Givens Health Center

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the fall history on the Minimum Data Set (MDS) assessment for 1 of 3 residents reviewed for accidents (Resident #4).

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure 5 of 36 dishes ready for use on the tray line were free from dried scattered crumb like particles, provide expiration dates for 4 of 4 frozen boxes of pureed foods, label and date one stainless steel container of gravy and four cookie sheets of bacon that was located in 1 of 5 reach in coolers, and ensure 1 of 4 dietary staff restrained hair during food preparation. These practices had the potential to affect food served to residents.

Inspectors wroteBased on record review, observation, staff and physician interviews, the facility failed to ensure residents had pain patches removed at bedtime as ordered for 2 of 29 residents reviewed for medication errors (Residents #45 and #31).

Inspectors wroteBased on observation, record review, and staff and physician interviews the facility failed to ensure a resident was provided supplemental oxygen per physician's orders for 1 of 2 residents (Resident #43) reviewed for oxygen.

Inspectors wroteBased on record review, observation, staff and physician interviews, the facility failed to ensure accurate documentation in the medical record for 2 of 29 residents (Residents #45 and #31) reviewed for accurate medical records.

Inspectors wroteBased on record review, observation, and staff and physician interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a urinary catheter for when Nursing Assistant (NA) #1 emptied the resident's urinary catheter bag without wearing a gown for 1 of 2 staff (NA #1) observed for infection control practices.

Inspectors wroteBased on observation, record review, family and staff interviews the facility failed to honor a resident's choice to have a beard for 1 of 2 residents (Resident #10) reviewed for choices.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure the code status information was accurate throughout the medical record for 2 of 2 residents reviewed for advanced directives (Resident #47 and Resident #53).

Inspectors wroteBased on record review and interviews with staff the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to discharge from Medicare Part A services for 1 of 3 residents reviewed for Beneficiary Notification (Resident #10).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after the facility determined a significant change had occurred for 2 of 9 sampled residents reviewed for hospice and resident assessments (Residents #28 and #47).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code Minimum Data Set Assessments (MDS) in the areas of Preadmission Screening and Resident Review (PASRR) and hospice for 2 of 4 residents reviewed for PASRR and hospice (Residents #6 and #18).

Inspectors wroteBased on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) before the expiration date for 1 of 2 sampled residents reviewed for PASRR (Resident #6).

Inspectors wroteBased on record review and staff interviews, the facility failed to refer residents who were admitted with mental health disorders for a Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination of specialized services for 1 of 2 residents reviewed for PASRR (Residents #57).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a comprehensive care plan that addressed a resident's individual care needs for 1 of 3 sampled residents whose closed records were reviewed (Resident #65).

Inspectors wrote2. Resident #48 was admitted to the facility on [DATE]. Resident #48's diagnoses included dementia and chronic obstructive pulmonary disease (COPD). Review of the active physician orders included Resident #48 received continuous oxygen at a rate of 2 liters per minute (LPM) as needed and continuous oxygen at 2 LPM twice daily when working with therapy for hypoxia (low levels of oxygen in the body's tissues). During an observation made on 12/19/23 at 9:24 AM, Resident #48 was sitting in his room in his wheelchair wearing oxygen via nasal cannula set at 2 liters per minute. There was no warning sign posted on the outside of the entry door to indicate oxygen was in use in the room of Resident #48. During an interview on 12/20/23 at 11:25 AM Nurse #1 explained she occasionally was the assigned nurse for Resident #48. [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following the annual recertification and complaint surveys conducted on 04/09/21 and 08/26/22. This was for a repeat deficiency for failure to provide beneficiary notice originally cited on 04/09/21 and subsequently recited on the annual recertification survey conducted on 12/21/23. The repeat deficiency for failure to develop and implement a comprehensive care plan was originally cited during the recertification and complaint survey conducted on 08/26/22 and subsequently recited on the annual recertification survey conducted on 12/21/23. [...]

Inspectors wroteBased on record review and interviews with the resident and staff the facility failed to offer and administer the influenza vaccine for 1 of 5 residents reviewed for immunizations (Resident #5).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (abbreviated as ARD and referring to the last day of the assessment period) for 1 of 9 residents reviewed for resident assessments (Resident #2).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (abbreviated as ARD and referring to the last day of the observation period) for 7 of 9 residents reviewed for resident assessments (Residents #2, #6, #16, #20, #28, #48, and #52).