St. Clara's Rehab & Senior Care

Inspectors wroteBased on interview and record review, the facility failed to follow its procedure for transportation and failed to adequately supervise and safely secure resident during transport to prevent a fall for one (R1) resident of three residents reviewed for accidents/incidents in a sample of three. These failures resulted in R1 sustaining a subdural hematoma and left scapula fracture.

Inspectors wroteFacility failures resulted in two deficient practices. A. Based on record review and interview the facility failed to provide skin treatments as ordered by the physician for two of three residents (R1 and R2) reviewed for skin alterations in the sample of three. B. Based on record review and interview the facility failed to obtain blood sugars as ordered by the physician for one of three residents (R2) reviewed for blood sugar monitoring in the sample of three.

Inspectors wroteBased on record review and interview the facility failed to administer insulin as ordered for one of three residents (R1) reviewed for medication errors in the sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement specific pressure relieving interventions to prevent pressure ulcer development and worsening, conduct a pressure ulcer risk assessment once a week for four weeks after admission as directed by the facility's Wound and Ulcer Policy for one of four residents (R9) reviewed for facility acquired pressure ulcers in the sample of 33. These failures resulted in R9 developing a painful pressure ulcer to the right heel that deteriorated from a blister to a stage four pressure ulcer to R9's right heel, that required surgical debridement.

Inspectors wroteBased on observation, interview and record review, the facility failed to use temperature testing strips that reflect the required dish surface temperature and check the surface temperature daily, to ensure dishes reach the required temperature during the rinse cycle of a high temperature sanitation dish machine, and complete and record cool down temperatures for meals containing meat that were prepared ahead and stored in the facility's freezer for future use. These failures have the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide an appropriate indication for use of antipsychotic medications for four of five residents (R2, R5, R54, R82) with a diagnosis of dementia and failed to do a gradual dose reduction for one of five residents (R54) reviewed for antipsychotics in a sample of 33.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to complete hand hygiene and glove changes prior to administering invasive medications and failed to ensure the facility implemented and followed Enhanced Barrier Precautions for four of 27 residents (R59, R63, R77, R347) reviewed for Infection Control in the sample of 33.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to complete hand hygiene and glove changes prior to providing urinary catheter care for one of two residents (R51) reviewed for indwelling urinary catheters in the sample of 33. Findings Include: The Catheter Care/Incontinent Care policy dated 8/1/05 documents Objective: To cleanse the urinary meatus and adjacent catheter. Procedure: 1. Obtain wash basin, washcloth, soap, water, and vinyl gloves. 4. Wash hands thoroughly. 6. Expose genitalia. 7. Put on vinyl gloves. The Infection Prevention and Control Standard and Transmission-Based Precautions for Communicable Diseases documents Standard Precautions: Gloves- gloves (clean, not sterile) should be worn whenever there is direct contact with blood, body fluids, mucous membranes, non-intact skin and other potentially infected material. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure physician ordered daily weights were obtained and the physician notified of a significant weight increase for one of one resident (R347) reviewed for daily weights in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to place an oxygen sign on the door (R346) and failed to obtain a physician's order for oxygen use (R84) for two of two residents (R84 and R346) reviewed for oxygen in the sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to notify in writing, and maintain a copy in the medical record notification to the Ombudsman of residents that were reviewed for notices before transfers. This failure has the potential to affect all 94 Residents residing in the Facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure pressure ulcer wound treatment was completed in a manner to prevent potential cross contamination of the wound for one resident (R55) of five residents reviewed for pressure wounds, in a total sample of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify target behaviors to warrant the use of an antipsychotic medication, failed to ensure a resident received the lowest effective dose of psychotropic medication (R17), and failed to ensure PRN (as needed) psychotropic medication had a 14 day stop date (R295) for two of six residents (R17 and R295) reviewed for unnecessary medications in the sample of 39.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for three of twenty residents (R10, R47, R68) reviewed for care plans in the sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provided ROM (Range of Motion) programming for a resident with limited ROM for one of one resident (R10) reviewed for limited ROM in the sample of 36.

Inspectors wroteBased on record review and interview the facility failed to develop a comprehensive plan of care to address Dementia needs and treatments for three of three residents (R5, R56,R63) reviewed for Dementia Care in the sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document appropriate diagnoses/condition to warrant the use of an antipsychotic medication, have documented behaviors to justify the use of an antipsychotic medication, implement an individualized care plan for the use of antipsychotics, perform a gradual dose reduction of an antipsychotic medication for two of three residents (R63 and R56) reviewed for antipsychotic medications in the sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to post nurse staffing hours. This failure had the potential to affect all 91 residents within the facility.

Inspectors wroteBased on interview and record review, the facility failed to state in the arbitration agreement that the agreement can be rescinded within 30 days of signing it and that it is not required to sign an agreement for binding arbitration as a condition of admission to, or to continue to receive care at, the facility. They also failed to explain the arbitration agreement in a manner that the resident and their representative understands and acknowledge if the resident and their representative understood the agreement. This had the potential to affect all 91 residents residing in the facility.