Strasburg Nursing Home

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 1 of 14 residents (Resident #21) reviewed for self-administration of medication (SAM). Failure to assist/observe residents who are not SAM take their medications may result in adverse health consequences.

Inspectors wroteBased on observation, record review, review of professional reference, and staff interview, the facility failed to ensure medication labels and provider's orders matched for 1 of 8 residents (Resident #21) observed during medication pass. Failure to ensure medication labels matched the provider's order placed residents at risk for medication errors.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 2 sampled residents (Resident #2 and #24) observed during dressing changes. Failure to practice infection control standards related to use of personal protective equipment (PPE) for a resident in enhanced barrier precautions (EBP), hand hygiene, and providing a clean surface area for dressing supplies has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, review of facility policy, and resident and family interviews, the facility failed to ensure an alleged violation of misappropriation of resident property was reported within 24 hours to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #20) with a report of missing money. Failure to report the alleged violation to the SSA placed Resident #20 and other residents at risk for misappropriation of property.

Inspectors wroteBased on record review, policy review, and staff, resident and family interviews, the facility failed to initiate an investigation of an alleged violation of misappropriation of resident property for 1 of 1 sampled resident (Resident #20) with reports of missing money. Failure to investigate the alleged misappropriation of the resident's property and ensure all residents are protected placed them at risk for emotional and mental distress.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for 2 of 3 residents (Resident #9 and #12) observed for insulin preparation and administration. Failure to prime insulin pens correctly may result in residents receiving an inaccurate dose.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received the necessary service to maintain personal hygiene for 1 of 8 sampled residents (Resident #18) who required staff assistance for personal hygiene. Failure to assist residents who cannot perform personal hygiene independently may result in poor hygiene, skin issues, and decreased self-esteem.

Inspectors wroteBased on observation, record review, and resident and staff interview, the facility failed to ensure appropriate care and services for 1 of 2 sampled residents (Resident #16) with an indwelling urinary catheter. Failure to empty Resident #16's catheter bag may result in urinary tract infections (UTIs), unnecessary discomfort, and urinary retention and/or obstruction.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 2 sampled residents (Resident #9) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP) and hand hygiene has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide care for 1 of 2 sampled residents (Resident #12) with an indwelling catheter in a manner and environment that maintained, enhanced, and respected the resident's dignity. Failure to cover the resident's catheter drainage bag does not preserve the resident's personal dignity or enhance their quality of life.

Inspectors wroteBased on record review review of facility policy, and staff interview, the facility failed to provide the resident's representative and/or the State Long Term Care (LTC) Ombudsman a written notice of transfer for 1 of 4 sampled residents (Resident #14) with a recent hospital transfer. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights or inform the Ombudsman of the transfer.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide a bed hold notice upon transfer to the hospital for 1 of 4 sampled residents (Resident #14). Failure to provide a bed hold notice does not allow residents or their legal representatives to make informed choices regarding their readmission rights.

Inspectors wroteBased on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 1 sampled resident (Resident #7). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on observation, record review, and review of facility policy, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 1 of 1 sampled resident (Resident #26) observed during a transfer. Failure to provide a gait belt during transfers placed the resident at risk for accidents, falls, or injuries.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of medications during 1 of 2 observations of insulin administration. Failure to store insulin pens securely may result in unauthorized access to the medication.