Jenkins Care Community

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure timely services were provided for a head injury as ordered by the physician, notification to the family of the incident, and ensure fall interventions in place. This affected one (Resident #22) of three residents reviewed for falls. The facility census was 44.

Inspectors wroteBased on interview and record review the facility failed to implement pressure ulcer prevention precautions for Resident #206 identified as having a facility acquired deep tissue injury (DTI) (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). This affected one ( Resident #206) of three residents reviewed for skin impairment. The facility census was 43.

Inspectors wroteBased on interview and record review the facility failed to maintain a complete and accurate medical record affecting Resident #206. This affected one (Resident #206) of nine resident medical record reviews. The facility census was 43.

Inspectors wroteBased on closed record review and interviews, the facility failed to provide an appropriate transfer notice with Ombudsman notifications to either the resident or designated representative. This affected one resident (Resident #5) out of three residents reviewed for facility discharge. The facility census was 40.

Inspectors wroteBased on record review and interview, the facility failed to complete a significant change Pre admission Screening and Resident Review (PASARR) for Resident #7 and failed to ensure the admission PASARR was completed accurately for Resident #31. This affected two (Resident #7 and Resident #31) of four residents reviewed for PASARR. The facility census was 40.

Inspectors wroteBased on interview and record review, the facility failed to invite Resident #31 to attend quarterly care conferences. This affected one resident of 12 reviewed for care planning and care conference. The facility census was 40.

Inspectors wroteBased on record review and interviews, the facility failed to provide an ordered psychiatric consult following a gradual dose reduction (GDR) recommendation. This affected one (Resident #35) out of five residents reviewed for unnecessary medications. The facility census was 40.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure interventions to prevent the worsening of contracture's were implemented. This affected one resident (#7) out of the two residents reviewed for limited range of motion during the annual survey. The facility census was 40.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify causes and triggers for trauma. This affected one resident (#7) reviewed for PTSD during the annual survey. The facility identified one resident having a diagnosis of PTSD. The facility census was 40.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure parameters for the monitoring and reporting of hypoglycemia (low blood sugar) were in place. This affected one resident (#31) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 40.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident #25 had the appropriate diagnosis for an antipsychotic medication. This affected one (Resident #25) of five residents reviewed for unnecessary medications. The facility census was 40.

Inspectors wroteBased on record review, staff interview, review of the facility Self-Reported Incident (SRI), and policy review, the facility failed to prevent physical abuse for one resident (#10) of three residents reviewed. The facility census was 48.

Inspectors wroteBased on observation, review of the medical record, facility investigation, staff statements, facility Fall Risk Assessment/Reassessment and Prevention policy and staff interview the facility failed to ensure one resident (Resident #20) was provided assistance with bed mobility by two staff members, as assessed, during incontinence care. Actual Harm occurred when one staff member provided incontinence care to Resident #20 resulting in the resident falling from the bed and sustaining an acute impacted left femoral intertrochanteric fracture (occur when a force presses against both ends of the femur at the femoral neck, pushing the broken ends of the bone together) and unspecified fracture of the lower end of the right femur requiring surgical repair. [...]

Inspectors wroteBased on observation and staff interview the facility failed ensure residents who resided on the secured dementia unit were provided the necessary utensils to assist with independent meal consumption resulting in a potential undignified dining experience for the residents on the unit. This affected 13 residents (#20, #39, #22, #7, #17, #31, #15, #44, #13, #29, #2, #38 and #21) 13 residents who resided on the secured dementia unit. The facility census was 57. Findings Include: On 11/12/19 at 11:34 A.M. observation of the lunch meal revealed Resident #20, #39, #22, #7, #17, #31, #15, #44, #13, #29, #2, #38 and #21 were served only a spoon and a fork with their meal. The residents were not provided with a knife. At 12:00 P.M. State Tested Nursing Assistant (STNA) #189 was observed to cut Resident #39's hamburger in half using a fork and a spoon. [...]

Inspectors wrote3. Review of Resident # 17's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, senile dementia, major depression recurrent, anxiety disorder, macular degenerations, type two diabetes, femur fracture and peripheral vascular disease. Resident #17 resided on the secure care unit (SCU). Review of Resident #17's activity assessment, dated 07/07/15 revealed her past and present interests were card games, bingo, outdoors, television, music, religious, van outings, arts and crafts, reading, and discussion. Resident #17 wanted to walk and stay busy during the day. Record review revealed Resident #17 did not have a plan of care for activities. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to develop and implement a comprehensive activities program designed to meet the total care needs of all residents. This affected five residents (#15, #17, #20, #21 and #22) of nine sampled residents reviewed for activities. Findings Include: 1. Review of Resident # 17's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, senile dementia, major depression recurrent, anxiety disorder, macular degenerations, type two diabetes, and femur fracture, and peripheral vascular disease. Resident #17 resided on the secure care unit (SCU). [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure residents had adequate indication for the use of psychotropic medications and/or failed to ensure the justified use of an as needed (PRN) antipsychotic medication for greater than 14 days. This affected four residents (#21, #22, #31 and #197) of five residents reviewed for unnecessary medication use. Findings Include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia, delusional disorder, glaucoma, essential hypertension, abnormal weight loss, dementia with behavioral disturbance, major depressive disorder, hypothyroidism and malignant neoplasm of female breast. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure care plans were revised for Resident #31 related to pain management, Resident #20 related to mobility devices and for Resident #197 related to Hospice services. This affected three residents (#31, #20 and #197) of 21 sampled residents whose care plans were reviewed. Findings Include: 1. Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood others, and his cognition was severely impaired. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #21 and Resident #22 were provided the necessary care and services to maintain the resident's dining ability, ability to eat independently. This affected two residents (#21 and #22) of four residents reviewed for activities of daily living (ADL) care. Finds Include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia, delusional disorder, glaucoma, essential hypertension, abnormal weight loss, dementia with behavioral disturbance, major depressive disorder, hypothyroidism,and malignant neoplasm of female breast. Review of Resident #21's plan of care, dated 02/20/19 revealed to assist her as needed with her activities of daily living. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure Resident #15 and Resident #31, who were dependent on staff for activities of daily living received timely and adequate assistance with dressing and personal hygiene. This affected two residents (#15 and #31) of four reviewed for activities of daily living. Findings Include: 1. Review of Resident #15's medical record revealed an admission date of 08/20/19 with the admitting diagnoses of anxiety, dementia and depression. Review of the resident's plan of care, dated 08/21/19 revealed the resident had a self-care performance deficit related to Alzheimer's disease progression. Interventions included to set-up supplies for care and assist with activities of daily living. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #31's oxygen tubing and humidification/water bottle were dated. This affected one resident (#31) of one resident reviewed for oxygen therapy. The facility identified seven residents received respiratory care. Findings Include: Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood others, and his cognition was severely impaired. Resident #31 did not reject care. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to implement a comprehensive and individualized pain management program for Resident #31. This affected one resident (#31) of one resident reviewed for pain. Findings Include: Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's plan of care, dated 02/08/19 revealed it did not address non-verbal expressions of pain. Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood others, and his cognition was severely impaired. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #197's medical record was accurate to reflect the discontinuation of Hospice services. This affected one resident (#197) of 24 residents whose medical records were reviewed. Findings Include: Review of the medical record for Resident #197 revealed an admission date of 11/01/19 with diagnoses of dementia without behavioral disturbances, hypertension and anxiety. Review of the progress notes for Resident #197 revealed multiple notes including notes on 11/12/19, and 11/13/19 revealing the resident was receiving Hospice services. Interview on 11/13/19 at 4:10 P.M. with Assistant Director of Nursing (ADON) #154 revealed Resident #197 was discharged from Hospice on 11/05/19. However, nursing staff continued to document the resident was receiving Hospice services after this date.