State Center Specialty Care

Inspectors wroteBased on observation, staff interview, menus and policy review, the facility failed to follow the menu approved by the facility Dietician for the pureed meal. The staff failed to provide bread as listed on the menu. In addition, the staff didn't post the menu correctly after substitution changes. The facility reported a census of 36 residents.

Inspectors wroteBased on observation, record review, staff interview, and policy review the facility failed to revise a resident's Care Plan to indicate current transfer status for 1 of 12 residents reviewed (Resident #11). The facility reported a census of 36 residents.

Inspectors wroteBased on clinical record review, policy review, resident, and staff interviews, the facility failed to assess and follow-up on a rash for 1 of 1 resident reviewed for skin concerns (Resident #16). The facility reported a census of 36 residents.

Inspectors wroteBased on clinical record review, observation, staff interview and policy review the facility failed to maintain head of bed elevated to avoid complications during tube feeding for 1 of 1 resident reviewed with a gastrostomy tube (G-tube), Resident #40. The facility reported a census of 36 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interview and policy review, the facility failed to contact a resident's representative after she had voiced, she had suicidal thoughts and a plan in place for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 33 residents.

Inspectors wroteBased on observations, clinical record review, staff interview, resident interview and policy review the facility failed to ensure resident call light within in reach for 2 of 16 residents reviewed (Resident #13, #28). The facility reported the census is 35.

Inspectors wroteBased on facility document review, staff interview and policy review, the facility failed to comply with all applicable Federal Regulations regarding Medicare requirements governing billing practices by failing to serve a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) form 48 hours before the resident ended skilled services for 1 of 3 residents reviewed for liability and appeal notices (Resident #90). The facility identified a census of 35 residents.

Inspectors wroteBased on record review, resident interview, staff interview and policy, the facility failed to ensure quarterly interdisciplinary team meeting with inclusion of the resident to discuss resident changing goals and revisions to the care plan for 1 of 2 residents reviewed, (#28). The facility reported a census of 35 residents.

Inspectors wroteBased on resident interview, staff interview, record review and policy the facility failed to follow professional standards of medication administration leaving medication at bedside for 1 of 1 resident's (Resident #6). The facility reported a census of 35.

Inspectors wroteBased on observations, clinical record review, staff interview and resident interview. The facility failed to ensure resident treatment per the physician order for 1 of 3 residents reviewed (Resident #28,). The facility reported the census is 35.

Inspectors wroteBased on clinical record review, observation, staff interview and facility policy review, the facility failed to maintain proper infection control practices to prevent cross contamination and potential infection of residents when providing medications and treatments. The facility reported a census of 35 residents.

Inspectors wroteBased on observations, staff interview, resident interview and policy review the facility failed to ensure a clean, sanitary environment in a kitchen storage room and failed to ensure a clean comfortable environment for 1 of 14 resident rooms (Resident #28). The facility reported the census is 35.

Inspectors wroteBased on clinical record review, policy review, resident, and staff interviews the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 4 residents reviewed (Resident #3). The facility identified a census of 33 residents.

Inspectors wroteBased on resident and staff interviews, and facility policy review the facility failed to assure one (1) staff member remained awake and in full work status while working and failed to assure staff not use an e-cigarette ([NAME] pen) while in the facility and/or during provision of direct cares. The facility reported a census of 39 residents. Findings Include: During an interview 12/12/23 at 2:28 p.m., Resident #1 (identified by the facility as cognizant) indicated one (1) night Staff A, Certified Nursing Assistant (CNA), entered her room and slept in her recliner. The resident indicated there had been another night the same staff member used a [NAME] pen and smoked it in her room. The resident asked the staff member to not [NAME] in her room and the staff member stated, you can not smell it. [...]

Inspectors wroteBased on clinical record review, staff, resident, and police officer interviews and review of the facility's Resident Rights the facility failed to treat 1 of 3 residents with dignity and respect while requesting cares (Resident #1). The facility reported a census of 39 residents. Findings Include: A Minimum Data Set (MDS) Assessment form dated 6/11/23 identified Resident #1 with diagnosis that included a cerebrovascular accident (CVA) and prediabetes. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact), required extensive assistance of two (2) staff with bed mobility, transfers, ambulation, toilet use and frequently incontinent of urine. An Incident Report form dated 8/31/23 at 3:14 p.m. included the following documentation: a. At 9:30 p.m., staff assisted the resident to bed. At 11:30 p.m. [...]

Inspectors wroteBased on observation, resident interview, family interview, and staff interview, the facility failed to maintain a homelike environment related to urine odors in the hallways and resident rooms, stains and debris on the hallway carpet, scratches on and holes in the walls of resident rooms. The facility reported a census of 35 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to correctly document resident assessments in the Minimum Data Set (MDS) for 1 out of 16 residents reviewed (Resident #1). Resident #1's most current MDS revealed she required an assist of 1 for ADLs, when she was independent with most of her ADLs. The facility reported a census of 35 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to correctly document/revise resident needs and interventions in the Care Plan for 2 out of 16 residents reviewed (Resident #1 and Resident #20). Resident #1's Care Plan directed that she required an assist of 1 for ADLs, when she was independent with most of her ADLs. Resident #20's Care Plan directed staff that he required assist of 1 for showers, when he required set up help only. The facility reported a census of 35 residents.

Inspectors wroteBased on interviews and record review, the facility failed to provide a shower twice a week for 1 of 3 residents reviewed (Resident #20). The facility reported a census of 35 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide wound care while following infection control guidelines, for 1 of 1 resident reviewed (Resident #33). Staff C, Certified Medication Aide (CMA), failed to remove her gloves, sanitize her hands, and apply new gloves after removing a soiled dressing. Staff C failed to properly dispose of a dressing that had discharge from a wound on it. The facility reported a census of 35 residents.