Temple View Transitional Care Center

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all residents who resided in the facility whose environment were observed. This deficient practice created the potential for harm if: a) residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, or undignified or b) residents were injured due to unsafe areas in the facility.

Inspectors wroteBased on observation, review of the State Operations Manual, and staff interviews, the facility failed to treat residents who needed assistance with eating their meals with dignity and respect. This failed practice had the potential to negatively affect resident's self-esteem, decreased enjoyment of meals and mealtime, and may impact resident's food and fluid intake.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an advanced directive. This was true for 2 of 17 residents (Resident #35 and #41) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning.

Inspectors wroteBased on observation, policy review, record review, and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 2 of 17 residents (#35 and #41) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in their care plan.

Inspectors wroteBased on observation, resident and staff interview, and record review, it was determined the facility failed to ensure professional standards of practice were followed for 2 of 17 Residents (#2 and #46) reviewed for quality of care. Resident #2 and Resident #46 were at risk for adverse outcomes when physician orders were not written correctly and/or followed as ordered. This failed practice had the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practices.

Inspectors wroteBased on observations, staff interview, and review of the facility policy, the facility failed to ensure residents were handled safely during transfers. This was true for 2 of 3 residents (Resident #35 and #68) reviewed for transfers. This failure had the potential to cause injury for residents requiring staff assistance with transfers.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure resident received oxygen as prescribed by the provider. This was true for 2 of 17 residents (#9 and #30) reviewed for respiratory care. This failure created the potential for respiratory difficulties or impaired breathing.

Inspectors wroteBased on policy review, record review, observation, and staff interview, it was determined the facility failed to ensure that prior to the placement of bed rails, alternatives to bed rails were attempted and how the alternatives failed to meet the resident's assessed needs. This was true for 1 of 17 residents (Resident #41) reviewed for bed rails. This failure created the potential for harm due to the risk for injury, entrapment, and/or death.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 3 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were assessed appropriately for adequate indications for the use of opioid pain medications. This was true for 1 of 17 residents (Resident #2) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse consequences or increased risk of death.

Inspectors wroteBased on observations, record review and staff interviews it was determined the facility failed to ensure medications were properly stored and not expired. This was true for the facility. This failure created the potential for residents to receive expired medications with decreased efficacy.

Inspectors wroteBased on review of the State Operations Manual, interview, and record review, it was determined the facility failed to employ a qualified Director of Food and Nutrition Services. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure accurate medical records were maintained for each resident. This was true for 2 of 17 residents (#2 and #4) whose records were reviewed for pain management. This deficient practice resulted in inaccurate documentation and created the potential for harm if inappropriate care and/or treatments were provided to the resident.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to treat each resident with respect and dignity. This was true for 1 of 1 resident (Resident #101) observed for dignity. This deficient practice had the potential for residents to experience embarrassment, and low feelings of self-worth.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure the food was stored in a safe and sanitary manner. These deficiencies had the potential to affect all residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all 65 residents who resided in the facility whose equipment and environment were observed. This deficient practice created the potential for harm if: a) cross contamination due to equipment not being cleaned between use b) residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, undignified, or c) residents were injured due to unsafe areas in the facility.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not offer or encourage residents hand hygiene prior to meals and follow proper handling of medications. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure dignity of residents when staff enter their rooms without knocking and waiting for acknowledgement to enter. This was true for 2 out of 2 resident rooms observed during the morning meal tray delivery. This deficient practice placed residents at risk of embarrassment and diminished sense of self-worth.

Inspectors wroteBased on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure residents were assessed to determine if they were safe to self-administer medications for 2 of 6 residents (#3 and #36) reviewed for self-administration of medications. This failure created the potential for adverse effects if residents self-administered medications inappropriately.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 4 of 4 residents (#3, #4, #15, and #38) reviewed for accuracy of MDS assessments. This deficient practice created the potential for residents to have their mental health needs not met due to inaccurate assessments.

Inspectors wroteBased on record review, policy review, and interview, it was determined the facility failed to ensure a baseline care plan was developed within 48 hours of resident's admission. This was true for 1 of 5 residents (Resident #52) reviewed for baseline care plan. This failure created the potential for harm when the care plan failed to provide direction for care.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 2 of 17 resident's (#3 and #21) whose care plans were reviewed. This placed resident at risk of adverse outcomes if care and services were not provided due to care plans not being revised as resident's needs changed.

Inspectors wroteBased on policy review, record review, observation, and interviews, the facility failed to ensure residents were free from accidents. This was true for 1 of 1 resident (Resident #9) reviewed for accidents. This failure had the potential to cause residents significant injuries.

Inspectors wroteBased on policy review, observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 3 of 15 residents (#14, #28, and #52) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents were monitored appropriately for medication, therapeutic range, and toxicity levels. This was true for 1 of 17 residents (Resident #49) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse reactions due to the lack of appropriate monitoring.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and stored appropriately. This was true for 1 of 1 medication storage rooms inspected, 2 of 46 residents (#3 and #36) resident rooms inspected, and 1 of 2 treatment carts observed. This failure created the potential for residents to receive expired medications with decreased efficacy, the potential for adverse effects if residents self-administered medications inappropriately, and the potential for residents to obtain prescribed wound care supplies used for other residents and presented the risk for cross-contamination of wound care products stored in the treatment cart.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition services, including resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population. These deficiencies had the potential to affect all residents requiring medical nutrition therapy, nutritional assessments, and appropriate supplementation and dietary interventions.

Inspectors wroteBased on policy review, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, resident interview, and staff interview, it was determined the facility failed to report allegations of potential abuse to the State Survey Agency within 24 hours. This affected 1 of 15 residents (Resident #1) whose records were reviewed for abuse. This deficient practice created the potential for harm if allegations were not acted upon in a timely manner and the alleged abuse continued.

Inspectors wroteBased on policy review, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, resident interview, and staff interview, it was determined the facility failed to ensure allegations of potential abuse were thoroughly investigated. This was true for 1 of 15 residents (Resident #1) whose records were reviewed for abuse. This failure created the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility.

Inspectors wroteBased on observation, record review, policy review, facility I&A review, and staff interview, it was determined the facility failed to ensure fall prevention interventions were implemented following a fall and that the care plan interventions were put into place, reviewed, and updated and carried out consistently. This was true for 1 of 15 residents (Resident #2) whose records were reviewed. This had the potential for harm if the resident sustained an injury from a fall. The facility's policy Fall Management, revised 1/2022, stated the following: - Each resident will have an appropriate assessment and interventions to prevent falls and minimize complications should a fall occur. - Care plan interventions would address the risk factors for the resident and be individualized. - After a fall, a fall risk evaluation will be completed. [...]

Inspectors wroteBased on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' call lights were within reach for 1 of 12 (Resident #13) residents reviewed for call lights. This deficient practice had the potential to cause harm if the resident could not request assistance when needed or experienced an adverse medical event requiring prompt staff attention.

Inspectors wroteBased on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' were assessed for the safe use of enabling devices. This was true for 1 of 12 residents (Resident #14) whose assessments were reviewed. This deficient practice placed Resident #14 at risk of injury if the transfer pole in his bedroom was assessed and found to be unsafe for his use.

Inspectors wroteBased on staff interview, record review, and policy review, it was determined the facility failed to ensure physician orders for as needed psychotropic medications were limited to 14 days unless the physician documented rationale for the continued use of the medication and specified a duration for its use. This was true for 1 of 5 residents (Resident #26) who were reviewed for unnecessary medications. This deficient practice created the potential for harm if residents experienced adverse effects from unnecessary psychotropic medications.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure nurse staffing information was posted daily, at the beginning of each shift, and was complete. This failed practice had the potential to affect the 36 residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels.