Karcher Post Acute

Inspectors wroteBased on observation, review of the FDA Food Code, policy review, and staff interviews, it was determined the facility failed to ensure 3 of 3 dumpsters and 1 of 1 garbage can were properly closed to prevent attracting pests and rodents into the facility. This deficient practice had the potential to affect all residents and staff in the facility.

Inspectors wroteBased on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure residents were provided respiratory services consistent with professional standards of practice. This was true for 5 of 16 residents (#16, #33, #37, #38, and #52) whose respiratory devices were not cleaned and stored properly and 2 of 16 residents (#22 and #38) reviewed for physician orders for oxygen therapy. This deficient practice created the potential for residents to develop infection and to receive too little or too much oxygen.

Inspectors wroteBased on observation, policy review, FDA Food Code review, resident and staff interviews, it was determined the facility failed to appropriately store, distribute and label foods. This deficient practice had the potential to affect all residents who received food prepared in the facility. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food borne illnesses.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 1 of 1 resident (Resident #16) reviewed for respect and dignity. This deficient practice placed residents at risk of embarrassment and diminished self-worth.

Inspectors wroteBased on review of the State Operations Manual (SOM), record review, and staff interview it was determined the facility failed to ensure residents exercised their right to formulate an Advanced Directive. This was true for 1 of 3 residents (Resident #33) whose records were reviewed. This failed practice created the potential for an adverse outcome if the resident's wishes were not followed.

Inspectors wroteBased on policy review, record review, review of the facility grievances, and resident and staff interview, it was determined the facility failed to ensure grievances were investigated and prompt corrective action was taken to resolve them. This was true for 1 of 1 resident (Resident #6) reviewed for grievances. This failure created the potential for psychological harm if residents' grievances were not acted upon.

Inspectors wroteBased on observation, staff interview, policy and record review, it was determined the facility failed to ensure a seatbelt was assessed as potential restraints and a consent from the residents and/or their representatives was obtained. This was true for 1 of 1 resident (Resident #6) reviewed for potential restraint. This deficient practice had the potential for harm if the seatbelt were improperly used.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents were appropriately monitored for side effects of anti anxiety medication. This was true for 1 of 5 residents (Resident #9) reviewed for unnecessary medications. This failure created the potential for inappropriate pharmacological interventions and adverse outcomes, including oversedation.

Inspectors wroteBased on record review and staff interviews, it was determined the facility failed to ensure the required discharge process was followed when residents were transferred to a higher level of care. This was true for 2 of 2 residents (#6 and #16 ) reviewed for hospital discharge process. This failure created the potential for incomplete information of transfers, delay in care, and lack of required notifications.

Inspectors wroteBased on the State Operations Manual (SOM), record review, and staff interview, it was determined the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) was completed when new mental health diagnoses were identified for 1 or 4 residents (Resident #4), whose records were reviewed for PASRR screenings. This failure created the potential for harm if the resident required but did not receive specialized services for mental health while residing in the facility.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure PASRR screening for serious mental illness, intellectual disability, or related conditions were completed accurately. This was true for 2 of 4 residents (#22 and #44) whose PASRR records were reviewed. This failure placed Resident #22 at risk for harm if their needs went unmet when a diagnosis of serious mental illness was omitted from their PASRR level 1, and placed Resident #44 at risk for harm when a new PASRR level 1 was not completed.

Inspectors wroteBased on policy review, record review, and staff interviews, it was determined the facility failed to ensure residents were provided with a comprehensive, person centered care plan as required. This was true for 2 of 17 residents (Residents #5 and #6) reviewed for care plans. Comprehensive, person centered care plans are essential for identifying resident needs, directing staff actions, and ensuring coordinated care. This deficient practice created the potential for unidentified or unmet care needs.

Inspectors wroteBased on observation, record review, the National Council of State Boards of Nursing (NCSBN) website, and staff interview, it was determined the facility failed to ensure physician orders were clarified to verify the correct route of medication administration. This was true for 1 of 2 residents (Resident #2) whose physician orders were reviewed. This deficient practice created the potential for harm if residents were to receive oral medications when they were ordered to receive nothing by mouth.

Inspectors wroteBased on observation, policy review, and staff interview it was determined the facility failed to ensure professional standards of practice were followed for 1 of 2 residents (Resident #2) reviewed for enteral feeding. This failure created the potential for adverse outcomes when Resident #2's physician orders were not followed for enteral flush and medication administration.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service training and performance reviews. This was true for 1 of 3 CNAs reviewed for skills and qualifications. This failure created the potential to affect resident safety by limiting staff competency in providing care.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure resident records accurately reflected active medical diagnoses. This was true for 1 of 17 residents (Resident #5) reviewed for accuracy of records. This failure created the potential for miscommunication and unmet or unidentified care needs.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure immunizations were offered and/or provided as indicated. This was true for 1 of 5 residents (Resident #4) reviewed for pneumococcal immunization. This deficient practice placed residents at risk of developing pneumococcal pneumonia and developing serious, potentially life-threatening complications.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure a resident was free from abuse. This was true for 1 of 3 residents (Resident #50) whose incidents during transferring were reviewed. This failure resulted in actual harm when Resident #50 was injured during a transfer from her bed to a wheelchair against her will.

Inspectors wroteBased on record review, review of Incidents and Accidents (I&A's) reports, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 8 of 8 residents (#4, #5, #6, #7, #8, #9, #10, and #11) reviewed for medication errors. Resident #4 was harmed after being administered her roommate's opioid pain medication and required medical intervention. Resident #5 was harmed when her narcotic medication was omitted resulting in increased pain. There was potential for harm and adverse outcomes when Residents #6, #7, #8, #9, #10, and #11's medications were not administered following physicians' orders.

Inspectors wroteBased on the Long Term Care State Reporting Portal, Incident and Accident (I&A) report, record review and staff interview, it was determined the facility failed to provide an environment free from accidental hazards over which the facility has control and provides supervision to each resident to prevent avoidable accidents. This was true for 1 of 4 residents (Resident #36) reviewed for accidents. Resident #36 was harmed when a CNA failed to notify the nurse Resident #36 was using a heating pad. Resident #36 was found to have a burn at the hospital.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident's missing property was investigated and prompt corrective action was taken. This was true for 1 of 3 residents (Resident #28) whose missing items were reviewed. This failure created the potential for psychological harm if residents' missing items were not investigated.

Inspectors wroteBased on interviews of residents, resident representatives, and staff, and record review, it was determined the facility failed to ensure a resident's cultural/religious rights were honored. This was true for 1 of 1 resident (Resident #28) whose record was reviewed for resident rights. This failure resulted in psychosocial harm to Resident #28 when a certified nursing assistant (CNA) cut her hair without her consent.

Inspectors wroteBased on record review, review of the State Survey Agency's Long-Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to report alleged verbal abuse to the State Survey Agency within 5 days. This was true for 1 of 6 residents (Resident #11) reviewed for abuse. This failure created the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility.

Inspectors wroteBased on record review, review of facility Grievance Logs, and staff interview, it was determined the facility failed to ensure allegations of verbal abuse were thoroughly investigated for 1 of 6 residents (Resident #11) reviewed for abuse. This failure created the potential for Resident #11 to be subjected to ongoing abuse without detection and intervention.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents' MDS documented correct assessment information. This was true for 2 of 14 residents (#16 and #30) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments.

Inspectors wroteBased on interviews of residents, resident representatives, and staff, and record review, it was determined the facility failed to ensure a resident's cultural/religious preferences were included in their care plan. This was true for 1 of 14 residents (Resident #28) whose care plans were reviewed. This failure placed Resident #28 at risk for their religious rights not being honored.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure residents and their representatives were provided the opportunity to participate in care planning and attend care conferences. This was true for 1 of 14 residents (Resident #27) whose care plans were reviewed. This placed resident #27 at risk for adverse outcomes if care and services were not provided due to care plans not being reviewed and revised as the resident's needs changed.

Inspectors wroteBased on reviews of incident reports and medical records, and staff interviews, it was determined the facility failed to implement interventions to reduce residents' risk of accidents. This was true for 1 of 4 residents (Resident #20) reviewed for accidents. This failure resulted in Resident #20 experiencing a fall when her soft touch call light was not available for use.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure a resident was free from duplicate pain medication therapy without clear parameters for administration. This was true for 1 of 6 residents (Resident #9) whose records were reviewed for unnecessary medications. This failure created the potential for harm and adverse effects if Resident #9 was to receive inappropriate opioid medication.

Inspectors wroteBased on record review, review of facility's policy and procedure, review of Incidents and Accidents reports, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 2 of 2 residents (#11 and #16) reviewed for medication errors.

Inspectors wroteBased on observation, resident interview, test tray evaluation, and staff interview, it was determined the facility failed to ensure food was served at an appropriate temperature. This affected 1 of 4 residents (Resident #40) who were reviewed for dietary concerns. This failed practice created the potential to negatively affect residents' nutritional status and psychosocial well-being.

Inspectors wroteBased on observation, Food Drug Administration (FDA) Food Code, and staff interview, it was determined the facility failed to ensure kitchen equipment was maintained, cleaned, and sanitized. These deficiencies had the potential to affect the 54 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes due to contaminated food services equipment.

Inspectors wroteBased on policy review, record review, review of the State Agency's Long Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to ensure a resident's right to stay in the facility and the right to appeal the decision for a facility-initiated discharge. This was true for 1 of 3 residents (Resident #1) reviewed for facility-initiated discharges. This deficient practice caused Resident #1 to experience psychosocial harm when he was discharged to a motel without the ability to check his blood sugar and safely administer insulin.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure pertinent health information was provided to the receiving hospital for 3 of 3 residents (#2, #7, and #41) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if residents were not treated in a timely manner due to a lack of information provided upon transfer.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives upon transfer to the hospital. This was true for 3 of 3 residents (#2, #7 and #41) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure food was stored, labeled, and food served in a sanitary manner in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 53 residents residing in the facility who consumed food prepared by the facility at risk for contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 2 of 13 residents (#28, and #41) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in their care plan.

Inspectors wroteBased on observation, policy review, record review and resident and staff interview, it was determined the facility failed to ensure a resident was assessed quarterly to determine if they were safe to smoke cigarettes for 1 of 1 resident (Resident #39). This failure created the potential for negative outcomes if Resident #39 was not assessed for safe smoking.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents receiving a psychoactive medication had resident-specific target behaviors identified and monitored. This was true for 1 of 5 residents (Resident #41) reviewed for psychoactive medications. This deficient practice created the potential for harm if residents received medications that may result in negative outcomes without clear indication of need.