Lefa Seran SNF

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure the facility's Quality Assurance and Performance Improvement Program identified areas of concern with the facility's Infection Prevention and Control Plan including concerns with pneumococcal immunizations and the immunization policy affecting 21 of 21 residents residing in the facility. This deficient practice had the potential to result in high-risk areas of concern and deficient infection control practices not being corrected and leading to infectious disease outbreaks and residents suffering severe illness or death from lack of vaccinations.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure the facility's immunization policy was accurate and included correct, up to date information for vaccinations, resident's were provided vaccinations when the resident's consented to receive pneumococcal vaccines, and staff were training on accurate and correct information related to pneumococcal vaccinations affecting 21 of 21 residents residing in the facility (Residents #12, #17, #14, #8, #6, #20, #13, #2, #4, #5, #16, #19, #15, #11, #7, #10, #21, #3, #18, #1, and #9). [...]

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 12 sampled residents (Resident #1). This deficient practice had the potential to deprive the resident of a person-centered care plan and the associated interventions relative to their current health management needs.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to 1) develop a person-centered Comprehensive Care Plan for the use of psychotropic medications for 1 of 12 sampled residents (Resident #18), and 2) ensure a resident's persistent symptoms associated with an ongoing concern of a low sodium level were care planned for 1 of 12 sampled residents (Resident #14). These deficient practices had the potential to result in health management concerns to remain unidentified and unaddressed.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to 1) ensure a resident's nutrition care plan was updated after the resident had a significant weight loss for 1 of 12 sampled residents (Resident #11). This deficient practice had the potential to result in a resident with significant weight loss not receiving interventions to correct the weight loss or prevent further weight loss; and 2) to ensure a resident's activity care plan included interventions related to activity preferences and services for 1 of 12 sampled residents (Resident #21). This deficient practice had the potential to result in a resident with activity preferences not receiving the activity, care, and services for the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure 1) a resident did not have a wooden trap (a trap using a spring-loaded mechanism with a metal bar designed to snap shut with sufficient force to trap and kill a rodent when the trap was triggered) set and baited with peanut butter in a resident's bathroom for 1 of 12 sampled residents (Resident #15). This deficient practice had the potential to result in a resident accidentally triggering the trap when entering the bathroom and sustaining injury to the resident's foot; and 2) unsecured medications prescribed to facility staff were not left unattended at the Nurse's Station. This deficient practice had the potential to cause harm by ingestion of unsecured medications by residents residing in the Long Term Care Unit.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the facility policy for weight loss was followed when a resident experienced a significant weight loss for 1 of 12 sampled residents (Resident #11). This deficient practice had the potential to result in a resident experiencing adverse outcomes from a significant weight loss not identified by the facility and a delay in care from the Registered Dietitian (RD) not being notified of the resident's weight loss.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure nursing staff responsible for administering vaccinations had been trained according to accurate vaccination guidelines and were not instructed to follow a facility policy containing outdated and inaccurate information affecting 21 of 21 residents residing in the facility.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure side effects and behaviors were monitored related to an ordered psychotropic medication for 1 of 12 sampled residents (Resident #18). This deficient practice had the potential to result in an unmanaged medication regimen, missed signs of worsening condition, and compromised resident safety.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the Facility Assessment (FA) was accurate and included nicotine dependence and addiction with the facility's common diagnoses and conditions. This deficient practice had the potential to result in facility staff not receiving adequate training on the care of residents with nicotine dependence and addiction diagnoses and the needs of those residents not being met.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the Infection Prevention and Control Plan included a method of ongoing surveillance of active infections in the facility. This deficient practice had the potential to result in a delay in recognition of infection outbreaks and reversible trends going unrecognized leading to missed opportunities for staff education and infection spreading among residents and staff in the facility.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure resident consents for the COVID-19 (Covid) vaccination were offered or completed correctly for 2 of 5 residents sampled for vaccinations (Resident #18 and #21). This deficient practice had the potential to result in residents wishing to receive a Covid vaccination not receiving the vaccine and experiencing severe or prolonged illness, hospitalization, or death as the result of infection with the Covid virus.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure initial communications training was completed timely per facility policy for 1 of 18 sampled employees (Employee #4). This deficient practice had the potential to prevent residents with communication needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure initial resident rights training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #10). This deficient practice had the potential to prevent residents from being able and encouraged to practice their rights as residents.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure elder abuse prevention training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #8). This deficient practice had the potential to place all residents at risk for abuse and neglect.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure initial infection control training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #10). This deficient practice had the potential to put residents at risk of contracting avoidable infections and diseases.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure initial compliance and ethics training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #10). This deficient practice had the potential to put residents at risk of receiving care from employees unaware of facility regulations.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure initial behavioral health care training was completed timely per facility policy for 1 of 18 sampled employees (Employee #4). This deficient practice had the potential to prevent residents with behavioral health care needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure residents were screened for eligibility to receive a COVID-19 (COVID) vaccine, education regarding the vaccine was provided to the resident or resident representative, and if the vaccine was offered and either administered or declined 19 of 20 residents sampled for immunizations (Resident #17, #2, #13, #19, #15, #9, #6, #8, #14, #3, #5, #18, #16, #12, #7, #11, #4, #1, and #10).

Inspectors wroteBased on observation, interview and document review, the facility failed to provide a comfortable, homelike environment when the facility utilized an overhead paging system to communicate with the adjoining hospital staff and temperatures in the facility were below 71 degrees. The overhead paging system and the temperature had the potential to affect the entire facility census.

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to obtain informed consent prior to placing the resident in a scoop mattress for 1 of 12 sampled residents (Resident #14).

Inspectors wroteBased on clinical record review and interview, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 2 of 12 sampled residents (Resident #17 and #2).

Inspectors wroteBased on observation, interview, clinical record review and document review the facility failed to update a fall care plan with new interventions for 2 of 12 sampled residents (Resident #1, and #5) and to include the use of a scoop mattress in a resident's care plan for 1 of 12 sampled residents (Resident #14).

Inspectors wroteBased on observation, clinical record review, interview and document review, the facility failed to remove floor mats from the bedside when residents were not in bed for 1 of 12 sampled residents (Resident #5), and assess a resident with a scoop mattress for risk of entrapment for 1 of 12 sampled residents (Resident #14). The deficient practices had the potential to increase falls and injury in the facility. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter. On 05/20/2024 at 11:08 AM, Resident #5 was in bed with a fall mat at the bedside. [...]

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure cognitive assessments for the use of a grab bar device (Halo Safety Ring) were completed quarterly for 1 of 20 residents residing in the facility (Resident #12).

Inspectors wroteBased on observation, interview, clinical record review and document review the facility failed to ensure medication was administered with an error rate less than 5 percent (%). There were 35 opportunities and two medication errors. The medication error rate was 5.71%.

Inspectors wroteBased on interview and document review, the Quality Assessment Performance Improvement (QAPI) Committee failed to identify the lack of COVID-19 (COVID) booster vaccinations offered to residents with the potential to affect the entire facility census.

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for 1 of 12 sampled residents (Resident #12).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the alternatives were attempted, risks and benefits were explained, consents were obtained prior to installation of bedrails or grab bar (Halo ring) and mobility assessments were completed for 15 of 21 residents residing in the facility (Resident #1, #2, #3, #4, #5, #7, #9, #10, #12, #14, #15, #16, #17, #171, and #172). Resident #1 Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and falls. On 07/31/23, Resident #1's bed had a Halo ring on the left side. Resident #1's physician's order dated 04/19/22, documented may use Halo for bed mobility. [...]

Inspectors wroteResident #4 Resident #4 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, with psychotic disturbance, and major depressive disorder, recurrent, in remission, unspecified. Resident #4's clinical record documented the following psychotropic orders: -[DATE], Mirtazapine oral tablet 7.5 mg, give 7.5 mg by mouth at bedtime related to insomnia, unspecified. -[DATE], duloxetine hcl oral capsule delayed release sprinkle 30 mg, give 1 capsule by mouth one time a day related to major depressive disorder, recurrent, in remission, unspecified. Resident #4's care plan for the antidepressant medication, initiated on [DATE], included the following interventions: -Educate Resident #4 and guardian about risks, benefits, and the side effects and/or toxic symptoms of duloxetine. [...]

Inspectors wroteBased on personnel record review, interview and document review, the facility failed to ensure resident rights training was completed by staff for 7 of 20 sampled employees (Employee #1, #6, #10, #11, #13, #14, and #16.

Inspectors wroteBased on interview, clinical record review and document review, the facility failed to ensure a resident gave informed consent prior to administration of a psychotropic medication for 4 of 12 sampled residents (Resident #5, #6, #14 and #12).

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to honor a resident's choice to smoke for 1 of 12 sampled residents (Resident #4).

Inspectors wroteBased on interview and document review the facility was out of compliance due to late completion and/or transmission of Minimum Data Set (MDS) assessments, Care Area Assessments (CAA) and/or care plans for 8 of 12 months, starting July, 2022.

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure a care plan was developed related to 1) wound care for a resident with pressure ulcers for 1 of 12 sampled residents (Resident #17), 2) the use and monitoring of high-risk medications for 1 of 12 sampled residents (Resident #4), 3) the administration of psychotropic medications to include specific behaviors associated with the administration for 4 of 11 residents (Resident #4, #12, #3, and #6) reviewed for unnecessary medications, and 4) a resident requiring pain management for 1 of 12 sampled residents (Resident #10).

Inspectors wroteBased on interview, observation, clinical record review, and document review, the facility failed to ensure a comprehensive care plan for smoking included revisions or updates upon readmission and included documentation of the smoking assessment with evaluation of cognitive ability, judgement, manual dexterity, and mobility for 2 of 12 sampled residents (Resident #6 and #4), a comprehensive care plan for smoking was revised to include an update for an imposed smoking restriction for 1 of 12 sampled residents (Resident #4), and a comprehensive care plan was updated to include interventions for residents' nutrition status for 1 of 12 residents (Resident #5).

Inspectors wroteBased on interview, observations, clinical record review and document review, the facility failed to ensure a resident received supervision and assistance to prevent a resident from burning a blanket and cigarette case on the resident's person for 1 of 12 sampled residents (Resident #4), and ensure a smoking resident had a smoking assessment completed quarterly for safety and the assessment determined safety interventions resulting from information gathered on the assessment for 2 of 12 sampled residents (Resident #4 and #6).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to provide a therapeutic diet for an edentulous resident for 1 of 12 sampled residents (Resident #5).

Inspectors wroteBased on interview, observation, clinical record review and document review, the facility failed to ensure a resident's pain was managed with care planned interventions, pain was evaluated per a physician order, and appropriate administration of pain medication for 1 of 12 sampled residents (Resident #10).

Inspectors wroteBased on interview and document review the facility failed to ensure the facility had a full-time Director of Nursing (DON).

Inspectors wroteBased on interview and clinical record review, the facility failed to ensure a physician responded to a pharmacist recommendation to add an end date to a psychotropic as needed (PRN) physician's order for 1 of 11 residents receiving psychotropic medications (Resident #12)

Inspectors wroteBased on interview, observation, clinical record review and document review, the facility failed to ensure a resident did not receive an unnecessary pain medication when a nurse administered Voltaren gel for a different location of pain than indicated in a physician order for 1 of 12 sampled residents (Resident #10).

Inspectors wroteBased on interview and document review the facility failed to ensure the facility had a full-time Director of Nursing (DON), resulting in a lack of clinical oversight for safe bedrail implementation, and psychotropic medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure the last revised Facility Assessment reflected an open Director of Nursing (DON) position.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Quality Assessment Performance Improvement (QAPI) Committee identified areas of concern related to use of widespread implementation of bedside rails and unnecessary psychotropic medications and implemented Performance Improvement Projects (PIPs) to reduce the risk of Substandard Quality of Care (Cross-reference tags F700 and F758).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure signage regarding COVID-19 (COVID) was present at the facility's point of entry and at the internal and external entrance doors of the Long-Term Care (LTC) Unit.

Inspectors wroteBased on interview and document review, the facility failed to ensure the required verbiage was in the facility's arbitration agreement.