Trellis Centennial

Inspectors wroteBased on interview, record review and document review the facility failed to ensure nursing documentation accurately reflected the care provided. Nursing staff documented splint care was completed when the care had not been performed for 1 of 32 sampled residents (Resident 54). The deficient practice placed the residents are risk of not receiving ordered treatment interventions and inaccurate documentation of care provided.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure physician orders were followed for a resident's suprapubic catheter for 1 of 32 sampled residents (Resident 6). The deficient practice placed residents at risk of catheter complications such as infection and trauma.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a resident's infection status was communicated to the dialysis provider for 1 of 32 sampled residents (Resident 93). The deficient practice placed the community at risk for transmission.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to develop a care plan, monitor behaviors, and provide behavioral health services for 1 of 19 sampled residents (Resident 215). Specifically, the facility failed to document the resident's hospital-diagnosed anxiety as an active medical condition, develop a baseline care plan addressing behavioral health interventions for anxiety, and implement timely interventions until after the resident expressed suicidal ideation. This deficient practice resulted in psychosocial harm as evidenced by the resident's reported feelings of suicidal ideations.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure: 1) The shared glucometer device was disinfected using Environmental Protection Agency (EPA)-approved disinfectant wipes for 1 of 19 sampled residents (Resident 171). 2) Handwashing with soap and water was performed before and after entering the room of a resident on contact isolation for Clostridium difficile (C. diff) for 1 of 19 sampled residents (Resident 166) and required personal protective equipment (PPE) was donned when entering rooms in contact isolation precautions in 2 of 2 units. This deficient practice had the potential to expose residents to bloodborne pathogens and other infectious agents, increasing the risk of cross-contamination and facility-acquired infections.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a care plan for anticoagulant use was formulated and a physician order was obtained for monitoring the resident while on anticoagulant (blood thinning) therapy for 1 of 19 sampled residents (Resident 166). This deficient practice had the potential to result in unrecognized bleeding complications, delayed medical intervention, and serious adverse outcomes such as internal bleeding, hospitalization, or death.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a physician's order for the use of Oxygen (O2) and corresponding care instructions were obtained for 1 of 19 sampled residents (Resident 166). This deficient practice had the potential to result in improper administration of O2 therapy, increased risk of respiratory complications, and failure to monitor the resident's response to treatment.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure pain medication was administered per the physician order and physician order obtained for pain level rated 4-6/10 using the numerical pain scale 0-10 (0= no pain and 10= worst pain) for 1 of 19 sampled residents (Resident 265). The deficient practice had the potential to lead to inadequate pain management, an increased risk of adverse effects, and compromised patient safety.

Inspectors wroteBased on interview, record review and document review, the facility failed to provide documented evidence the residents were provided assistance with activities of daily living (ADLs) for 2 of 4 sampled residents (R1 and R2). The deficient practice had the potential for the residents' skin integrity to be compromised.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a resident's weight was taken and recorded upon admission for 1 of 4 sampled residents (Resident 4). This failure could have compromised the nutritional and medical well-being of the resident.

Inspectors wrote3) TED hose (compression stockings) Resident 43 (R43) R43 was admitted on [DATE], with diagnoses including hypertensive heart disease with heart failure, morbid obesity, and spondylosis of cervical region. A physician's order dated 05/13/2024, documented thrombo-embolic deterrent (TED) hose on bilateral legs two times a day for edema on for 12 hours, off for 12 hours. On 06/04/2024 at 8:55 AM, R43 laid alert in a bariatric specialty mattress. The resident was not covered with blanket which revealed edema on bilateral lower extremities, R43 was not wearing TED hose. There was no TED hose observed in the resident's room. On 06/05/24 at 8:50 AM, R43 laid in bed with a fully consumed breakfast tray on bedside table. R43 indicated having a history of wearing compression stockings for edema in the past but had not used compression stockings since admission to this facility in March 2024. [...]

Inspectors wroteBased on observations, interviews, record reviews, and document review, the facility failed to ensure: 1) an ACE wrap (elastic bandage) was applied as ordered or the order was clarified for 1 of 17 sampled residents (Resident 9); 2) skin assessments were completed as ordered for 1 of 17 sampled residents (Resident 9); 3) TED hose was applied as ordered for 1 of 17 sampled residents (Resident 43); and 4) Heparin medication was administered as ordered for 1 of 17 sampled residents (Resident 43). These deficient practices could have led to several potential risks, including compromised patient care, delayed healing, an increased risk of injury or infection, and potential harm due to improper support or circulation issues.

Inspectors wroteBased on observations, interviews, record reviews, and document review, the facility failed to ensure: 1) a resident's wound was cleansed and dressing was replaced or applied as ordered after the wound was soaked with urine or feces, and 2) the wound dressing applied was dated per policy for 1 of 17 sampled residents (Resident 63). These deficient practices could have the potential to cause delayed healing, worsened wounds, infection, missed treatments and further complications. Findings Include: Resident 63 (R63) R63 was admitted on [DATE], with diagnoses including stage IV (four) pressure ulcers of sacral region, and stage III (three) of right and left buttocks. R63's Braden Scale for Predicting Pressure Sore Risk dated 05/01/2024, documented a score of 11, indicating a high risk for developing pressure sores. [...]

Inspectors wroteBased on observations, interviews, record reviews, and document review, the facility failed to ensure the Lidocaine patch was applied as ordered and removed on schedule to manage the resident's pain for 1 of 17 sampled residents (Resident 166). This deficient practice could potentially lead to inadequate pain management, an increased risk of adverse effects, and compromised patient safety.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure the medication error rate was below five percent (%), based on three errors identified out of 29 opportunities observed, resulting in an error rate of 10.34%. Failure to follow physician orders during medication administration had the potential to cause harm or injury to residents.

Inspectors wroteBased on observation, interview, record review, and document review the facility failed to ensure 1) a single dose of narcotic medication was documented as administered in the Narcotics Logbook, and 2) medication cart was free of loose pills, personal food items and an unlabeled white powdery substance in a plastic cup. The failed practice could have increased the potential for medication administration errors and a breach of infection control measures.

Inspectors wroteBased on observations, interviews, record reviews, and document reviews, the facility failed to ensure the transmission-based precautions (TBP) and Enhanced Barrier Precautions (EBP) were followed upon entering the rooms for 2 of 17 sampled residents (Residents 166 and 33), and the vial topper was disinfected prior to drawing the medication for 1 of 17 sampled residents (Resident 34). These deficient practices could potentially lead to the spread of infectious diseases, an increased risk of cross-contamination, and compromised health and safety for both residents and staff.