We Care Skilled Nursing Facility

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan and meet the needs of three of three sampled residents (Resident 1, 9 and 14) when: 1. The facility did not develop a care plan to address Resident 1's peripherally inserted central catheter (PICC, a tube used to deliver medications and other treatments directly to the large central veins near the heart) care. 2. The facility did not develop a care plan to address Resident 9's weight loss of 2.4lbs (pounds) in one week due to very low food and fluid intake. 3. The facility did not develop a care plan to address Resident 14's hearing loss. These failures had the potential to result in Residents 1, 9, and 14 not receiving appropriate care, monitoring, and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication rate was five (5) percent or less when three medication errors were observed out of 25 opportunities (medication error rate was calculated as followed: three divided by 25 then multiplied by 100, which was equal to 12 percent) when: 1. Resident 71 did not receive snack/food with Metformin (an oral medication to control blood glucose in the blood) tablet. 2. Licensed Nurse did not instruct Resident 12 to press inner canthus (inner corner of the eye where the upper and lower eyelids meet) after administering eye drops. 3. Licensed Nurse did not check Resident 5's Vital Signs (measurements of the body's most basic functions, including heart rate, pulse, temperature, respirations) before, during, and/or after nebulizer treatment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in accordance with professional standards of food service safety when: -Frozen meats inside the refrigerator were thawed on top of ready-to-drink fresh milk. -Multiple kitchen staff used the wrong test strip to check sanitizer concentration for the three-compartment sink and dishwasher. -Frozen chicken was thawed on the food preparation counter before cooking. -Two kitchen staff did not wear hair cover during food preparation. These failures had the potential to result in cross-contamination and food-borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure for one of four sampled residents (Resident 14), reviewed for communication deficit, received proper treatment to maintain hearing ability when hearing loss was not addressed by ht facility. This failure had the potential to result in the delayed access to hearing services.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and services to prevent urinary tract infection for one of one sampled resident (Resident 70), when staff did not follow-up on Resident 70's complaint of painful urination. This failure had the potential to result in delayed treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and assist in maintaining a sufficient food and fluid intake and for one of 20 sampled residents (Resident 9), when Resident 9 was not offered sufficient fluid intake and weight loss was not addressed to maintain proper hydration and health. This failure had the potential to result dehydration (dangerous loss of body fluid causes by illness or inadequate fluid intake) and further decline in Resident 9's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 1) with peripherally inserted central catheter (PICC, a long, thin, flexible tube that is placed into a small vein in the upper arm and moved forward until it is in a larger vein near the heart) received appropriate care and services consistent with professional standards of practice and in accordance with physician orders when Resident 1's PICC line dressing was not changed and monitored for complications. These failures had the potential for Resident 1 to develop complications such as infection and dislodgement (PICC line catheter displacement).

Inspectors wroteBased on interview and record review, for two of 15 sampled residents (Resident 3 and Resident 14), the facility failed to ensure; 1. An irregularity in Resident 14's medication regimen was identified by Consultant Pharmacist (CP) when fleet enema (laxative in the relief of occasional constipation, contains high levels of phosphates and sodium) was included in the bowel regimen despite Resident 14's constant refusal of phosphate binder. This failure had the potential to result in adverse events that included kidney injury. 2. Recommendation about Resident 3's medication regimen was not followed-through. This failure had the potential to result in increased risk of medication side effects.

Inspectors wroteBased on interview and record review, for one of five sampled residents (Resident 71) reviewed for unnecessary medications, the facility failed to ensure Resident 71 received apixaban (anticoagulant medication that has black box warning) with adequate monitoring for adverse effects. This failure had the potential to result in undetected adverse effects from the medication. Definition: Black Box Warning (BBW) is the strongest warning that the FDA (Food and Drug Administration) requires, and signifies that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the food preference and therapeutic diet as ordered by the physician for one out of 20 sampled residents (Resident 10). These failures had the potential to result in Resident 10 feeling disrespected and placed Resident 10 at risk for choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices when following was noted: 1. Seven (7) out of seven expired Intravenous Administration sets (IV kit, a medical device used to deliver nutrients and medications in a fluid form directly into patient's bloodstream) were kept in the medication storage room. 2. One (1) out of one expired Peripherally Inserted Central Catheter (PICC, a long, flexible thin tube, also known as catheter, put into a vein in upper arm for extended use) stabilizing device (a device to stabilize the wings of PICC line) were kept with ready to use medication administration supplies. This failure placed facility residents at risk for receiving medications via expired and with compromised sterility IV/ PICC line devices.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one (Resident 1) of three sampled residents was free from unnecessary drugs when facility's interdisciplinary team (IDT) did not re-evaluate use of Seroquel (an antipsychotic medication) at the time of admission and/ or within two weeks for its appropriateness and indication for use to consider whether or not the medication could be reduced, tapered, or discontinued. Interdisciplinary team is a group of healthcare professionals who work together to treat a patient condition. This failure had the potential for Resident 1 to receive unnecessary medications and placed her at risk to suffer adverse effects from the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food safely when food in the refrigerator, chest freezer, reach-in freezer, and dry storage were unlabeled and undated. This failure has the potential of placing 21 out of 21 residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications below a five percent (5%) error rate when: 1. Licensed Vocational Nurse (LVN )1 gave Insulin Aspart (a drug used to treat diabetes; a condition that develops when a person's blood sugar is too high) 2 units, late to one (Resident 10) of 10 sampled residents. 2. LVN 1 gave Metformin 850 mg (a drug used to treat diabetes; a condition that develops when a person's blood sugar is too high), after lunch was finished and not with lunch, to one (Resident 12) of 10 sampled residents. These errors resulted in Resident 10 and 12, not receiving medication as prescribed by their physicians.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve puree meals on plates (they were served in cups) for two residents (Resident 3 and Resident 120) out of 12 sampled residents. This failure had the potential to cause residents, who are on altered textures to lose their rights to be treated with dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders when administering oxygen to one resident (Resident 170) out of 12 sampled residents. This failure has the potential to cause Resident 170 to be given too much oxygen, which could result in hospitalization.

Inspectors wroteBased on interview, and record review, the facility failed to ensure dialysis (a treatment to remove extra fluid and waste products from the blood when the kidneys cannot) communication records were completed for one (Resident 6) of one sampled resident. This failure had the potential to miss signs of illness such as fever or bleeding, which could lead to hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility gave Insulin Aspart (a drug used to treat diabetes; a condition that develops when a person's blood sugar is too high) 2 units, late to one (Resident 10) of 10 sampled residents. This failure resulted in Resident 10 not receiving medication as prescribed by the physician and placed Resident 10's health at risk due to risk of a negative effect on Resident 10s blood sugar.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed the infection control program designed to prevent the spread of infection for one of 10 sampled residents (Resident 10) when Licensed Vocational Nurse (LVN) 1 failed to perform hand hygiene after removing gloves, LVN 1 had put on to give eye drops. This failure had the potential to cause infection or spread infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide 80 square foot of space per resident for residents who occupied 3 multi-bed bedrooms. This condition had the potential to result in lack of sufficient space for the provision of care both routine and emergency and for residents to have their personal belongings at bedside.

Inspectors wroteBased on observation, record review and interview, the facility failed to follow the lunch menu set for 4/18/22 when cut up watermelon was served to residents instead of apple crisp. This deficient practice resulted in Resident 20 feeling disappointed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner when ground pork was thawing on top of strawberry gelatin inside the refrigerator. This deficient practice had the potential to cause food borne illness and affect all residents. The facility census was 17.

Inspectors wroteBased on interview and record review, the facility failed to meet the needs for two (Resident 8 and Resident 10) of 16 sampled residents when the facility did not develop and implement a care plan for Resident 8's dialysis (treatment of kidney failure that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood) care and for Resident 10's hospice care. This deficient practice may result in Resident 8 and Resident 10's physical, psychosocial and functional needs to go unmet.

Inspectors wroteBased on interview record review, the facility failed to provide care for one (Resident 8) requring dialysis when staff did not do a complete physical assessment before and after Resident 8's dialysis treatment. This deficient practice resulted in an incomplete assessment of Resident 8's dialysis access site before treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications according to manufacturer recommendations and label medications appropriately when one bottle of Dorzolamide (prescription eye drops given for glaucoma, a condition where there is increased pressure in the eye) was stored in the refrigerator at 39 degrees Fahrenheit. This failure had the potential to cause resident to be administered ineffective medication resulting in worsening of their condition leading to damage of the eye.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one nursing staff performed hand hygiene (handwashing or use of an alcohol-based hand sanitizer) during medication administration when Licensed Vocational Nurse 1 (LVN 1) failed to perform hand hygiene after removing gloves after giving medications to Resident 5 and Resident 8. These failures had the potential to cause or spread infection which could result in hospitalization for Resident 5 and Resident 8.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide 9 of 17 residents in the following multiple resident bedrooms 3, 10, 15 with at least 80 square feet per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for residents to have personal belongings at the bedside.