Jasper Point of Journey LLC

Inspectors wroteBased on observations, staff interviews, record review, facility policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to establish and maintain an infection prevention and control program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility and failed to ensure heavy duty gloves were available for the laundry room for 49 of 49 census residents. These failed practices had the potential to affect the 49 residents residing in the facility.

Inspectors wroteBased on observations, record review, resident family member and staff interviews, and facility policy review, the facility failed to ensure personal information was kept confidential for one of one resident (Residents (R) 10) reviewed for privacy of 34 sample residents. This failure had the potential to cause emotional distress.

Inspectors wroteBased on resident family member and staff interviews, record review, and facility policy review, the facility failed to include proper reasons for a discharge/transfer for one of one resident (Resident (R) 10) reviewed for discharge of 34 sample residents. This had the potential for the resident to have significant stress.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to ensure a resident and Resident Representative (RR) received a written transfer agreement and bed hold notice for one (Resident (R)59) out of two reviewed for transfers from a sample of 34 residents. This failure had the potential to affect the resident and their RR by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired, and contribute to the possibility of denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital.

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to ensure the comprehensive assessment accurately reflected a facility fall for one (Resident (R) 4) of two residents reviewed for falls in the sample of 34 residents. This failure had the potential for unmet care needs.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to ensure residents' care plans reflected current level of care for two of 34 sample residents (Resident (R) 4 and R54) reviewed for care plans. This failure had the potential to affect resident care outcomes.

Inspectors wroteBased on record review, resident and staff interviews, and facility policy review, the facility failed to ensure one (Resident (R)4) out of four reviewed for accidents out of a total sample of 34 residents was properly secured during a Hoyer lift (mechanical lift) transfer and sustained a fall. This had the potential for the resident to sustain serious injury.

Inspectors wroteBased on observations, staff interview, record review, and facility policy review, the facility failed to provide respiratory care in accordance with professional standards for one of one (Resident (R) 21) residents reviewed for respiratory care out of a total sample of 34 residents. Specifically, respiratory equipment, such as nebulizer masks, were not stored in a sanitary manner and physician orders for oxygen levels were not followed. The deficient practice had the potential for a risk of infection and respiratory distress.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the clinical records were complete for one of three residents (Resident (R) 10) reviewed for pressure ulcers out of a total sample of 34 residents. This failure created the opportunity for inaccurate medical records to be accessible to staff.

Inspectors wroteBased on staff interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to offer one of five residents (Resident (R) 26) reviewed for flu/pneumonia vaccinations out of 34 sample residents and/or their representatives the opportunity for the residents to be vaccinated in accordance with nationally recognized standards. In addition, the facility failed to have an acute policy displaying the CDC's recommendation. This practice had the potential to increase the risk for residents to contract pneumonia.

Inspectors wroteBased on interviews and record review the facility failed to complete Fall Risk Assessments during the admission process and post falls for two Residents (R) (R3 and R4) of three residents reviewed for falls.

Inspectors wroteBased on record review, staff interviews, and review of facility documents titled, Facility Assessment Tool and the PBJ (payroll-based journal) Staffing Data Report, the facility failed to ensure that the facility had adequate nursing staff on the weekends. The deficient practice had the potential to affect the care provided to the 51 residents that resided in the facility.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain the walk-in freezer in a manner to prevent ice buildup from forming on the freezer unit. This failure had the potential to contaminate food items located under the ice and place the 51 residents receiving an oral diet from the kitchen at risk of contracting a foodborne illness. The facility census was 51.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI), the facility failed to ensure the Medical Director or an appointee of the Medical Director's attendance and participation in QAPI committee meetings, at least quarterly. Specifically, the Medical Director or their appointee was not present and did not attend three of the six QAPI committee meetings reviewed.

Inspectors wroteBased on staff interviews, record review, and a review of the facility policy titled, Resident Assessment-Coordination with PASARR (preadmission screening and resident review) Program, the facility failed to submit a PASARR Level II for two of four residents (R) (R5 and R19) reviewed after a new mental illness diagnosis was added. This deficient practice had the potential to affect the appropriate level of care and services provided for R5 and R19.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policies titled Comprehensive Care Plan and Oxygen Administration, the facility failed to develop a person-centered comprehensive care plan for one of 20 sampled residents (R) (R15). This failure increased the potential for R15 not to receive treatment and/or care according to their needs.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policies titled, Nebulizer Therapy and CPAP/BiPAP (continuous/bilevel positive airway pressure machine) Cleaning, the facility failed to ensure that respiratory supplies were stored properly for two of 21 sampled residents (R) (R14 and R27). This deficient practice increased the risks of spreading microorganisms and placed R14 and R27 at risk for respiratory infections and a diminished quality of life.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Use of Psychotropic Medications, the facility failed to ensure that a psychotropic medication, with appropriate diagnoses, including antianxiety medication, was not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of six residents (R) (R19) reviewed for unnecessary medications.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Medication Storage, the facility failed to maintain medications in a locked and secure environment when not under direct supervision of the nurse for one of two medication carts (the 300 Hall cart). This failure placed residents, staff, and visitors at risk of having unauthorized access to residents' medications.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Clean Dressing Change, the facility failed to ensure hand hygiene was performed during wound care for one of five residents (R) (R1) with pressure ulcers. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Resident Environmental Quality, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment on three of three halls (Unit 100 hallway, Unit 200 hallway, and Unit 300 hallway). Specifically, all three hallways were filled with equipment and clutter, a wall behind a resident's bed was scuffed up, a wall across from the nurses' station was broken and covered with tape, and the shower room was cold with broken and stored clutter and a leaking shower head.

Inspectors wroteBased on observations, resident family and staff interviews, record review, and review of the facility policy titled, Falls Prevention Program, the facility failed to ensure residents received adequate supervision or intervention to prevent accidents for one of eight sampled residents (R) (R3).

Inspectors wroteBased on staff interviews, record review, and review of the facility policies titled, Behavioral Health Services, Suicide Prevention, and Suicide Assessment, the facility failed to provide timely treatment and services for one of eight sampled residents (R) (R5). Specifically, R5 was not provided adequate protection for possible self-harm during a suicide attempt with anxiety and depression.

Inspectors wroteBased on observation, record review, staff and resident interviews, and review of the facility policy titled Comprehensive Care Plan, the facility failed to follow the person-centered care plan to ensure pain interventions were implemented during wound care for one resident (R) (#43), resulting in harm to the resident, of 30 sampled residents.

Inspectors wroteBased on observation, record review, staff and resident interviews, and review of facility policy titled Pain Management, the facility failed to stop and address one resident's expression of severe pain during a wound treatment, resulting in harm for resident #43, of 30 sampled residents.

Inspectors wroteBased on record review, interviews, and review of the facility policy titled Communication of Code Status, the facility failed to communicate and ensure family preference for the change in code status from full code to do not resuscitate (DNR) was updated in the medical record for one of 30 sampled residents (R) (R#59).

Inspectors wroteBased on record review, staff interviews, and review of the facility policy, Comprehensive Care Plans, the facility failed to revise and update the care plan to include appropriate interventions for restorative care for one of 30 sampled residents (R) (#14).

Inspectors wroteBased on observation, record review, staff interviews, and review of the facility policy titled Catheter Care, the facility failed to ensure one staff implemented infection control standard precautions by not washing/sanitizing hands before and after glove removal and not double gloving during and after catheter care was performed for one resident (R) (R #11) reviewed of three residents with indwelling urinary catheter.

Inspectors wroteBased on record review and staff interview the facility failed to transmit Minimum Data Set (MDS) assessments within 14 days after completion for seven residents (R) (R#1, R#2, R#3, R#5, R#7, R#8, and R#33) triggered for past due MDS assessment, of 30 sampled residents.