The Waterview Woods LLC

Inspectors wroteBased on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight hours a day. This had the potential to affect all 55 residents who resided at the facility.

Inspectors wroteBased on observation, interview, and document review the facility failed to follow a self-administration of medication (SAM) form which indicated the resident should not self-administer medications. The facility also failed to have a provider order to self-administer medications and to keep medications at bedside. Lastly the facility failed to appropriately assess a resident with memory and decision-making concerns that was allowed to self-administer medications. This effected 2 of 3 (R25, R29) residents reviewed for self-administration of medications.

Inspectors wroteBased on interview and document review, the facility failed to provide a bed hold notice for 1 of 1 resident (R2) reviewed for hospitalization.

Inspectors wroteBased on observation, interview and document review, the facility failed to revise resident care plans with updated interventions for 2 of 2 residents (R7, R63) reviewed for behaviors and transmission-based precautions (TBP).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a resident's hearing devices were in use for 1 of 1 resident (R35) reviewed for communication and hearing. In addition, the facility failed to ensure the family member was kept updated on changes of condition for 1 of 1resident (R35) reviewed for change of condition. Based on observation, interview and document review, the facility failed to ensure a resident's hearing devices were in use for 1 of 1 resident (R35) reviewed for communication and hearing. In addition, the facility failed to ensure the family member was kept updated on changes of condition for 1 of 1resident (R35) reviewed for change of condition.

Inspectors wroteBased observation, interview and document review, the facility failed to provide timely assistance with repositioning to prevent the worsening or development of pressure ulcers for 1 of 3 residents (R1) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review the facility failed to implement interventions to prevent falls for 1 of 3 (R44) residents reviewed for falls.

Inspectors wroteBased on observation, interview, and document review the facility failed to monitor pain, provide non-pharmacological pain management, and consistently administer as needed pain medication to minimize pain for 1 of 1 resident (R61) who had pain. R61's admission Minimum Data Set (MDS) dated [DATE], identified R61 was cognitively aware and had diagnoses that included chronic obstructive pulmonary disease (COPD) (a progressive group of lung diseases that includes emphysema and chronic bronchitis, making it difficult to breathe due to airflow obstruction. Common symptoms are chronic cough, mucus, and shortness of breath, which worsen over time and are often exacerbated by smoking or exposure to irritants.), emphysema (a progressive group of lung diseases that includes emphysema and chronic bronchitis, making it difficult to breathe due to airflow obstruction. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to make sure all medications in a resident room had active orders and were not expired. This affected 1 of 1 (R29) resident reviewed for medication storage.

Inspectors wroteBased on interview and document review, the facility failed to ensure the consultant pharmacist recommendations were addressed for 1 of 5 residents (R1) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review the facility failed to correctly label a prescribed medication for 1 of 1 resident (R29) reviewed for medication labeling.

Inspectors wroteBased on observation, interview, and document review the facility failed to arrange dental services for a resident with broken teeth and possible cavities. This affected 1 of 2 (R44) residents reviewed for dental concerns.

Inspectors wroteBased on interview and document review the facility failed to establish a process for antibiotic review in order to determine appropriate indications and resistance for use of an antibiotic for 1 of 1 resident (R3).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure ceiling tiles were maintained in a safe manner for 1 of 1 resident (R49) reviewed for environment.

Inspectors wroteBased on interview and document review the facility failed to ensure accurate doses of buprenorphine (an opioid pain medication) were administered to 1 of 3 residents (R1) investigated for a significant medication error.

Inspectors wroteBased on observation, interview and document review, the facility failed to properly assess, care plan, and ensure the correct sling was used during transfers for 1 or 1 resident (R1) reviewed for mechanical lift transfers. The resident was transferred using a ceiling lift with a reported toileting sling (a sling which does not cover the buttocks) of unknown size, fell out of the sling during the transfer, and sustained a laceration to the back of head. The deficient practice was identified as an immediate jeopardy (IJ) situation, however, the provider had implemented corrective action prior to the investigation, therefore, the deficiency was issued as past non-compliance. The IJ began on 12/22/24 at 8:10 p.m., when R1 was transferred with a ceiling lift using a reported toileting sling of unknown size. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to develop a comprehensive person-centered care plan based on the resident assessment which identified the type and size of sling required during transfers for 3 of 3 residents (R1, R3, R4) reviewed for mechanical lift use.

Inspectors wroteBased on interview and document review, the facility failed to ensure a resident with an allergy to shellfish was not served shellfish for 1 of 1 resident (R209) reviewed for food allergies. The resident was fed a dinner containing shellfish, had an allergic reaction, and was sent to the emergency department (ED) for treatment. The deficient practice was identified as an immediate jeopardy (IJ) situation, however, the provider had implemented corrective action prior to the investigation, therefore, the deficiency is issued as past non-compliance. The IJ began on 10/13/24 at 5:15 p.m. when R209 was served, and consumed, shrimp. R209 complained of numbness of the tongue and lips and was sent to the ED for treatment of allergic reaction. The administrator and director of nursing (DON) were informed of the IJ on 10/24/24 at 11:13 a.m. [...]

Inspectors wroteBased on interview and document review the facility failed to have 8 hours of continuous registered nursing coverage on a daily basis. This had the potential to affect all residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to offer and provide a substantive snack after dinner and before bedtime, when there were 15 hours between the evening and morning meals. This had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff properly utilized personal protective equipment (PPE) for 1 of 3 residents (R37) reviewed for enhanced barrier precautions (EBP). In addition, the facility failed to annually review the infection control policy and procedures, ensure a current list of reportable communicable diseases was a part of the program, perform infection surveillance of staff members, test staff members during a COVID-19 outbreak, and to provide evidence-based surveillance criteria to define infections to licensed nursing staff. This had the ability to affect all residents who reside at the facility. Findings for R37 include: [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure provider orders and care plan interventions were followed for 1 of 2 residents (R37) reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and obtain informed consent prior to resident bed rail use for 1 of 1 residents (R39) reviewed for bed rails.

Inspectors wroteBased on observation, interview and document review, the facility failed to notify the provider, monitor, determine root cause and revise interventions to address pressure ulcers for 1 of 2 residents (R21) reviewed who was at risk for pressure ulcer development/deterioration. The facility's failure resulted in harm when R21 developed 2 pressure ulcers, one that deteriated to a stage 3 and another to a stage 4. In addition, R1 had documented redness and skin breakdown to the buttocks area and a right heel wound that both deteriorated to unstageable pressure ulcers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to promptly obtain opioid medication and failed to notify the physican to prevent opioid withdrawal for 1 or 1 residents (R13) reviewed for pain management. This practice resulted in a significant medication error and actual harm when R13 did not receive opioid medication for 7 consecutive days resulting in R13 being sent to the emergency room to receive care for acute opioid withdrawal.

Inspectors wroteBased on interview and document review the facility failed to have 8 hours of continuous registered nursing coverage on a daily basis. This had the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were safely stored in a secured area that prevented residents and unauthorized individuals access to the improperly stored medications. This deficient practice had the potential to affect all residents who received stock medications and/or any residents that had the physical ability enter the office and access the unsecured medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were not left at bedside for 1 of 2 residents (R41) reviewed for safe self-administration of medications.

Inspectors wroteBased on observation, record review and interview, the facility failed to accurately assess and implement interventions for 1 of 1 resident (R21) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and record review the facility failed to update the care plan after a change in assessment for 1 of 4 (R21) reviewed for pressure ulcers and 1 of 4 R25) reviewed for accidents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oral care and tube feeding orders were followed for 1 of 3 residents (R48) reviewed for provider orders.

Inspectors wroteBased on interview and document review, the facility failed to comprehensively reassess falls to determine possible causative factors in order to develop resident centered interventions to minimize the risk of further falls for 1 of 1 residents (R265) reviewed for falls. In addition, the facility failed to insure aspiration precautions were followed for 1 of 1 resident (R48) reviewed for aspiration.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure only trained licensed staff managed tube feeding care for 1 of 1 resident (R48) reviewed for competent care.

Inspectors wroteBased on interview and document review, the facility failed to discontinue administration of antidepressant medication as ordered for 1 of 5 residents (R7) reviewed for unnecessary medication use. Findings Include: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 was cognitively intact and receiving hospice care. R7's diagnoses inluded non-Alzheimer's dementia, depression, bipolar disorder, psychotic disorder, and encounter for palliative care. In addition, MDS identified R7 was taking antipsychotic, opioid, and antidepressant medications. Physician's order dated 1/9/24, stated to discontinue R7's Remeron (an antidepressant medication). R7's medication administration record (MAR), identified R7 had been administered Remeron daily from 1/10/24 to 2/7/24. During interview on 2/8/2024 at 9:09 a.m., registered nurse (RN)-B stated orders received are completed within 1 day. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff properly sanitized urinary devices and completed appropriate hand sanitization and glove use during resident cares for 1 of 1 resident (R48) reviewed for infection control and prevention.

Inspectors wroteBased on interview and document review, the facility failed to ensure timely notification of change in condition to the provider and the resident representative for 3 of 3 residents (R1, R2, R3) reviewed for change of condition.