Sunterra Springs Independence

Inspectors wroteBased on interview and record review, the facility failed to provide trauma informed care (understanding a resident's life experiences to provide effective care) for one sampled resident (Resident #178) who had a diagnosis of Post Traumatic Stress Disorder (PTSD-a mental health condition caused by an extremely stressful or terrifying event) out of 12 sampled residents. The facility census was 38 residents. Review of the facility's Trauma Informed Care Policy, revised July 2024, showed: -It was the policy of the facility to provide care and services which, in addition to meeting professional standards, were delivered using approaches which were culturally competent, accounted for experiences and preferences, and addressed the needs of trauma survivors by minimizing triggers and/or re-traumatization. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient staff present to provide resident cares and to answer call lights in a timely manner for two sampled residents (Resident's #181 and #1)out of 12 sampled residents. The facility census was 38 residents. Review of the facility's Call Lights: Accessibility And Timely Response Policy, revised July 2024, showed: -Call lights would directly relay to a staff member or centralized location to ensure appropriate response. -All staff members who saw or heard an activated call light were responsible for responding. -The process to respond to call lights was to first turn off the signal light in the resident's room. **Note: the policy did not specify the expected time staff were expected to respond to call lights. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP-a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms) were used upon providing resident cares for three sampled residents (Resident #228, #3, and #229) out of 12 sampled residents. The facility census was 38 residents. Review of the facility's undated Transmission Based Precautions (Isolation Precautions) policy and procedure showed the facility will use standard approaches, as defined by the Centers of Disease Control (CDC) for transmission based airborne, contact and droplet precautions. The category of transmission based precautions will determine the type of personal protective equipment (PPE-gowns, gloves, face masks/shields) to be used. [...]

Inspectors wroteBased on interview and record review, the facility failed to document a comprehensive wound assessment and obtain physician's order for a pressure ulcer (a 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) upon admission for one sampled resident (Resident #10) out of seven sampled residents. The facility census was 36 residents. Review of the facility's Wound Management Policy dated revised 7/2024 showed: -To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. --Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a controlled drug (medications that fall under the US Drug Enforcement Agency (DEA) of Schedules II through V, having a potential for abuse ranging from low to high and the potential to lead to physical or psychological dependence) card of 30 pills was accounted for and locked up and immediately reported as missing after documenting delivery of the medication from the pharmacy for one sampled resident (Resident #1) out of three sampled residents who received controlled medications. The facility census was 37 residents. On 12/26/23 the Administrator was notified of the past noncompliance which took place between 11/29/23 and ended on 12/2/23 when the facility discovered the resident's card of 30 oxycodone tablets, delivered by pharmacy on 11/29/23 were missing. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure five sampled residents (Resident #231, #232, #283, #284, and #3) were offered the right to formulate and/or obtain existing (advanced directives (legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) out of 12 sampled residents. The facility census was 31 residents. Review of the facility policy Advanced Directives revised 4/2013 showed: -Upon admission the Social Services Director (SSD) or designee would provide written information regarding medical care and the right to formulate advanced directives. -Prior to or upon admission, the SSD or designee would inquire about existing advance directives. 1. Review of Resident #231's admission record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation services. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a background screening through the Certified Nurse Assistant (CNA) Registry was completed prior to hire to determine if there was a Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) for four out of ten new employees whose files were sampled. This had the potential to affect any facility resident who received services from or whose medical records or belongings could have been accessed by one or more of the four employees. The facility census was 31 residents. Review of the facility's Abuse and Neglect policy, most recently reviewed May, 2022 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or their representative with a summary of a Baseline Care Plan (BCP) that was developed within the first 48 hours of admission for four sampled residents (Residents #132, #21, #231, and #82) out of 12 sampled residents. The facility census was 31 residents. Review of the facility's Preliminary Care Plan policy revised 8/2006 showed: -To assure the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within 24 to 48 hours of the resident's admission. -The Interdisciplinary Team (IDT) will review the Attending Physician's order (e.g., dietary needs, medications, and routine treatments, etc.) and implement a nursing care plan to meet the resident's immediate care needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a process in place to ensure Cardiopulmonary Resuscitation (CPR- an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who was in cardiac arrest) certified staff were available on all shifts. The facility census was 31 residents. Review of facility's policy Cardiopulmonary Resuscitation (CPR) dated 2001 revised 4/2016 showed: -Personnel have completed training on the initiation of CPR and basic life support (BLS) including defibrillation (shocking the heart), for victims of sudden cardiac arrest. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three sampled residents (Resident #21, #231, and #232) signed arbitration agreements (a private process where disputing parties agree that one or several individuals can make decisions about the dispute after receiving evidence and hearing arguments) after this was explained in a manner they understood; and also to ensure the agreement contained arbitration was not required to be signed as a condition of admission and the resident had the right to communicate with state officials out of 12 sampled residents. The census was 31 residents. A policy on arbitration was requested from the facility but not received. 1. Review of Resident #21's admission Record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation services. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three sampled residents (Resident #21, #231, and #232) signed arbitration agreements (a private process where disputing parties agree that one or several individuals can make decisions about the dispute after receiving evidence and hearing arguments) that contained a neutral arbitrator and a venue to hold the arbitration meeting agreed upon by both parties (resident and facility) out of 12 sampled residents. The census was 31 residents. A policy on arbitration was requested from the facility but not received. 1. Review of Resident #21's admission record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation services. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a recapitulation of stay was completed for two sampled residents (Resident's # 22 and #18) out of five sampled closed records. The facility census was 31 residents. Review of the facility's policy Discharge Summary and Plan revised 9/2012 showed the discharge summary would include a recapitulation of the resident's stay at the facility and a final summary of the resident's status upon discharge. 1. Review of Resident #22's admission record showed the resident was admitted to the facility on [DATE] with a primary diagnosis of displaced fracture (the bone is out of alignment) of shaft of right clavicle (middle portion of collarbone), subsequent encounter with routine healing. Review of the resident's Discharge and Transition Form dated 5/22/23 showed: -The resident was being discharged to a Skilled Nursing Facility (SNF). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess one sampled resident (Resident #232) to ensure he/she could monitor and maintain his/her insulin pump (a device that regulates insulin mediation and blood sugar); and to ensure staff were educated on insulin pumps out of 12 sampled residents. The facility census was 31 residents. Review of the facility's policy Self-Administration of Medications revised 12/2012 showed: -Residents in the facility who wish to self-administer their medication may do so if it was determined they were capable of doing so. -As part of their overall evaluations, the staff and practitioner would assess each resident's physical and mental capabilities to determine whether they were capable of self-administering medications. 1. Review of Resident #232's admission record showed he/she: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders for one sampled resident's (Resident #82) Continuous Positive Airway Pressure (CPAP - a machine that uses mild air pressure delivered by mask to keep breathing airways open during sleep) and oxygen use until five days after his/her facility readmission, and to ensure the cleansing and sanitary storage of the resident's CPAP nasal mask, machine and supplies, to assess and document the use of the resident's CPAP and ensure the resident's oxygen tubing was dated and properly stored when not in use and to ensure the resident's care plan addressed the use of CPAP and supplemental oxygen. The facility also failed to ensure one sampled resident's (Resident #81) oxygen tubing was dated, maintained off the floor, and properly stored when not in use, out of 12 sampled residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's hemodialysis (a procedure involving diverting blood into an external machine, where it is filtered before being returned to the body to remove waste products and excess fluid from the blood when the kidneys stop working properly) access (the way the resident's blood is reached) was correctly identified in his/her physician's orders, treatment administration record and comprehensive care plan and was correctly assessed by facility licensed nurses, out of 12 sampled residents. The facility census was 31 residents. Review of the facility Hemodialysis Access Care policy, revised September 2010 showed: -Vascular access may be accomplished by three methods, including by central catheters (CVC - a long, soft tube placed into a large blood vessel in the neck, upper chest or groin). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report allegations of abuse and injuries of unknown origin to the State Agency (SA) for one closed record sampled resident (Resident #10) and one sampled resident (Resident #16); and to report misappropriation of a controlled substance when the medications were taken from one sampled resident (Resident #41) and administered to two sampled residents (Resident #16 and #149) out of 12 sampled residents and 10 closed record sampled residents. The facility census was 37 residents. Record review of the facility's Abuse and Neglect Policy last reviewed 4/2021 showed: -After the facility submitted an immediate report of an alleged violation, the facility must conduct a thorough investigation; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nurse Assistants (CNA's) received twelve hours of training based on their performance reviews. The facility census was 37 residents. Record review of the facility's policy titled Staff Development Program dated 11/17/17 showed: -CNA's were required to complete no less than twelve hours of in-service training that was sufficient to ensure continued competency. -The training should address any specific areas of weakness identified in performance evaluations. 1. Record review of the facility's training in the past year showed the following training had been completed: -On 6/24/21, Abuse and Neglect training. -On 7/22/21 Activities of Daily Living (ADL's-transfers, cares, bathing, hygiene), Abuse and Neglect, and Abuse Coordinator training. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff. The facility census was 37 residents. Record review of the facility's Controlled Substances policy dated 2001 and revised on 12/12 showed: -Nursing staff must count controlled medications at the end of each shift. -The nurse coming on duty and the nurse going off duty must make the count together. -They must document and report any discrepancies to the Director of Nursing (DON). 1. Record review of the facility's Controlled/Narcotic Count Sheet dated July 2021 for the 100 hall medication cart showed: -12 out of 124 opportunities were not signed by oncoming staff. -14 out of 124 opportunities were not signed by the off going staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of weight gain for one sampled resident (Resident #37) who was being treated for edema (swelling caused by excess fluid trapped in your body's tissues) out of 12 sampled residents. The facility census was 37 residents. Record review of the facility's policy titled Change in a Resident's Condition or Status dated 11/17/21 showed the facility would promptly notify the resident's physician of medical or status changes. 1. Record review of Resident # 37's admission Record showed he/she was admitted to the facility on [DATE] for Medicare Part A skilled services and a diagnosis of Congestive Heart Failure (CHF-disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body). [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent the diversion (the unauthorized removal) of Lorazepam (a controlled medications used to treat anxiety that had a higher potential of dependence and abuse) from one sampled resident (Resident #41) to two sampled residents (Residents #16 and #149) out of 12 sampled residents and 10 closed records. The facility census was 37 residents. Record review of the facility's policy on Abuse and Neglect revised 5/2018 showed: -Residents have the right to be free from theft and/or, misappropriation of property. -The resident was to be free from abuse and neglect, and that swift and immediate action would be taken to investigate and adjudicate alleged instances of resident abuse and neglect. [...]

Inspectors wroteBased on interview and record review, the facility failed to fully investigate an allegation of abuse and injuries of unknown origin for one closed record sampled resident (Resident #10) and one sampled resident (Resident #16) out of 12 sampled residents and 10 closed record sampled residents. The facility census was 37 residents. Record review of the facility's Abuse and Neglect Policy last reviewed 4/2021 showed: -It was the responsibility of every employee of the facility to report the following types of alleged violations: -In the event an employee witnessed or had knowledge of any abuse situation occurring in the facility, that employee was to immediately notify the Supervisor who would notify the Administrator and the Director of Nursing Services (DON). -Any allegation of abuse, where it was substantiated or not, reported by the resident, staff or responsible party. [...]

Inspectors wroteBased on interview and record review, the facility failed to withhold basic life support, including cardiopulmonary resuscitation (CPR- an emergency procedure that is performed when a person's heartbeat or breathing has stopped) per the resident's choice for one sampled resident (Resident #150) out of 12 sampled residents and 10 closed record residents. The facility census was 37 residents. Record review of the facility's policy titled Emergency Procedure-CPR revised 4/2016 showed: -If an individual was found unresponsive and not breathing normally, a licensed staff member should initiate CPR unless: --The individual was a Do Not Resuscitate (DNR-instructs health care providers not to do CPR if a patient's breathing stops or if the patient's heart stops beating) code status. --The individual showed obvious signs of irreversible death. 1. [...]