Via Christi Village Ridge

Inspectors wroteThe facility reported a census of 69 residents. The sample included 17 residents, with one resident reviewed for pain and activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to ensure Resident (R) 55 remained free from neglect when the facility failed to provide necessary care and services staff were aware R55 needed and had multiple failures, which resulted in delayed healing, physical discomfort, and decreased quality of life.

Inspectors wroteThe facility reported a census of 69 residents. The sample included 17 residents. Based on interviews, observation and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) and failed to follow appropriate infection control practices related to hand hygiene, sanitization of shared equipment, and sanitary storage of respiratory equipment.

Inspectors wroteThe facility had a census of 69 residents. The sample included 17 residents with five reviewed for discharge and two for hospitalization. Based on interviews and record review, the facility failed to provide a written bed hold policy at the time of transfer for Resident (R)75 and R3.

Inspectors wroteThe facility had a census of 69 residents. The sample included 17 residents. Based on interview, observation, and record review, the facility failed to provide services to meet professional standards of care when staff failed to ensure Resident (R) 7's Electronic Medical Record (EMR) contained appropriate documentation for the schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) diagnosis.

Inspectors wroteThe facility identified a census of 69 residents. The sample included 17 residents with two residents reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to ensure staff provided ADL assistance with personal hygiene for Resident (R) 55 and R63, who did not receive fingernail care and facial hair removal, and R8 who did not receive staff assistance to get dressed.

Inspectors wroteThe facility reported a census of 69 residents. The sample included 17 residents with one reviewed for hearing aid use. Based on interview and record review, the facility failed to ensure Resident (R) 8 received the necessary services, including staff assistance, with his hearing devices.

Inspectors wroteThe facility reported a census of 69 residents. The sample included 17 residents. Based on observation, interview and record review the facility failed to ensure Resident (R) 31 remained free from significant medications errors when staff held metoprolol without a physician's order and did not contact the physician regarding the held medication.

Inspectors wroteThe facility reported a census of 69 residents. Based on observation and interview, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment for residents and staff in the facility laundry.

Inspectors wroteThe facility reported a census of 72 residents. Three residents were reviewed for privacy and confidentiality in their care at the facility. Based on observation, interview and record review, the facility failed to protect the privacy of Resident (R) 1 when Certified Nurse Aide (CNA) M took a video of R1 without R1's consent.

Inspectors wroteThe facility identified a census of 56 residents with three residents reviewed for falls. Based on record review and interview, the facility failed to immediately implement interventions to prevent further falls for Resident (R) 1 after R1 had to be lowered to the floor when her left leg buckled underneath her. This failure led to another staff-assisted fall later the same day. As a result of this deficient practice, R1 sustained a severe fracture of the left ankle. This deficient practice also placed R1 at risk for pain, impaired mobility, and decreased independence.

Inspectors wroteThe facility reported a census of 72 residents. The facility identified four medication storage rooms and six medication carts used to administer medication to the residents. Based on observations, interviews, and record review, the facility failed to ensure that the medication administration error rate was no greater than five percent (%) when errors occurred with 22 of 27 observed medications had errors when the Licensed Nurse (LN) failed to confirm the medications administered against the physician's order or the eMAR (electronic medication administration record). The medication errors were due to failure follow nursing standard of care which resulted in an error rate of 81.48%.

Inspectors wroteThe facility census totaled 72 residents residing on four neighborhoods. Based on observation, interview, and record review. the facility failed to secure medications by the failure to lock two medication carts on two separate neighborhoods during administration of medications when nursing staff left the medication cart unlocked and unattended. This had the potential to affect 20 residents residing on neighborhood D2 and 20 residents on B2.

Inspectors wroteThe facility reported a census of 72 residents with 18 residents sampled. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff to follow infection control standards when delivering meal trays to residents in the dining area, appropriately clean respiratory equipment for Resident (R) 8, R45 and R223 or perform hand hygiene between phases of wound care for R28. This deficient practice has the potential to lead foodborne illness, respiratory illness and wound infections.

Inspectors wroteThe facility reported a census of 72 residents with 18 residents included in the sample. Based on interview and record review, the facility failed to ensure the five residents/ resident representatives acknowledged receipt related to COVID-19 (highly contagious respiratory virus) vaccination information/education for five of five residents, that included Resident (R)126, R124, R45, R6, and R16.

Inspectors wroteThe facility reported a census of 72 residents with 18 residents sampled, that included three residents reviewed for accident hazards. Based on observations, interviews, and record review, the facility failed to provide an environment as free of accident hazards as possible for Resident (R)28, when the facility failed to prevent multiple electrical cords plugged into two power strips next to R28's recliner from being strewn about the floor in the walking path between R28's recliner and R28's bed and the oxygen tubing on the floor in the walking path from the bathroom to R28's bed and recliner area. This deficient practice had the potential to create a trip hazard for R28 that could potentially lead to injury.

Inspectors wrote- R8's diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), other disorders of the lung and obstructive sleep apnea (OSA - a sleep disorder that causes repeated breathing interruptions during sleep). The 09/29/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance for all cares except eating and ambulation which were independent. The MDS documented no falls since admission and R8 received oxygen and a non-invasive mechanical ventilator via CPAP (continuous positive airway pressure - a ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep). [...]

Inspectors wroteThe facility reported a census of 61 residents with 15 sampled. Based on observation, interview, and record review the facility failed to promote dignity when staff failed to empty a suction canister for Resident (R) 10, which contained yellow liquid and was visible to all visitors who entered the room, through three days of observations.

Inspectors wroteThe facility reported a census of 61 with 15 residents in the sample. Based on observation, interview, and record review the facility failed to revise a care plan for one Resident (R) 30 regarding the use of a nebulizer (a respiratory treatment).

Inspectors wroteThe facility reported a census of 61 residents with 15 sampled. The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for three residents. The facility failed to notify the provider of weight fluctuations greater than two pounds (lbs.) as ordered and failed to document the application of ace wraps and tubigrip bandages (an elasticated tubular bandage used for support) for Resident (R) 16. The facility also failed to document treatments as ordered by the provider for R15 and failed to change the wound dressing daily, as ordered for R25.

Inspectors wrote- R20's Electronic Health Record (EHR) documented the following diagnoses under the medical diagnoses tab: chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 11/20/21 Annual Minimum Data Set (MDS) documented R20 had a Brief Interview for Mental status (BIMS) score of four, indicating severely impaired cognition, with use of oxygen noted. The 02/15/22 Care Plan documented staff were to provide R20 treatments as ordered and monitor for response. [...]

Inspectors wroteThe facility reported a census of 61 residents, with 15 in the sample, and five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to report three blood sugars over the parameters of 290 milligrams per deciliter (mg/dL) as ordered by the physician for Resident (R) 4.

Inspectors wroteThe facility reported a census of 61 residents. Based on observation, interview, and record review the facility failed to ensure nursing staff stored a suction catheter sanitarily to prevent infection for Resident (R) 10. The facility further failed to clean a glucometer (instrument used to calculate blood glucose) after use to reduce the risk of spread of infectious diseases. Findings Included: - On 04/04/22 at 03:32 PM observed R10's room with a suction canister on suction machine, with yellow liquid in the canister and sitting on the bedside table with the tubing and a Yankauer (an oral suctioning tool used in medical procedures) suction catheter tip set directly on the bedside table, with no barrier noted. [...]