Triple Creek Retirement Community

Inspectors wroteBased on medical record review, staff interview, and physician interview, the facility failed to obtain weights in a timely manner to monitor a resident's need for medications as an intervention per physician orders. This affected one (#5) of three residents reviewed for medication administration and orders. The census was 48.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure proper personal protective equipment (PPE) was worn while providing care and services for a resident on Enhanced Barrier Precautions (EBP). This affected one (Resident #29) of three residents reviewed for infection control. The facility census was 45. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including toxic encephalopathy, Parkinson's disease, and gastrostomy status. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #29 was moderately cognitively impaired, was dependent on staff for toileting and lower body dressing and occasionally incontinent of urine and frequently incontinent of bowels. [...]

Inspectors wroteBased on record review, interview, and facility document review the facility failed to ensure residents were free of significant medication errors for four (Residents #46, #103, #107, and #199) of four sampled residents reviewed for medication errors. The facility census was 50.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to notify a physician of the facility's failure to administer ordered medications in a timely manner to three (Residents #46, #107, and #199) of four residents reviewed for notification of changes. Additionally, the facility failed to notify the Infectious Disease specialist of the addition of an antifungal medication for Resident #107. The facility census was 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment by failing to ensure an intravenous (IV) pole utilized for tube feeding was clean for one (Resident #27) of two residents reviewed for tube feeding. The facility census was 50.

Inspectors wroteBased on record review, interview, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed timely, which affected one (Resident #103) of 13 sampled residents. Specifically, the facility failed to ensure Resident #103's admission assessment was completed timely. The facility census was 50.

Inspectors wroteBased on record review, interview, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed for one (Resident #11) of one resident reviewed as part of the resident assessment task. The facility census was 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a tube feeding formula bag was labeled and dated for one (Resident #27) of two residents reviewed for tube feedings. The facility census was 50.

Inspectors wroteBased on observation, interview, record review, and facility standard operating procedure review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) during close-contact activities for residents on enhanced barrier precautions (EBP), which affected one (Resident #27) of two residents reviewed for tube feeding and one (Resident #26) of two residents reviewed for non-pressure related skin conditions. The facility census was 50.

Inspectors wroteBased on medical record review, staff interviews and policy review, the facility failed to ensure documentation was completed regarding a resident's meal/dietary intake. This affected one (#45) out of three residents reviewed for meal service. The facility census was 43.

Inspectors wroteBased on observation, staff interview, medical record review, and policy review, the facility failed to ensure staff utilized proper hand hygiene during wound dressing change procedures. This affected one (#06) resident of three residents reviewed for wound care. The facility census was 47.

Inspectors wroteBased on medical record review, observations, staff and resident interviews and policy review, the facility failed to maintain an effective pest control program. This had affected two (#10 and #36) out of two residents reviewed for pest control. The facility census was 52.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide written notification to the resident and/or their representative prior to the resident's transfer to the hospital. This affected four (#10, #36, #50 and #204) out of four residents reviewed for discharge from the facility. The facility census was 52.

Inspectors wroteBased on medical record review staff interview and review of the facility policy, the facility failed to provide notification of bed hold days available to residents who have discharged from the facility. This affected four (#10, #36, #50 and #204) out of four residents reviewed for discharge from the facility. The facility census was 52.

Inspectors wroteBased on personnel file review, medical record review, observation, staff interview and facilty policy review, the facility failed to follow their tuberculosis control plan when a new employee, a Dietary Services Assistant (DSA) #9 of six reviewed did not receive a two step Mantoux (PPD) test. This had the potential to affect all 45 residents of the facility. Additionally, the facility failed to ensure oxygen tubing was labeled and kept in a sanitary manner. This affected one resident (#37) of 16 reveiwed for oxygen therapy.

Inspectors wroteBased on medical record review, observation, resident and staff interview, the facility failed to ensure the accuracy of assessments regarding dental status and catheter use. This affected two residents (#41 and #45) of 16 residents sampled. The census was 45.

Inspectors wroteBased on medical record review and staff interview, the facility failed to develop a comprehensive care plan to include the resident's dental status. This affected one resident (#45) of two residents investigated for dental concerns. The census was 45.

Inspectors wroteBased upon record review and staff interview, the facility failed to ensure the services of a registered nurse were in place for at least 8 consecutive hours per day, seven days per week. This had the potential to affect all 45 residents residing in the facility.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility's medication storage policy, the facility failed to ensure medications were properly labeled with dates and stored. This affected two of two residents (#16 and #45) medications reviewed for proper labels. The facility census was 45.

Inspectors wroteBased medical record review, observation, resident and staff interview, the facility failed to ensure a resident received routine dental services. This affected one resident (#45) of two residents investigated for dental concerns. The facility census was 45.