Life Care Center of Auburn

Inspectors wroteBased on records reviewed and interviews for one of three residents (Resident #1), whose Physician's Orders indicated he/she was NPO (nothing by mouth) with medications to be administered via his/her percutaneous endoscopic gastrostomy tube (PEG tube, a flexible tube inserted through the abdominal wall into the stomach to deliver nutrition, fluids and medications directly), the Facility failed to ensure he/she was free from a significant medication error when Nurse #1 administered a medication to him/her orally instead of through his/her PEG tube placing him/her at risk for aspiration (when food, liquid, or saliva enters the airway and lungs).

Inspectors wroteBased on interviews, and record reviews, the facility failed to notify the state mental health authority (Pre-admission Screening and Resident Review [PASRR] Office) promptly of the need for Resident Review for one Resident (#12) out of a total sample of 30 total residents, when the Resident experienced a significant change in his/her mental condition from his/her initial Level I PASRR. Specifically, the facility failed to notify the PASRR Office of the need for Resident Review when Resident #12, who was diagnosed with Depression, acquired new diagnoses of Delusional Disorders and Hallucinations during his/her stay at the facility and a new medication treatment of Seroquel (antipsychotic medication) was implemented.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to identify a change in condition relative to bilateral lower extremity edema (swelling) in a timely manner, for one Resident (#37) out of a total sample of 30 residents. Specifically, the facility failed to: -identify the onset of Resident #37's bilateral lower extremity edema in a timely manner when the Resident had previously been assessed to have no edema. -assess the Resident's bilateral lower extremity edema timely once the bilateral lower extremity (BLE) edema was identified, putting the Resident at risk for delayed assessment and treatment.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to adhere to infection control standards of practice to prevent contamination and the spread of infections for two Residents (#101 and #4) out of a total sample of 30 residents. Specifically, 1) for Resident #101, the facility failed to ensure that appropriate Personal Protective Equipment (PPE: items such as gowns and gloves worn to prevent the spread of infection) was worn as required for the Resident on Enhanced Barrier Precautions (EBP), and that hand hygiene was performed before donning (putting on) PPE and during provision of urinary catheter care, placing the Resident at increased risk of contamination and the spread of infections. [...]

Inspectors wroteBased on record reviews, and interviews, the facility failed to complete Comprehensive Minimum Data Set (MDS) Assessments that accurately reflected the status of two Residents (#14 and #141) out of a total sample of 30 residents. Specifically, 1. For Resident #14, the facility failed to accurately code for Hospice services when Resident #14 was ordered for and had been receiving Hospice services during the assessment period. 2. For Resident #141, the facility failed to accurately code for discharge return anticipated when the Resident was transferred to the hospital for evaluation of an acute change in health status.

Inspectors wroteBased on interviews and records reviewed, for two of five sampled residents (Residents #2 and #3), the Facility failed to ensure staff implemented and followed the Facility Abuse Prohibition Policy, when Resident #2 and the family member of Resident #3 (Family Member #1) reported allegations of abuse by Housekeeper #1 to multiple staff members and staff did not immediately report the allegations to their immediate Supervisor, Administrator or designee.

Inspectors wroteBased on interviews and records reviewed, for two of five sampled residents (Residents #1 and #4), the Facility failed to ensure they reported allegations of abuse by Housekeeper #1 to the Department of Public Health (DPH) as required, when after being notified by staff that Housekeeper #1 potentially sexually abused Residents #1 and #4, the Director of Nursing and the Administrator did not report the allegations to the DPH, as required.

Inspectors wroteBased on interviews and records reviewed, for two of five sampled residents (Resident #1 and #4), the Facility failed to ensure that after being made aware of allegations of potential sexual abuse by a staff member that they obtained and maintained evidence that a thorough investigation was completed, including conducting and documenting assessments of both residents and obtaining and documenting staff member interviews.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide care consistent with professional standards to prevent and treat a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and prevent further skin and pressure injury for one Resident (#85), out of a total sample of 25 residents. Specifically, the facility staff failed to: -Assess the fit and use of an orthopedic surgical shoe (type of shoes that provides support and stability for the foot after an injury or surgery) for Resident #85 who had a high risk of developing pressure ulcers due to a history of Diabetes (condition that result in too much sugar [glucose] in the blood). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pain management that was consistent with professional standards of practice for one Resident (#18) out of a total sample of 25 residents. Specifically, the facility staff failed to offer Resident #18 prescribed pain medication prior to an identified painful dressing change procedure.

Inspectors wroteBased on interview, record and policy review, the facility failed to notify the Physician/Non Physician Practitioner (NPP: Nurse Practitioner) of a significant change in physical status for one Resident (#102) out of a total sample of 25 residents, resulting in a lack of medical evaluation of the Resident's status relative to weight loss. Specifically, the facility staff failed to notify Resident #102's NPP of the Resident's severe weight loss (greater than five percent (%) in one month and greater than seven point five % in three months) when: a. Staff identified the Resident had a severe weight loss. b. The NPP requested to be notified if the severe weight loss was verified.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide nutrition care and services for one Resident (#102) out of a total sample of 25 residents, with a history of weight loss. Specifically, facility staff failed to do the following when Resident #102 experienced severe weight loss (greater than: five percent[%] in one month, 7.5% in three months, and 10% in six months): a. Obtain weekly weights as ordered by the Physician. b. Monitor weights weekly as recommended by the Registered Dietician (RD). c. Coordinate care among the facility's interdisciplinary team (IDT), to include Resident #102's Physician/Non Physician Practitioner (NPP). d. Evaluate for causative factors relative to Resident #102's severe weight loss to determine if the Resident's weight loss was avoidable.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure that staff adhered to infection control standards for four residents (#18, #95, #58, and #44) out of a total sample of 25 residents, on two out of three Units observed (Primrose and Magnolia). Specifically, the facility staff failed to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment, services and care that met professional standards of quality for one Resident (#18) out of a total sample of 25 residents. Specifically, the facility staff failed to provide the correct topical wound medication as ordered by the Physician resulting in removal and re-application of the dressing causing additional discomfort to the Resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services and to assist with obtaining a specialist consultation for one Resident (#102), out of a total sample of 25 residents. Specifically, the facility staff failed to provide assistance for Resident #102, who had an indwelling urinary catheter (flexible tube inserted into the bladder to drain urine), to obtain a consultation with a Urologist (Physician who specializes in treatment of the urinary tract) when: a. The Resident developed a Ventral Erosion (complication of an indwelling urinary catheter that can result in a partial or full thickness wound and can increase one's risk for urinary tract infection [UTI]) of his/her [genitalia]. b. The Resident's Physician ordered facility staff to obtain a consultation appointment with a Urologist for Resident #102.

Inspectors wroteBased on observation, interview, and record reviewed the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one Resident (#18) out of a total sample of 25 residents. Specifically, the facility failed to: -ensure that Nurse #1 had the specific competencies and skills necessary to provide appropriate pain management prior to administering dressing change procedure resulting in poor pain control for Resident #18. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to adhere to professional standards of practice for food service safety in the facilty's main kitchen, and for one Resident (#86) out of a total sample of 25 residents. Specifically, the facility staff failed to: 1. Ensure that three Dietary Staff (#3, #4, and #2) wore hair restraints while they worked in the food preparation and food service areas of the facility's main kitchen, increasing the risk for contamination of food and the spread of foodborne illness. 2. Re-heat Resident #86's meal in a safe and appropriate manner to prevent accidental burns and kill microorganisms that may cause foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete, encode and transmit Minimum Data Set (MDS) Assessments as required for three Residents (#101, #164, and #131) out of a total sample of 25 residents. Specifically, the facility failed to: 1. Elecronically transmit a Discharge MDS Assessment for Resident #101, within 14 days of completing the Discharge MDS Assessment. 2. Complete a Death in Facility Tracking Record for Resident #164, when the Resident expired at the facility. 3. Complete a Discharge MDS Assessment for Resident #131, within 14 days of the Resident's discharge from the facility when the Resident's return to the facility was not anticipated.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure its staff provided a Notice of Transfer and Discharge to the Resident and/or Resident Representative in writing upon transfer from the facility for four Residents (#7, #140, #122 and #78), out of a sample of 29 residents.

Inspectors wroteBased on interviews, record reviews, and policy review, the facility failed to ensure its staff provided the Resident and/or the Resident Representative with a written notice regarding the facility's Bed-Hold Policy upon transfers out of the facility for three Residents (#7, #140 and #122), out of a total of 29 sampled residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure its staff: 1) implemented recommendations for infection control and prevention relative to the use of personal protective equipment (PPE), 2) implemented their policy relative to monitoring vital signs and respiratory symptoms three times a day while providing care to one Resident (#292) who had confirmed COVID-19 infection, out of three residents reviewed, 3) disinfected resident care equipment between resident use on one of three resident care units observed, 4) appropriately handled soiled items in order to help prevent the transmission of infections, including COVID-19, and 5) followed the guidance of contact precautions required when managing an intra-venous (IV) catheter.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure its staff provided dignity and privacy for one Resident (#30), out of a total sample of 29 residents, relative to placement of a sign over the Resident's bed indicating the Resident's care needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure its staff provided notification of a change in condition for one Resident (#30), out of 29 sampled residents. Specifically, failure to notify the Resident's invoked (putting into effect) health care proxy (HCP, the Physician determined the Resident did not have the mental capacity to make their own health care decisions) when the Resident required diagnostic testing.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure its staff developed and/or implemented the plan of care for four Residents (#90, #105, #35 and #125), out of a sample of 29 residents. Specifically, 1) failure to implement the Physician's Orders relative to the administration time of scheduled medications for Resident #90, 2) failure to accurately implement the Physician's Order for the administration of Oxygen for Resident #105, 3) failure to create a written plan of care when Resident #35 signed onto Hospice services, and 4) failure to initiate a comprehensive care plan related to mood and behavior for Resident #125.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure its staff provided activities designed to support the physical, mental, and psychosocial well-being for one Resident (#30), out of 29 sampled residents. Specifically, the facility failed to ensure the staff offered and/or provided an activity program customized to the preferences and interests of Resident #30, who had limited ability to speak, was unable to sit upright for greater than 30 minutes at a time, and was at increased risk of isolation due to spending most of his/her time in his/her room.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure its staff provided timely care and treatment for a chronic ulcer (open area) located on one Resident (#104)'s lower extremity when a change in the treatment was recommended by the Wound Specialist, out of a total of 29 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure its staff provided appropriate treatment and services to address one Resident's (#30) limited range of motion, out of a sample of 29 residents. Specifically, the facility failed to ensure its staff evaluated the Resident who was admitted to the facility with an existing contracture (a fixed tightening of muscles, tendons, ligaments, or skin which prevents normal movement of the associated body part), resulting in failure to appropriately assess the contracture, putting the Resident at risk for pain and further immobility of the affected body part.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure its staff assessed the safety of one Resident (#42), out of 29 sampled residents, to self-administer Albuterol (a medication used to treat and prevent difficulty breathing, wheezing, shortness of breath, coughing and chest tightness). Inapproriate use of this medication could result in tachycardia (rapid heart rate), palpitations (fluttering heart), blurred vision, chest pain, high or low blood sugar and low potassium levels in your blood.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure its staff provided care and services according to professional standards of practice, related to the use of indwelling catheters (a tube used to drain urine from the bladder to a collection bag outside the body) for three Residents (#4, #128 and #104), out of a total sample of 29 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure its staff provided appropriate care and services relative to respiratory care for one Resident (#42), out of 29 sampled residents. Specifically, failure to ensure: 1) a Physician's order was in place for the use of a Continuous Positive Airway Pressure (CPAP- a type of non-invasive device which uses mild air pressure to keep the airways open, typically used by patients who have breathing problems during sleep), 2) respiratory equipment was stored in such a manner to prevent contamination and risk of infection, and 3) provide supplemental Oxygen at the rate ordered by the Physician, placing the Resident at risk for respiratory compromise.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its staff provided comprehensive behavioral health services for one Resident (#4), out of a total sample of 29 residents. Specifically, obtaining a consultation for psychiatric (psych) services as ordered by the Physician.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff obtained orders for a PRN (as needed) antipsychotic medication (medication used to manage psychotic disorders) that were limited to 14 days, for two Residents (#35 and #54), out of a sample of 29 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure its staff maintained accurate documentation for one Resident (#128), out of a total of 29 sampled residents. Specifically, failure to accurately document the turning and positioning required of the Resident who was at risk for skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff maintained a record that contained the most recent plan of care from Hospice and Hospice documentation that could be utilized by facility staff to collaborate care between Hospice and the facility for one Resident (#35), out of a total of 29 sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure its staff maintained a medical record that included documentation that residents were offered, received or declined the pneumococcal immunization (a vaccine used to prevent possible life-threatening Pneumonia) for one Resident (#106), out of a total of five sampled residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure Minimum Data Set (MDS) Assessments were coded accurately for two Residents (#111 and #8), out of a total of 29 sampled residents.