Prairie Village Healthcare Ctr

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food is stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 52 residents living in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to respect resident rights for 4 (R3, R7, R34, R61) of 4 residents reviewed for resident rights in a sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat residents with dignity for 1 (R3) of 1 resident reviewed for dignity in the sample of 33.

Inspectors wroteBased on interview and record review the facility failed to review and revise the care plan for resident's needs for transfer assistance for 1 of 8 (R49) residents investigated for accidents in a sample in 33.

Inspectors wroteBased on interview and record review the facility failed to properly transfer a resident using a mechanical lift with one staff member for 1 of 8 (R49) residents investigated for accidents in a sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's orders regarding tube feeding for 1 (R2) of 2 residents reviewed for tube feeding the sample of 33.

Inspectors wroteA. Based on interview and record review the facility failed to obtain a urine sample timely and properly insert a catheter for 1 of 5 residents (R13) reviewed for urinary tract infections in the sample of 27. This failure resulted in the untimely collection of a urine specimen, with collection not occurring until 4 days after the order was received. During this time R13 suffered increasing symptoms with ultimately a malposition foley catheter being inserted into R13's urethra with a partially inflated balloon, despite the order given being for a straight catheter. R13 developed urosepsis and septic shock with hospital stay from [DATE]-[DATE] with ICU care for 7 days and ultimately death on [DATE] caused by sepsis and UTI.The immediate jeopardy began on [DATE] when R13 was transferred to local hospital due to change in condition in which the facility had not obtained a urine sample. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to don Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precaution (EBP) and Contact Isolation, and to do hand hygiene and glove changes when necessary for 4 of 4 residents (R9, R12, R15, R21) reviewed for infection control in the sample of 30.

Inspectors wroteBased on interview, observation, and record review the facility failed to properly treat pressure sores, including following physician orders, for 1 of 4 residents (R9) reviewed for care of a pressure ulcer in the sample of 30.

Inspectors wroteBased on interview and record review the facility failed to replace a broken c-pap mask timely for 1 of 3 residents (R1) reviewed for respiratory therapy in the sample of 30.

Inspectors wroteBased on interview, observation, and record review, the facility failed to administer an antibiotic to a resident with a diagnosis of Urinary Tract Infection (UTI) and failed to follow physician orders to administer medications for 2 of 5 residents (R21, R22) reviewed for medication administration in the sample of 30.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a residents' foot was free of insects for 1 of 3 residents (R2) reviewed for foot health.

Inspectors wroteBased on record review and interview the facility failed to maintain a complete and accurate medical record for 1 (R2) of 3 sampled residents in review of complete and accurate medical records.

Inspectors wroteBased on interview, observation and record review, the facility failed to follow physician's orders for twice-daily pulse oximetry checks for 2 of 3 residents (R1 and R2) reviewed for quality of care in the sample of 4.

Inspectors wroteBased on interview, observation and record review, the facility failed to identify a stage 2 pressure ulcer on the upper intergluteal cleft in a timely manner for 1 of 3 (R2) residents reviewed for pressure ulcers in a sample of 4.

Inspectors wroteBased on interview, and record review, the facility failed to provide 8 consecutive hours of Registered Nurse (RN) Coverage. This failure has the potential to affect all 48 residents residing in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to cleanse a multi-use blood glucose machine completely to insure disinfection for 7 of 16 residents (R4, R12, R17, R23 R38, R45, R47) reviewed for infection control in the sample of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the Physician Ordered treatment to pressure sore to left heel for one of 3 residents ( R10) reviewed for pressure ulcers in the sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to provide 8 hours of consecutive Registered Nurse coverage. This failure has the potential to affect all 55 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to employ a trained Infection Preventionist. This failure has the potential to affect all 55 residents living in the facility.

Inspectors wrote2. R49's Care Plan, dated 4/28/23, documents ADLs, (activities of daily living), Functional Status/Rehabilitation Potential PROBLEM: (R49) admitted to facility from outlying hospital after suffering from a Cerebral infarct. (R49) has dx of, but not limited to: Huntington's disease, HTN, (Hypertension), atherosclerotic heart disease, autoimmune thyroiditis, type II diabetes, hyperlipidemia, hemiplegia, and hemiparesis to right side following CVA, (Cerebral Vascular Accident), dysphagia, abnormalities in gait and mobility, urinary retention, and convulsions. (R49) has an upper and lower partial. 6/15/22 June is able to ambulate short distances with two staff and a gait belt. Her primary mode of locomotion is a w\c, (wheelchair), that she requires assistance to propel. (R49) is alert and able to voice needs. It continues, APPROACH: [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to perform hand hygiene and change soiled gloves to prevent cross contamination for 3 of 24 residents (R12, R19, R49) reviewed for infection control in the sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to educate residents and offer the Pneumococcal Immunizations yearly, to residents that had previously refused it, for 2 of 5 residents (R32, R46) reviewed for immunizations in the sample of 28.