ensure there was a physician's order for O2 prior to administering O2 to one resident (R57) out of five sampled residents receiving oxygen therapy. These deficient practices had the potential to place R19 and R57 at increased risk of respiratory complications.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that staff followed infection-control practices for Transmission-Based Precautions (TBP) in one of one resident room (room [ROOM NUMBER]) on TBP from a sample size of 33 residents. This deficient practice had the potential to place the residents, staff, and visitors at increased risk of infectious illness due to cross-contamination.

Inspectors wroteBased on observation, staff interviews, review of facility documents, and review of the facility policy titled Food Preparation and Service, the facility failed to ensure recipes for the puree diet were followed to preserve its nutritional value during processing. The facility also failed to ensure residents consuming a puree diet were served the recommended amount of protein and vegetables during meal service. This deficient practice placed the ten residents who received a puree diet from the kitchen at risk for decreased nutritional intake.

Inspectors wroteBased on staff interviews, record review, document review, and review of the facility policy titled Advanced Directives, the facility failed to obtain a concurring Physician's signature for a Physician Order for Life Sustaining Treatment (POLST) for Do Not Resuscitate (DNR) document for two of five residents (R) (R1 and R10). Specifically, the facility failed to ensure R1 was cognitively intact before signing the POLST document indicating DNR status and failed to ensure the Power of Attorney (POA) documents were obtained during the implementation of the POLST document for R10.

Inspectors wroteBased on staff interviews, record review, and a review of the facility policy titled Preadmission Screening and Resident Review (PASARR), the facility failed to submit for a PASARR Level II for one of five residents (R) (R29) reviewed after a new qualifying mental illness diagnosis was added. This deficient practice had the potential to affect the appropriate level of care and services provided for R29.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Oxygen Administration and Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to obtain a physician's order for the administration of oxygen (O2) and failed to prevent the spread of infections by not cleaning the O2 concentrator for one of three residents (R) (R47) receiving O2 therapy. The deficient practice had the potential to place R47 at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observation, staff interviews, and a review of the facility policy titled Installation of Eye Drops, the facility failed to ensure infection control practices were followed during the administration of ophthalmic drops for one of three residents (R) (R12) observed for medication administration. This deficient practice placed R12 at risk of infection due to cross-contamination.

Inspectors wroteBased on record review, staff interview, review of policy titled Infection Control Program - Antibiotic Stewardship F 881 and Infection Prevention and Control Program, revised 10/2022, the facility failed to provide evidence of a process for periodic review of antibiotic prescribing practices, and to document follow-up measures in response to the data for twelve of twelve months of 2022 and 2023 infection control data reviewed (May 2022 through April 2023). This had the potential to affect any resident who was prescribed an antibiotic. The facility census was 47 residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to apply for a Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one resident (R) #41 that had a positive Level I PASRR for mental illness and diagnoses of schizophrenia, depression, and bipolar disorder prior to and on admission to the facility. The sample size was 18.

Inspectors wroteBased on observation, staff interviews, record review and review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to prevent the spread of infections by not cleaning and storing a nebulizer mask for one resident (R) (#29), of six sampled residents receiving nebulizer treatments.

Inspectors wroteBased on observations, interview and review of the facility policy titled Storage of Medications F 761, the facility failed to ensure proper disposal of unused narcotic medication in one of two medication carts.

Inspectors wroteBased on interviews, record review, and review of facility policy titled Influenza (Flu) Vaccine (Residents), F883 and Pneumococcal Vaccine F883, the facility failed to provide evidence that residents were offered the Influenza and/or Pneumococcal vaccine for two residents (R#4 and R#28) of five sampled residents reviewed for immunizations.

Inspectors wroteBased on staff interviews, record review, and review of facility policy titled F883 F884 F887 Vaccination of Residents, Including Influenza and COVID-19 and Reporting of, the facility failed to offer and/or administer the COVID-19 vaccine to one resident (R) (R#4) of five residents reviewed for the vaccines.