Indigo Manor

Inspectors wroteBased on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to maintain sanitary conditions in the cooking area, with significant accumulation of grease buildup, food debris and residue, and heavy soilage on both floor surfaces and equipment. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.

Inspectors wroteBased on observations, interviews, record review, and policy and procedure review, the facility failed to provide fingernail care for one (Resident #3) of five residents reviewed for Activities of Daily Living (ADLs), from a total survey sample of 7 residents.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure one (Resident #7) of five sampled residents' room were maintained in a safe, functional, sanitary, and comfortable environment by leaving disposable razors unattended on the resident's bedside table.

Inspectors wroteBased on kitchen food service observations, staff interviews, record review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to log proper temperatures for the dish machine and chemical sanitization for the 3-compartment sink, and clean food buildup stuck on the back handle and under the safety guard of the mixer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide toenail care for one (Resident #33) of four residents reviewed for Activities of Daily Living (ADLs), from a total survey sample of 41 residents. Resident #33's toenails extended approximately one half inch beyond the nailbed and were jagged.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision to prevent accidents for one (Resident #7) of three residents reviewed for accidents, from a total survey sample of 41 residents. Resident #7 was discovered keeping smoking materials on self.

Inspectors wroteBased on observation, interview, record review, and policy and procedure review, the facility failed to ensure ensure that one (Resident #137) of 39 residents receiving respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Resident #137 was not receiving oxygen at the ordered flow rate.

Inspectors wroteBased on observations, staff interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that its medication error rate was not 5% or greater. Two medication errors out of 25 opportunities for error, resulted in an error rate of 8 % and involved Residents #45 and #113.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to maintain the kitchen in a safe and sanitary manner due to a ceiling area having a plastic sheet covering an opening that was dripping liquid where food is prepared, and by failing to maintain missing ceiling tiles in the dish room.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to convey within 30 days upon discharge the resident's funds, and a final accounting of those funds for 2 (Residents #2 and #7) of 4 residents reviewed for personal funds; and failed to notify the resident or the resident's representative when the amount in the residents account reached $200 less than the eligibility limit for 1 (Resident #6) of 4 residents reviewed, from a total sample of 8 residents.

Inspectors wroteBased on observations, a review of resident records and facility policies, and interviews with staff, the facility failed to ensure residents were free from neglect, by failing to provide supervision and interventions to maintain safety, prevent elopement (leaving the premises without supervision or permission) and minimize the risk of injury or death for one (Resident #92) of three residents reviewed for elopement risk, from a total of 52 residents in the sample. The facility's neglect to provide appropriate services and interventions to prevent elopement after identifying the resident as at risk, permitted Resident #92 to exit the facility and wander to a busy intersection without staff supervision, placing him at risk for serious bodily harm or death. On 2/27/23, Resident #92 was admitted to the facility's first floor. [...]

Inspectors wroteBased on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper food safety and sanitation practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to ensure the ice machine located in the kitchen and one of three microwaves located on the 1st floor at the nursing station was clean. Food safety and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to store all drugs and biologicals in locked compartments for three (Residents #31, #260, and #133) in a total sample of 52 residents.

Inspectors wroteBased on observations, staff interviews, and facility policy and procedure review, the facility failed to ensure process surveillance, the review of practices by staff directly related to resident care, specifically hand hygiene, for two residents (#31 and #260) from a total sample of 52 residents.

Inspectors wroteBased on a review of facility records and interviews with staff, the facility failed to provide advanced notice to two (Residents #36 and #63) of three Medicare beneficiaries reviewed when Medicare skilled services were terminating, from a total of 52 residents in the sample.

Inspectors wroteBased on observations, staff interviews, and facility document and policy review, the facility failed to protect the residents' right to personal privacy and confidentiality of his or her personal/medical records for three (Residents # 26, 31, and 28) out of a total sample of 52 residents.

Inspectors wroteBased on a review of resident records, facility policies, and interviews with staff, the facility failed to coordinate with the state pre-admission screening and resident review (PASARR) program under Medicaid to determine whether a Level II screening was indicated after one (Resident #25) of two residents reviewed for PASARR, from a total of 52 residents in the sample, received a post-admission diagnosis of serious mental illness (SMI).

Inspectors wroteBased on observations, a review of resident records and facility policies, and interviews with staff, the facility failed to provide supervision and implement interventions to maintain resident safety, prevent elopement (leaving the premises without supervision or permission) and minimize the risk of injury or death for one (Resident #92) of three residents reviewed for elopement risk, from a total of 52 residents in the sample. The facility's failure to provide appropriate supervision and implement identified and/or available interventions, allowed Resident #92 to exit the facility and wander to a busy intersection without staff supervision, placing him at risk for serious bodily harm or death. On 2/27/23, Resident #92 was admitted to the facility's first floor. The same day, at 2:15 p.m., he was assessed as an elopement risk and a Wanderguard (alarm bracelet) was to have been applied. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that one (Resident #70) of 26 residents receiving respiratory treatment, from a total of 52 residents in the sample, was provided respiratory care consistent with professional standards of practice and the resident's comprehensive care plan. The facility was administering oxygen at a greater flow rate than was ordered.

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and a review of the facility's dialysis agreement, the facility failed to ensure shared communication between the nursing home and the dialysis center for one (Resident #269) of two residents receiving hemodialysis services, from a total of 52 residents in the sample.

Inspectors wroteBased on staff and resident interviews, and medical record review, the facility failed to provide routine medications to one (Resident #269) in a total sample of 52 residents.

Inspectors wroteBased on a review of resident records and interviews with staff, the facility failed to ensure psychotropic medications were only utilized with appropriate monitoring for one (Resident #63) of five residents reviewed for unnecessary medications, from a total of 52 residents in the sample.

Inspectors wroteBased on observations, staff interviews, medical record review, and facility policy review, the facility failed to ensure its medication error rate was less than 5%, based on three errors over 27 opportunities for two (Residents #31 and #260) of five residents observed during medication administration, and resulting in an error rate of 11.11%.

Inspectors wroteBased on observations, staff and resident interviews, and medical record review, the facility failed to maintain resident medical records that were accurately documented for one (Resident #269) in a total sample of 52 residents.

Inspectors wroteBased on the observations, interview, record review and facility policy and procedure review, the facility failed to store food in accordance with professional standards for food service safety by failing to ensure that staff implemented the facility policy and procedures for monitoring refrigerator and freezer temperatures.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that residents with an indwelling catheter were assessed for removal of the catheter as soon as possible for one (Resident #52) of seven residents with Foley catheters, out of a total sample of 38 residents. Failure to assess residents for indwelling catheter removal predisposes residents to catheter acquired urinary tract infections (CAUTI).

Inspectors wroteBased on resident observations, interviews, and record review, the facility failed to ensure pain management was provided to residents requiring such services, consistent with professional standards of practice by failing to appropriately assess pain and provide interventions for pain relief for one (Resident #102) of one sampled resident reviewed for pain management, out of a total sample of 38 residents.

Inspectors wroteBased on observation, interview, and review of manufacturers information for use, the facility failed to appropriately store the Glucose Control Solutions (GCS) on three of five medication carts observed.