Golden Crest Nursing Centre

Inspectors wroteBased on clinical record review, and family and staff interview, the facility failed to ensure a resident received the necessary monitoring and assistance to maintain proper hydration for 1 of 3 residents reviewed, Resident ID #1.

Inspectors wroteBased on clinical record review, and family and staff interview, the facility failed to ensure that resident records are complete and accurately documented related to assistance with activities of daily living for 2 of 3 residents reviewed, Resident ID #s 1 and 2.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to prevent a new pressure ulcer from developing for 1 of 1 resident reviewed (Resident ID #7) with a physician's order to off load heels. The physician-ordered intervention to offload the resident's heels was not consistently implemented for Resident ID #7, despite the resident's identified risk factors for pressure ulcer development, including impaired mobility, malnutrition, and a moderate risk score on the Norton Plus Pressure Ulcer Scale (a tool utilized to assess a resident's risk for developing a pressure ulcer). This failure resulted in the development of a deep tissue injury (DTI) to the resident's left heel, which was identified during a skin assessment requested by the surveyor.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, it has been determined that the facility failed to accurately maintain the resident's medical record in accordance with accepted professional standards and practices relative to 2 of 6 residents reviewed with an identified skin impairment, Resident ID #s 21, and 67 and 1 of 3 residents reviewed who are dependent on staff for activities of daily living (ADLs), Resident ID #118.

Inspectors wroteBased on surveyor observation, clinical record review, resident representative, and staff interview, the facility failed to provide the necessary services to a resident who is unable to carry out activities of daily living (ADLs); for 1 of 1 resident reviewed with a delay in personal care, Resident ID #40, and for 1 of 3 residents reviewed relative to transfers, Resident ID #118.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to provide an ongoing activity program to support a resident in his/her choice of activities based on the comprehensive assessment, care plan, and preferences for 1 of 1 resident reviewed, Resident ID #118.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to develop and implement individualized care plans that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment relative to Activities of Daily Living (ADL's, e.g. eating, oral hygiene, toileting hygiene, showering and bathing, personal hygiene, dressing, rolling to the left and right, all transfers and mobility) for 5 of 5 residents reviewed, Resident ID #s 1, 4, 5, 6, and 7.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to store medications in accordance with currently accepted professional principles for 1 of 1 resident reviewed relative to storing lidocaine patches in his/her room without an assessment for self-application, Resident ID #2.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 2 of 5 medication carts reviewed and 1 of 2 medication rooms.

Inspectors wroteBased on record review, staff and resident interviews, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent the development of infections for 1 of 1 resident reviewed relative to the use of a Bilevel positive airway pressure (BIPAP, a device that provides breathing support which is administered through a face mask or nasal mask) device, Resident ID #77.

Inspectors wroteBased on record review, and staff interview, it has been determined that the facility failed to meet professional standards of quality for 1 of 2 residents reviewed with medication refusals, Resident ID #73.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure a resident who is at risk for pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 1 resident who was observed during a wound dressing change, Resident ID #102.

Inspectors wroteBased on record review and staff interview, it has been determined the facility failed to ensure the residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight, relative to a weight gain for 1 of 2 residents reviewed, Resident ID #134.

Inspectors wroteBased on record review and staff interview, it has been determined that the pharmacist failed to report irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) for 1 of 2 residents reviewed for as needed antipsychotic medications, Resident ID #67.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 32 opportunities for errors observed during the medication administration task there were 2 errors resulting in an error rate of 6.25%, involving Resident ID #62.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined the facility failed to provide person centered care in accordance with a resident's plan of care for 1 of 2 residents reviewed relative to his/her call light being within reach, Resident ID #67.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following a physician's order for nutritional supplements for 1 of 3 residents reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the residents' environment remains as free from accident hazards as possible for 2 of 4 residents reviewed related to fall risk prevention, Resident ID #s 2 and 3.

Inspectors wroteBased on surveyor observation, record review, and staff and resident interviews, it has been determined that the facility failed to protect the resident's right to be free from abuse for 1 of 3 residents reviewed, Resident ID #102.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality for 1 of 1 resident reviewed related to abdominal girth measurements, Resident ID #25.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide the necessary services to a resident who is unable to carry out activities of daily living (ADLs), relative to transfers for 1 of 7 residents reviewed, Resident ID #125.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice to promote wound healing and prevent new ulcers from developing for 2 of 5 residents reviewed for pressure ulcers (a localized injury to the skin or the underlying tissue due to pressure), Resident ID #'s 46 and 243.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the residents environment remains as free of accident hazards as possible for 1 of 8 residents reviewed, relative to supervision while eating, Resident ID #46.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident with a nephrostomy receives care, consistent with professional standards of practice and the comprehensive person-centered care plan, for 1 of 1 sample resident who has a PCN (percutaneous nephrostomy - an artificial opening created between the kidney and the skin which allows for urinary drainage), Resident ID #243.

Inspectors wroteBased on record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 1 resident reviewed related to abdominal girth measurements, Resident ID #25.

Inspectors wroteBased on surveyor observations, record review, and staff interview, it has been determined that the facility failed to follow standard precautions to prevent the spread of infection for 1 of 3 residents observed for wound care, Resident ID #84.

Inspectors wroteBased on staff interview and record review, it has been determined that the facility failed to conduct a Minimum Data Set (MDS) Assessment within 14 days of discharge for 2 of 8 resident closed clinical records reviewed, Resident ID #s 77 and 120.