Surrey Place St. Lukes Hospital Skilled Nursing

Inspectors wroteSee the deficiency cited at LUGT12. Based on interview and record review, the facility failed to ensure residents were free from significant medication error after one resident with an allergy to penicillin (a class of antibiotics that are commonly used to treat bacterial infections) was ordered and administered Zosyn (a penicillin antibiotic used to treat infections) intravenously (IV, into the vein) to treat a urinary tract infection (UTI) (Resident #503). The facility failed to get a detailed account of the resident's reaction to penicillin after it was reported and the resident's reactions were not documented in the medical record. The resident's family reported to facility staff the resident's reaction to penicillin was blood clots, he/she was highly allergic, and it could kill him/her. The nurse reported he/she was informed the resident's reaction was only blood clots. [...]

Inspectors wroteBased upon document review and interview, the facility failed to ensure staff were trained in required infection control practices such as enhanced barrier protection (EBP) and/or other isolation precautions. The facility failed to have staff's competencies in relation to the infection control training. This failure placed all 80 residents at risk of infection. The lack of adequate training and evaluation of staff's competencies had the potential for residents' needs to go unmet and/or result in a lack of services provided by the facility.

Inspectors wroteBased on observation, interview, review job description, and facility policy review, the facility failed to ensure one of one dietary freezer, and three of three nourishment room (Alpine Park, Canyon Creek, and Dakota) refrigerators had all food labeled, dated and was free of dirt and sticky shelves. This failure has the potential to create the environment for food-borne illnesses to occur throughout the population of 80 residents.

Inspectors wroteBased on record review, interview and policy review, the facility failed to conduct and document a comprehensive Facility-wide Assessment to determine what resources were necessary to care for its residents competently during day-to-day operations. The facility failed to ensure the Facility Assessment included infection control services, such as surveillance and antibiotic use, as well as the facility employing an Infection Preventionist (IP) who would was responsible for overseeing the infection control program. The lack of an adequate facility assessment had the potential for residents' needs to go unmet and/or result in a lack of services provided by the facility to competently care for all 80 residents who resided at the facility. at the time of the survey.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure two of three medication carts (Alpine unit and Canyon unit), and one of two treatment carts (Alpine unit) were locked and secured on three of three resident halls. This failure created a risk of medications being misappropriated or tampered with. Also, the facility failed to remove expired blood collection tubes from two of the three medication rooms (Alpine unit and Dakota Bluffs unit).

Inspectors wroteBased on observations, record review, review of policies, interviews, and review of Centers for Disease Control (CDC) guidelines and Centers for Medicare & Medicaid Services (CMS) guidance, the facility failed to follow acceptable standards of practice for infection prevention and control when providing wound care for Resident #35. The facility also failed to ensure one (Resident (R)144) of one resident with a diagnosis of Methicillin-Resistant Staphylococcus Aureus (MRSA) was placed in contact precautions. This had the potential for MRSA to spread to staff and to other residents. The facility failed to ensure R1 and R36 were placed in enhanced barrier precautions (EBP) for wounds and R294, R6, R35 for use of a catheter. This had the potential for the residents to develop multi-drug resist organisms. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assess one of one sampled resident (Resident (R) 37) for the safe self-administration of medications. This failure could potentially lead to medications being left by staff at the resident's bedside where other residents could access them.

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (Resident #38) from misappropriation of property when a staff member took the resident's wallet, and used his/her credit card to purchase take-out food and groceries. The census was 79. The administrator was notified on 7/24/24 of the past non-compliance. The facility had completed their investigation, interviewed staff and residents, notified the police and terminated Certified Nurse Aide (CNA) A. The deficiency was corrected on 7/24/24. Review of the Abuse and Neglect (Suspected) Policy, revised March 2022, included the following: -Residents have the right to be free from any type of abuse, including verbal, physical, psychological, sexual, and emotional abuse and/or exploitation; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication error after one resident with an allergy to penicillin (a class of antibiotics that are commonly used to treat bacterial infections) was ordered and administered Zosyn (a penicillin antibiotic used to treat infections) intravenously (IV, into the vein) to treat a urinary tract infection (UTI) (Resident #503). The facility failed to get a detailed account of the resident's reaction to penicillin after it was reported and the resident's reactions were not documented in the medical record. The resident's family reported to facility staff the resident's reaction to penicillin was blood clots, he/she was highly allergic, and it could kill him/her. The nurse reported he/she was informed the resident's reaction was only blood clots. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to regularly offer/assist a resident with removal of facial hair to maintain good grooming and hygiene for 1 (Resident #100) of 2 sampled residents reviewed for activities of daily living.

Inspectors wroteBased on observation and interview, the facility failed to maintain the residents' bathroom exhaust ventilation system in proper working condition when all residents' bathrooms on the C hallway did not have functioning exhaust vents. This affected all residents on the C hallway. The facility had a capacity of 80 residents with a census of 67. 1. Observation on 8/21/19 beginning at 9:00 A.M., showed the exhaust ventilation system, in all residents' bathrooms of the C hallway, did not work when tested. During an interview on 8/21/19, at approximately 3:15 P.M., the maintenance supervisor said he did not know the residents' bathroom exhaust system did not work. He said the facility had recently had some work done and the ventilation was worked on at that time.

Inspectors wroteBased on interview and record review, the facility failed to complete the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, Form CMS-10055) for one sampled resident (Resident #5) out of three sampled residents. The facility census was 67. Record review of Resident #5's SNF Beneficiary Protection Notification Review showed the following: - The resident's Medicare Part A skilled services episode had a start date of 3/16/19; - The resident's last covered day of Part A service was 3/28/19; - A SNF ABN, Form CMS-10055 was not provided to the resident because the resident was discharged from the facility and did not receive non-covered services. Spoke with POA (Power of Attorney) who was not concerned about charges but wanted to ensure patient was able to be in Medicaid bed and bill Medicaid for coverage. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to provide written notification of transfer to the resident or the resident's representative for four residents (Residents #7, #20, #34, and #66) who transferred to the hospital. The facility census was 67. 1. Review of Resident #7's medical records, showed staff documented the resident was admitted to the facility on [DATE]. Review of the resident's transfer form, dated 7/27/2019, showed staff documented there was a medical reason for transfer because the resident fell a day ago and now showed symptoms of pain and swelling in his/her left hip. Review of the resident's nurses notes, dated 7/27/2019, showed the resident complained of pain in the left upper leg. When turning the resident to change his/her brief and when the resident stood for the transfer his/her pain level became intolerable. [...]