South Campus Care Center and Rehab

Inspectors wroteBased on interview and record review the facility failed to inform the resident representative of discharge for one (Resident #2) of 3 residents reviewed for discharge.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a homelike physical environment when access to the pull cords for the lighting fixtures behind the resident's beds were unavailable for residents for one of three hallways.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident # 0) of 8 residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living, receive the necessary services to maintain good grooming and clean clothing for 1 of 7 residents (Resident #33) reviewed for activities of daily living.

Inspectors wroteBased on observation, interview and record review, the facility failed to adhere to professional standards of practice for the care and maintenance of a venous access catheter port for 1 (Resident #50) of 2 residents reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain complete and accurate medical records for 1 (Resident #117) of 3 residents reviewed for advance directives and respiratory services.

Inspectors wroteBased on observations and interviews, the facility failed to provide a clean homelike environment for 2 of 9 residents, Residents #1 and #7, reviewed for environment.

Inspectors wroteBased on record reviews and interviews the facility failed to document blood glucose levels and administration of insulin for one of 3 residents, Resident #1, reviewed for medication administration, and 1 of 3 residents, Resident #1, reviewed for wound care.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure food was stored, covered, labeled, or discarded in the kitchen walk-in coolers and dry storage areas and maintained standards of practice for cleaning and sanitary conditions in the dietary department.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflect the resident's status for 1 (Resident #109) of 3 residents reviewed for range of motion and 1 (Resident #20) of 2 residents reviewed for gastrostomies.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who needed assistance to perform activities of daily living (ADLs) received assistance for 1 of 3 residents reviewed for ADL care, Resident #367.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received medication per physician orders for 1 (Resident #37) of 7 residents reviewed for medication administration.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received oxygen according to physician order for 1 of 3 residents sampled for respiratory care, Resident #366.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for unattended medications in 1 unit of 3 units. Findings Include: During an observation on 7/21/2024 at 9:25 AM in Resident #109's room, there was one unopened packet of zinc oxide formula barrier cream on top of the room drawer. [photographic evidence obtained] Review of Resident #109's physician's orders on 7/21/2024 did not document orders for medication self-administration. During an observation on 7/21/2024 at 9:37 AM of Resident #38's room, there was one unopened packet of zinc oxide formula barrier cream on top of resident's bedside table. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene while providing dining services and failed to ensure staff used appropriate personal protective equipment while providing high contact direct care to residents on enhanced barrier precautions to prevent the possible spread of infection and communicable diseases.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse staffing information was posted on a daily basis.

Inspectors wroteBased on record review and interview, the facility failed to maintain accurate and complete medical records for 2 of 3 residents reviewed for documentation, Residents #1 and #10.

Inspectors wroteBased on record review and interview, the facility failed to utilize the Quality Assessment and Process Improvement (QAPI) process to monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained for the concerns identified with documentation of wound care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 3 of 6 residents reviewed for oxygen administration, Residents #84, #227, and #321, in a total sample of 52 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accommodate resident needs were accommodated by failing to have functioning call light system for 1 of 3 residents reviewed for falls, Resident #102.

Inspectors wroteBased on record review and interview, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed in a timely manner for 7 of 12 residents reviewed for resident assessments, Residents #22, #37, #68, #79, #88, #110, and #112, in a total sample of 52 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care for 2 of 3 residents reviewed for comprehensive care plans, Residents #19 and #116, in a total sample of 52 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in a timely manner for 3 of 7 residents observed for medication administration, Residents #79, # 371, and #30, and failed to ensure physician ordered bed rail adaptations were in place 1 of 6 residents reviewed for safety, Resident #83.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents received the necessary services for personal hygiene for 2 of 2 residents sampled for activities of daily living, Residents #25 and #87, in a total of 52 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents with central venous access devices, Resident #106.

Inspectors wroteBased on interview and record review, the facility failed to provide laboratory services to meet the needs of 1 of 6 residents reviewed for Medication Regimen, Resident #29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents with central venous access devices, Resident #106, in a total sample of 52 residents.