Moore Few Care Center

Inspectors wroteBased on interview and record review, the facility failed to provide respiratory care consistent with standards of practice when staff failed to administer oxygen as ordered, failed to notify the physician of respiratory changes, and failed to create a timely comprehensive care plan that addressed oxygen usage for one residents (Resident #1). The resident went into respiratory distress and was sent to the emergency department. The facility census was 46. Review showed the facility did not provide a policy regarding change of condition procedures. Review showed the facility did not provide a policy regarding physician notification. 1. Review of the Resident #1's face sheet (brief look at resident information) showed the following information: -admission date of [DATE]; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain and effective pain management regimen when the facility failed to accurately assess, monitor, address, care plan, and notify the physician of increased and unrelieved pain for one resident (Resident #1) resulting in increased pain. The facility census was 46. Review of the facility policy titled, Pain Management Program, reviewed on 11/17/16, showed the following information: -The facility will assess all resident's on admission, quarterly, and as needed; -Complete pain assessment for all residents. Monitor for persistent as needed (PRN) medication use; -Assess pain presence, frequency, effect on function, and intensity; -Ask resident to rate pain using the pain scale; -Determine if staff assessment for pain is needed; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff adhered to the facility policy and standards of care for wearing the appropriate Personal Protective Equipment (PPE) for residents that had tested positive for COVID for four of four residents (Resident #95, #22, #94, and #144) observed for transmission-based precautions. Review of the facility's policy titled COVID-19, effective 09/19/23, showed the following: -Residents who test positive will be in a private rooms unless another resident is positive. In this case, cohorting will be permissible. Cohorting is not permissible for a positive resident and a presumptive resident. Movement outside the room will be extremely limited during quarantine period. -Staff will be required to wear full PPE including goggles, gloves, and N95 (K95) (filtration) masks when providing care or entering the room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assessed for safety and physician orders obtained prior to self-administration of medication when one resident (Resident #28) had medications for self-administration at his/her bedside. Review of the facility's policy titled Self-Administration of Medications, dated 02/2021, showed the following: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. -If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record, and the care plan. -The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision making status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were as free from accident hazards as possible when staff failed to have an effective process in place to reduce the likelihood of residents burning themselves with hot liquids resulting in one resident (Resident #13) suffering a burn on his/her foot from hot chocolate and when the facility staff left a mechanical lift stored in a resident's room resulting in one resident (Resident #1) falling. 1. Review of the facility's policy titled Safety of Hot Liquids, dated 10/2014, showed the following: -Residents will be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission and on change of condition; -Appropriate precautions will be implemented to maximize choice of beverages while minimizing the potential for injury; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide respiratory care per standards of practice when staff failed to ensure proper storage of oxygen/nebulizer supplies for two residents (Resident #3 and #28) of two residents reviewed for oxygen management out of a total sample of 16 residents. Review of the facility's policy titled Oxygen Therapy, dated 07/2023, showed staff to store cannulas and masks in plastic bags when not in use. Staff to change cannula, mask, tubing, and storage bag every seven days or as indicated. 1. Review of Resident #3's admission Record, undated, located under the ''Profile'' tab, showed the following; -admission date of 02/10/16; -Diagnoses included acute and chronic respiratory failure with hypoxia (oxygen is insufficient at the tissue level). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all residents who wished to receive pneumococcal vaccines received them when staff failed to administer one pneumococcal vaccine to one resident (Resident #9) of five residents reviewed for immunizations. Review of the facility's policy titled Immunization Records, dated 07/2023, showed the following: -Adult pneumococcal recommendations if previous PPSV23 [pneumococcal polysaccharide vaccine - Pneumovax 23] only administer PCV20 or PCV15. 1. Review of the Resident #9's admission Record, undated, located in the resident's electronic medical record (EMR), under the Profile tab, showed the resident was admitted on [DATE] with a readmission on [DATE]. Review of the resident's Vaccine Consent Form, dated 09/22/23, showed the requested vaccines included Pneumovax23 and Prevnar13 (pneumococcal conjugate vaccine (PCV) 13). [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure all residents were kept free from possible accident hazards when the facility staff did not fully secure one resident (Resident #1) in a wheelchair during transport in the facility's van. The facility census was 53. On 03/05/24, at 3:00 P.M., the Interim Administrator and the Acting Director of Nursing (DON) were notified of the Past Non-Compliance that occurred on 01/10/24. On 01/10/24, DON E notified the Department of Health and Senior Services (DHSS) of the incident, began an investigation, educated the employees involved, and initiated a new competency checklist for all transportation drivers. The noncompliance was corrected on 01/12/24. Review showed the facility did not have a policy and procedure specific to transporting residents in the facility van. 1. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan, that includes measurable objectives to meet the resident's medical and nursing needs identified in the comprehensive assessment, for four residents (Residents #24,#25, #31, and #95). The facility census was 42. Record review of the facility's policy entitled MDS and Care Plan Policy, reviewed 2/20/2012, showed the following information: -The purpose of this policy is to initially and periodically conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity, to provide the facility with the information necessary to develop a care plan and to provide the appropriate care and services for each resident; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases when the facility failed to follow their policy and infection control practices when staff did not ensure staff completed and read employee tuberculosis (TB - a potentially serious infectious bacterial disease that mainly affects the lungs) screening tests timely on hire for four staff members. The facility census was 42. Record review of the facility's policy Tuberculosis, Employee Screening, dated July 2010, showed the following: -The oversight of the TB monitoring will be designated to one person; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer, for two residents (Residents #34 and #41). The facility census was 42. Record review of the facility's policy entitled Transfer or Discharge Documentation, revised December 2016, showed the following information: -When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: -The basis for the transfer or discharge; [...]

Inspectors wroteBased on interview and record review, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for two residents (Residents #34 and #41) who were transferred out to the hospital. The facility census was 42. Record review of the facility's policy entitled Bed-Holds and Returns, revised March 2017, showed the following information: -Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy; -Residents may return to and resume residence in the facility after hospitalization as outlined in this policy; -Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail the rights and limitations of the resident regarding bed-holds; [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete an annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument, completed by facility staff) assessment for one resident (Resident #1) within the required 14 days from the assessment reference date (ARD). The facility had a census of 42. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete a quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument, completed by facility staff) assessment for one resident (Resident #4) within 14 days from the assessment reference date (ARD). The facility had a census of 42. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type; [...]

Inspectors wroteBased on record review and interview, the facility failed to transmit a Discharge Assessment - Return Anticipated Minimum Data Set (MDS - a federally mandated assessment instrument, required to be completed by facility staff for care planning) record within 14 days of discharge for two residents (Resident #2 and #3). The facility had a census of 42. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The discharge assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed when the resident is discharged from the facility and the resident is expected to return to the facility within 30 days; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents (Residents #86 and #89) out of three sampled residents who remained in the facility upon discharge from Medicare Part A services. The facility census was 74. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a side or bed rail evaluation form, to include a risk/benefit review and alternatives attempted prior to the use of side or bed rails; failed to document ongoing evaluations; failed to complete a side or bed rail safety check with regular inspections of the bed frame and side or bed rail for risk of entrapment; and failed to develop care plan interventions and approaches for side or bed rails for seven residents (Resident #9, #27, #28, #31, #55, #64 and #68) out of 21 sampled residents. The facility census was 74. Record review of the facility's policy titled, Proper Use of Side Rails, dated October 2010, showed the following: -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of the resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide catheter care per nursing standards of infection control for one resident (Resident #4) with an indwelling catheter (a sterile tube inserted into the bladder to drain urine) out of a sample of 21. The facility census was 74. According to the Center for Disease Control's (CDC) Guideline for Hand Hygiene in Healthcare Settings, 2002, volume 51 showed the following: -The hands are the most common mode of transmitting pathogens (microorganisms); -Clean hands are the single most important factor in preventing the spread of pathogens and antibiotic resistance (infections caused by microorganisms that are resistant to antibiotics) in healthcare settings; -There is substantial evidence that hand hygiene reduces the incidence of infections. [...]