Grande Lake Healthcare Center

Inspectors wroteBased on medical record review, review of hospital documentation, staff interview, nurse practitioner interview, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure medication orders for treatment of Influenza (Flu) Type A were timely initiated for a resident which caused a significant medication error. Actual harm occurred to Resident #13 when the resident exhibited a change in condition, tested positive for Influenza Type A, and was evaluated by a nurse practitioner who recommended the implementation of an antiviral medication which was not ordered timely or administered. This resulted in Resident #13 becoming difficult to arouse and responded only to painful stimuli. Resident #13 required hospitalization and was diagnosed with renal insufficiency, hypoxia, and pneumonia. [...]

Inspectors wroteBased on observation, medical record review, review of infection control tracking documents, staff interview, and facility policy review, the facility failed to ensure proper infection control monitoring was timely and accurately maintained during an active influenza outbreak and failed to ensure a urinary catheter was maintained in a manner to prevent infection. This had the potential to affect all 41 residents residing in the facility. The census was 41.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure urinary catheter collection bags were covered to maintain dignity. This affected one (#195) of four residents reviewed for respect and dignity. The census was 41.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to determine if residents were clinically appropriate to self-administer their medications. This affected two (#7 and #10) of four residents observed during medication administration. The facility census was 41.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to provide privacy during a mechanical lift transfer. This affected one (#27) of one residents reviewed for privacy. The census was 41.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure residents were provided assistive drinking devices as care planned. This affected one (#15) of one residents reviewed for assisted eating devices. The census was 41.

Inspectors wroteBased on medical record review, review of arbitration agreements, and staff and resident interviews, the facility failed to ensure arbitration agreements were explained and presented to residents with appropriate cognition to understand the document content. This affected one (#145) of four residents reviewed for arbitration agreements. The census was 41.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure care conferences were completed as required. This affected two (#15 and #48) of three residents reviewed for care conferences. The facility census was 42.

Inspectors wroteBased on record review, observations, resident and staff interviews, review of the activity calendar, review of activity documentation, resident council meeting minutes, and review of policy, the facility failed to provide sufficient and quality activities to meet the needs of residents. This affected seven (#5, #15, #18, #22, #23, #29, and #30) of seven residents reviewed for activities with the potential to affect all residents the facility. The facility census was 36.

Inspectors wroteBased on observations, review of activity calendars, review of resident council minutes, review of personnel file and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect 36 of 36 residents in the facility.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure resident assessments were complete and accurate. This affected four (#1, #17, #26, and #28) of 16 residents reviewed for accurate assessments. The facility census was 36.

Inspectors wroteBased on medical record review, staff, resident, and resident representative interviews, and policy review; the facility failed to conducted care conferences. This affected two (#18 and #26) of two resident reviewed for care planning. The census was 36.

Inspectors wroteBased on record review, observations, resident and staff interviews, and policy review, the facility failed to ensure a resident received the care and services for daily use of alcohol. This affected one (#17) of one resident reviewed for alcohol. The facility census was 36.

Inspectors wroteBased on observation, staff interview, record review, and review of the policy, the facility failed to ensure fall interventions were in place for a resident at risk for falls. This affected one (#20) of three residents reviewed for falls. The facility census was 36.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to follow physician orders regarding tube feed administration. This affected one (#138) of one resident reviewed for tube feed. The facility census was 36.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to provide rationale for gradual dose reduction (GDR) not indicated. This affected one (#21) of five residents reviewed for GDR's. The facility census was 36.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to administer medications per physician order. This affected one (#25) of three residents reviewed for medication administration. The facility census was 36.

Inspectors wroteBased on medical record review, resident and staff interview, and policy review, the facility failed to ensure a resident was seen by a dentist timely. This affected one (Resident #23) of one resident reviewed for dental concerns. The facility census was 36.

Inspectors wroteBased on review of a snack sign out sheet, observations, staff and resident interview and policy review, the facility failed to ensure residents received substantial bedtime snacks due to the time span of greater than 14 hours between the dinner meal and breakfast. The facility identified all 31 residents residing in the facility who received food from the kitchen. Facility census was 31.

Inspectors wroteBased on documentation/record review, staff interview and review of policy and procedures, the facility failed to establish and implement specific testing protocols for their water management program through the Legionella policy and procedure. This had the potential to affect all 31 residents residing in the facility. Facility census was 31.

Inspectors wroteBased on medical record review, observation, staff and resident interview and policy review, the facility failed to ensure residents were free from involuntary seclusion when the facility used a coded secure entrance/exit door at the main entrance of the facility without providing the code to resident's who were cognitively intact, alert, oriented and independently mobile. This affected four (#4, #2, #10, #3) of four residents reviewed for involuntary seclusion. The facility identified 12 (#28, #9, #31, #15, #12, #25, #24, #27, #18, #26, #30 and #29) additional residents who were cognitively intact, alert, oriented and independently mobile who could potentially be affected by the secured entrance/exit door. The facility census was 31.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure resident's were offer and administer the influenza and pneumococcal vaccine. This affected five (#6, #11, #84, #7 and #33) out f five residents reviewed for immunizations in the infection control task. The facility census was 31.

Inspectors wroteBased on medical record review and resident and staff interviews the facility failed to arrange appropriate transportation to a wound clinic for one resident (#11) of three residents reviewed for pressure and non pressure ulcers. The facility census was 31.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) included the explanation of estimated cost. This affected two (#19 and #31) out of three residents review for beneficiary protection notification. The facility census was 31.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure residents were provided written notification of transfer upon transfer from the facility. This affected one (#11) of five residents reviewed for hospitalizations. The facility census was 31.

Inspectors wroteBased on closed medical record review and staff interview, the facility failed to ensure a Discharge-return not anticipated Minimum Data Set (MDS) assessment was completed and submitted within 14 days to Center for Medicare & Medicare Services (CMS) database. This affected one (#1) out of one resident reviewed for resident assessments based on information submitted to CMS. The facility census was 31.

Inspectors wroteBased on medical record review, staff, resident and family interview and policy review, the facility failed to ensure residents and responsible parties were provided personalized care planning conferences on admission and on a quarterly basis. This affected two (#2 and #21) of two residents reviewed for care planning. Facility census was 31.

Inspectors wroteBased on medical record, observation, and staff interview the facility failed to assess and implement interventions for a resident who was exhibiting exit seeking behaviors. Additionally, the facility failed to implement physician orders fall interventions for a resident at risk for falling. This affected two (#33 and #7) out of three residents reviewed for accidents and hazards. The facility census was 31.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure physician ordered pre and post dialysis evaluations were completed. This affected one (#16) out of one resident reviewed for dialysis. The facility identified two resident currently receiving dialysis treatment.

Inspectors wroteBased on medical record, and staff interview, the facility failed to administer Coumadin (anticoagulant) as ordered by the physician. This affected one (#7) out of five residents reviewed for unnecessary medication. The facility census was 31.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure monthly medication reviews were completed for Resident #7 and failed to ensure pharmacy recommendations were followed up on for Resident #3. This affected two (#7 and #3) out of five residents reviewed for unnecessary medications. The facility census was 31.

Inspectors wroteBased on medical record review and staff interview, the facility failed to notify the physician of the results of a urine culture and sensitivity resulting in the use antibiotic which the organism was not sensitive to. This affected one (#6) of five residents laboratory results reviewed during review of unnecessary medications. The facility census was 31.

Inspectors wroteBased on medical record review, staff interviews, and policy review the facility failed to implement antibiotic stewardship policy to ensure a resident received optimal antibiotic therapy. This affected one (#6) out of five resident reviewed for unnecessary medications. The facility census as 31.