Mineral Springs

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow the health care provider's order for a therapeutic diet for a swallowing issue for 1 of 2 residents reviewed for nutrition in a final sample of 14 residents (Resident identifier is #43).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure the residents' right to formulate advance directives for 2 out of 2 residents reviewed for Advance Directives in a final sample of 15 residents. (Resident Identifier's are #102 and #152.)

Inspectors wroteBased on interview and record review, it was determined that the facility failed to inform each resident before, or at the time of admission, of services available in the facility and of charges for those services for 1 resident in a final sample of 15 residents. (Resident identifier is #43.)

Inspectors wroteBased on interview and record review, it was determined that the facility failed to follow physician's orders for 1 of 2 residents review for pain management in a final sample of 15 residents (Resident identifier is #44.)

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 4 days in the month of September 2024.

Inspectors wroteBased on observation, interview and manufacturer's instruction review, it was determined that the facility failed to ensure that medications were labeled and dated in accordance with currently acceptable professional principles for 2 out of 2 medication carts observed. (Resident identifiers are #152 and #36.)

Inspectors wroteBased on interview, record review, and policy review, it was determined that the facility failed to ensure that medical records were accurately documented for 1 out of 1 resident reviewed for Post Traumatic Stress Disorder. (Resident Identifier is #202.)

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide sufficient nursing staff, as determined by their facility assessment, to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in a census of 48 residents. Interview on 9/10/24 at approximately 1:40 p.m. with Resident #26 revealed that he/she was frequently told that staff were too busy and it caused delays in the care that he/she needed, and medications administered were frequently late. Interview on 9/10/24 at approximately 1:00 p.m. with Resident #45 revealed that the facility was short staffed, and it caused longer responses to call lights and getting the assistance he/she needed. Resident #45 stated: I waited on the toilet for 45 minutes the other day. Interview on 9/11/24 at approximately 8:00 a.m. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to follow established infection control guidelines for facility water management by not having a system to monitor control measures to minimize the risk of Legionella and other opportunistic pathogens that has the potential to effect the facility census of 48 residents who resided at the facility.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to follow physician orders or provide medications timely for 5 residents in a final sample of 19 residents (Resident Identifiers are #1, #17, #26, #34, #47).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure the activities program was directed by a qualified professional for a facility census of 78 residents.

Inspectors wroteBased on interview and record review, it was determined the facility failed to designate an Infection Preventionist that completed specialized training in infection prevention and control.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure resident's needs were accommodated by keeping their call bell within reach for 1 of 1 reviewed for environment in a final sample of 16 residents (Resident Identifier #12).

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide a clean and homelike environment on 1 of 2 units observed. Observation on 9/11/24 from approximately 7:00 a.m. until 7:20 a.m. of the [NAME] Unit revealed three large areas of smeared brown substance adhered to the carpet. One area (approximately 4 feet (ft.)) long and 1 ft. wide) was on the floor in the hallway and the two other areas (approximately 2 ft. long and 1 ft. wide) were on the floor in front of the nursing station. Further observation revealed two residents walking on the areas. Interview on 9/11/24 at approximately 7:15 a.m. with Staff H (Licensed Nursing Assistant) revealed that the areas on the floor were from a resident having loose stools on 9/10/24 in the evening.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide showers for 1 out of 3 residents reviewed for Activities of Daily Living (ADL's) in a final sample of 19 residents (Resident Identifier #42).

Inspectors wroteBased on interview, and record review, it was determined that the facility failed to ensure that facility-sponsored groups and individualized activities were provided to support residents based on the resident's preferences, interests, and all needs for each resident for the weekend days in September 2024.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer had necessary treatment and services, which included documentation of weekly assessments that contained measurements and descriptions of the pressure ulcer and treatment orders for pressure ulcers for 1 out of 1 residents reviewed for pressure ulcers (Resident Identifier #1).

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that resident's diabetes regimen included timely medication administration and adequate monitoring for 1 of 3 residents reviewed for insulin in a final sample of 19 residents (Resident Identifier #30). Findings Include: Resident #30 Interview on 9/10/24 at approximately 10:45 a.m. with Resident #30 revealed he/she was a diabetic and concerned about his/her blood sugars being inconsistent and he/she questioned whether he/she was receiving the correct insulins. Review on 9/10/24 of Resident #30 medical record revealed physician orders for Fiasp FlexTouch Subcutaneous Solution Pen-injector 100 unit/milliliter (ML), Inject 10 units subcutaneously two times a day for Diabetes Mellitus with breakfast and lunch, scheduled at 8 a.m. and 12 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a medication error rate was less than 5 percent (%) for medication administration for 2 of 36 medications observed (5.56 % error rate) (Resident Identifier #34).

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to maintain locked storage of medications, failed to ensure resident medications had accurate labeling of medications in 1 of 2 med carts, and medications were discarded after expiration in 1 of 1 medication rooms observed ([NAME] Medication Room and Brettonwoods Medication Cart).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to develop, implement and maintain an effective comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) plan.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that a resident receiving anticoagulant (blood thinner) therapy received the necessary care and services for anticoagulation treatment for 5 days for 1 of 3 residents reviewed for anticoagulation therapy (Resident Identifier #1).

Inspectors wroteBased on interview and record review it was determined that the facility failed to follow its policy for tracking, investigating, and prompt resolution for 2 out of 4 residents reviewed for grievances (Resident Identifiers are #1 and #2).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide sufficient staffing numbers to meet the residents' needs.

Inspectors wroteBased on interview and record review it was determined that the facility failed to report allegations of abuse to the State Survey Agency (SSA) for 3 out of 4 grievances reviewed for alleged abuse (Resident Identifiers are #2, #3, and #4).

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure that alleged violations of neglect were thoroughly investigated for 2 out of 4 grievances reviewed (Resident Identifiers are #2 and #3).

Inspectors wroteBased on interview and record review it was determined that the facility failed to follow physician orders for 1 of 2 residents reviewed for physician orders (Resident Identifier is #1).