Tallgrass Creek, Inc

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organism which employ targeted gown and glove use during high contact care) were used for Resident (R) 18, who had a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag).

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale for the continued use of Resident (R) 13's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. This placed R13 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents, with eight reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure the Consult Pharmacist identified and reported the lack of appropriate indication, or a required physician documentation, for Resident (R) 13's use of an antipsychotic (a class of medication used to treat any major mental disorder characterized by a gross impairment testing) medication. This placed R13 at risk for unintended effects related to psychotropic (alters mood or thoughts) drug medication.

Inspectors wroteThe facility had a census of 42 residents. The sample included 13 residents with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from hazardous materials for nine cognitively impaired independently mobile residents. The facility additionally failed to ensure an environment free from avoidable accidents for Resident (R)15 who was injured during a lift-assisted transfer. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 05/06/24 at 07:10 AM an initial walkthrough of the facility was completed. An inspection of the west hall's laundry room revealed the door was unlocked. An inspection of the room revealed a bottle of Oxivir-TB spray (disinfectant that kills bacteria and viruses) left on top of the washing machine. [...]

Inspectors wroteThe facility identified a census of 42 residents. The facility had two medication rooms. Based on observation, record review, and interview, the facility failed to the facility failed to ensure an accurate reconciliation of controlled medications (substances that have an accepted medical use, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) was completed consistently. This placed residents at risk of medication misappropriation, diversion, and ineffective medication regimens.

Inspectors wroteThe facility identified a census of 42 residents. The facility had one main kitchen and one kitchenette and dining area. Based on observation and interview, the facility failed to ensure staff stored, prepared and served food items and maintained the freezer unit in accordance with the professional standards for food service safety. This placed residents at risk of foodborne illness and cross-contamination (the transfer of harmful substances to food).

Inspectors wroteThe facility identified a census of 42 residents. The sample included 13 residents. Based on record review, observations, and interviews, the facility failed to ensure infection control standards were followed during shared equipment use, transport of clean linens, and storage of Resident (R)12's oxygen therapy equipment. This deficient practice placed the residents at risk for infectious diseases. Findings Included: - On 05/06/24 at 07:15 AM an inspection of R12's bathroom revealed her supplemental oxygen face mask and two oxygen connector ports stored on a paper towel on a shared sink. On 05/07/24 at 08:44 AM, an unidentified nurse completed blood pressure checks for R29 and R136. The nurse failed to sanitize the shared blood pressure equipment in between taking the residents' vitals. On 05/07/24 at 09:49 AM staff pushed the Hoyer (total body mechanical lift) lift into R28's room. [...]

Inspectors wroteThe facility identified a census of 42 residents. The sample included 13 residents with one resident reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide a dignified care environment for Resident (R)23. This placed R23 at risk for impaired dignity and quality of life. Findings Included: - R23's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), cognitive-communication disorder, dysphagia (difficulty swallowing), and aphasia (difficulty speaking). R23's Quarterly Minimum Data Set (MDS) completed 03/27/24 indicated a Brief Interview for Mental Status (BIMS) was not completed due to severe cognitive impairment. The MDS indicated she required maximal assistance with bed mobility, transfers, dressing, personal hygiene, and bathing. [...]

Inspectors wroteThe facility identified a census of 42 residents. The facility had one main kitchen and one kitchenette area. The facility had two residents that required a pureed diet. Based on observation, record review, and interview, the facility failed to ensure that dietary staff prepared food that conserved the nutritive value, flavor, and appearance when preparing pureed foods. This placed the residents who received pureed foods at risk of decreased palatability and impaired nutritional status.

Inspectors wroteThe facility identified a census of 42 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 28's therapeutic diet as ordered by his physician. This deficient practice placed R28 at risk for complications including choking.

Inspectors wroteThe facility identified a census of 43 residents. The sample included two residents reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) risk. Based on observations, record review, and interviews, the facility failed to provide adequate supervision to cognitively impaired Resident (R) 1, who was at risk for elopement and exited the facility. On 10/06/23 at 06:21 PM R1 pressed on an exit door for 30 seconds, which opened the door. The door alarm sounded, but the staff failed to promptly respond to the alarm. R1 wore a WanderGuard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on her wheelchair, which alarmed as well, but staff failed to respond. [...]

Inspectors wroteThe facility identified a census of 43 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure staff followed infection control standards of practice. The facility failed to appropriately store/cover residents' clean laundry. The facility failed to properly store the scoop for an ice machine in a sanitary manner. This placed the residents at risk for increased infection and transmission of communicable disease.

Inspectors wroteThe facility identified a census of 43 residents. Based on observation, record review, and interviews, the facility failed to promote a dignified dining experience during meal service for Resident (R)17, R26, and R28. This deficient practice placed the residents at risk for impaired dignity and decreased psychosocial well-being. Findings Included: - On 10/25/22 at 11:55AM R28 attempted to eat his meal in the dining room. R28 sat across from R26 (severely physically and cognitively impaired resident). R26 struggled to eat his meal and began coughing. R26 was unable to cover his mouth due to his physical impairment and coughed in the direction of R26's plate and drink. Staff did not intervene or help R26 during this time. At 12:05PM R28 requested to be moved to a different table and stated, I can't enjoy my meal with him coughing all over my food. [...]

Inspectors wroteThe facility identified a census of 43 residents. The sample included 12 residents with five reviewed for activities of daily living (ADL's). Based on observation, record review, and interviews, the facility failed to provide Resident (R)26's assistance with eating to prevent aspiration (inhaling liquid or food into the lungs) during his meals. This deficient practice placed him at risk for aspiration and related complications. Findings Included: [...]

Inspectors wroteThe facility identified a census of 43 residents. The sample included 12 residents with four residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to follow Resident (R) 24's plan of care which directed extensive assistance of two staff members for transfers. This placed R24, who had a history of falls, at increased risk for accidents and potential major injuries related to falls.

Inspectors wroteThe facility identified a census of 43 residents. The sample included 12 residents with two reviewed for bowel and bladder incontinence. Based on observation, record review, and interviews, the facility failed to establish an individualized bowel and bladder programs for Resident (R)16 and R34. This deficient practice placed the residents at risk for complications related to incontinence and increased incontinence. Findings Included: -The Medical Diagnosis section within R16's Electronic Medical Records (EMR) included diagnoses of major depressive disorder (major mood disorder), moderate weakness, epilepsy (brain disorder characterized by repeated seizures), chronic pain syndrome, lack of coordination, overactive bladder, and arthritis (inflammation of a joint characterized by pain, swelling, heat, redness and limitation of movement). [...]

Inspectors wroteThe facility identified a census of 43 residents. The sample included 12 residents with five reviewed for specialized diets. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 26's physician ordered nectar thick liquids during meal service. This deficient practice placed him at risk for complications related to aspiration (inhaling liquid or food into the lungs) . Findings Included: [...]