Odebolt Specialty Care

Inspectors wroteBased on clinical record review, Center for Medicare and Medicaid (CMS) Long Term Care (LTC) Facility Resident Assessment Instrument (RAI) User Manual and staff interview the facility failed to complete a Minimum Data Set (MDS) Significant Change in Condition Assessment (SCSA) for 1 of 12 residents reviewed (Resident #3). The facility reported a census of 29 residents.

Inspectors wroteBased on clinical record review, staff interviews, and the Center for Medicare and Medicaid (CMS) Long Term Care (LTC) Facility Resident Assessment Instrument (RAI) User Manual the facility failed to represent an accurate picture of the resident's status during the observation period of the Minimum Data Set (MDS) by not accurately recording medication use for 3 of 5 residents reviewed (Resident #2, #3, #1). The facility reported a census of 29 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents reviewed for (Resident #19 and Resident #28). The facility reported a census of 29 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to represent an accurate picture of the resident's status during the observation period of the Minimum Data Set (MDS) by not accurately recording medication use for 3 of 3 residents reviewed, (Resident #24,#26, and #27). The facility reported a census of 33 residents.

Inspectors wroteBased on clinical document review, staff interview, and policy review the facility failed to provide a comprehensive care plan related to high risk medications for 2 of 5 residents reviewed (Residents #26, and #27) . The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to provide assessment and interventions necessary for the care and services, to maintain the residents' highest practical physical well- being for 1 of 14 residents reviewed (Resident #7). The facility failed to complete and document vital signs and nursing assessments after Resident #7 returned from the emergency room (ER) for chest pain. The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record reviews, staff interviews and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 1 resident reviewed (Resident #5). The facility reported a census of 33 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents reviewed for catheter care (Resident #9). The facility reported a census of 33 residents.

Inspectors wroteBased on observations, record review, staff, family and hospital staff interview the facility failed to prevent an accident from occurring for 1 of 3 residents (Resident #1) reviewed for wandering with cognitive impairments. The kitchen staff members left the main kitchen door propped open and unsupervised. Resident #1 self-propelled in to the kitchen, through the kitchen, through two more doors, which included the basement door where she fell down 13 concrete stairs in her wheelchair. A kitchen staff member heard someone yelling for help. She found Resident #1 at the bottom of the basement stairs with her wheelchair next to her. She alerted nursing staff. Staff provided first aide to the left side of her head until EMS arrived and transported her to the hospital. The facility reported a census of 29 residents. [...]

Inspectors wroteBased on observations, staff interviews, and facility policy reviews the facility failed to store and prepare food sanitary conditions. The facility identified a census of 30 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to represent an accurate picture of the resident's status during the observation period of the Minimum Data Set (MDS) by not completing a discharge assessment for 1 of 3 residents reviewed (Resident #31).

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to accurately complete skin assessments to prevent delay in treatment and to prevent a decline in condition of a diabetic ulcer for 1 out of 3 residents reviewed (Resident #21).

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to provide appropriate infection prevention practices related to catheter drainage bags for 1 of 4 residents reviewed (Resident #8).

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to assess or treat a resident's wound as order by the physician to promote healing for 1 of 5 residents reviewed (Resident #10) for wound care. Resident #10 admitted to the facility on [DATE] following a stay in the hospital. On admission, she had a wound to her right lower leg that required treatment of a wound vacuum (vac) to promote healing. Since the time of her admission, the facility only assessed her right lower leg wound on the day of admission and the day of her discharge, 19 days later. The facility then only assessed the left leg wound on day after admission and the date of discharge, 18 days later. In addition, during that period, the facility did not complete Resident #10's dressings due to her being asleep, or the time of day, of the staff did not document the treatment. [...]

Inspectors wroteBased on clinical record review, facility policy review, staff, resident, and family interviews, the facility failed to provide adequate oxygen therapy for 1 of 1 resident reviewed (Resident #9). Due to a diagnosis of congestive heart failure and a recent hospital stay that included Resident #9 requiring the use of a ventilator, she required the use of supplemental oxygen. The staff failed to monitor Resident #9 vital signs and the oxygen tank to ensure she received the proper amount of oxygen. When the staff went to help Resident #9 to lunch, they found her unresponsive with an oxygen saturation of 45% and an empty oxygen tank. While at the hospital, the staff found Resident #9 had anoxic brain injury (a type of brain injury caused by the deprivation of oxygen). The initial hospital transferred Resident #9 by life flight to a larger hospital, where she died a few days after admission.

Inspectors wroteBased on interview record review and policy review, the facility failed to include signed physician's orders in residents clinical record for 5 of 5 residents reviewed (Residents #2, #9, #10, #14 and #15).

Inspectors wroteBased on record reviews, staff, and resident interviews, the facility failed to treat all residents with dignity and respect for 2 of 15 residents reviewed (Residents #14 and #15). Resident's #14 and #15 reported the staff treated them disrespectfully because they preferred to stay in their room for a meal.

Inspectors wroteBased on clinical record review, family interview, staff interviews, and facility protocol the facility failed to notify the physician about a resident's discharge for 1 of 3 residents reviewed (Resident #2). In addition, the facility failed to document the reason they could no longer meet the needs for 1 of 3 residents reviewed (Resident #2).

Inspectors wroteBased on clinical document review, family interview, staff interview, and policy review the facility failed to provide sufficient notice of discharge for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 30 residents.

Inspectors wroteBased on clinical document review, family interview, staff interview, and policy review the facility failed to provide adequate nursing supervision for 1 of 3 residents (Resident #2) reviewed.