Intersect Healthcare of Roscommon

Inspectors wroteBased on observation, interview and record review the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify a change in bowel health for one Resident (#20) of one resident reviewed. This deficient practice resulted in the potential for constipation, intestinal blockage and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:(1) the correct dosage of medication was administered and(2) medication administration according to manufacturer recommendations for two Residents (R28 and R38) of three residents reviewed for medication administration. This deficient practice resulted in a medication error rate of 6.4% from 2 of 31 opportunities for error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medications in one medication cart of two medications carts reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide barriers for resident care equipment and maintain infection control practices during medication administration for four Residents (#10, #15, #28, & #38) of seven residents reviewed for infection prevention and control.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure interventions to address fall prevention were implemented for two Residents (#5 & #6) of four residents reviewed for falls. Findings Include: Resident #5 (R5) Review of the care plan revealed R5 was identified on 11/21/23 at risk for accidents, injuries, and falls r/t (related to) hx (history) of falls with major injury, insomnia, heart failure, COPD (Chronic Obstructive Pulmonary disease) & emphysema with dependence on oxygen, impaired mobility and balance, generalized weakness, forgetfulness, impaired vision . Interventions on 11/21/23 included: Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. Ensure that I am wearing non-skid footwear prior to assisting me with transfers and/or ambulation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and maintain accurate and complete documentation for 15-minute safety checks for two Residents (#5 & #6) of two residents reviewed for documentation related to 15-minute safety checks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: (1) Ensure proper hand sanitizing during hall tray pass; (2) Ensure donning of proper personal protective equipment (PPE) in droplet precaution resident rooms and; (3) Ensure disinfection of an insulin pen prior to returning it to the medication storage cart during a facility influenza outbreak, (4) Ensure infection control practice was maintained for respiratory equipment, (5) Ensure opened containers of distilled water were dated for proper identification of expiration and discarding. These deficient practices resulted in the potential for transmission of infections and further spread of an influenza outbreak to all 36 facility residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and monitor a resident's urostomy for complications, skin integrity, and proper function for one Resident (#238) of one resident reviewed for bowel and bladder.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately store topical treatment medication for one Resident (#1) of twelve residents reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dining adaptive equipment for one Resident (#17) of three residents reviewed for dining assistive devices.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in a food borne illness among any and all 38 residents.

Inspectors wroteResident #9 (R9): Review of R9's Electronic Medical Record (EMR) revealed initial admission to the facility on 2/8/22 with diagnoses including congestive heart failure, bipolar disorder, panic disorder, and cognitive communication deficit. Review of R9's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment. On 3/12/24 at 9:30AM, R9 was observed sleeping in bed in his private room. A white [Brand Name] camera was observed on the bedside dresser, aimed at R9. A green light was observed next to the camera power switch reading, ON, indicating the unit was in use. On 3/12/24 at 9:32AM, R9 was observed on a [Brand Name] video monitor screen which was unattended at the nurse's station in a high traffick, central location within the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a secured/locked medication cart and maintain clean and sanitary medication carts for two of two medication carts reviewed for medication storage and one of one medication rooms. This deficient practice had the potential for medications to be misappropriated, medication loss, and contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store oxygen supplies per standards of practice and administer oxygen services per physician orders for one Resident (#30) of two residents reviewed for oxygen services. This deficient practice resulted in the potential for respiratory infection and hypoxia (below-normal level of blood oxygen) resulting in respiratory and/or medical decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: a) Staff donned appropriate personal protective equipment (PPE) for one (Resident #8) of five residents reviewed for Enhanced Barrier Precautions (EBP). b) Catheter care was performed in accordance with acceptable standards of practice for one (Resident #30) of one residents reviewed for urinary catheters. These deficient practices resulted in the potential for the development and transmission of communicable disease and infections. Findings Include: Resident #8 (R8): Review of R8's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including a non-pressure chronic ulcer of the left ankle, acquired absence of the right leg below the knee, and history of infectious and parasitic diseases. [...]