Stevens County Hospital Ltcu Dba Pioneer Manor

Inspectors wroteThe facility identified a census of 73 residents. The sample included five residents and two staff reviewed for background checks. Based on interview and record review, the facility failed to develop and implement a process that prohibited and prevented the facility from employing or engaging staff with criminal backgrounds when the facility failed to conduct a background check as required for two employees.

Inspectors wroteThe facility had a census of 73 residents, with 18 sampled, and four reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene for Resident (R)20, which placed R20 at risk for poor personal hygiene and related complications. The facility also failed to assist R72 to the dining area for meals or provide assistance with meals in her room, to help prevent the 10.75% weight loss over four months.

Inspectors wroteThe facility identified a census of 73 residents, with 18 residents sampled, and four residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record review, the facility failed to prevent the development of pressure ulcers and failed to provide treatment to promote healing for two residents, Resident (R) 24 and R14, who both developed pressure ulcers while a resident at the facility.

Inspectors wroteThe facility identified a census of 73 residents with 18 sampled. Based on observation, interview, and record review, the facility failed to initiate weight loss interventions for cognitively impaired Resident (R) 72, who had an identified weight loss of 10.75% in four months. This deficient practice had the potential to negatively affect the resident's physical well-being.

Inspectors wroteThe facility reported a census of 73 residents. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program (IPCP) to provide a safe and sanitary environment for all residents through the following: The facility failed to ensure an effective infection control surveillance program regarding the tracking of infections of Resident (R)12 and R48. The facility failed to ensure staff performed hand hygiene prior to and during care for R20, R27, and R14. The facility failed to ensure the implementation of enhanced barrier precautions (EBP - a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs] in nursing homes) when providing wound care for Resident (R) 24, R14, R27, and R20. These deficient practices had the potential to affect all residents in the facility.

Inspectors wroteThe facility reported a census of 73 residents. Based on interview and record review the facility failed to implement an effective antibiotic stewardship program that included antibiotic use protocols, an effective system to monitor antibiotic use, and/or an effective system to track and trend infections in the building for the facility's Infection Prevention and Control Program (IPCP). This failure had the potential to affect all 73 residents.

Inspectors wroteThe facility reported a census of 73 residents. Based on interview and record review the facility failed to ensure the Infection Preventionist (IP) assessed, implemented, and monitored the facility Infection Prevention and Control Program (IPCP). This failure has the potential to affect all 73 residents.

Inspectors wroteThe facility reported a census of 73 residents. Five Certified Nurse Aide (CNA) staff, who worked in the facility over a year, were reviewed for required annual in-service training. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for Certified Nurse Aide (CNAs) with the required topics and no less than 12 hours per year. Two CNA staff lacked the required training topics, and one CNA lacked the required 12 hours per year of in-service training.

Inspectors wroteThe facility reported a census of 73 residents with 18 residents sampled. Based on observation, interview, and record review, the facility failed to verify valid advanced directives (a legal document in which a person specified what actions should be taken for their health, which may or may not include a do not resuscitate [DNR - a decision whether or not to withhold medical intervention in the even the resident's heart stops] order) for three residents, Resident (R) 20, R60, and R72. These deficient practices had the potential to lead to uncommunicated needs specifically to end-of-life care.

Inspectors wroteThe facility reported a census of 73 residents with 18 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately revise four residents care plans after psychotropic (alters mood or thought) medication changes for Resident (R) 62, R65, and R20. The facility did not revise the care plan for R20 and R24 to reflect pressure ulcer/injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) interventions. This failure placed the residents at risk for uncommunicated care needs.

Inspectors wroteThe facility reported a census of 73 residents with 18 in the sample revied six for respiratory care. Based on observation, interview, and record review, the facility failed to provide respiratory care and services including the safe handling, storage, and dispensing of oxygen consistent with professional standards of practice for five residents, Residents (R)11, R27, R16, R60, and R42 to prevent the spread of illnesses.

Inspectors wroteThe facility had a census of 73 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to ensure two of the four households observed and reviewed during the medication administration pass remained free of medication errors. Forty-two medication opportunities were observed with fifteen medication errors identified This placed the residents at risk for adverse reactions from the medications and resulted in a medication error rate of 35.71%. Findings Included: R65's Physician Orders included for staff to flush the resident's Percutaneous Endoscopic Gastrostomy tube (PEG-tube surgically placed through an artificial opening into the stomach) with 150 milliliters (ml) of water before and after administration of medications, date ordered 11/14/24. [...]

Inspectors wroteThe facility reported a census of 73 residents with 18 residents sampled. Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in locked compartments and permitted only authorized personnel to have access to the keys. This deficiency had the potential to affect three of the four households with expired medications for multi person use and unsecured medications in the room of Resident (R)5, R48, R16, and R57.

Inspectors wroteThe facility reported a census of 73 residents with 18 residents sampled. Based on interview and record review the facility failed to provide the pneumococcal vaccine (vaccine designed to prevent pneumonia (inflammation of the lungs which can be debilitating or lethal in the elderly)) or the consent/declination form to Resident (R) 65 and R27. The facility further failed to provide the influenza (highly contagious viral infection) vaccine or the consent/declination form to R65, R27, and R240 and failed to complete and document an assessment prior to giving the influenza vaccine to R48.

Inspectors wroteThe facility identified a census of 73 residents. The sample included 18 residents with one resident reviewed for discharge. Based on record review and interviews, the facility failed to ensure active discharge planning occurred for Resident (R) 75. This deficient practice had the risk for miscommunication of discharge goals and missed services for R75.

Inspectors wroteThe facility census totaled 73 residents with 18 residents included in the sample with 11 residents reviewed for accident hazards failed to identify and remove accident hazards for three dependent residents, Resident (R) 65 related to staff not using fall mats as directed, R20 with incorrect use of a mechanical lift, and R60 left unattended with a disposable razor in reach and his emergency call light out of reach. These deficient practices had the potential to lead to accidents that would negatively affect the resident's physical and psychosocial well-being.

Inspectors wroteThe facility reported a census of 73 residents, with 18 residents in the sample, and one resident reviewed for treatment/services for mental and psychosocial concerns. Based on observation, interview, and record review the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident (R) 5, who had been sad and tearful since admission on [DATE].

Inspectors wroteThe facility reported a census of 73 residents with 18 residents selected for review. Based on observation, interview, and record review, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) (a rating scale to measure involuntary movements known as tardive dyskinesia [TD is abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs and trunk]) assessment for two of the five residents reviewed for unnecessary medications, Resident (R) 62 and R20, who received Seroquel (antipsychotic- class of medications used to treat major mental conditions which cause a break from reality). The facility failed to provide a rationale regarding why the Pharmacy recommendation for a gradual dose reduction (GDR, to gradually reduce the dose of certain medications) for R20's Seroquel was not completed.

Inspectors wroteThe facility reported a census of 67 residents residing in four houses with 17 residents selected for review that included one resident sampled for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) care. Based on observation, interview, and record review, the facility failed to provide sanitary placement of Resident (R)34's urinary catheter collection bag, failed to provide proper infection control techniques related to the urinary catheter care/perineal care, and failed to specify the size of the catheter tubing and catheter balloon to secure the catheter in the bladder. Furthermore, the facility failed to provide an anchor device to prevent possible trauma. This had the potential to cause urinary tract infections (UTI) and injury from accidental removal of the catheter.

Inspectors wroteThe facility census totaled 69 residents with 17 included in the sample and two medication rooms reviewed for outdated medications. Based on observation and interview the facility failed to remove 11 expired stock medications and one Lidocaine 2% jelly (used to temporarily numb pain skin or mouth) for Resident (R)31.

Inspectors wroteThe facility census totaled 69 residents with five residents reviewed for unnecessary medications. Based on interview, observation, and record review the facility failed to ensure the consultant pharmacist identified, report, and follow-up with the facility that Resident (R) 65 received an as needed (PRN) psychotropic drug longer than 14 days without a renewed physician order or reason provided by the physician stating why R65 should continue receiving Lorazepam (antianxiety medication) on a PRN basis.

Inspectors wroteThe facility census totaled 69 residents with five residents reviewed for unnecessary medications. Based on interview, observation, and record review the facility failed to ensure one of five residents did not receive unnecessary medications when the facility allowed Resident (R) 65 to continue receiving an as needed (PRN) psychotropic drug longer than 14 days without a renewed physician order or reason provided by the physician stating why R65 should continue receiving Lorazepam (antianxiety medication) on a PRN basis.