Senior Care Center - St. Marys

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled, Foodborne Illnesses, and Food Ordering, Receiving, and Storage, the facility failed to ensure food for residents was stored, prepared, and served in a sanitary manner in the kitchen. Specifically, the facility failed to label and date food in the freezer, the refrigerator/walk-in cooler, and the dry storage pantry, with a received by date, open date, expiration, and/or use-by date, failed to discard food by the expiration or use-by date, and failed to ensure meat was thawed properly and in a sanitary manner. This deficient practice could have affected 62 of 65 residents receiving an oral diet.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled Abuse Prevention and Reporting, the facility failed to ensure three of 15 residents (R) (R1, R2, and R3) were protected from verbal and/or physical abuse by staff. This deficient practice had the potential to affect the quality of life for all residents reviewed.

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and review of the facility's policies titled Restorative Nursing Program and Therapy Evaluations, the facility failed to ensure that restorative nursing services were consistently provided following the completion of therapy for four of eleven residents (R ) (R12, R13, R14, and R15) reviewed for restorative nursing services. Specifically, the facility failed to provide required restorative interventions, including transfer assistance for R12; ambulation/walking programs for R13 and R14; and Range of Motion (ROM) exercises for the upper or lower body for R12, R13, and R14. This deficient practice has the potential to diminish residents' quality of life.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled Occurrences, the facility failed to provide protective oversight and supervision to prevent elopement and ensure resident safety. This deficient practice resulted in one of four sampled residents (R) (R1 and R10) exiting the facility and remaining unaccounted for by staff for over one hour, and in R10 experiencing a fall with major injury in the shower, resulting in a subarachnoid hemorrhage.

Inspectors wroteBased on resident and staff interviews, record review, review of facility documents titled, PBJ (payroll-based journal) Staffing Data Report, and review of the policy titled, State Minimum Staffing for Healthcare Centers, The facility failed to ensure adequate nursing staff to meet residents' needs in a timely manner. This failure delayed the provision of care, increased the risk of elopement and falls resulting in major injury, and could have decreased the quality of life of 61 residents residing in the facility.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Accident Reporting and Investigation Program, the facility failed to ensure hot water temperatures were in the acceptable range (110 degrees F (Fahrenheit) or less) in the bathroom sink for 13 of 38 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). The deficient practice had potential for residents to receive a scalding injury due to the water temperature.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to ensure one of 29 sampled residents (R) (R57) did not have unauthorized, unsecured medications at bedside. This deficient practice had the potential to allow unauthorized access to medications to other residents and visitors in the facility.

Inspectors wroteBased on observation, staff interview, and review of the facility policy titled, Food and Supply Storage, the facility failed to ensure all pans and dishes were allowed to be air dried before stacked and failed to ensure all food in the freezer was sealed closed. These failures had the potential to affect 63 of 65 residents who consumed an oral diet.

Inspectors wroteBased on staff interview, facility document review, and review of the facility policy titled, Quality Assurance/Performance Improvement, the facility staff failed to maintain an effective Quality Assurance/Performance Improvement (QAPI) program regarding the facility's Performance Improvement Plan (PIP) for Certified Nursing Assistants (CNAs) documentation. This had the potential to affect all residents of the facility.

Inspectors wroteBased on staff interviews, document review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy titled, Antibiotic Ordering, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional Antibiotic Stewardship Program that followed the McGeer Criteria for antibiotics. This had the potential to affect all 65 resident of the facility, specifically being prescribed antibiotics that were potentially unnecessary.

Inspectors wroteBased on observations, record review, staff interviews, and review of facility policy titled, Resident Call Lights, the facility failed to ensure one of 30 Residents (R) 22 had their call light in reach during multiple observations. This had the potential for the resident to have unmet care needs.

Inspectors wroteBased on observation, record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure that two residents (Resident (R) 47 and R14) out of 30 sampled residents had an accurate Minimum Data Set (MDS) assessment.

Inspectors wroteBased on observations, record review, staff interviews, and review of Rehab Department Procedures, the facility failed to ensure an order for a resident's palm protector was followed for one of two residents (Resident (R) 47) reviewed for range of motion (ROM). The deficient practice had the potential to inhibit optimal independence for R47 by not applying splints as ordered for contractures.

Inspectors wroteBased on record review, staff interview, and review of the facility policy titled, Pain & Assessment Control, the facility staff failed to perform a pain assessment prior to administering a narcotic as needed (PRN) pain medication and failed to assess the effectiveness after the medication was administered for one of ten Residents (R) 2. The deficient practice had the potential to prevent the accurate determination of the effectiveness of the pain medication regimen.

Inspectors wroteBased on record review, staff interview, review of the Dialysis Agreement, and review of the facility policy titled, Dialysis, the facility failed to have collaboration of care between the facility and the dialysis center for one of three (Residents (R) 45) receiving dialysis treatments. This had the potential for R45 to have unmet care needs.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a psychotropic medication was discontinued when ordered by the physician for one of five residents (Resident (R) 55) reviewed for unnecessary medications. The resident continued to receive the medication for two months after it was discontinued.

Inspectors wroteBased on observation, record review, staff interviews, review of Lippincott procedures, and review of facility policy titled, Medication Administration-General, the facility failed to ensure there was less than a five percent (%) medication error rate. Two errors were observed out of 27 opportunities for one Resident (R)6 out of the six residents observed during medication administration resulting in a mediation error rate of 7%.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to maintain infection control during incontinence care during a dressing change for one of five (Residents (R)8) observed for incontinence care.

Inspectors wroteBased on observation, interviews, record review, and review of facility policy titled Infection Prevention and Control Program Overview the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection. The facility census was 53.

Inspectors wroteBased on staff interviews, and review of facility documents, the facility failed to establish an Antibiotic Stewardship Program that included antibiotic use protocols and a monitoring system to track and trend antibiotic use. The facility census was 53 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that PRN [as needed] orders for antipsychotic drugs were limited to 14 days and failed to document the rationale for the extended duration for the PRN order for one of five residents (R) #10) reviewed for medication management.