St. Clare Living Community of Mora

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the code alert system (a wander management system to protect residents from elopement) was functioning properly, failed to follow manufacture recommendation for weekly testing, and failed to follow manufacture recommendations for inspection. This resulted in an immediate Jeopardy situation for two residents (R19, R12) who were at risk for elopement and were able to get through the main doors, due to failure of the doors to lock as required per the code alert system. In addition, the facility failed to adequately assess and develop care plans for residents identified at risk for elopement and wandering for 14 of 14 residents (R19, R12, R3, R4, R13, R17, R18, R22, R25, R28, R32, R34, R37, R46) who were assigned code alert devices and had the potential for elopement. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure accurate MDS coding of the use of a code alert device occurred for 14 of 14 residents (R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, R46) who were identified as at risk for elopement and wandering.

Inspectors wroteBased on interview and document review the facility failed to develop a comprehensive care plan with individualized elopement and wandering interventions with review and revision after subsequent MDS assessments or elopement status changes for 14 of 14 residents (R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, R46) who were identified as at risk for elopement and wandering. In addition, the facility failed to care plan necessary interventions for 3 of 3 residents (R7, R14, and R26) who were addressed for care planning.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure proper hand hygiene and use of an ice scoop was followed during the snack pass. This deficient practice affected 3 of 3 residents (R29, R30, R7) and any other residents who received snacks during the snack pass.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure resident preferences for nail care were honored for 1 of 1 resident (R8).

Inspectors wroteBased on observation, interview, and document review, the facility failed to monitor orthostatic blood pressures with the use of an antipsychotic medication for 4 of 5 residents (R1, R19, R7, and R13); failed to obtain signed consent with use of an antidepressant medication for 1 of 5 residents (R38); failed to implement other interventions before initiating antipsychotic medication for 1 of 5 (R38); failed to implement appropriate target behaviors for 1 of 1 resident (R1); and failed to have an appropriate diagnosis for 1 of 1 resident (R19) reviewed for unnecessary medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure correct use of personal protective equipment (PPE) to prevent the spread of COVID. This had the potential to affect all 4 residents, visitors and staff in short term stay unit. In addition, the facility failed to develop and implement a comprehensive infection control program that incorporated virasurveillance ofl infections and illnesses not treated with antibiotics to reduce the risk of spreading infections to other residents in the facility. This has the potential to affect all 44 residents who resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 2 of 2 residents (R3, R10) reviewed and observed for self-administration of medications.

Inspectors wroteBased on interview and document review, the facility failed to provide smoking opportunities to promote quality of life and resident choice for 1 of 1 resident (R13) reviewed for choices. Findings Include: R13's Continuity of Care document (CCD) printed 2/11/25, included diagnosis of tobacco use, weakness and dementia without behavioral disturbance. R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had intact cognition. R13's diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy, hypertension, non-Alzheimer's dementia, chronic obstructive pulmonary disease, dysphagia, unspecified mood disorder and peripheral vascular disease. R13's electronic health record (EHR) lacked evidence R13 was asked about or assessed for smoking. Progress note dated 6/17/24, indicated R13 expressed concerns and anger towards someone confiscating her cigarettes. [...]

Inspectors wroteBased on interview and document review the facility failed to complete neurological assessments following falls for 2 of 2 residents (R7 and R25) who had unwitnessed falls. Facility also failed to ensure medications were administered per physician's orders for 1 of 2 residents (R30) reviewed for bowel management and failed to ensure vitals were obtained per physician's order for 1 of 1 resident (R30) reviewed for following physician orders.

Inspectors wroteBased on interview and document review, the facility failed to ensure proper treatment was provided to maintain hearing for 1 of 1 resident (R10) reviewed for hearing.

Inspectors wroteR25 R25's quarterly Minimum Data Set (MDS) dated [DATE], identified R25 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R25's diagnoses included progressive neurological conditions, Parkinson's disease with dyskinesia (involuntary, erratic movements of the face, arms, legs or trunk), non-Alzheimer's dementia, anxiety disorder, adult failure to thrive and severe protein-calorie malnutrition. MDS indicated R25 was at risk for the development of pressure ulcers and currently had one stage four pressure ulcer (stage 4 ulcers are deep wounds that may impact muscle, tendons, ligaments, and bone). [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess to assure safety with smoking for 1 of 1 resident (R13) who was smoking outside the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure the development of parameters for administration of heart rate control medication was assessed and implemented with pulse monitoring to ensure the parameters were met, if needed, to decrease the risk for complications for 2 of 5 residents (R13 and R40) reviewed for unnecessary medication use.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 5 residents (R30) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s).

Inspectors wroteBased on interview and document review, the facility failed to manage bowel and constipation needs for 1 of 3 residents (R2) who were reviewed.

Inspectors wroteBased on interview and document review, the facility failed assess and implement new intervention(s) to prevent future falls for 1 of 3 residents (R2) reviewed for accidents.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure 2 of 3 medication carts and 1 of 2 treatment carts were kept locked or under direct observation of authorized staff in areas where residents, staff and guests could access medications. This deficient practice had the potential to affect 46 of 46 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure confidential information was not readily available for all residents, staff, and visitors to view for 20 of 20 residents whose confidential information was observed to be visible on an open computer screen in a common area.

Inspectors wroteBased on interview and document review, the facility failed to provide written notice of a bed hold after transportation to the hospital for 1 of 1 residents (R43) reviewed for hospitalization.

Inspectors wroteBased on observation, record review and interview, the facility failed to reassess need for rehabilitation services for 1 of 1 residents (R44) reviewed for rehab.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide audiology services to 1 of 1 (R29) resident reviewed for hearing.

Inspectors wroteBased on interview and document review, the facility failed to identify indications (reason) for medications for 3 of 5 residents (R17, R43, and R31) reviewed for unnecessary medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure an as needed (PRN) psychotropic (mood altering) medication order was renewed beyond 14 days without an end date. In addition, the facility failed to obtain consent for Ativan (anti-anxiety) for 1 of 5 residents (R31) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and record review the facility failed to provide diet as ordered for 1 of 1 residents (R34) reviewed for therapeutic diet.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the required nursing information was posted and updated daily. This had to potential to affect all 45 residents living in the facility, visitors, and family members who may want to review the information.

Inspectors wroteBased on observation, interview and document review the facility failed to follow fall interventions for 1 of 3 residents (R1) reviewed for falls.