The Springs of Barrow

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure a comprehensive Care Plan was developed and implemented to include oxygen therapy interventions for one (Resident #67) of three residents reviewed for Respiratory Care.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure physician's orders for oxygen therapy were in place before administering supplemental oxygen for one (Resident #67) of three residents reviewed.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure a trash can was cleansed and had a liner inside and the inside of a resident's toilet bowl was clean for 1 (Resident #4) of 3 whose rooms were reviewed for cleanliness; failed to ensure walls and baseboards were cleansed in the hallways of the facility; failed to ensure cigarette butts were removed from the grounds of a smoking area and shower rooms were maintained in a clean and sanitary condition for 3 of 4 showers in the facility.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure a resident's emergency contact was notified of a change in a resident's plan of care for 1 (Resident #5) of 1 sampled resident reviewed for plan of care changes.

Inspectors wroteBased on interviews, record review, and facility document review, it was determined the facility failed to provide needed care or services resulting in an actual decline in one resident's physical well-being (Resident #1) of 3 sampled residents reviewed for Quality of Care.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were consistently implemented during resident care activities for 1 (Resident #4) of 1 sampled resident reviewed for enhanced barrier precautions.

Inspectors wroteBased on observation, interview, and faculty policy review, the facility failed to ensure dietary staff washed their hands and changed gloves when contaminated; the ice machine was maintained in a clean and sanitary condition; opened food items in the refrigerator and freezer were sealed or covered to maintain freshness and prevent potential cross-contamination; expired dressing products were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; cold beverages were held at 41 degrees Fahrenheit to maintain the quality of food items and beverages.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 5 (Residents #2, #13, #14, #33, and #65) of 5 sampled residents residing on the 300 Hall.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure the storage closet and the janitor's closet near the dining area, and the water heater closet off the 100 Hall were locked to ensure residents did not have access to equipment that could result in accidents or injuries.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure clear, legible medication labels were on narcotics to prevent medication errors, and misappropriation of resident medications in the 100 Hall/200 Hall Medication Room.

Inspectors wroteBased on observation, record review and interview the facility failed to demonstrate competent direct care staffing to provide nursing and related services, to assure resident safety and to maintain the highest practicable physical, mental, and psychosocial well-being for 20 (#16, #27, #31, #32, #33, #39, #45, #49, #53, #57, #59, #62, #63, #64, #65, #69, #72, #71, #73, #182) sampled residents. This had the potential to affect all residents listed on the Resident Matrix provided by the administrator on 10/30/23 at 09:35 am.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were. prepared and served in accordance with the planned written menu were consistently utilized for preparation of altered consistency diets to meet the nutritional needs of the residents for 1 of 1 meal observed. These failed practices had the potential to affect 20 residents who received mechanical soft diets and 5 residents who received pureed diets from the kitchen according to a list provided by the Dietary Supervisor on 10/31/2023 at 02:05 PM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 79 residents who receive meal trays from 1 of 1 kitchen, their rooms on the as documented on a list provided by the Dietary Supervisor #1 on 010/31/2023 at 02:05 PM.

Inspectors wroteBased on observation and interview the facility failed to ensure a suprapubic urinary catheter bag did not come into contact with the floor for 1 sampled resident (Resident #60) on hall 100 and failed to ensure proper wound care was performed for 1 sampled resident (Resident #60) to prevent potential cross contamination and infection. This failed practice had the potential to effect 2 residents (Resident #60) and 1 non sampled resident on hall 100 with urinary catheters based on a list of residents on hall 100 with foley catheters and 1 sampled resident with wounds provided by the facility Chief Executive Officer (CEO).

Inspectors wroteBased on observation, interview and record review the facility failed to provide nail care for 1 sampled resident (#57) dependent upon staff for nail care to prevent infection, injury and promote good hygiene. This failed practice had the potential to affect 5 case mix residents (R#32, R#49, R#57, R#60 and R#72) on hall 100 dependent upon staff for nail care based on a list provided by the Administrator on 11/2/23 at 2:46 PM.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure that oxygen was administered at the rate ordered, equipment was assessed and maintained to prevent respiratory complications and infections by not securing humidifier bottle with tubing to concentrator, positioning nasal cannula correctly, and changing contaminated tubing, for 1 sampled resident (R#16). This failed practice had the potential to affect 3 residents on hall 100 who were receiving oxygen therapy per physician orders.

Inspectors wroteBased on Observation and Interview the facility failed to ensure that call lights were within reach for 1 sampled resident (R#16). This failed practice had the potential to affect 80 residents based on a resident matrix provided by the Administrator on 10/30/23 at 10:39 AM.