Meade District Hosp Ltcu Dba Lone Tree Retirement

Inspectors wroteThe facility reported a census of 33 residents, and one main kitchen. Based on observation, record review and interview the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. This placed the residents at risk for food borne illnesses.

Inspectors wroteThe facility reported a census of 33 residents. Based on observations, interviews and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. This placed facility residents at risk for insect or rodent infestation.

Inspectors wroteThe facility reported a census of 33 residents. Based on interview and record review the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program (IPCP). This failure has the potential to affect all 33 residents.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for five residents: Resident (R) 7, and R4 related to personal alarms; R5 related to pressure ulcers and medications; R2 related to dental; and R25 related to nutrition. This deficient practice placed the affected residents at risk for impaired care due to unidentified care needs.

Inspectors wroteThe facility reported a census of 33 residents. The sample included 12 residents. Based on interviews, observation and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to a Resident (R) 5 with a Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure injury. The facility further failed to ensure adequate hand hygiene during personal care for R5 and R32 when staff failed to complete adequate hand hygiene. The facility failed to deliver food in a sanitary manner for several residents in the dining room. These deficient practices had the potential to spread infections to the residents in the facility.

Inspectors wroteThe facility reported a census of 33 residents. The sample included 12 residents with two reviewed for dignity. Based on observation, interview and record review, the facility failed to treat residents in a dignified manner when Resident (R)4 received care without privacy. This deficient practice placed the resident at risk for decreased psychosocial well-being and embarrassment.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents with one resident reviewed for discharge. Based on observation, interview, and record review, the facility failed to provide a written discharge summary or recapitulation of the stay for Resident (R) 37. This placed the resident at risk for impaired rights related to continuity of care.

Inspectors wroteThe facility reported a census of 33 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the Payroll-Based Journaling (PBJ) as required.

Inspectors wroteThe facility reported a census of 32 residents, with three residents reviewed for risk of elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, record review, and interview, the facility failed to provide adequate supervision and a safe environment as free of accident hazards as possible, to prevent the elopement of cognitively impaired and independently mobile Resident (R)2, who the facility identified as an elopement risk. On 05/25/24 R2 displayed an increase in his wandering/exit seeking behavior which included statements he was going to leave, and he attempted to push open the front. On 05/26/24 R2 pushed on the doors leading to the apartments, displayed agitation, and thought the facility was a jail. [...]

Inspectors wroteThe facility reported a census of 27 residents with one central kitchen. Based on observation, interview, and record review, the facility failed to store foods safely and ensure proper sanitization and food handling practices to prevent the outbreak of foodborne illnesses for the residents of the facility.

Inspectors wroteThe facility census totaled 27 residents with all residents receiving meals from the one main kitchen. Based on observation and interview the facility failed to maintain mechanical, electrical, and patient care equipment in good working condition by the failure to have a functioning dish machine since 08/08/23. This failure has made it necessary to manually wash all dishes used in the kitchen and for residents with questionable sanitization. This had the potential to affect all residents residing in the facility.

Inspectors wroteThe facility has a census of 27 with 12 residents included in the sample, two reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to provide necessary respiratory care consistent with professional standards of practice regarding the use of nebulizer (a device that delivers medication as a mist to the lungs) for Resident (R) 26, and R27.

Inspectors wroteThe facility reported a census of 27 with 12 residents included in the sample. Based on observation, interview and record review the facility failed to provide a sanitary environment by the failure to clean the nebulizer equipment between uses for Resident (R)26, R27 and on R16 failed to provide proper hand hygiene during incontinent care.

Inspectors wroteThe facility reported a census of 27 residents. Based on interview and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hour data for all nursing personnel by the required deadline.

Inspectors wroteThe facility reported a census of 33 residents, with 12 in the sample, and four reviewed for oxygen/respiratory care. Based on observation, interview, and record review the facility failed to change oxygen tubing and nebulizer tubing routinely and failed to ensure the nebulizer and oxygen tubing were stored sanitarily for Resident (R)9, R28, R17, and R25.

Inspectors wroteThe facility reported a census of 33, with 12 residents in the sample. Based on observation, interview, and record review the facility failed to ensure Resident (R) 6 was treated with dignity when they did not provide a privacy bag for an indwelling catheter bag.

Inspectors wroteThe facility census totaled 33 residents, with 12 included in the sample. Based on interview and record review the facility failed to provide Resident (R) 26 or the resident representative with a bed-hold policy upon transfer to a hospital.

Inspectors wroteThe facility census totaled 33 residents, with 12 included in the sample. Based on observation, interview, and record review the facility failed to revise care plans for Resident (R) 9 and R28 in include care of the oxygen both residents were receiving.