The Springs of Harrison

Inspectors wroteBased on observations, interviews, records review, and facility policy review, the facility failed to ensure residents, or their representatives were notified of the high concentrations of [NAME] gas in the facility, depriving them of the right to choose to remain in the facility or move to another facility. This failed practice had the potential to affect all residents residing in the facility.

Inspectors wroteAccording to observation, interview, and record review, the facility failed to ensure food was stored properly, kitchen equipment was maintained properly, and disinfectant was in use for the dishwasher.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and homelike environment for the residents to promote dignity and prevent the potential injury or spread of disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received care and treatment to prevent potential infection or deterioration and promote healing for 1 (Resident #29) of 1 sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures, including hand hygiene, were implemented during wound care for 1 (Resident #29) of 1 sampled resident; and failed to ensure hand hygiene was performed during meal service to prevent potential infection and or the spread of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were in place for a contracture for 1 (Resident #20) of 1 sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items stored in the refrigerator, freezer, and dry storage areas were dated when received and/or opened to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed/discarded by the expiration or use by dates to prevent potential for food bone illness; and dietary staff washed their hands before handling clean dishes and trays or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 64 residents who received meals from 1 of 1 kitchen (total census: 64), as documented on the Diet list provided by Administrator on 03/08/23.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident fingernails were cleaned, trimmed and filed for 1 (Resident #23) of 24 (Residents #1, #4, #5, #9, #11, #13, #14, #15, #16, #17, #19, #21, #23, #27, #34, #41, #42, #49, #50, #51, #54, #56, #57 and #62) sampled residents who were dependent for nail care as documented on a list provided by the Administrator on 03/08/23 at 3:22 PM and failed to ensure facial hair was removed to promote dignity and good grooming for 1 (Resident #23) of 6 (Residents #14, #15, #19, #23, #34 and #42) sampled residents who required assistance with shaving as documented on a list provided by the Administrator on 03/09/23 at 1:44PM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the call light systems were maintained to prevent accident hazards for 2 (Residents #14 and #41) sampled residents whose call light was in reach. This failed practice had the potential to affect all 63 residents in the facility as documented on a list provided by the Administrator on 03/08/23 at 3:22 PM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that oxygen was administered at the ordered flow rate for 1 (Resident #21) of 7 (R #14, 15, 19, 21, 23, 34 and 42) sampled residents who had a physician's order for oxygen as documented on a list provided by the Administrator on 3/8/23 at 3:22PM.

Inspectors wroteBased on record review, interview, the facility failed to ensure performance reviews were completed at least every 12 months to assist in the development of education needs, to include demonstrated competencies of each nurse aide in applying the interventions necessary to meet the needs of the residents for 5 Certified Nursing Assistants (CNA) (CNAs #3, #4, #5, #6 and #7) identified.

Inspectors wroteBased on observation, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets and temperature changes to pureed foods were minimized to prevent loss of nutritional value for 1 of 1 meal observed. The failed practices had the potential to affect 5 residents who received pureed diets as documented on the Diet list provided by the Administrator on 03/08/23.

Inspectors wroteBased on interview, and record review, facility failed to ensure pneumococcal immunizations were administered to eligible residents and immunization records were accurate for 4 (Residents #52, #54, #56 and #62) of 5 (Residents #51, #52, #54, #56 and #62) sampled residents to help protect against pneumococcal bacteria which can cause serious infections and is potentially fatal and influenza immunizations were administered to eligible residents and immunization records were accurate for 3 (Residents #51, #56 and #62) of 5 (Residents #51, #52, #54, #56 and #62) sampled residents to help protect against influenza which can cause serious illness and is potentially fatal.

Inspectors wroteBased on interview, and record review, the facility failed to ensure COVID-19 vaccinations were administered to eligible residents and the immunization records were accurate for 3 (Residents #51, #56 and #62) of 5 (Resident #51, #52, #54, #56, and #62) sampled residents to help protect against COVID-19 disease which can cause serious illness and is potentially fatal.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the call systems in all areas were functioning properly for 2 (Residents #14 and #41) sampled residents whose call light was in reach. This failed practice had the potential to affect all 63 residents in the facility as documented on a list provided by the Administrator on 03/08/23 at 3:22 PM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medications were administered timely and per Physician's Orders and facility policy for 1 (Resident #117) of 5 (Residents #21, #50, #52, #54 and #117) sampled residents who received medications from the medication cart on the East Hall. This failed practice had the potential to affect 17 residents residing on the East Hall who received medications from the East Hall medication cart per the list provided by the Director of Nursing (DON) on 03/09/23 at 2:57 PM.