St. Patrick's Residence

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident did not fall out of bed after being turned during incontinence care. This failure resulted in the resident slipping off the bed and experiencing bilateral distal femur fractures requiring bilateral femoral retrograde rodding. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3. Findings Include:Review of R1's care plan shows R1's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting her left side, osteoarthritis, and dementia with impaired thought processes. R1 was at increased risk for falls related to her weakness, hemiplegia, poor balance/coordination, and medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough and impartial investigation of resident abuse by a staff member. The facility also failed to maintain documentation from the witnesses of the abuse. R1 experienced pain and was crying following the incident. The alleged perpetrator was allowed to return to work another two shifts with R1. A reasonable person would experience fear and anxiety having the alleged perpetrator provide care for a dependent resident with a history suffering from abuse. This applies to 1 of 3 residents (R1) reviewed for abuse in a sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident from physical and mental abuse from staff. These failures caused R1 to sob and experience pain following the episode of witnessed abuse. This applies to 1 (R1) of 3 residents reviewed for abuse in a sample of 3. A reasonable person would experience fear and anxiety of the alleged perpetrator to provide care for a dependent resident with a history of suffering from abuse and has experienced significant trauma during their lifetime as stated in the care plan.

Inspectors wroteBased on interview and record review, the facility failed to notify the local law enforcement agency regarding allegations of resident abuse per the facility policy. This applies to 2 (R1 and R2) of 3 residents reviewed for abuse allegations in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance to residents who were identified as needing assistance with feeding, positioning, and incontinence care. This applies to 4 of 6 (R45, R100, R107, R121) residents reviewed for activities of daily living in the sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure their staff performed hand hygiene and gloving when providing perineal care and failed to ensure that the proper PPE (Personal Protective Equipment) was donned prior to providing urinary catheter care and perineal care for residents identified on (EBP) Enhanced Barrier Precaution. This applies to 4 of 7 residents (R4, R89, R144, R169) reviewed for infection control in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a doctor's order for monitoring daily weight for a resident with history of congestive heart failure. This applies to 1 of 2 residents (R160) reviewed for daily weights in the sample of 33.

Inspectors wroteBased on interview and record review the facility's Arbitration Agreement failed to have the required language in the Arbitration Agreement Contract. This applies to all 170 residents residing in the facility.

Inspectors wroteBased on interviews and record review the facility's Arbitration Agreement failed to have a process for selecting a neutral arbitrator. The facility also failed to provide a selection of venues that is suitable for residents or their representatives. This applies to all 170 residents residing the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow their Water Management Plan for Legionella. The facility also failed to perform hand hygiene during provisions of care. This applies to all 170 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, identify, and document a resident's skin lesion. The facility also failed to follow physician orders to consult a dermatologist for skin lesions. This applies to 1 of 4 residents (R18), reviewed for skin conditions in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to notify the physician of a resident's significant weight loss and to consult the dietitian to evaluate a resident with significant weight loss. This applies to 1 of 5 residents (R98) reviewed for nutrition in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for laboratory tests for a resident receiving intravenous hydration. This applies to 1 of 1 resident (R149) reviewed for laboratory services in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label, date, and store food items and maintain a clean kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents dependent upon staff for ADLs (Activities of Daily Living) received nail grooming for 4 of 38 residents (R18, R101, R139, & R146) reviewed for ADLs in a sample of 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control while entering isolation, while feeding residents, and during incontinent care. This applies to 10 of 10 residents (R1, R9, R59, R60, R76, R77, R89, R98, R104 and R109) reviewed for infection control in a sample of 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dignified dining experience to residents and failed to provide privacy during incontinence care. This applies to 3 of 3 residents (R9, R60, R77) reviewed for dignity in a sample of 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an appropriate size wheelchair for a resident. This applies to 1 of 1 resident (R70) reviewed for wheelchairs in a sample of 38.

Inspectors wrote3. R107's face-sheet showed, R107 was admitted to the facility on [DATE] and her diagnoses included inflammation of the gallbladder and laparoscopic cholecystectomy. R107's MDS (Minimum Data Set) dated 4/14/23 showed, R107 is cognitively intact (BIMS-Brief Interview of Mental Status-score of 15) and required extensive assist for ADLs (activities of daily living). R107's progress notes dated 4/17/23 at 7:51 PM showed R107 was sent to the hospital for investigation and confirmation of fracture of the right hip. Records lacked documentation to show that the notice of transfer or discharge was given in writing to the resident or her representative upon transfer or discharge or as soon as practicable. Records lacked documentation to show, the facility sent a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman within 30 days. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide in writing to residents and their families/POA (Power of Attorney) regarding bed hold and return at the time of discharge to the hospital. This applies to 3 of 3 residents (R41, R107, R208) reviewed for discharge in a sample of 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide interventions and supervision to 2 of 2 residents (R9, R29) who were at risk for falls in a sample of 38.