La Plata Nursing Home

Inspectors wroteBased on observation, interview, and record review , the facility failed to serve food under sanitary conditions in accordance with professional standards for food service safety, failed to follow proper hygienic practices when preparing and serving food to residents, including using hand hygiene techniques, and failed to ensure food service equipment and surfaces were appropriately cleaned and ceilings above food preparation and serving areas were maintained. The facility census was 42. Review of the facility's policy, Food Preparation and Service General Guidelines, last revised November 2022, showed the following: -Cross contamination can occur when harmful substances, i.e., chemical, or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately document appropriate diagnoses of residents or resident behaviors to justify the implementation or continued used of antipsychotic medications (a type of psychiatric medication used to treat certain types of mental health problems, such as schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), for three residents (Residents #16, #28, and #30) in a review of 15 sampled residents. The facility also failed to complete a 14-day review for the as needed (PRN) use of a benzodiazepine (a drug that produces sedation and hypnosis) for one resident (Residents #10). The facility census was 42. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for infection control by failing to wash their hands or use hand sanitizer and properly use gloves when preparing and administering medications for one resident (Resident #17), and when providing personal care for three residents (Resident #10, #28 and #194), in a review of 15 sampled residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a system to ensure staff did not administer insulin (a hormone that helps regulate blood sugar levels by moving glucose from the bloodstream into cells throughout the body) or insulin-like products beyond the manufacturer's guidelines once opened for one resident (Resident #16) in a review of 15 sampled resident and one additional resident (Resident #5). The facility census was 42. Review of the manufacturer's guideline for use for Lantus insulin (long-acting insulin) showed it was good for 28 days after it was opened. Review of the manufacturer's guideline for use for Victoza (insulin-like medication) showed it was good for 30 days after it was opened. Review of the manufacturer's guideline for use for Toujeo insulin (long-acting insulin) showed it was good for 56 days after it was opened. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for three residents, (Resident #2, #1 and #3), when staff failed to remain with the resident when staff administered medications, and failed to ensure staff did not leave medications in the resident's room for one resident (Resident #1), when the resident did not have an order to keep medications at bedside or to self-administer, in a sample of four residents. The facility census was 43. Review of the facility policy, Administering Oral Medications, dated (revised) October 2010, showed the following: -The purpose of this procedure is to provide guidelines for the safe administration of oral medications; -Remain with the resident until all medications have been taken. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of misappropriation of a resident's medications to the state survey agency, when the director of nurses (DON) received information an unnamed resident was hoarding his/her pain medications and giving them to a Certified Nursing Assistant (CNA) employed by the facility, who in turn was giving them to his/her spouse, also employed by the facility, in a review of four sampled residents. The facility census was 43. Review of the facility policy, Abuse Prevention Program, dated (revised) August 2006, showed the following: -The residents of the facility have the right to be free from abuse, exploitation or mistreatment, misappropriation of resident property, corporal punishment, and involuntary seclusion. [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of misappropriation of a resident's medications, when the Director of Nurses (DON) received information that an unnamed resident was hoarding his/her pain medications and giving them to a Certified Nursing Assistant (CNA) employed by the facility, who in turn was giving them to his/her spouse, also employed by the facility, in a review of four sampled residents. The facility census was 43. Review of the facility policy, Abuse Prevention Program, dated (revised) August 2006, showed residents of the facility have the right to be free from abuse, exploitation or mistreatment, misappropriation of resident property, corporal punishment, and involuntary seclusion. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #5), in a review of five sampled residents, received the necessary care and treatment to prevent and/or heal pressure ulcers (an injury to skin and underlying tissue resulting from prolonged pressure on the skin, most often on bony areas of the body). Staff failed to ensure the resident, who had a pressure ulcer on his/her right buttock, had a dressing in place on the wound as ordered and a Roho cushion (pressure relieving cushion) in his/her wheelchair when he/she was up sitting in the wheelchair. The facility census was 42. Review of the facility's wound care policy, revised October 2010, showed the following: -The purpose of this procedure is to provide guidelines for the care of wounds to promote healing; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident, (Resident #13) of 14 sampled residents, was free from a significant medication error. Staff failed to transcribe the resident's order for prednisone (steroid) correctly following his/her discharge from the hospital and return to the facility on 2/8/23. The facility administered 30 milligrams (mg) of prednisone daily for 46 days instead of the ordered three day tapered dose. As a result, the resident presented to the emergency room on 3/26/23 with diagnoses that included acute pulmonary edema (condition caused by excess fluid in the lungs), steroid induced hyperglycemia (excessive amount of sugar in the blood), tachycardia (heart rate that exceeds the normal resting rate; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen. The census was 44. 1. Review of the policy, Ice Machines Cleaning and Maintenance Procedure, dated 12/7/20, showed ice and ice-making machines may be contaminated through improper handling of ice by patients and/or staff, improper storage of ice, poor cleaning or maintenance of associated equipment and ice handling equipment/implements. Ice from contaminated ice machines may result in adverse events for patients. These include colonization of microorganisms, blood stream infections, gastrointestinal illness, surgical site and skin infections, and respiratory infections including Legionnaires' disease. Observation on 3/20/23 at 9:11 A.M., showed the ice machine in kitchen had white debris and white dried runs and deposits on the exterior. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD), and failed to perform detection and surveillance of possible cases of LD. The facility failed to ensure staff washed their hands and changed soiled gloves after direct resident contact and when indicated by facility policy to prevent the spread of infection during personal care for one resident (Resident #38 ) and during medication administration for four residents (Residents #31, #38, #5, and #13), in a review of 14 sampled residents, and for two additional residents (Residents #32 and #26). The facility census was 44. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for one resident (Resident #36) of 14 sampled residents, when staff did not ensure ordered medications at hospital discharge were transposed correctly. The resident did not receive a treatment as ordered to disinfect his/her skin from a methicillin-resistant staphylococcus aureus (MRSA) infection (a contagious bacterial infection of the skin). The facility also failed to obtain physician orders for treatments before performing them and did not check or change applied dressings timely for one resident (Resident #345). The census was 44. Review of the facility policy titled, Medication and Treatment Orders, revised July 2016, showed the following: -Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy addressing cardiopulmonary resuscitation (CPR) requirements for staff. The facility failed to ensure there was an adequate number of staff present at all times who were properly trained and/or certified in CPR for Healthcare Providers to be able to provide CPR until emergency services arrived. The facility had no system to ensure staff were certified in CPR for Healthcare Providers to include a hands-on and in-person skills assessment. Facility staff identified 11 residents as being full code status. The facility also failed to ensure the code status for one resident (Resident #39) matched in all areas of the medical record and all areas which listed the resident's code status. The facility census was 44. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely safely transport two (Residents #17 and #245) of 14 sampled residents and four additional residents (Resident #11, #21, #28, and #29) in wheelchairs by ensuring footrests were in place. Facility staff also failed to transfer Resident #11 appropriately with a gait belt. The facility census was 44. The facility did not have a policy that addressed how to safely transport a resident in a wheelchair. Review of the undated facility policy, taken from the Nurse Assistant in a Long-Term Care Facility, Restorative Nursing training, lesson plan four, unit VII, showed the following: -STEPS OF PROCEDURE FOR AMBULATING RESIDENT USING A GAIT BELT: Wash your hands. Identify and greet resident. Identify self. Explain what you are going to do. Lower bed to lowest level; assist resident to sit on edge of bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for the use of bed rails/assist bars prior to installation and quarterly thereafter; failed to document interventions attempted prior to the use of bed rails/assist bars; failed to complete a bed rail entrapment assessment; and failed to review the risks and benefits with the residents/resident representatives and obtain consent for the use of bed rails/assist bars prior to installation for one resident (Resident #20), in a review of 14 sampled residents, and for two additional residents (Residents #1 and #7). The facility census was 44. Review of the facility's Proper Use of Side Rails Policy, revised December 2016, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two nurse aides (NA H and NA B) completed a nurse aide training program within four months of their employment in the facility. The facility census was 44. Review of the facility policy titled, Nurse Aide Qualifications and Training Requirements, revised August 2022, showed the following: -Policy Statement: Nurse aides must undergo a state-approved training program; -Nurse Aide is any individual providing nursing or nursing-related services to residents in a facility. This term may also include an individual who provides these services through an agency or under a contract with the facility, but is not a licensed health professional, a registered dietitian, or someone who volunteers to provide such services without pay; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an antibiotic stewardship protocol/program and a system to monitor appropriate antibiotic use for residents. The facility census was 44. Review of the facility's Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes Policy, revised December of 2016, showed the following: -Antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form; -The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship; -As part of the antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist (IP) or designee; [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and vaccinate eligible residents with pneumococcal vaccines as indicated by the current Centers for Disease Control (CDC) guidelines, for four residents (Residents #5, #11, #17, #38), in a review of 14 sampled residents. The facility census was 44. Review of the facility policy titled Pneumococcal Vaccine, revised August 2016, showed the following: -Policy Statement: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections; -Policy Interpretation and Implementation 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated, will be offered the vaccine series within thirty (30) days of admission to facility unless medically contraindicated or the resident has already been vaccinated; 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide documentation to show staff inspected bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for one resident (Resident #20), in a review of 14 sampled residents, and for two additional residents (Residents #1 and #7). The facility census was 44. Review of the facility's Proper Use of Side Rails Policy, revised December 2016, showed the following: -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the risk of entrapment from the use of side rails and the bed's dimensions are appropriate for the resident's size and weight; -The resident will be checked periodically for safety relative to side rail use; [...]

Inspectors wroteBased on record review and interview, the facility failed to complete an admission Minimum Data Set (MDS), (a federally mandated assessment instrument) in the time frame required by Centers for Medicare and Medicaid (CMS) for one newly admitted resident (Resident #145), in a sample of 14 residents. The facility census was 44. Review of the Resident Assessment Instrument (RAI) manual, revised October 2019, showed the following: -admission refers to the date a person enters the facility and is admitted as a resident. A day begins at 12:00 A.M. and ends at 11:59 P.M. regardless of whether admission occurs at 12:00 A.M. or 11:59 P.M., this date is considered the 1st day of admission; -Completion of an Omnibus Budget Reconciliation Act (OBRA) admission assessment must occur in any of the following admission situations: when the resident has never been admitted to this facility before; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a baseline care plan that accurately reflected the resident's needs to include instructions needed to provide effective and person-centered care within 48 hours of admission, and failed to give a written summary of the baseline care plan to the resident/resident representative for one newly admitted resident (Resident #145) in a review of 14 sampled residents. The facility census was 44. Review of the facility's policy Baseline Care Plan, revised December 2016, showed the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to revise care plans timely with changes in condition for two residents of 14 sampled residents (Residents #345 and #37). The facility census was 44. Review of the facility policy, titled Care Plans, Comprehensive Person-Centered, dated December 2016, showed the following: -Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -Policy Interpretation and Implementation: I. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -13. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services consistent with acceptable standards of practice to prevent a urinary tract infection (UTI) for one resident (Residents #345) with an indwelling urinary catheter (a tube inserted into the bladder to drain urine), and failed to include the presence/care of the urinary catheter in the care plan in a review of 14 sampled residents. The facility census was 44. The facility did not provide a policy for indwelling urinary catheters or prevention of urinary tract infections. 1. Review of Resident #345's care plan dated, 10/26/21, showed his/her diagnoses included history of urinary tract infections: -It did not include the presence of a urinary catheter; -It did not provide instruction on the care of a urinary catheter. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #17), in a review of 14 sampled residents, received the necessary services and assistance to maintain his/her nutritional status and to prevent weight loss. The facility census was 44. Review of the facility's policy, revised October 2017, showed the following: -The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparison over time; -The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition; [...]

Inspectors wroteBased on interview and record review the facility failed to give appropriate Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) (CMS-10055) and the CMS Notice of Medicare Non-Coverage (NOMNC) (CMS-10123) in writing to two residents of three sampled residents(Residents #4 and #17), or the resident's representatives, when the facility initiated discharge from Medicare Part A Services when benefit days were not exhausted. The facility census was 44. During an interview on 3/22/23 at 4:45 P.M., the Administrator (ADM) said the facility does not have a policy for SNF ABN CMS-10055 and the CMS NOMNC CMS-10123 forms. 1. Review of Resident #4's entry tracking Minimum Data Set (MDS), dated [DATE], showed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer/discharge to the resident and/or resident representative when two of 14 sampled residents (Residents #13 and #17) and one additional sampled resident (Resident #18), were transferred to the hospital. The facility did not provide any written documentation to the resident or resident representative of the reason and date for the transfer/discharge, where the resident was to be transferred/discharged , ombudsman contact information, information on how to appeal a transfer/discharge, and how to contact the mental health advocacy group for resident with intellectual disabilities or mental illness. The facility census was 44. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold policy to the resident and/or resident representative for two of 14 sampled residents (Residents #13, and #17) and one additional resident (Resident #18), when they were transferred to the hospital. The facility census was 44. 1. Review of Resident #13's Face Sheet showed the resident was admitted to the facility on [DATE]. Diagnoses include Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Raynauds' (spasms in extremities worsens with cold restricting blood flow causing numbness, and pain), Corticobasal degeneration (nerve cells controlling movement degenerate). Resident has an emergency contact, but no guardian or power of attorney listed. [...]

Inspectors wrote5. Review of Resident #29's care plan, dated 9/11/18, showed the following: -The resident was at risk for falling related to balance impairment and confusion; -The resident often refused assistance. Staff should re-approach the resident often and check on the resident frequently because he/she did not use the call light; -Give the resident verbal cues to use the assist device and keep it reach at all times; -If the resident is observed attempting unsafe tasks, walk the resident to the couch by the nurse's station to be in line of sight of staff; -Attempt to toilet the resident before and after each meal and during bed checks. Review of the resident's Significant Change in Status Assessment Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 11/30/18, showed the following: -Diagnoses included dementia and anxiety; [...]

Inspectors wrote3. Review of Resident #2's care plan, dated 9/25/18, showed the following: -The resident had poor memory/recall related to dementia; -The resident often forgot what he/he had been told. The resident obsessed about his/her shower through the early morning hours; -Allow the resident to sit on the couch and wait for his/her shower and redirect the resident with validation, redirection, and distraction techniques. Review of the resident's care plan, dated 10/29/18, showed the following: -The resident could be disruptive by asking for showers over and over. Staff should try offering snacks and reminding the resident he/she had already had a shower; -The resident has anxiety and was most anxious when he/she wanted to take a shower. The resident would ask to take more than one shower a day and would ask repeatedly for a shower when he/she was anxious. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff served the correct portion size of protein per the dietary spreadsheet menu to all residents with a physician's order for a mechanical soft diet and failed to offer or serve bread to all residents with an order for a regular or mechanical soft diet. The facility census was 39 residents. 1. Review of the Order Report by Category, dated 6/29/19 to 7/29/19, provided by the Dietary Manager, showed nine residents had a physician's order for a mechanical soft diet. Review of the Diet Spreadsheet, Week 3, Day 16, showed residents on a mechanical soft diet were to receive a #8 (1/2 cup) serving of ground pork chop with gravy. Observation on 7/29/19 at 11:40 A.M. showed Dietary Staff A placed a #10 scoop in the pan of ground pork chops with gravy. He/She began plating the lunch meal. [...]