Little Sisters of the Poor

Inspectors wroteBased on interview and document review the facility failed to ensure all required discharge documentation was provided to the resident and receiving facility; and failed to ensure transfer and discharge notices were sent to the Office of the State Long-Term Care Ombudsman (OOLTC) for 1 of 1 resident (R37) reviewed for discharge.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene care (i.e., nail care) was provided for 1 of 1 resident (R19) reviewed for activities of daily living (ADLs), and who was dependent on staff for her care.

Inspectors wroteBased on interview and record review, the facility failed to ensure narcotic and controlled substances destruction was completed in accordance with established policies and procedures to reduce the risk of diversion and/or theft for 1 of 1 resident (R7) reviewed for fentanyl patch removal.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure open refrigerated items were dated and covered. Furthermore, the facility failed to ensure expired items were removed from storage. This had the potential to impact all 32 residents residing in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure oxygen was administered according to physicians orders for 1 of 2 residents (R11) reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess and implement individualized person centered dementia care for 1 of 2 residents (R2) reviewed for dementia care.

Inspectors wroteBased on interview and document review, the facility failed to ensure consultant pharmacist recommendations were acted upon timely for 2 of 5 residents (R2, R29) reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review the facility failed to ensure a topical antibiotic was transcribed as written and further failed to ensure the topical antibiotic was still necessary for 1 of 1 residents (R14) reviewed for antibiotic use.

Inspectors wroteBased on interview, and document review, the facility failed to ensure physician notification of an abnormal lab for 1 of 1 resident (R29) reviewed for diabetes.

Inspectors wroteBased on interview and document review the facility failed to identify, comprehensively assess, implement individualized interventions for wandering, exit seeking behaviors, and elopement for 2 of 2 residents (R1, R2) who had a history of repeated exit seeking behaviors. The facility's failures resulted in immediate jeopardy (IJ) when R1 eloped from the facility, was found on a city street, and returned by a passerby. The immediate jeopardy began on 9/5/24 after R1 attempted elopement multiple times, the facility failed to complete comprehensive wandering/elopement assessments, monitoring system, and appropriate intervention resulting in R1's actual elopement on 9/21/24. The immediate jeopardy was identified on 9/26/24 and the chief executive officer and director of nursing (DON) were notified of the immediate jeopardy on 9/26/24 at 6:18 p.m. [...]

Inspectors wroteBased on interview and document review, the facility's governing body failed to establish and implement policies regarding the management and operation of the facility and further failed to ensure the administrator reported to and was held accountable to the governing body. This had to effect all current and future residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Facility Assessment (FA) was complete and included an evaluation of the resident population and its needs using evidence-based data driven methods, the competencies and skill sets for all personnel necessary to provide that care, information on staffing levels needed based on the resident population, a plan for maximizing recruitment and retention of direct care staff, and all contracted services required to meet resident needs. The facility further failed to ensure the FA was conducted with input from all necessary individuals. This had the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on document review and interview the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Q3), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This had the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. This had the potential to affect all 36 residents residing at the facility who received care from facility staff, contracted staff, and volunteers.

Inspectors wroteBased on interview and document review, the facility failed to ensure completion of 12 hours of annual in-service training for 2 of 5 nursing assistants (NA-F, NA-G) reviewed for annual training. Additionally, 1 of 5 nursing assistants had no abuse or dementia training which had the potential to affect all 36 residents in the facility.

Inspectors wroteBased on interview and document review, the facility failed to complete annual performance evaluations for 4 of 5 nursing assistants (NA-D, NA-E, NA-F and NA-G) who had been employed by the facility for over one year.

Inspectors wroteBased on interview and document review, the facility failed to have a written transfer agreement with a hospital approved for participation under Medicare or Medicaid programs which reasonably ensured residents would be transferred to the hospital and ensured timely admission. This had the potential to affect all 36 residents in the facility who could require hospitalization on an emergency basis.

Inspectors wroteBased on interview and document review, the facility failed to report allegations of an unwitnessed fall with serious injury immediately (within two hours) to the State Agency (SA) for 1 of 3 residents (R1) reviewed for falls.

Inspectors wroteBased on interview and document review, the facility failed to designate one or more individuals as the infection preventionist who would be responsible for the facility's Infection Prevention and Control Program. This had the potential to affect all 38 residents residing in the facility.

Inspectors wroteBased on observation, interview, and documentation review, the facility failed to ensure hot foods are to be held at 135 degrees Fahrenheit or higher for 1 out of 3 steam tables used to serve food. This has the ability to affect 12 of 38 residents who ate food from the first floor dining room.

Inspectors wroteBased on interview and document review, the facility failed to ensure a clinical shared discussion regarding pneumococcal vaccinations according to Centers for Disease Control (CDC) and have a process to assess, offer and provide the most recent CDC education regarding the potential risks and benefits of the pneumococcal vaccine for 3 of 5 residents (R32, R25, and R37) reviewed for immunizations.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1 of 3 residents (R32) reviewed for accidents was assessed for safe use of a curling iron. Findings Include: R32's annual minimum data set (MDS) dated [DATE], indicated R32 had moderate cognitive impairment and required limited assistance with transfers and supervision when ambulating. R32's face sheet printed 2/1/23, indicated R32 diagnosis included cerebrovascular disease (an interruption in the flow of blood to cells in the brain) mild cognitive impairment, age related macular degeneration (is an eye disease that can blur your central vision. It happens when aging causes damage to the macula, the part of the eye that controls sharp, straight-ahead vision) to right and left eye. R32's care plan lacked documentation of a focus, goals, and interventions for R32's safety with curling iron use. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure hand hygiene was performed for 1of 2 residents (R24) observed for incontinent cares and failed to ensure a Hoyer lift was cleaned between resident use for 2 of 2 residents (R18, and R24), observed for infection control practices. Findings Include: Hand Hygiene: R24's quarterly minimum data set (MDS) dated [DATE], indicated R24 was cognitively impaired, had impairment to both lower extremity and was dependent on staff for toileting hygiene, transfers and was incontinent of bowel and bladder. R24's face sheet printed 2/1/24, indicated diagnosis of dementia and osteoarthritis (a degenerative joint disease in which the tissues in the joint break down over time) of the left knee. [...]

Inspectors wroteBased on interview, and document review, the Quality Assurance (QA) committee failed to ensure required members of the committee attended the quarterly meetings. This had the potential to affect all 38 residents who resided at the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide meaningful activities for 3 of 3 residents (R1, R3, R4) who were dependent on staff for activities.

Inspectors wroteBased on interview and document review, the facility failed to have a qualified activities director to oversee the development, implementation, and ongoing evaluation of the activities program for the facility. Upon interview on 10/3/23 at 10:44 a.m. the assistant activities director (AD)-A stated she was hired at the facility four years ago for facility gardening. AD-A stated when there was not gardening to be done, she would assist the activities department with activities. She stated the facility had been without an activity director since 2/2023 and she has been filling in since that date. She stated she mainly spends her mornings in the garden and spends her afternoons doing activity assessments or performing an activity. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse and an injury of unknown origin to the State Agency (SA) within two hours for 2 of 2 residents (R1 and R3) reviewed for abuse. A staff reported to administration an allegation of abuse involving R1 three days after an incident, and R3 was hospitalized with two fractured ribs and a pneumothorax (air leaks into the space between the lungs and chest wall, a blunt or penetrating chest injury).

Inspectors wroteBased on observation, interview and record review, the facility failed to update the plan of care for 1 of 1 resident (R3) reviewed for care plans when R3 was moved to a different floor of the facility and not allowed to her previous floor she resided on without assistance due to inappropriate affectionate behaviors.

Inspectors wroteBased on interview, and document review, the facility failed to ensure required abuse, neglect, and exploitation training was completed for 2 of 4 staff, (licensed practical nurse (LPN-A and nursing assist (NA)-A) whose personnel records were reviewed.