Shelby Pointe

Inspectors wroteBased observation and staff interview the facility failed to maintain a clean and sanitary environment. This had the potential to affect all 43 residents residing in the facility. The census was 43.

Inspectors wroteBased on observation, staff interview, medical record review, review of investigations, and review of a facility policy, the facility failed to ensure fall interventions were in place as ordered and care planned, failed to ensure falls were properly investigated, and failed to ensure interventions to prevent future falls were appropriate to the nature of the incident. This affected one (#8) of two residents reviewed for falls. The facility census was 43.

Inspectors wroteBased on medical record review and staff interview, the facility failed to adequately monitor a resident's targeted behaviors as ordered. This affected one (#3) of two residents reviewed for mood and behavior. The facility census was 43.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident met established criteria for use of an antibiotic medication prior to administration. This affected one (#8) of one residents reviewed for urinary tract infections (UTIs). The facility census was 43.

Inspectors wroteBased observation and staff interview, the facility failed to maintain total visual privacy for residents. This affected two (#33 and #39) of 38 residents residing in semi-private rooms in the facility. The census was 43.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure all required postings were displayed in the facility in a manner which was accessible at all times. This affected all 44 residents residing in the facility. The facility census was 43.

Inspectors wroteBased on review of the facility assessment document and staff interview, the facility failed to ensure its facility assessment contained all required information. This had the potential to affect all 43 residents. The facility census was 43. Findings Include: Review of the current facility assessment document revealed the assessment did not contain specific staffing needs for each shift, such as day, evening, night and shifts. The assessment also did not contain information on how the facility would develop and maintain a plan to maximize recruitment and retention of direct care staff. Interview with the Administrator on 12/31/24 at 8:15 A.M. verified the assessment did not contain all required information.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident Preadmission Screening and Resident Review (PASRR) status was correctly coded on the Minimum Data Set (MDS) assessment. This affected eight (#1, #11, #16, #18, #25, #30, #36, and #41) of 43 residents reviewed for MDS assessment accuracy. The facility census was 43. Findings Include: 1. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, type two diabetes, and epilepsy. Review of the PASRR level two evaluation from the state PASRR agency dated 10/24/23 revealed Resident #1 was ruled out from further review indicting Resident #1 did not have a serious mental illness (SMI), intellectual disability (ID), developmental disability (DD), or related condition. [...]

Inspectors wroteBased on observations, staff interviews and contractor interviews, the facility failed to ensure the low temperature dishwasher was functioning properly to sanitize the dishes and utensils. This had the potential to affect all 38 residents who the facility identified as receiving meals from the facility. The facility also failed to handle, prepare, distribute, and serve food in accordance with professional standards for food service safety. This affected seven residents (#4, #5, #8, #12, #14, #21 and #26) who the facility identified as receiving mechanical soft diets. The facility census was 38.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure call lights were within reach and accessible for residents. This affected four residents (#02, #30, #14, and #15) of 38 residents reviewed for call light placement. Findings Include: 1) Record review for Resident #02 revealed the resident was admitted on [DATE] with diagnoses that included, but not limited to, major depressive disorder, chronic obstructive pulmonary disease (COPD), schizophrenia, and personality disorder. Review of the most recent Minimum Data Set (MDS) assessment 3.0 dated 07/21/23 for Resident #02, revealed the resident had severely impaired cognition and required extensive assistance of one staff member for mobility, transfer, and toilet use. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to serve food at the proper portion size to meet the resident's nutritional needs. This affected seven residents (#4, #5, #8, #12, #14, #21 and #26) who the facility identified as receiving mechanical soft diets. The facility census was 38.

Inspectors wroteBased on record review and staff interview, the facility failed to submit a new Pre-admission Screening and Resident Review (PASARR) when a resident received a new diagnosis of schizoaffective disorder. This affected one resident (#27) of three residents reviewed for PASARR. The facility census was 38.

Inspectors wroteBased on observations and staff and resident interviews, the facility failed to ensure resident's equipment was clean and in good repair. This affected three residents (#07, #08 and #30) of the 38 residents observed during the initial screening process. The census was 38. Finds Included: 1) Observation of Resident #08 on 10/10/23 at 11:08 A.M. revealed the resident's wheelchair was dirty with grime and crumbs around the wheels, foot pedals, and seat cushion. Interview with Resident #8 at the same time, revealed his wheelchair had never been cleaned and it would be nice if it was clean. 2) Observation of Resident #07 on 10/10/23 at 11:29 A.M. revealed the resident wheelchair was dirty with dried food, liquid and grime on wheelchair wheels, foot pedals and the arm rests and the left arm rest was torn. [...]

Inspectors wroteBased on review of medical records, staff interviews, and review of facility policy, the facility failed to ensure as-needed anti-anxiety medication had a rationale for continued use past 14 days for one (#18) of six residents reviewed for unnecessary medications. The facility identified 10 residents who were prescribed anti-anxiety medications. The census was 35.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure transmission-based precautions were implemented to prevent the spread of COVID-19. This affected one (#235) of two residents in the facility that were new admissions presumed COVID-19 positive. The facility identified no current positive COVID-19 residents. The census was 35.