Woods at Sparta of Journey LLC, the

Inspectors wroteBased on observation, staff interviews, and review of the facility's policy titled Food Safety Requirements, the facility failed to ensure sanitary conditions in the kitchen. This deficient practice had the potential to place the 37 residents who received food or nutrition from the kitchen at increased risk of foodborne illness.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that one resident (R) (R35) with a qualifying diagnosis, from a sample of 28 residents, was referred to the appropriate state-designated authority for Level II PASRR (Preadmission Screening and Resident Review). This deficient practice had the potential to place R35 at risk of not having her mental and psychological care needs met.

Inspectors wroteBased on record review, staff and resident interviews, review of the facility policy titled, Incidents and Accidents, facility's tool titled Electrical Stimulation Prep, Precautions, and Contraindications, and Operational Manual, the facility failed to ensure three of 19 sampled residents (R) (R14, R15, R30) were free of accidents and hazards. Actual harm occurred on 6/5/2024, when physical therapy staff failed to oversee an electrical stimulation (e-stim) treatment (a device that sends electrical impulses through electrodes attached to the skin to help with physical therapy and fitness) treatment for R14, resulting in a burn to the right leg with 100% slough in the wound bed. Additionally, the facility failed to ensure resident's (R) (R14), (R15), and (R30) safety by having power strips maintained on the floor and bedside table while being utilized with medical equipment.

Inspectors wroteBased on observation, staff and resident interviews, record review, and a review of the facility's Facility Assessment, the facility failed to ensure the physical therapy staff were informed or educated prior to applying an electronic medical device for electrical stimulation treatment (also known as e-stim, which is a treatment method often used in physical therapy and pain management to deliver mild electrical currents through the patient's skin to either target the muscles to stimulate quicker recovery or the nerves to reduce pain) for one of one resident (R) (R 14). Actual harm occurred on 6/5/2024, when physical therapy staff failed to oversee an e-stim treatment for R14, resulting in a burn to the right leg with 100% slough in the wound bed.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled Manual Warewashing-3 Compartment Sink and Food Receiving and Storage, the dietary staff failed to prevent wet nesting with stacks of steam table pans to prevent bacteria growth, failed to store food items off the floor in the dry storage area, and failed to demonstrate the proper usage of the three compartment sink to prevent cross-contamination. The deficient practices had the potential to place 40 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness.

Inspectors wroteBased on observations and staff interviews, the facility failed to properly maintain one of two dumpsters to prevent leakage onto the ground. The facility census was 40 residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled Infection Prevention and Control Program and Laundry Services, the facility failed to maintain an effective infection control program by failing to ensure infection control policies were followed during the handling, storage, and processing of linens. In addition, the laundry staff failed to ensure the washing machine was clean and free from chemical deposits, dust, and lint. These failures had the potential to spread infection due to cross-contamination to 40 residents residing in the facility.

Inspectors wroteBased on staff interview, record review, and a review of the facility policy titled Notification of Changes, the facility failed to timely notify the health agent of a significant change related to a burn for one of 18 sampled Residents (R) (R14). This deficient practice places the resident at risk for complications such as infection and further deterioration of the burn wound. Findings Include: A review of the facility's undated policy titled Notification of Changes, revealed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 1. Accidents a. Resulting in injury. b. Potential to require physician interventions. Additional considerations: 1. Competent individuals: a. [...]

Inspectors wroteBased on observations, staff interviews, and a review of the facility policies titled Maintenance Inspection and Preventative Maintenance Program, the facility failed to ensure a safe, clean, comfortable home-like environment in four of 29 resident rooms (Rooms 111, 113, 102, and 302) and one common area (the Resident Dining Room). The deficient practices placed residents at risk of living in an unsanitary and unsafe living environment and the potential for diminished quality of life.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Abuse, Neglect, and Exploitation, the facility failed to ensure pre-employment screenings, specifically reference checks, were conducted prior to employment for eight of 60 employees. This deficient practice had the potential to place residents residing in the facility at risk of abuse, neglect, and exploitation from staff. The census was 40 residents.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Resident Assessment-Coordination with PASARR (preadmission screening and resident review) Program, the facility failed to ensure two of four residents (R) (R34 and R35) reviewed with a serious mental disorder (MD) were referred for a Level II PASARR assessment on admission or within 30 days of a new diagnosis. This deficient practice had the potential to affect the appropriate level of care and services provided for R34 and R35.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Resident Assessment-Coordination with PASARR (preadmission screening and resident review) Program, the facility failed to ensure one of four residents (R) (R19) reviewed with a serious mental disorder (MD) was referred for a Level II PASRR assessment on admission or within 30 days of a new diagnosis. This deficient practice had the potential to affect the appropriate level of care and services provided for R19.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to develop or implement a comprehensive, person-centered care plan for two of 19 sampled residents (R) (R14 and R15). Specifically, the facility failed to develop a care plan for pain management for R14 and implement a care plan for oxygen therapy for R15. The deficient practice had the potential to place R14 and R15 at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled Comprehensive Care Plans, the facility failed to revise the care plan for one resident (R) (R3) who had a change in code status. The sample size was 19.

Inspectors wroteBased on observations, staff interviews, record review, and a review of the facility policies titled, Oxygen Administration and Nebulizer Therapy, the facility failed to provide respiratory care consistent with professional standards of practice for two of five residents (R) reviewed for respiratory services (R15 and R30). Specifically, the facility failed to ensure oxygen (O2) was administered as ordered for R15 and failed to properly store the nebulizer mouthpiece, when not in use, for R30. The deficient practices had the potential to cause respiratory distress for R15 and respiratory infection for R30.

Inspectors wroteBased on record review, staff interview, and review of the facility policy titled Use of Psychotropic Medication, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for one of six residents (R) reviewed for unnecessary medications (R3).

Inspectors wroteBased on observation, staff interviews, review of facility menus, and review of the facility policy titled Therapeutic Diet Orders, the facility failed to follow established menus posted to ensure the appropriate nutrition was provided to residents. In addition, the facility also failed to notify the Registered Dietitian (RD) of meal/menu substitutions. This deficient practice affected three residents receiving a mechanical soft ground diet and six residents receiving a puree diet, from 40 residents consuming an oral diet.

Inspectors wroteBased on observation, staff interviews, review of the posted menu, review of the recipe for puree fried chicken, and review of the facility policy titled Food Preparation Guidelines, the dietary staff failed to follow the recipe for fried chicken as printed, compromising the nutrient value. This deficient practice affected six residents who received puree consistency and three residents who received mechanical soft ground consistency from 40 residents receiving an oral diet.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Labeling and Dating Guidelines, the facility failed to discard expired foods in the dry goods storage room and refrigerator. In addition, the facility failed to clean and secure overhead vents in the kitchen. These failures had the potential to promote foodborne illnesses associated with bacterial growth and cross contamination for 45 of 46 residents consuming an oral diet.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to complete an oxygen (O2) therapy care plan for one of 21 Residents (R) (R#2) receiving O2 therapy. This failure had the potential for residents to not receive treatment and/or care according to their needs.

Inspectors wroteBased on observations, staff, and resident interviews the facility failed to provide ADL care related to showers for one of 21 Residents (R) (#40) reviewed for showers. This failure had the potential to decrease the quality of life related to the unmet needs of the resident.