New Richland Care Center

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide physician ordered dressing changes and assess wounds during those dressing changes, monitor for signs and symptoms of a worsening known infection, notify the physician of a change of condition and the need to acquire antibiotics from the E-Kit, acquire needed dressing change supplies, follow professional standards of practice by dating wound dressings and educate staff on identifying early signs and symptoms of sepsis (life-threatening infection) for 3 of 3 resident (R1, R2, and R3) reviewed.

Inspectors wroteBased on interview and record review, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan to guide facility efforts in assuring care and services were maintained at acceptable levels of performance and continually improved. This had the potential to affect all 38 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Centers for Disease Control (CDC) guidance was followed for fit testing for N95 filtering facepiece respirators prior to use and annually.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the ability to safely operate power lift reclining chair and develop and implement policies and procedures related to the operation/use of power lift chairs for 1 of 1 (R137) resident reviewed for accidents. R137's admission Minimum Data Set (MDS) dated [DATE], indicated R137 was admitted to the facility on [DATE], no cognitive impairment, utilized a wheelchair, dependent on staff for toileting, lower body dressing, toilet transfer, sit to stand, chair transfer; required substantial/maximal assistance with personal hygiene, roll left to right, sit to lying and diagnoses included need for assistance with personal care, obesity, and surgery on the digestive system. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure most recent survey results were readily accessible for residents or visitors to view. This had the potential to affect all residents who resided in the facility and visitors.

Inspectors wroteBased on interview and document review the facility failed to comprehensively assess and monitor for signs/ symptoms of fluid overload and evaluate the effectiveness of physician prescribed treatments for 1 of 3 residents (R1) who had diagnosis of congestive heart failure.

Inspectors wroteBased on observation, interview and document review, the facility failed to have a system in place for pressure ulcer prevention and management that included comprehensive assessments, monitoring, physician involvement, and individualized wound treatments and interventions for 4 of 4 residents (R1, R2, R3, R4) who had ongoing, recurrent, and deteriorating pressure wounds. As a result of the facility's systemic failure, R1 developed a stage 4 pressure ulcer that resulted in sepsis, osteomyelitis, and death resulting in immediate jeopardy. The IJ began on [DATE], when the facility failed to monitor, assess, and immediately notify the physician when R1's wound had increased drainage and pain which resulted in delay of care for four days followed by hospitalization and death. The Director of Nursing (DON) was notified of the IJ on [DATE] at 5:30 p.m. The IJ was removed on [DATE] at 4:39 p.m. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain a Quality Assurance Performance Improvement/Quality Assurance Activity (QAPI/QAA) that was effective in identifying, assessing, performing, developing, and implementing appropriate plans of action related to impaired skin integrity and/or pressure injuries. This deficient practice had the potential to affect all 34 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the physician and family/resident representative of new/existing wounds for 4 of 4 residents (R1, R2, R3, R4) reviewed for pressure injuries.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 1 licensed nursing staff were trained and competent in pressure ulcer assessment and management. This had the potential to affect all residents who were at risk for pressure ulcers and/or residents with existing pressure ulcers.

Inspectors wroteBased on observations, interview, and document review the facility failed to ensure enhanced barrier precautions (EBP) was used for 3 of 3 (R2, R3, R5) residents. In addition, the facility failed to ensure proper cleaning of vital sign equipment for 2 of 2 (R5, R6) residents and failed to ensure handwashing/hand hygiene was implemented for 5 of 7 (R2, R3, R5, R7, R8) residents observed for handwashing/hand hygiene.

Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of abuse/neglect were reported to the State Agency (SA), in accordance with established policies and procedures, for 2 of 3 residents (R2 and R5) reviewed for allegations of abuse.

Inspectors wroteBased on interview and document review, the facility failed to thoroughly investigate following an allegation of staff to resident abuse for 1 of 3 residents (R5) reviewed for allegation of abuse.

Inspectors wroteBased on interview and document review the facility failed to ensure 1 of 3 residents (R1) was treated with respect, dignity, and provided with self-determination in choosing bedtime.

Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of abuse were reported immediately, within two hours, to the State Agency (SA) for 1 of 3 residents (R1) reviewed for allegations of abuse.

Inspectors wroteBased on interview and document review, the facility failed to develop written policy and procedure for the time frame in which allegations of abuse and neglect must be reported to the State Agency (SA).

Inspectors wroteBased on interview and document review, the facility failed to ensure that in the absence of a full-time registered dietician (RD), the dietary manager (DM) was certified to oversee nutrition and food services. This had potential to affect all 36 residents who resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure condiments were used or discarded in a timely manager to maintain freshness and quality. In addition, the facility failed to monitor and ensure water temperature in the 3-compartment sink met regulatory requirements. This had the potential to affect all 36 residents who were served food from the kitchen.

Inspectors wroteBased on observation, interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas, identified thorough and appropriate data collection, analysis and evaluation of the identified concern(s) during Quality Assurance and Performance Improvement (QAPI). This had the potential to affect all 36 residents.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) guidelines to prevent the spread of Covid-19 when during a Covid-19 outbreak, failed to ensure appropriate use of personal protective equipment (PPE) when staff were observed not wearing PPE or not wearing appropriate PPE, in rooms of 8 of 8 residents (R1, R6, R9, R21, R25, R27, R28, R87) in transmission based precautions (TBP) for Covid-19; failed to remove masks after caring for residents in TBP for 5 of 5 residents (R6, R21, R27, R28, R87) on TBP; failed to ensure residents on TBP had a PPE cart outside of their room for 2 of 2 residents (R8, R25); [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure restorative services to maintain and/or improve mobility was received for 1 of 2 residents (R27) reviewed for mobility.