Mason Pointe Care Center

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure that 1.) one of two treatment carts (A3 skilled unit) was locked and secured. This failure created the risk of unauthorized access to medications and supplies by residents and staff, and 2.) failed to ensure expired medical supplies; including urinary catheters, intravenous (IV) catheters, and syringes; were removed from one of two medication rooms (M3 skilled unit). This failure created the risk of less effective medical supplies being used for residents.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice to the resident or their legal representative of the facility bed hold policy at the time of transfer to the hospital for five of 28 sampled residents, who were recently transferred to the hospital for various medical reasons (Residents #67, #27, #138, #66 and #90). The census was 205 with 140 residents in certified beds. 1. Review of Resident #67's electronic medical record, showed: -Discharge to the hospital on 3/29/19; -Returned to the facility on 4/2/19; -No documentation the resident and/or the representative received written notice of the facility's bed hold policy at the time of transfer. 2. Review of Resident #27's electronic medical record, showed: -discharged to the hospital on 2/25/19; -Returned to the facility from the hospital on 3/4/19; -discharged to the hospital on 3/6/19; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident receives adequate assistive devices to prevent accidents by failing to ensure a resident's electronic wheelchair had been charged and was available for use during transport to a scheduled appointment. The resident had a history of slipping out of the chair used in place of the electric wheelchair and this resulted in a fall during transportation. In addition, the facility failed to follow the safe medication storage policy when medications were left accessible, on top of a medication cart and in an unlocked nurse cart. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's right to self-administer medications is supported, only if the interdisciplinary team has determined that this practice is clinically appropriate, for two residents observed to self-administer medications (Residents #45 and #11). The census was 205 with 140 in certified beds. Review of the facility's Policy and Procedure for Administering Medication, dated 1/25/17, and reviewed on 9/25/18, showed: -Policy Statement: Medication shall be administered in a safe and timely manner and as prescribed. The community shall provide residents with necessary medication(s) when they leave the community temporarily; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain all survey reports, certifications and complaint investigations made during the three preceding years and any plan of correction in effect with respect to the facility. The census was 205 with 140 residents in certified beds. Observations on 6/5/19 at 8:10 A.M., on 6/6/19 at 6:30 A.M., on 6/7/19 at 1:00 P.M., on 6/10/19 at 11:42 A.M. and on 6/11/19 at 1:40 P.M., showed a sign posted at the front entrance of the Arborview building, Facility state survey results are available for viewing. A binder containing results is located at the Arborview reception desk. Observation of the Arborview reception desk, showed no state survey results binder available for viewing. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy for abuse and neglect by failing to report an incident of potential resident to resident abuse to the State Survey Agency when a resident slapped another resident (Residents #14 and #62). The census was 205 with 140 residents in certified beds. Review of the Centers for Medicare and Medicaid services (CMS) State Operations Provider Certification, showed §483.12 Freedom from Abuse, Neglect, and Exploitation: -The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation; -Definitions: Abuse, is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; -Guidance: Resident to Resident Abuse of Any Type: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice by failing to provide weight parameters for daily ordered weights, notify the physician when a weight increase occurred and provide appropriate diagnoses with the use of antibiotic administration. This affected two of 28 sampled residents (Residents #142 and #344). The census was 205 with 140 residents in certified beds. 1. Review of Resident #142's medical record, showed: -admitted to the facility on [DATE]; -Diagnoses of heart failure, vascular disease and kidney disease; -Extensive assistance required for transfers and personal hygiene. Review of the resident's admission electronic physician order sheet (ePOS), showed an order dated 5/21/19, for daily weights in the early morning. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with pressure ulcers (injury to the skin and/or underlying tissue as a result of pressure or friction) or are at risk for the development of pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for two of two sampled residents with specialty mattresses on their beds (Residents #3 and #2). The census was 205 with 140 residents in certified beds. 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/7/19, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate treatment and services for residents who used indwelling urinary catheters by failing to ensure residents had complete physician orders for the catheter use to include catheter size, balloon size and diagnoses. The facility also failed to ensure appropriate catheter drainage bag positioning and ensure the urinary drainage bag remained covered. This affected four of five facility identified residents that used indwelling urinary catheters (Residents #66, #138, #142 and #90). The census was 205 with 140 residents in certified beds. Review of the facility's urinary catheter (a tube placed into the bladder to drain urine) care policy, revised on 11/19/18, showed: -Purpose: To prevent catheter associated urinary tract infections (UTIs); -Maintaining unobstructed urine flow: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide oxygen therapy consistent with professional standards of practice for three of four residents investigated for respiratory care, who received oxygen therapy (Residents #3, #65 and #23). The sample was 28. The census was 205 with 140 residents in certified beds. Review of the facility's policy for Oxygen Administration, dated 12/10/17 and revised on 7/23/18, showed: -Oxygen humidifier bottle and tubing should be changed monthly; -Oxygen tubing should be stored in a plastic bag when not in use. 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/7/19, showed: -Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease); -Received oxygen therapy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assure the facility provided services in sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: Licensed nurses and other nursing personnel, including but not limited to nurse aides, by failing to assure facility staff were assigned to and provided care for three of three spine or orthopedic surgery center residents followed by a contracted spine and orthopedic surgery center for post-surgical care (Residents #244, #245 and #246). The contract between the surgical center and facility specified that the clinic staff would provide services related to intravenous medication administrations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 29 opportunities observed, two errors occurred, resulting in a 6.89% medication error rate (Resident #344). The census was 205 with 140 residents in certified beds. Review of the facility Policy and Procedure for Administering Medication, dated 1/25/17 and reviewed on 9/25/18, showed: -Policy Statement: Medication shall be administered in a safe and timely manner and as prescribed. The community shall provide residents with necessary medication(s) when they leave the community temporarily; -Policy Interpretation and Implementation: -Medications must be administered in accordance with the orders, including the required time frame; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable by failing to properly date and label insulin flexpens (prefilled injectable insulin) and insulin vials for six of 15 insulin pen or vial observations. The census was 205 with 140 residents in certified beds. 1. Review of the facility's storage of medication policy, dated [DATE], showed: -Policy statement: The community shall store all drugs and biologicals in a safe, secure and orderly manner; -Policy interpretation and implementation: Drug containers that have missing, incomplete, improper or incorrect labels should be returned to the pharmacy or destroyed. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct and document a complete facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies by not identifying a resource of agency staff used to fulfill staffing needs, address an evaluation of the facility's training program to ensure any training needs are met for all new and existing staff, individuals providing services under a contractual arrangement and volunteers, consistent with their expected roles, and include an evaluation of any contracts, memorandums of understanding including third party agreements for the provision of goods, services or equipment to the facility during both normal operations and emergencies. The census was 205 with 140 residents in certified beds. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible, in accordance with accepted professional standards and practices, for three of three spine or orthopedic surgery center residents followed by a contracted spine and orthopedic surgery center for post-surgical care (Residents #244, #245 and #246). The sample was 28. The census was 205 with 140 residents in certified beds. 1. Review of Resident #244's medical record, showed the resident followed by a contracted spine and orthopedic surgery center for post-surgical care: -admitted [DATE] at 9:12 P.M.; -An order dated 6/5/19, for neurological checks per shift; -An order dated 6/5/19, for vital signs per shift; -Vital signs (blood pressure, pulse, temperature, respirations, oxygen saturation and pain) documented on 6/5/19 at 9: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff used acceptable infection control procedures for a resident on isolation precautions for one sampled resident who was on isolation precautions for an infectious disease (Resident #111). In addition, the facility failed to maintain appropriate infection control by failing to ensure staff handled medications properly to prevent the potential spread of infection during medication administration when staff used bare hands to administer medications to one resident (Resident #124). The sample was 28. The census was 205 with 140 residents in certified beds. 1. Review of the facility's care of the resident with Clostridium Difficile infection (C-diff, a bacterial infection that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon), revised 1/29/18, showed: -Statement: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent gnats in resident rooms for one resident (Resident #138). The sample was 28. The census was 205 with 140 residents in certified beds. Review of Resident #138's quarterly Minimum Data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/12/19, showed the following: -Moderate cognitive impairment; -Two person staff assistance for bed mobility, toilet use and transfers; -One person staff assistance for dressing, eating and personal hygiene; -Upper extremity impairment on both sides; -Lower extremity impairment on both sides; -Mobility, wheelchair; -Diagnoses included high blood pressure, multiple sclerosis (an autoimmune disease of the nervous system) and anemia. [...]