The Terrace at Courtenay Springs

Inspectors wroteBased on observation, interview and record review, the facility failed to establish routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections, infection risks, communicable disease outbreaks, and to maintain or improve resident health status. The facility also failed to provide accurate influenza consent forms for 5 out of 5 residents reviewed for immunizations, of a total sample of 30, (#2, #7, #44, #50, and #68).

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, and behavior needs for 4 of 4 residents reviewed for comprehensive care plans, of a total sample of 30 residents, (#8, #59, #44 and #95).

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond to recommendations for 1 of 1 residents reviewed for cardiac management out of 30 sampled residents, (#92).

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and provide ongoing monitoring of identified past trauma for 4 of 4 residents reviewed for Trauma Informed Care, of a total sample of 30 residents, (#40, #4, #16, #49).

Inspectors wroteBased on observation and interview, the facility failed to store and serve food in a manner to prevent foodborne illness in the resident population that received dietary services from the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to complete and submit discharge assessments timely for 6 of 6 residents reviewed for resident assessments, of a total sample of 39 residents, (#12, #40, #53, #55, #73 and #76).

Inspectors wroteBased on interview and record review, the facility failed to provide the appropriate notices of financial liability for 2 of 3 resident reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification, out of a total sample of 43, (#50 and #54).

Inspectors wroteBased on observation, interview, and record review the facility failed to report an alleged violation of neglect to the State Agency (SA) as required for 1 of 2 residents reviewed for abuse/neglect, of a total sample of 39 residents, (#435).

Inspectors wroteBased on interview and record review, the facility failed to provide written Notification of Transfer to the resident or their representative for 2 of 2 residents reviewed for hospitalizations, of a total sample of 39 residents, (#15 and #25).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was accurately completed following a new mental health diagnosis for 1 of 1 resident reviewed for PASRR, of a total sample of 77 residents, (#80).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall prevention interventions for 1 of 3 residents reviewed for accidents, of a total sample of 39 residents, (#63).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Midline intravenous (IV) dressing was changed in accordance with professional standards to prevent the potential for infection for 1 of 1 resident reviewed for IVs, of a total sample of 39 residents, (#384).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe supplemental oxygen administration for 1 of 1 resident reviewed for respiratory care, of a total sample of 39 residents, (#54).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee implemented effective Performance Improvement Plans to correct and monitor previously identified deficiencies and ensure sustained improvements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring of the status and activities of a vulnerable, cognitively impaired resident to prevent unsupervised exit from the facility through an unmonitored courtyard for 1 of 4 residents reviewed for elopement, out of a total sample of 32 residents, (#25). This failure contributed to the elopement of resident #25 and placed her at risk for serious injury/impairment/death. While resident #25 was out of the facility unsupervised, there was a likelihood she could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. On [DATE] at approximately 8:30 AM, resident #25 left the [NAME] Wing dining room and walked away from the unit. [...]

Inspectors wroteBased on observation, interview, and record review, the facility's administration failed to effectively utilize its resources to mitigate vulnerabilities in the electronic wander monitoring system; failed to maintain a secure environment to prohibit unauthorized entry and egress through the courtyard; and failed to oversee the implementation of policies and procedures and interdisciplinary team (IDT) processes to ensure the safety of 5 of 5 physically and/or cognitively impaired residents identified to be at risk for elopement, of a total sample of 32 residents, (#11, #12, #14, #19 & #25). These failures contributed to the elopement of resident #25 and placed her at risk for serious injury/impairment/death. While resident #25 was out of the facility unsupervised, there was likelihood she could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen staff were competent to safely and effectively perform their duties to prevent or minimize the potential for food borne illnesses.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain the overall cleanliness of the kitchen and ensure food was stored and distributed in a sanitary manner.

Inspectors wroteBased on observation, and interview, the facility failed to ensure the dumpster and the immediate area was maintained in a safe, functional and sanitary manner. Findings. During the initial kitchen inspection on 11/7/22 at approximately 11:11 AM, the dumpster area was observed. There was a large dumpster that had two lids that slanted from back to front. The lids did not fit properly and there was a sizable gap between the lids that would not prevent vermin or pests from entering the dumpster. There was a round metal rod that ran through the lids that was bent and prevented the lids from closing properly. The facility's Dietetic Technician Registered (DTR) attempted to slide the lids closer together but was not successful. A large rectangular shaped used cooking oil receptacle was noted behind the dumpster. The top of this receptacle was noted with dark oily clumps of debris. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected wandering behaviors and use of wander/elopement alarms for 3 of 4 residents reviewed for elopement of a total sample of 32 residents (#25, #19 & #11).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services for 2 of 3 residents reviewed for non-pressure wounds out of a total sample of 32 residents, (#49, #11).

Inspectors wroteBased on interview and record review, the facility failed to report an alleged violation of verbal abuse for 1 of 2 residents reviewed for abuse/neglect of a total sample of 32 residents, (#41).

Inspectors wroteBased on interview, and record review, the facility failed to provide written notification of transfer and discharge to their residents/representatives nor copy to the Ombudsman for 1 of 3 residents reviewed for appropriate discharge out of a total sample of 32 residents, (#53).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans were reviewed and revised to reflect interventions after a fall for 1 of 8 residents reviewed for accidents out of a total sample of 32 residents, (#408).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen therapy was administered per physician's orders for 1 of 1 resident reviewed for respiratory therapy of a total sample of 32 residents, (#554).