Prairie Manor Nrsg & Rehab Ctr

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its enhanced barrier precautions (EBP) policy and don appropriate PPE (personal protective equipment) prior to entering an EBP resident room to provide direct resident care and failed to perform hand hygiene before exiting a resident's room after providing direct resident care. These failures affected four residents (R2, R3, R4, and R5) out of five residents reviewed for infection control in a sample of 6.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to have the low air loss mattress at the correct weight setting for one resident (R2) with a stage 4 pressure ulcer, who is at risk for skin breakdown and requires extensive assistance with turning/repositioning, out of three residents reviewed for wound management in a sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement effective fall interventions related to the root cause of a resident with multiple falls. This affected one of three residents (R1) reviewed for falls. This failure resulted in R1 having six falls in six months with no change in fall interventions. Findings Include: R1 is an [AGE] year old with the following diagnosis: Parkinson's disease, functional quadriplegia, difficulty in walking, and orthostatic hypotension. A Plan of Care note dated [DATE] documents the nurse was called to R1's room by another staff member. The nurse observed R1 on the floor sitting in front of the wheelchair. R1 was assisted back to the wheelchair. The Care Plan dated [DATE] documents R1 is a high fall risk related to diagnosis of Parkinsonism, weakness, syncope, depression, and coronary artery disease. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and monitor for pressure ulcers for a resident who is at high risk for pressure ulcers. This deficiency affects one (R2) of three residents reviewed for Pressure Ulcer Prevention Program.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately supervise residents assessed as being at risk for falls and in the dementia unit, failed to make sure that fall interventions were implemented for 2 residents (R2 and R3) and failed to have any base line fall intervention/ adequate supervision for a newly admitted resident with history of falls (R1). These failures affected three (R1, R2 and R3) of five residents reviewed for falls/injury. These failures resulted in R1 having a fall in the dining that resulted in a right femur fracture, requiring surgery; R2 had a fall in her room and sustained a femur fracture requiring a surgical procedure; and R3 had a fall in her room and sustained a right distal clavicle fracture, which required treatment at a local hospital.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor and record daily freezer and refrigerator temperatures for food safety. This deficiency may potentially affect all 123 residents receiving food from the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure coordinated care was implemented by failure to document hospice services rendered to resident's medical record that is available and accessible to interdisciplinary team (IDT). This deficiency affects two (R22 and R45) of three residents in the sample of 25 reviewed for Hospice care Management.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain dignity and respect during dining observation for one of one resident (R99) reviewed for resident rights in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light was within reach for one (R70) out of seven residents reviewed for accommodation of needs in a sample of 25. Findings Include: On 08/02/23 at 11:15 AM, R70 was observed sitting in her wheelchair. Her call light was on the floor and not within her reach. On 8/2/2023 at 11:20 AM, V24 (CNA) observed that R70 call light was on the floor and not within the reach of R70. V24 said that the call light should be within R70's reach. On 8/2/2023 at 11:22 AM, V16 (Licensed Practical Nurse) said that call light should be within R70 reach. On 8/3/2023 at 12:00 PM, V3 (Director of Nursing) said that the call light within the resident's reach. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop individualized comprehensive care plan to resident to meet his medical, nursing, and physiological needs in the facility. This deficiency affects one (R232) of three residents in the sample of 25 reviewed for Resident's comprehensive care plan.

Inspectors wroteBased on observation, interview and record review the facility failed to follow its policy on medication safety by finding medications without physician order at resident's bedside. This deficiency affects one (65) of three residents in the sample of 25 reviewed for Resident's safety.

Inspectors wroteBased on observation interview and record review the facility failed to monitor the low air loss mattress is functioning properly on a resident who has multiple stage 4 and unstageable of pressure ulcers. The facility also failed to follow the manufacturer recommendation of avoiding multiple layers of linens over the Low Air Loss mattress. This deficiency affects one (R122) of three residents in the sample of 25 reviewed for Pressure ulcer Management.

Inspectors wroteBased on observation, interview and record review the facility failed to complete smoking assessment of resident upon admission who has history of conviction of arson. This deficiency affects one (R87) of three resident reviewed for Smoking Safety management.

Inspectors wroteBased on observation, interview, and record review the facility failed to secure catheter tubing for one resident (R40) of three residents reviewed for catheters in the sample of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to follow its policy by failure to obtain physician order prior to provide hospice care services and resident's hospice medical records available and accessible to all interdisciplinary staff. This deficiency affects one (R108) of three resident in the sample of 25 reviewed for Hospice Care Services.

Inspectors wroteBased on observation, interview and record review the facility failed to perform hand washing after taking care of resident who is on isolation for clostridium difficile (C. Diff) infection. This deficiency affects one ( R232) of three residents in the sample of 25 reviewed for Infection control protocol.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to honor the residents' right to choose to be a resident of the facility by not honoring the residents' request to return home after completion of rehabilitation therapy. This failure applied to one of one (R93) resident reviewed for resident rights and has resulted in R93 suffering extreme stress and feeling symptoms of depression due to not being able to discharge from the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to keep a resident free from mental abuse by not providing the resident with an explanation of why the facility is requesting a court appointed guardian for the resident. This failure applied to one of one (R93) resident reviewed for mental abuse and has resulted in R93 suffering extreme stress and feeling symptoms of depression due to not being able to discharge from the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy by not completing a comprehensive assessment after a resident's change in medical condition and when adding new diagnoses' to residents' plan of care. This failure applied to one of one (R93) residents reviewed for comprehensive assessment and has resulted in R93 being deemed unfit to make decisions without thorough documentation that the physician verified or reconsider underlying causes of cognitive impairment (including recent urinary tract infection, known to cause delirium) and/or failing to include diagnostic tests and collaboration with other physician specialists (such as neurology) when giving the resident a new diagnosis of dementia.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policies and procedures for preparing food under sanitary conditions and infection control by not properly wearing masks, not properly wearing hairnets, not performing hand hygiene when indicated, not keeping outside items from the kitchen area, not storing food used for meal prep appropriately, not ensuring ice equipment is thoroughly clean, and not covering waste disposal bin when not in use. This failure has the potential to affect all 110 residents who currently reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to follow standard precautions and prevent the spread of COVID-19 by 1.) failing to properly wear PPE (Personal Protective Equipment) in resident care areas; 2.) failing to isolate confirmed COVID-19 cases; 3.) failing to prevent symptomatic staff from being on duty; 4.) failing to screen employees and residents upon entrance to the facility; 5.) failing to follow standard hand hygiene protocols. These failures affect all 110 residents residing in the facility and has contributed to an active outbreak of COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report active COVID-19 cases to resident's family members or representatives and failed to report their current COVID-19 outbreak status to the local health department. These failures have the potential to affect all 110 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies and procedures for facility-wide COVID-19 testing. This failure has the potential to affect all 110 residents currently residing in the facility at the time of this survey.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a physician's order for self-administration of medication for one (R72) of nine residents reviewed during medication administration and the facility failed to properly document that narcotic count was completed each shift per facility policy. These failures have the potential to affect 75 residents on the 1st and 3rd floor reviewed during medication storage and labeling observation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their protocol of labeling medication with open date; failed to discard expired insulin vials; and failed to ensure that inhalers were labeled with the residents name and medication open date. This failure applied to eight of eight (R7, R8, R12, R50, R66, R72, R88, and R91) residents reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report and investigate an injury of unknown origin for potential abuse due to staff not immediately reporting a new forehead injury to the abuse coordinator. This failure applied to one (R62) of one resident reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their care protocols by not providing nail care to residents who require assistance with ADLs (activities of daily living). This failure applied to two (R67 and R113) of two residents reviewed for assistance with ADLs in a sample of 47 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to notify the registered dietitian of a change in food intake and failed to follow their interventions and treatments for weight loss prevention for a resident with a history of weight loss and poor oral intake. This failure applied to one (R46) of one resident reviewed for nutrition in a total sample of 33 residents.