Logan Acres

Inspectors wrote3. Review of the medical record for Resident #21 revealed he was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder, bipolar type, sprain ligaments of the cervical and lumbar spine, hypertension, suicidal ideation, post traumatic stress disorder, chronic obstructive pulmonary disease, anxiety, and morbid obesity. Review of the quarterly MDS dated [DATE] revealed Resident #21 was cognitively intact. His functional status is listed as independent set up only. Review of the PASARR dated 06/21/19 revealed Resident #21 had no indications of serious mental illness nor a developmental disability. The resident had not qualified for a PASARR II at that time. Review of Resident #21's diagnosis revealed chronic post-traumatic stress disorder, schizoaffective disorder bipolar type, on his diagnosis list dated 06/14/19. [...]

Inspectors wroteBased on record review, staff, family, and resident representative interview, and policy review, the facility failed to ensure residents and representatives participated in care conference meetings. This affected one resident (#59) out of two residents reviewed for care conferences. The facility census was 88.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to develop a comprehensive care plan for contracture's. This affected one resident (#33) out of one resident reviewed for position and mobility. The facility identified three additional residents (#18, #55, and #14) with contracture's. The facility census was 88.

Inspectors wroteBased on medical record review, review of the Fall/Incident Statement, staff interview, and policy review, the facility failed to ensure care plans were timely updated. This affected one resident (#14) out of two residents (#12 and #14) reviewed for falls. The facility census was 88.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to ensure proper hand hygiene was performed during a wound/dressing treatment to promote healing and prevent infection. This affected one resident (#76) out of one resident reviewed for pressure ulcers. The facility identified four residents (#53, #71, #76, and #82) with pressure ulcers. The facility census was 88. Review of the medical record for Resident #76 revealed she was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, diabetes type II, hypertension, rheumatic tricuspid valve insufficiency, nonrheumatic aortic valve stenosis, nonrheumatic mitral valve insufficiency. Review of the Minimal Data Set (MDS) dated [DATE] revealed Resident #76 had extensive cognitive impairment. Her functional status was listed as extensive two person assist for all activities of daily living. [...]

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure a significant weight loss was timely notified to the Dietician and the resident family. This affected one resident (#71) out of four residents reviewed for nutrition. The facility census was 88.

Inspectors wroteBased on medical record review, review of the pharmacy recommendations, staff interview, and policy review, the facility failed to ensure a pharmacy recommendation were timely reviewed by the physician and included an appropriate reasoning for continuing the medication. This affected one resident (#59) out of five residents reviewed for pharmacy recommendations. The facility census was 88.

Inspectors wroteBased on medical record review, staff interview and review of standing house orders, the facility failed to monitor Resident #23's bowel status and implement their standing house orders as directed. This resulted in Actual Harm when Resident #23 did not have a bowel movement for six days and the resident was subsequently hospitalized for an acute large bowel obstruction. This affected one (#23) of two residents reviewed for hospitalization. Facility census was 91.

Inspectors wroteBased on observation, staff interview, review of a dietary listing and review of policy, the facility failed to ensure pans were appropriately dried to maintain proper sanitation. In addition, the facility failed to store ready to use icing in the refrigerator per label to prevent contamination. This had to the potential to affect all residents residing in the facility. The census was 91.

Inspectors wroteBased on observation, review of dietary spreadsheets, and staff interview the facility failed to serve bread per the dietician approved spreadsheet to residents receiving puree diets. This affected eight (#6, #8, #17, #43, #49, #61, #64, and #66) of eight residents receiving pureed diets. The census was 91.

Inspectors wroteBased on observation, staff interview, list provided by the facility and review of policy and procedures, the facility failed to appropriately clean a glucometer after checking a resident's blood sugar. This affected one (#283) out of one resident observed having their blood sugar checked during medication administration and had the potential to affect five (#2, #16,#32, #41 and #282) additional residents identified by the facility as using the same glucometer for blood sugar monitoring. Facility census was 91.

Inspectors wroteBased on medical record review, resident and staff interview, review of facility self-reported incidents (SRI's) and review of facility policy, the facility failed to implement their abuse policy to ensure allegations of abuse were immediately reported and thoroughly investigated. This affected two (#69 and #73) of two residents reviewed for abuse. The census was 91.

Inspectors wroteBased on medical record review, resident and staff interview, review of facility self-reported incidents (SRI's) and review of facility policy, the facility failed to report allegations of abuse to the state agency. This affected two (#69 and #73) of two residents reviewed for abuse. The census was 91.

Inspectors wroteBased on medical record review, resident and staff interview, review of facility self-reported incidents (SRI's) and review of facility policy, the facility failed to thoroughly investigate allegations of abuse. This affected two (#69 and #73) of two residents reviewed for abuse. The census was 91.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide written notice of discharge and transfer to residents, resident's representative, and the ombudsman. This affected two (#23 and #82) of two residents reviewed for hospitalizations. The census was 91.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide written notice of the bed hold policy to residents and resident's representative when transferred to the hospital. This affected two (#23 and #82) of two residents reviewed for hospitalizations. The census was 91.