Quality Life Services - Sugar Creek

Inspectors wroteBased on review of facility policy, observations and staff interviews, it was determined that the facility failed to ensure foods were not held in the danger zone temperatures which are between 41 degrees Fahrenheit (F) and 135 degree F and properly store food products.

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop and implement person-centered comprehensive care plans to meet resident care needs for three of five residents (Resident R10, R17, and R98).

Inspectors wroteBased on review of facility policy, job descriptions, clinical record review, and staff interview, it was determined that the facility failed to provide sufficient and timely social services for three of four residents reviewed (Residents R10, R15, and R17).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence medication regimen reviews (MRRs) were reviewed by the resident's attending physician monthly for three of five residents (Residents R8, R56, and R98).

Inspectors wroteBased on clinical record review, facility policy, and staff interviews, it was determined that the facility failed to ensure that residents' medication regime was free from unnecessary psychotropic (a mind-altering medication) medication for two of three residents (Resident R9 and R15).

Inspectors wroteBased on review of facility policy, clinical record review, staff interviews, and observations it was determined that the facility failed to provide supervision with meals as ordered for one of three residents (Resident R6).

Inspectors wroteBased on review of facility policy, clinical records, staff and resident interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for one of five residents (R8). Findings Include: Review of the RESmart CPAP and Auto-CPAP User Manual dated 8/3/16, revealed it is recommended that the air filter be changed every 30 days. Remove the filter cap by gently pressing on its bottom. Remove the foam filter by gently pulling around the edges of the filter. Remove filter and replace with blue side facing out. Replace filter cap so that the small opening on the cap is facing down. Insert the cap's tabs into the filter area opening. Opering a RESmart CPAP and Auto-CPAP with a dirty filter may keep the system from working properly and may cause damage to the device. [...]

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident with dementia receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one of three residents reviewed (Resident R15), and failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of three residents reviewed (Resident R98).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly secure a treatment cart while not in use for one of three treatment carts (Willow Hall Treatment Cart).

Inspectors wroteBased on facility policy review, medical literature review, clinical record reviews, review of facility documents, and staff interviews, it was determined that the facility failed to provide an altered texture diet, as prescribed by the physician, for one of 40 residents (Resident R1). This failure resulted in Resident R1 choking on food that he was not ordered which caused him to cease to breathe. This failure placed an additional 40 residents that had similar diet needs at risk which resulted in an Immediate Jeopardy situation for 40 of 107 residents.

Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident nutrition care needs for five of six residents reviewed (Resident R1, R2, R3, R4, and R5).

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of four nursing units (Willow Nursing Unit).

Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility when the facility failed to provide an altered texture diet, as prescribed by the physician, for one of 40 residents (Resident R1). This failure resulted in Resident R1 choking on food that he was not ordered which caused him to cease to breathe. This failure placed an additional 40 residents that had similar diet needs at risk, and resulted in an Immediate Jeopardy situation for 40 of 107 residents.

Inspectors wroteBased on a review of facility policy, observation and staff interview, it was determined that the facility failed to properly maintain cleanliness and sanitation of the Main Kitchen. (Main Kitchen).

Inspectors wroteBased on resident and staff interviews, and review of facility documentation, it was determined that the facility failed to provide residents with their quarterly banking statements for three of five residents.

Inspectors wroteBased on clinical record review, facility provided documents, and staff interview, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for three of five residents (Residents R4, R86 and, R106).

Inspectors wroteBased on review of facility policy, and resident and staff interview , it was determined that the facility failed to inform residents on the grievance policy and procedures for seven of seven residents.

Inspectors wroteBased on review of facility policies, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from neglect for two of five residents reviewed (Resident R48 and R260) which resulted in actual harm of a skin tear (Resident R48) and a dislocation of right elbow, fracture of the right distal radius (bone near wrist) and a fractured of the right coronoid process of the ulna (bone of forearm) (Resident R260).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation with a complete and thorough investigation of an incident involving the potential for neglect for one of four residents (Resident R260).

Inspectors wroteBased on review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of neglect for one of three residents (Resident R260).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse neglect for one of four residents (Resident R260).

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 one of three residents sampled with facility-initiated transfers (Resident R57) and failed to provide a discharge summary completed by a physician for one of two residents (Resident R108).

Inspectors wroteBased on a review of facility policy, clinical record, and staff interview, it was determined that the facility failed to provide an ongoing neurological assessment post unwitnessed fall for one of four residents (Resident R100).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to provide adequate supervision to prevent elopement for one of three residents (Resident R106).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripheral inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) in accordance with professional standards of practice for one of two residents (Resident R70).

Inspectors wroteBased on review of resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R4, and R9).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician for one of three residents (Resident R88).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two medication rooms (Hemlock Medication Room), and failed to store medications and biologicals properly and securely in three of five medications carts (Hickory hall, Hemlock hall, and [NAME] hall medication carts).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R107).

Inspectors wroteBased on observations, review of facility documentation, and staff interview, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of three crash carts (Exam Room).

Inspectors wroteBased on staff interviews, and employee file review, it was determined that the facility failed to employ a full-time qualified Food Service Director for ten of ten months (August 2023 through December 2023, and January 2024 through June 2024).

Inspectors wroteBased on 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 four out of four residents sampled with facility-initiated transfers (Residents R5, R37, R94, and R108).

Inspectors wroteBased on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for two of two residents reviewed (Resident R58 and R262).

Inspectors wroteBased on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for two of three residents (Resident R9 and Resident R58).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify the physician of increased Capillary Blood Glucose (CBG) levels as ordered for one of three residents (Resident R82) and obtain physician orders for a resident's wound for one of three residents (Resident R260).

Inspectors wroteBased on a review of clinical record, and staff interview, it was determined that the facility failed to ensure a resident was offered sufficient fluid intake to maintain proper hydration and health for one of two residents (Resident R54).

Inspectors wroteBased on observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Residents R75).

Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to date opened medications in one of three medication carts (Willow Medication Cart).

Inspectors wroteBased on facility policy, observation, and staff interview it was determined that the facility failed to properly contain and dispose of garbage in one of one outside dumpsters to prevent the potential for rodent and insect infestation.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurate for one of six residents reviewed (Resident R260).

Inspectors wroteBased on observation, staff interviews, resident interviews, it was determined the facility failed to maintain patient care equipment in a safe operating condition for one of three residents (Resident R11).

Inspectors wroteBased on Centers for Disease Control and Prevention (CDC) guidance, Pennsylvania Department of Health (PADOH) guidance, facility policy and documents, review of clinical records, and resident and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to timely investigate and document surveillance, exclude ill staff from working, failed to educate staff on appropriate precautions related to GI illness, and failed to implement preventative measures to address an outbreak of gastrointestinal illness among residents for 10 of 17 residents (Residents R1, R2, R3, R4, R5, R6, R7, CR8, R9, and R14) The facility's failure created a situation in which all 100 of 100 residents were placed in Immediate Jeopardy related to a lack of proper infection control procedures.

Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed effectively manage the facility to prevent the development and transmission of communicable infections.

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to notify the physician and a family representative of a change in condition for two of three residents (Resident R14 and CR8).