Quality Life Services - Sarver

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for three of five residents (Resident R4, R5, and R9).

Inspectors wroteBased on a review of facility policy and staff interviews, it was determined the facility failed to designate a consistent qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections for 12 out of 14 months.

Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to provide a dignified dining experience by failing to provide assistance with meals timely for one of six residents (Resident R42).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain a resident had an updated, person-centered care plan individualized to each specific resident's needs for one of five residents (Resident R39).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased Capillary Blood Glucose (CBG) levels for one of three residents reviewed (Residents R31), and failed to make certain that residents were provided appropriate treatment and care by failing to obtain an X-ray in an appropriate timeframe for one of four residents (Resident Closed Record (CR) R100).

Inspectors wroteBased on review of facility policy, clinical records, incident reports, facility documents, employee education, and staff interviews, it was determined that the facility failed to ensure that a resident was free from a preventable accident during a transfer for one of four residents (Resident R39).

Inspectors wroteBased on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to ensure direct care staff were aware of residents with fluid restriction orders to make certain acceptable parameters of nutritional status were maintained for one of four residents reviewed (Resident R27).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of two medication rooms (Liberty Medication Room) and one of three medication carts (Market Place Medication Cart).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions for one of two residents (Resident R25) with an indwelling foley catheter. Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions for one of two residents (Resident R25) with an indwelling foley catheter.

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that influenza immunization and pneumococcal immunization were offered to one of five residents (Residents R31).

Inspectors wroteBased on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for the facilities Automated External Defibrillator (AED-a portable, electronic device designed to diagnose and treat life-threatening cardiac arrhythmias) and crash cart (a supply cart used in an emergency).

Inspectors wroteBased on review of facility education documents, and staff interview, it was determined that the facility failed to provide training on effective communication for one of five staff members (Nurse Aide (NA) Employee E3).

Inspectors wroteBased on a review of facility policies, documents, resident medical records, and staff interviews it was determined that the facility failed to identify and determine the root cause of a physical injury as the potential for abuse or neglect for one of 59 residents. (Resident R1)

Inspectors wroteBased on a review of facility policies, documents, resident medical records and staff interviews, it was detrmined that the facility failed to implement an abuse and neglect policy to properly investigation of a physical injury or unknown origin for one of 59 residents (Resident R1).

Inspectors wroteBased on review of facility policy, resident clinical records, investigation documents and staff interview, it was determined that the facility failed to report injuries of unknown source for three of three residents (Resident R1, R2, and R3) reviewed.

Inspectors wroteBased on review of facility policy, resident grievances for 60 days, resident and staff interviews, it was determined that the facility failed to effectively resolve and provide responses to residents and/or their responsible parties in a timely manner in relation to concerns documented via Grievance procedure and complete the reports in their entirety for one of three grievances reviewed.

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to notify a physician of abnormal glucose levels as per physician's order for two out of five residents (Residents R20 and R33).

Inspectors wroteBased on review of facility policy, clinical record review, facility provided documents, and staff interview, it was determined that the facility failed to thoroughly investigate a potential allegation of abuse/neglect for misappropriation of property for one of two residents reviewed (Resident R37).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of seven residents sampled with facility-initiated transfers (Residents R28, R34, and R40). Review of facility policy Medical Emergency dated 12/1/23, indicated if transfer is required, complete transfer form and send appropriate documentation with the resident.

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for five of five residents (Residents R20, R28, R34, R40, and R67).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for five of five resident hospital transfers (Residents R20, R28, R34, R40, and R67). Review of facility policy Bed Holds dated 12/1/23, indicated upon transfer out, nursing will provide a copy of the Notice to the resident. Review of the clinical record indicated Resident R28 was admitted to the facility on [DATE]. Review of Resident R28's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/25/24, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and pain in left hip. [...]

Inspectors wroteBased on clinical records and staff interview, it was determined that the facility failed to update a care plan for one of eight residents (Resident R123) to accurately reflect the current status of the resident.

Inspectors wroteBased on review of facility policy, resident interview and observations, clinical record review, and staff interview it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of five residents observed (Resident R39).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to provide appropriate care and services for one of two residents receiving intravenous therapy (Resident R34) and failed to monitor resident wounds and complete weekly skin assessments for two of five residents (Residents R37 and R52). Review of facility policy Midline Dressing Changes dated 12/1/23, indicated midline catheter (a thin, flexible tube that is inserted into a large vein in the upper arm, used to safely administer medication into the bloodstream) dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. [...]

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to properly assess pressure ulcers for two of three residents (Residents R2 and R60).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure appropriate treatment and services were provided for two of two residents (Residents R25 and R34) with an indwelling urinary catheter (a tube inserted in the bladder to drain urine). Review of facility policy Indwelling Urinary Catheter dated 12/1/23, indicated the catheter bag should have a privacy cover applied at all times unless it has one built in by the manufacturer. Review of the clinical record indicated Resident R25 was admitted to the facility on [DATE]. Review of Resident R25's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/25/24, indicated diagnoses of obstructive uropathy (structural hindrance of normal urine flow), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. [...]

Inspectors wroteBased on review of facility policy, observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for three of four residents (Residents R33, R34, and R40). Review of facility policy Oxygen Therapy via Nasal Cannula dated 12/1/23, indicated to replace cannula every seven days, date and store in plastic bag when not in use. Review of the admission record indicated Resident R33 was admitted to the facility on [DATE]. Review of Resident R33's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/5/24, indicated diagnoses of renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), heart failure (heart doesn ' t pump blood as well as it should), and high blood pressure. [...]

Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to have accurate physician's orders for two of four residents with assist rails (Residents R25 and R26) and conduct ongoing accurate assessments for one of three residents (Resident R33).

Inspectors wroteBased on review of facility policy, clinical record review, controlled drug shift count record, and staff interview, it was determined that the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs for one of two medication carts (Pennsylvania Medication Cart).

Inspectors wroteBased on review of facility policy and documentation, clinical record reviews, and staff interview it was determined that the facility failed to accurately document education and immunization administration related to pneumococcal vaccines for one of five residents (Resident R26).

Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to update a care plan for one of four residents (Resident R1) to accurately reflect the current status of the resident.

Inspectors wroteBased on review of facility policy, clinical records, observations, and staff interviews it was determined that the facility failed to make certain each resident received adequate supervision that resulted in one elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy, personnel files and staff interview it was determined that the facility failed to complete required training on dementia management, communication, and behavioral interventions for five out of five nurse aide personnel files (Nurse aide- NA Employee E1, NA Employee E2, NA Employee E3, NA Employee E4, and NA Employee E5).

Inspectors wroteBased on facility policy review, resident observations and interviews, clinical record review and staff interviews, it was determined that the facility failed to make certain a physician order for use of and cleaning of a Bi-PAP/CPAP machine (machines used to make breathing easier), failed to develop a plan of care for two of three resident (Resident R25 and R212), and failed to properly date respiratory equipment and administer at the appropriate rate of flow for one of three residents (Resident R214).

Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct accurate assessments to ensure that bed rails were used to meet residents' needs and the risks associated with bed rail usage for two of three residents (Resident R5, and R42).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined the facility failed to implement measures to care for huber needles (a specially designed hollow needle used with a med port (a surgically placed intravenous access and the needle has a long, beveled tip that can go through your skin as well as the silicone septum of the implanted port's reservoir) for two of two residents (Residents R13 and R214).