Holiday Resort of Salina

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff provided consistent bathing and/or showers for five sampled residents who were dependent on staff for activities of daily living (ADL), Resident (R) 1, R2, R3, R4, and R5.

Inspectors wroteBased on record review, observation, and interview, the facility failed to develop and implement a comprehensive care plan for Resident (R) 1 to direct staff to provide R1 services for R1 to attain or maintain her highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on record review, observation, and interview, the facility failed to follow R1's primary care physician's orders to obtain a straight catheterization urine specimen to assess for a urinary tract infection.

Inspectors wroteThe facility had a census of 40 residents. The sample included five residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to provide the physician ordered medications for one of five sampled residents, Resident (R) 1. This deficient practice placed R1 at risk for ineffective treatment of HIV (Human Immunodeficiency virus, a virus that attacks the body's immune system, leading to a weakened immune system and increase in the risk for cancers and infections).

Inspectors wroteThe facility had a census of 40 residents. The sample included five residents. Based on the interview and record review, the facility failed to correctly transcribe physician orders to provide medication to Resident (R) 1 and R2, upon admission to the facility. This deficient practice caused R1 to not receive his prescription medication for 13 days and R2 to not receive the prescribed medication for four weeks.

Inspectors wroteThe facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to correctly prepare a pureed (a texture-modified diet where all foods are blended or mashed into a smooth, pudding-like consistency) diet for Resident (R) 8. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 45 residents. Based on observation, interview, and record review, the facility failed to prepare and serve food in a sanitary manner when dietary staff did not complete hair coverage with the hairnet and beard cover. This deficient practice placed the residents of the facility who received meals from the facility at risk for foodborne illness.

Inspectors wroteThe facility had a census of 45 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure that its Quality Assessment and Assurance Committee adequately identified deficient areas of practice and to develop and implement appropriate plans of action to correct the deficient practices for the 45 residents residing in the facility.

Inspectors wroteThe facility had a census of 45 residents. The sample includes 13 residents, with five residents reviewed for immunizations: Resident (R) 6, R8, R25, R26, and R33, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, obtain an informed declination or a physician documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the residents at risk for pneumococcal infection and related complications.

Inspectors wroteThe facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure and maintain the kitchen walk-in freezer was in a safe operating condition, as the freezer door would build up with ice and would not completely shut. This placed the 45 residents who resided in the facility and received their meals from the facility's kitchen at risk for foodborne illness.

Inspectors wroteThe facility had a census of 45 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure one resident, Resident (R) 5 was free from antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication without an appropriate indication for use. The facility failed to ensure the physician provided the risk versus benefit for the continued use of antipsychotic medications. This placed R5 at risk of unnecessary medication administration and related complications.

Inspectors wroteThe facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide a Bed Hold Notification and State Ombudsman Agency notification of Resident (R) 32's discharge from the facility. This placed R32 at risk for being uninformed.

Inspectors wroteThe facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan with individualized, resident-centered interventions for dementia (a progressive mental disorder characterized by failing memory and confusion) care, behaviors, and communication for one resident, Resident (R) 5. This placed the resident at risk for unmet care needs.

Inspectors wroteThe facility had a census of 45 residents. The sample included 12 residents, with one reviewed for communication. Based on observation, record review, and interview, the facility failed to implement alternative communication methods for one resident, Resident (R) 5, who spoke Spanish. This placed the resident at risk for unmet needs, frustration, and agitation.

Inspectors wroteThe facility had a census of 45 residents. The sample included 12 residents, with 4 reviewed for bathing. Based on observation, record review, and interview, the facility failed to provide consistent bathing services for two residents, Resident (R) 6 and R8. This placed the residents at risk for complications related to poor hygiene.

Inspectors wroteThe facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide adequate supervision for Resident (R) 32, who smoked and had a staff-assisted descent to the ground while being assisted with a chair-to-chair transfer. This placed R32 at risk for injuries from smoking and falls.

Inspectors wroteThe facility had a census of 45 residents. The sample included 12 residents, with two reviewed for dementia (progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to develop and implement an individualized dementia treatment plan for one resident, Resident (R) 5, who had dementia and received psychotropic (alters mood or thought) medication. This placed R5 at risk for decreased quality of life.

Inspectors wroteThe facility had a census of 45 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician of blood sugars (a system which measures blood glucose in the body) outside of ordered parameters for one resident, Resident (R) 20. This placed the residents at risk for adverse effects related to medication.

Inspectors wroteThe facility had a census of 45 residents. The sample included 12 residents, with two reviewed for Hospice (specialized care that mainly aims to provide comfort and dignity to the patients by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 5 and R2. This placed the residents at risk for inappropriate and/or unmet end-of-life care.

Inspectors wroteThe facility had a census of 45 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to post the actual scheduled hours worked for nursing staff directly responsible for resident care per shift. This placed the residents at risk of being uninformed of nursing staff hours.

Inspectors wroteThe facility had a census of 44 residents. The sample included eleven residents with eleven residents reviewed for residents right to dignity. Based on observation, record review, and interview, the facility failed to protect Resident (R) 1's dignity when R1 put on his call light because he had to have a bowel movement and a Certified Nurse's Aide (CNA) came into his room turned off his call light, stated she would be right back, and did not return to R1's room for two hours. R1 was incontinent of bowel in bed. This deficient practice placed the R1 at risk for impaired dignity and psychosocial impairment.

Inspectors wroteThe facility had a census of 44 residents. The sample included eleven residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to ensure staff provided consistent bathing and/or showers for three residents, Resident (R)1, R3, and R11. This deficient practice placed the residents at risk for impaired dignity, infection, and alteration in skin integrity.

Inspectors wroteThe facility had a census of 44 residents. The facility identified six residents with COVID-19 (highly contagious respiratory virus) in the facility. Based on observation, record review, and interview, the facility failed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection when reusable equipment was not disinfected between resident use and/or storage in common areas. The facility further failed to ensure Certified Nurse Aide (CNA) M informed the facility he had COVID-19 symptoms and tested positive for COVID-19. This placed the resident's at risk for infection.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure the kitchen walk-in freezer was in safe operating condition, when the freezer door continued to build up with ice and fail to completely shut. This placed the 41 residents who resided in the facility and received their meals from the facility kitchen at risk for foodborne illness.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise, update, and individualize the care plans for Resident (R) 9 who received oxygen and respiratory treatment, R13 with a urinary catheter (tube inserted in the bladder to drain urine), R24 who received insulin (a hormone to regulate blood sugar) and a diagnosis of diabetes mellitus when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), R25 who was on a fluid restriction, and R19 and R22 who were at risk for falls. This deficient practice placed the residents at risk for inadequate and/or inappropriate care related to uncommunicated care needs.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards with staff left one of two treatment carts unsupervised and unlocked in the hall by the living room area. This placed the six cognitively impaired, independently mobile residents at risk for preventable accidents or injuries.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents with one reviewed for dialysis (procedure where impurities or wastes were removed from the blood). Based on observation, record review, and interview, the facility failed to adhere to Resident (R) 25's fluid restriction, placing R25 at risk for fluid overload, and dialysis complications.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents, of which two were reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide the appropriate treatment and services to attain Resident (R) 23's highest practicable mental and psychosocial (interrelation of social factors and individual thought and behavior) well-being when staff failed to provide R23 with mental and behavioral health services. This placed the resident at risk for decreased quality of care and life.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents, of which two were reviewed for behaviors. Based on observation, record review and interview, the facility failed to provide adequate medical social services to meet Resident (R) 23's mental and behavioral health needs. This placed the resident at risk for decreased quality of care and life.

Inspectors wroteThe facility identified a census of 40 residents. The sample included three residents. Based on observation, interview, and record review, the facility failed to ensure residents remained free from significant medication errors when staff administered ten times the ordered dose of morphine sulfate (opioid pain medication) on three separate occasions. Resident (R)1 admitted to the facility for a Hospice respite stay on [DATE]. On [DATE] the facility received an order for morphine sulfate oral solution 10 milligrams (mg)/5 milliliters (ml), give 2.5 ml (5 mg) by mouth two times a day for pain management. The facility received a bottle of morphine concentrate 100 mg/5 ml from the pharmacy. Facility nursing staff administered and R1 received three 2.5 ml doses of the morphine, equaling 50 mg of morphine per dose (45 mg more than ordered) on three occasions: [...]

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to deliver mail in a timely manner which included Saturday. This placed the residents at risk to not receive their communications in a timely manner.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to correctly prepare a pureed diet for six residents, Resident (R)17, R15, R26, R19, R30 and R33. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide assistance at mealtime for dependent Resident (R) 139, who had a history of a 7.6 percent weight loss in one month. This placed the resident at risk for continued weight loss.

Inspectors wroteThe facility had a census of 40 residents. The sample included 16 residents with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The facility failed to prevent the development of a Stage 2 pressure ulcer (partial thickness loss of skin, presenting as a shallow open ulcer with a red pink wound bed) for Resident (R) 20 and R17. This placed the residents at risk for further skin breakdown, pain, and skin infection.

Inspectors wroteThe facility has a census of 40 residents. The sample included 12 residents with two reviewed for urinary catheter. Based on observation, record review and interview, the facility failed to ensure Resident (R) 25's urinary catheter system (tube placed in the bladder to drain urine into a collection bag) had not touched the floor. This placed R25 at risk for urinary tract infections (UTI - infection in the bladder or kidneys).

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents with three reviewed for nutrition. Based on observation, record review, and interview, the facility failed to provide routine weight monitoring for Resident (R) 139, who had a history of a 7.6 percent weight loss in one month. This placed the resident at risk for delayed identification and interventions to prevent further loss weight loss.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on observation and interview the facility failed to ensure staff possessed adequate competencies to store, prepare, and secure medication and medical information during medication pass. This placed residents at risk of compromised medications and exposure of medical information.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents, of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist identified and reported to the Director of Nursing, medical director, and physician, the inappropriate diagnosis for the use of an antipsychotic (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) for one of five residents, Resident (R) 137. This placed the resident at risk for inappropriate use of an antipsychotic medication.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents, of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain an appropriate diagnosis for Resident (R) 137's use of an antipsychotic (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) medication. This placed the resident at risk of receiving unnecessary psychotropic (medications that affect a person's mental state) medication.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents with one reviewed for dental care. Based on observation, record review and interview, the facility failed to provide timely dental care for one sampled resident, Resident R (20). This placed R20 at risk for pain, dietary concerns, and dental issues.

Inspectors wroteThe facility had a census of 40 residents. Based on observation, record review, and interview the facility failed to serve food under sanitary conditions for Resident (R) 18 and R9 during the meal service. This placed the residents at risk for contaminated food.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to post the actual scheduled hours worked for nursing staff directly responsible for resident care per shift. This placed the residents at risk to be uninformed of nursing staff hours.