Spring View Nursing & Rehabilitation

Inspectors wroteBased on interview, record review and review of the facility's investigations, documentation, and policy, the facility failed to ensure its licensed staffs' competencies included active Cardiopulmonary Resuscitation (CPR) certifications for 11 of 11 licensed nursing staffs' personnel files reviewed. On [DATE], staff found R71 unresponsive and without pulse or respirations. R71 had a Full Code status; however, staff failed to attempt and provide lifesaving measures. Immediate Jeopardy (IJ) was identified on [DATE]. The Administrator was provided a copy of the CMS Immediate Jeopardy Template on [DATE] at 11:32 AM and notified the facility's failure to ensure its licensed staffs' CPR certifications were current was likely to cause serious injury, impairment, or death and constituted IJ. [...]

Inspectors wroteBased on interview, record review and review of the facility's policy, the facility failed to ensure the physician was immediately notified of a significant change in a resident's status for 1 of 40 sampled residents, (Resident (R)71). R71 who was full code expired at the facility. Staff failed to initiate CPR and failed to immediately notify the physician. Immediate Jeopardy (IJ) was identified on [DATE]. The Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template on [DATE] at 11:32 AM and notified that the facility's failure to ensure immediate physician notification of a change was made was likely to cause serious injury, impairment, or death and constituted IJ. IJ was identified at 42 CFR S483.210, Notify of Changes, F580, and was determined to exist on [DATE], at a highest Scope and Severity (S/S) of J. [...]

Inspectors wroteBased on interview, record review and review of the facility's policy, the facility failed to ensure the care plan was implemented for one of thirty-three sampled residents, Resident 71 (R71). Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR S483.10 Notification of Changes at the scope and severity (S/S) of a J, 42 CFR 483.21 Comprehensive Care Plans, 42 CFR 483.24 CPR, and 42 CFR 483.35 Nursing Services, at the S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.24 On [DATE], at 11:32 AM the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure residents' comprehensive person-centered care plans were implemented was likely to cause serious injury, impairment, or death and constituted IJ at 42 CFR 483.210 at F580. [...]

Inspectors wroteBased on interview, record review and review of the facility's policy, the facility failed to ensure Cardiopulmonary Resuscitation (CPR) was initiated for 1 of 33 sampled residents, (Resident (R)71). Staff found R71 on [DATE] without pulse or respirations and unresponsive by staff. Resident was a Full Code status; however, no lifesaving measures were attempted. On [DATE], at 11:32 AM the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and was notified the failure to ensure residents were provided CPR was likely to cause serious injury, impairment, or death. This failure constituted IJ at 42 CFR 483.24 F678, 42 CFR 483.10 F580, 42 CFR 483.21 F656, and 42 CFR 483.35 F726. The IJ at F678 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.24, Quality of Care. [...]

Inspectors wroteAMENDED Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure residents received an accurate Minimum Data Set (MDS) assessment that was reflective of the resident's status at the time of the assessment for three of thirty-three sampled residents (Residents 30, 58, and 59).

Inspectors wroteBased on interviews, record reviews, and review of facility policy, it was determined that the facility failed to formulate an advance directive at the discretion of the resident for four of thirty-three sampled residents (R) (R6, 22, 51, and 55).

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to ensure the services provided or arranged by the facility met professional standards of quality for one of thirty-three sampled residents (R71). Record review and interviews revealed R71's provisional death certificate was signed by the Staff Development Coordinator (SDC) prior to R71's death.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure performance review evaluations were completed for every Certified Nursing Assistant (CNA) at least once every 12 months for 4 of 6 CNAs' personnel records reviewed, (CNA2, CNA6, CNA17, and CNA20).

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This deficient practice had the potential to affect all residents requiring Cardiopulmonary Resuscitation (CPR).

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five sampled residents reviewed for infection control (Resident (R)73).

Inspectors wroteBased on interviews, record reviews, document review, and facility policy review, it was determined the facility failed to report allegations of abuse to the State Survey Agency (SSA) within two hours for two (2) of three (3) sampled residents (Resident #1 and Resident #22)

Inspectors wroteBased on interviews, record reviews, and facility policy review, it was determined the facility failed to thoroughly investigate an allegation of resident-to-resident abuse for one (1) of three (3) sampled residents (Resident #1). Specifically, the facility failed to obtain and document witness statements from the involved residents and any resident/staff member who may have had knowledge of the alleged incident, when Resident #1 alleged that Resident #26 hit Resident #1's arm.

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to provide a safe smoking area for one (1) of one (1) sampled residents (Resident #22).

Inspectors wroteBased on observations, interviews, and policy review, it was determined the facility failed to develop and implement policies in accordance with applicable regulations for smoking areas and smoking safety for one (1) of one (1) resident smoking areas.