Katherine's Place at Wedington

Inspectors wroteBased on interviews, record review, document review the facility failed to provide incontinent care during an eight-hour shift for one resident (Resident #30) of four residents reviewed for neglect.

Inspectors wroteBased on record review, observation, interview and facility policy review the facility failed to ensure good hand hygiene was maintained for 1(Resident #54) of 2 sampled (Resident #54 and Resident #101) residents observed during perineal care and reviewed for bowel and bladder.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to report to the State Licensing Agency an incident of resident allegation of verbal abuse for one (Resident #5) resident of five residents reviewed for abuse.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dietary staff washed their hands and changed their gloves before handling food items to prevent the potential for cross contamination for the residents who received meals from 1 of 1 kitchen, the failed practice had the potential to affect 103 residents who received meals from the Kitchen (Total Census: 104).

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to initiate care areas and interventions on the resident care plan for oxygen usage and physician's orders for high risk medications for 3 (Resident #13, Resident #15, and Resident #99) of 3 sampled residents reviewed for care plans and interventions.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined that the facility failed to revise the resident care plan to reflect current physician orders for 3 (Resident #13, Resident #15, and Resident #46) of 3 residents reviewed for care plan revision.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure that the physicians order for wound care was following during a scheduled dressing change for 2 (Resident #4 and Resident #32) of 2 residents reviewed for wound care management.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were served in a method that maintained the appearance of cold product and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 11 residents who receive meal trays in their rooms on the 100 Hall, 8 residents who receive meal trays on the 200 Hall, 13 residents who receive meal trays in their room on the 300 Hall, 5 residents who receive meal trays in their room on 400 Hall, 25 residents who receive meal trays in their room on the 500 Hall, and 6 residents who receive meal trays in their room on the 600 Hall.

Inspectors wroteBased on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 9 residents who received pureed diets.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure proper hand hygiene was performed before and during wound care to maintain aseptic technique throughout wound care, ensure no cross contamination of Personal Protective Equipment (PPE) and during wound bed cleansing for 2 (Resident #4 and Resident #32) of 2 residents reviewed for wound care.

Inspectors wroteBased on interview, record review, and record review, the facility failed to ensure a bed hold notification was sent to a resident and/or resident representative following a hospital transfer and admission for 1 (Resident #13) of 1 resident reviewed for hospitalizations.

Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure the physicians orders were followed on changing oxygen tubing and humidifier bottle for 1 (Resident #99) of 1 resident reviewed for oxygen usage.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a medication regimen review was completed monthly for 1 (Resident #91) of 1 resident reviewed for unnecessary medication review.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food items stored in the refrigerator were dated, kitchen appliances (deep fryer shelf below the deep fryer) were clean and free of stains and spills; and staff washed their hands between dirty and clean tasks and before handling clean dishes or food items to prevent potential for cross contamination. These failed practices had the potential to affect all 94 residents who received meals from the kitchen (total census: 94), as documented on a list provided by the Dietary Supervisor on 05/16/23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' confidential and personal information was not overheard by family members of 16 residents on the 400 Hall during shift change as documented on the Census by Hall provided by the Administrator on 05/15/23 at 10:34 AM.

Inspectors wroteBased on observation, and interview, the facility failed to ensure residents were allowed to have personal property within reach creating a homelike environment and maximizing the resident's independence for 1 (Resident #19) of 58 (Residents #1, #2, #3, #7, #8, #11, #13, #14, #15, #16, #19, #23, #25, #26, #30, #31, #32, #33, #36, #38, #39, #41, #45, #47, #48, #51, #52, #53, #54, #56, #57, #59, #61, #62, #63, #66, #69, #71, #72, #73, #74, #79, #80, #82, #84, #85, #86, #87, #98, #145, #205, #245, #246, #346, #347, #348 and #349) sampled residents. The failed practice had the potential to affect 94 residents as documented on the Matrix provided by the Assistant Director of Nursing (ADON) on 05/15/23 at 11:05 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Care Plans were implemented and accessible for staff who were responsible for the interventions for 1 (Resident #245) of 1 sampled resident with diet and nutritional interventions for Gastro-Esophageal Reflux Disease (GERD) as documented on a list provided by the Administrator on 05/18/23 at 8:48 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 2 (Residents #53 and #346) of 53 (Residents #1, #2, #3, #5, #7, #8, #11, #13, #14, #15, #16, #19, #20, #23, #25, #26, #32, #33, #36, #37, #38, #39, #41, #45, #47, #48, #51, #52, #53, #56, #57, #61, #62, #63, #66, #69, #70, #71, #72, #73, #74, #80, #82, #84, #85, #86, #87, #245, #246, #346, #347, #348 and #349) sampled residents who were dependent for nail care and failed to ensure shaving and beard trimming services were regularly provided to maintain good hygiene for 2 (Residents #36 and #53) of 25 (Residents #2, #11, #13, #16, #20, #25, #26, #32, #36, #37, #39, #41, #45, #53, #57, #62, #69, #70, #72, #82, #87, #245, #346, #347 and #349) sample residents who were dependent on staff for shaving. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by properly storing toothbrushes for 2 (Residents #36, and #87) of 54 (Residents #1, #2, #3, #5, #7, #11, #13, #14, #15, #16, #19, #20, #23, #25, #26, #32, #33, #35, #36, #37, #39, #41, #45, #47, #48, #51, #52, #53, #56, #57, #59, #61, #62, #63, #66, #69, #70, #71, #72, #74, #80, #82, #84, #85, #86, #87, #88, #145, #245, #246, #346, #347, #348 and #349) sampled residents who utilize a toothbrush for oral care. This failed practice had the potential to affect 88 residents who required a toothbrush for dental hygiene as documented on a list provided by the Director of Nursing (DON) on 05/18/23 at 9:30 AM.

Inspectors wroteBased on observation, record review, interview, the facility failed to ensure the kitchen was free of pests to prevent the potential of cross contamination or bacteria growth. The failed practice had the potential to affect 101 residents who received food from 1 of 1 kitchen according to the list provided by the Assistant Administrator on 05/16/23 at 12: PM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure call lights were within reach to enable residents to call for assistance to meet their needs for 1 (Resident #145) of 43 (Residents #1, #2, #3, #5, #7, #13, #15, #16, #19, #23, #25, #26, #32, #33, #35, #36, #37, #39, #41, #45, #47, #48, #51, #52, #53, #56, #59, #62, #63, #66, #70, #73, #74, #82, #84, #85, #88, #145, #245, #246, #346, #348 and #349) sampled residents who were able to use a call light. This failed practice had the potential to affect 77 residents who were able to use a call light as documented on a list provided by the Director of Nursing (DON) on 05/18/23 at 8:10 AM.

Inspectors wroteBased on interview, and record review, the facility failed to ensure all staff received complete primary vaccinations, had an approved or pending medical or religious exemption, or a temporary delay per the Center for Disease Control (CDC) and the Centers for Medicare and Medicaid Services (CMS) COVID-19 Health Care Staff Vaccination regulations; failed to ensure staff COVID-19 vaccinations were accurately tracked, documented, and updated timely and failed to submit data weekly to the National Healthcare Safety Network (NHSN).