Monette Manor, LLC

Inspectors wroteBased on observation and interview, the facility failed to ensure the Infection Preventionist had completed specialized training in infection prevention and control before taking the position. The failed practice had the potential to affect all 79 residents residing in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to maintain an infection prevention and control program that included an Antibiotic Stewardship Program (ASP) ) this failed practice had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to develop and implement a Comprehensive Person-Centered Care Plan for one (Resident #36) of five residents reviewed that included measurable objectives and timeframes to meet a resident's medical, nursing, needs that were identified in the Comprehensive Assessment Specifically, Resident #36's Care Plan did not address or focus on an active diagnosis of type 2 diabetes, nor include interventions to guide staff in monitoring for complications.

Inspectors wroteBased on observations, interviews, record review and facility policy review, it was determined that the facility failed to ensure that antibiotic medications were administered promptly and as ordered, and that the accuracy of orders entered into a resident's electronic health record was verified for one (Resident #76) of one resident reviewed for medication administration. Specifically, the facility failed to ensure ordered antibiotics were not left in the medication room's overflow box for seven days prior to initiating administration, and to ensure the duration of the antibiotics were entered as ordered.

Inspectors wroteBased on observations, interviews, record review and facility policy review, it was determined that the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #83) of three residents reviewed for accidents. Specifically, the facility failed to follow the person-centered care plan interventions for Resident #83, resulting in an accident.

Inspectors wroteBased on observations, interviews, record review and facility policy review, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions for one (Resident #36) of three residents reviewed.

Inspectors wroteBased on observations, interviews, record review and facility policy review, it was determined that facility staff failed to wear proper Personal Protective Equipment (PPE) while providing direct care to a resident that had an indwelling catheter in place and was on Enhanced Barrier Precautions (EBP) for one (Resident #11) of one resident reviewed for Infection Control.

Inspectors wroteBased on record review, facility document review, interview, and facility policy review, it was determined that the facility failed to ensure fall interventions were placed in a person-centered care plan following falls for five (Resident #4, Resident #5, Resident #7, Resident #8, and Resident #9) of seven residents reviewed for fall interventions in a person-centered care plan.

Inspectors wroteBased on observations, interviews, record review, document review, and facility policy review, the facility failed to report 3 of 3 incidents of resident-to-resident abuse reviewed, failed to report an unwitnessed fall with serious injury, and failed to complete a thorough investigation of the incidents.

Inspectors wroteBased on facility document review and interview, it was determined the facility failed to electronically transmit encoded, accurate, and complete, Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required time frame of 14 days to provide accurate and up-to-date information for quality measures for 6 (Residents #1, #2, #26, #34, #41, and #44) sampled residents whose MDS assessments were reviewed.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan to reflect the residents needs and preferences for 5 residents (Resident #37, Resident #13, Resident #14, Resident #220, and Resident #120) of 19 residents reviewed for care plans. The facility failed to properly assess residents and implement care plan interventions which affect the residents' highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to complete clinical assessments to accurately portray the resident's care for the Minimum Data Set (MDS) and care plan intervention implementation for 6 (Residents #2, #14, #37, #48, #70, and #220) residents of 19 sampled residents affecting their quality of care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow the menu for pureed diets for the lunch service.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure infection control procedures were followed by not performing hand hygiene between residents while assisting at the assisted diner table in the dining room to prevent the potential spread of infection for 2 residents observed during a lunch meal, and failed to ensure infection control procedures were followed in the areas of perineal care, catheter care, and enhanced barrier precautions to prevent the spread of infections for 1 of 1 sampled resident (Resident #13).

Inspectors wroteBased on record review, and interview, it was determined the facility failed to ensure a baseline care plan was completed with the minimum necessary information within 48 hours after admission to promote continuity of care for 1 (Resident #120) sampled resident who was admitted within the last 30 days.

Inspectors wroteBased on observation, interviews, and record review, the facility's administration failed to ensure the administrator was knowledgeable regarding reporting requirements, which resulted in failure to immediately report a resident to resident altercations, and an unwitnessed fall with major injury, to the State Survey Agency (SSA).

Inspectors wroteBased on record review, and interviews, the facility failed to have an effective governing body in place to ensure proper management and operation of the facility's: Quality Assurance and Performance Improvement Plan (QAPI) feedback system to ensure resident care areas were addressed, for baseline, implementation, and revision of care plans and for timing and transmitting the Minimum Data Sets (MDS).

Inspectors wroteBased on record review, and interviews, the facility failed to ensure qualified staff was hired in a position to accurately encode, transmit, and implement assessments and care plans.

Inspectors wroteBased on record review and interview, the facility failed to ensure an effective feedback system was in place for the Quality Assurance and Performance Improvement Plan (QAPI).