La Crescent Health Services

Inspectors wroteBased on observation, interview, and document review, the facility failed to prevent complications of enteral feeding and failed to provide appropriate treatment and services for 1 of 1 resident (R5) reviewed who required tube feedings and medication administration through a gastrostomy tube (g-tube). This failure created the likelihood of serious harm for R5, including worsening symptoms of nausea and vomiting, and additional hospital visits. The immediate jeopardy (IJ) began on 4/8/26 when the facility failed to follow professional standards of medication administration through a g-tube, pharmacy directions for medication administration, identify the symptoms and side effects of incorrectly using the g-tube. Subsequently, R5 experienced nausea and vomiting and was sent to the hospital with a diagnosis of pneumonia. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food was served in a timely manner to preserve desired temperatures of food for 4 of 4 residents (R1, R10, R15, R30) reviewed who expressed concerns for food temperatures and palatability. This had the potential to affect all residents who consumed food from the facility kitchen.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess and care plan to ensure competency and safety with self-administration of medication for 1 of 1 resident (R20) observed to be self-administering medication in their room.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident representative/Power of Attorney (POA) about refusal of care and/or treatment for 1 of 1 resident (R5) reviewed for notification of changes.

Inspectors wroteBased on interview and document review, the facility failed to ensure appropriate side effect monitoring for potential orthostatic hypotension (sudden drop in blood pressure what occurs when a person stands up after sitting or lying down) was completed for 1 of 1 resident (R15) reviewed for unnecessary medication use and who consumed antipsychotic medication.

Inspectors wroteBased on interview and document review, the facility to implement policies and procedures to ensure the State agency (SA) was notified in a timely manner for allegations of abuse for 1 of 1 residents (R32) whose allegations were reviewed.

Inspectors wroteBased on interview and document review, the facility failed to notify the Office of the State Long-Term Cate (LTC) Ombudsman for 2 of 2 residents (R5 and R39) reviewed for hospitalizations and discharges.

Inspectors wroteBased on observation, interview, and document review, the facility failed to develop and implement a person-centered care plan for 1 of 1 resident (R5) reviewed for comprehensive care plans.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure professional standards of practice were followed during medication administration for 1 of 1 resident (R5) reviewed for gastrostomy tube (g-tube) medication administration.

Inspectors wroteBased on observation, interview, and document review the facility failed to monitor and implement individualized interventions to prevent/mitigate the risk of pressure ulcers and/or deterioration for 1 of 1 resident (R5) reviewed for pressure ulcers. Findings Include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. R5 was independent with eating, required set up/clean up assistance with oral hygiene, and required partial to moderate assistance with toileting, showering/bathing, dressing, and personal hygiene. R5 had occasional urinary incontinence but was always continent of bowel. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to monitor daily oral intake and daily output; additionally, the facility failed to develop a system to monitor and assess daily intake and output for 1 of 1 resident (R5) reviewed who required nutritional and hydration support via a gastrostomy tube (g-tube). Findings Include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 required hydration and nutrition via a feeding tube (g-tube). R5's current face sheet identified diagnoses of moderate protein-calorie malnutrition, dysphagia (difficulty swallowing) requiring the placement of a gastrostomy tube (g-tube) for nutrition and medication administration. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed according to standards of care to prevent respiratory infections for 1 of 1 residents (R16) who required oxygen for chronic respiratory failure with hypoxia (a condition where the lungs are unable to adequately oxygenate the blood).

Inspectors wroteBased on interview and document review, the facility failed to implement or maintain an appropriate communication and collaboration system with an outside dialysis clinic to promote continuity of care and reduce the risk of complication (i.e., missed orders, insufficient preparation for treatment), ensure contact information for dialysis clinic was on the care plan and ensure orders were accurate for monitoring dialysis site for 1 of 1 residents (R16) reviewed for dialysis care and services.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 1 primary care physician assistant (PA-A) had appropriately managed the care for 1 of 1 resident (R5) who experienced complications from tube feedings and medication administration through a gastrostomy tube (g-tube). Refer to F684Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. R5 was independent with eating, required set up/clean up assistance with oral hygiene, and required partial to moderate assistance with toileting, showering/bathing, dressing, and personal hygiene. R5 had occasional urinary incontinence but was always continent of bowel. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify irregularities in monthly drug regimen monitoring review for 1 of 5 residents (R15) reviewed for unnecessary medications who received antipsychotic medications. Additionally, the facility failed to identify potential medication side effects for 1 of 1 resident (R5) reviewed for medication administration.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a medication administration error rate of less than 5 percent (%) resulting in an 8.57 % medication error rate, identified during 3 of 25 medication administration observations.

Inspectors wroteBased on interview and document review, the facility failed to implement their facility assessment to identify 1 of 1 resident (R5) who required specialty care and services and the facility failed to train and perform skill competencies as outlined in the facility assessment.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 1 medical director had appropriate oversight of policies and procedures and ensured appropriate medical care was being provided for 1 of 1 (R5) resident who experienced complications from tube feedings and medication administration through a gastrostomy tube (g-tube).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 2 of 2 residents (R5, R20) reviewed for transmission-based precautions.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff completed mandatory communication training for 2 of 10 staff (nursing assistant (NA)-A, licensed practical nurse (LPN)-B) reviewed for training requirements. This had the potential to affect all 34 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff completed mandatory quality assurance and performance improvement training for 6 of 10 staff (registered nurse (RN)-A, licensed practical nurse (LPN)-B, nursing assistant (NA)-A, NA-D, NA-E, and NA-F) reviewed for training requirements. This had the potential to affect all 34 residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the most recent survey results were posted in a prominent location and readily accessible to person wishing to review such information. This had potential to affect all 34 residents residing in the nursing home or any visitors who wanted to review this information.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure refrigerated food items were disposed of after expiration date and were properly stored, labeled and dated. This had the potential to affect 28 of 28 residents, staff and visitors who may eat from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper use of personal protective equipment (PPE) during cares for 1 of 3 residents (R14) reviewed for enhanced barrier precautions (EBP).

Inspectors wroteBased on interview and document review, the facility failed to develop an antibiotic stewardship program which included the development of protocols and a system to monitor antibiotic use for 5 of 5 residents (R3, R8, R10, R14, R21) who were prescribed antibiotics prophylactically. This deficient practice had the potential to affect all 5 residents.

Inspectors wroteBased on interview and document review, the facility failed to implement the current standards of vaccinations regarding pneumonia for 5 of 5 (R2, R7, R8, R10, R19) over [AGE] years old whose vaccination histories were reviewed.

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean, sanitary, and homelike environment when R19's curtain was observed to be in disrepair. In addition, the facility failed to ensure a homelike environment for all 23 residents when carpet in the lobby at the entrance to the facility were observed to be darkly stained and soiled.

Inspectors wroteBased on interview and document review, the facility failed to ensure routine bathing was offered or provided to promote good hygiene for 1 of 2 residents (R2) reviewed for activities of daily living (ADLs) and who was dependent on staff for their cares.

Inspectors wroteBased on interview and document review, the facility failed to complete annual performance reviews for 5 of 5 nursing assistants (NA-A, NA-B, NA-C, NA-D, NA-E) whose employee files were reviewed. This had the potential to affect all 24 residents who resided at the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to label and date food items in the dietary refrigerator.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide appropriate hand hygiene when providing care, and handling of a catheter bag and tubing for 1 of 1 resident (R15) reviewed for infection prevention and control.

Inspectors wroteDuring observation and interview, the facility failed to ensure hand rails were securely attached to the wall. This had the potential to affect all residents, staff, and visitors who had access to the handrails.