Moundridge Manor

In the surveyor’s words

From the most serious findings on record at Moundridge Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 18, 2023

  The facility identified a census of 77 residents. The sample included three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to provide adequate supervision to prevent an elopement (when a cognitively impaired resident leaves the facility without staff knowledge) for cognitively impaired Resident (R)1, who was at high risk for falls and had recent exit seeking comments and behaviors. The facility staff last saw R1 in the library on 04/08/23 at 05:45 PM. Around 05:55 PM, R1's pressure alarm in her wheelchair sounded and staff began looking for her. During this time, R1 propelled herself out the front door in her wheelchair, following another resident's family member through the automatic doors. […]

• Actual harm, isolatedF689Sep 25, 2024

  The facility had a census of 71 residents. The sample included 18 residents, with 12 reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide adequate supervision to ensure a safe environment for Resident (R) 10, after a fall while outside alone. As a result, R10 had a second fall while outside alone resulting in abrasions and a laceration (cut) to his right palm (the underside of the hand), that required sutures (stitches) as well as right rib fractures. The facility also failed to evaluate R17 for his ability to safely handle hot liquids to identify risk and implement interventions and education to prevent accidents. […]

• Actual harm, isolatedF689Mar 15, 2023

  The facility had a census of 78 residents. The sample included 18 residents, with five reviewed for accidents. Based on observation, record review, and interviews, the facility failed to prevent an avoidable accident when staff failed to ensure Resident (R) 20 was secured in the whirlpool seat and failed to provide adequate assistance and/or supervision. As a result of the failures, R20 fell out of the whirlpool chair and sustained facial injuries which required emergency treatment and sutures (stitches.) The facility further failed to follow R31's plan of care, resulting in two falls. The deficient practice placed R31 at risk for further falls and avoidable injuries. […]

• No harm, potential for more than minimal, patternF804Sep 25, 2024

  The facility had a census of 71 residents. The sample included 18 residents. Seven residents received ground meat. Based on observation, record review, and interview, the facility failed to serve palatable food during the noon meal for two of the residents in the facility who received ground meat from the facility kitchen. This placed the residents at risk for foodborne illness and decreased quality of life. Findings included: - The 09/24/24 lunch menu recorded hamburgers, baked beans, potato chips, and ice cream. On 09/24/24 at 11:50 AM, observation during the noon meal revealed seven portions of ground hamburger placed on the steam table to be served. […]

• No harm, potential for more than minimal, isolatedF849Sep 25, 2024

  The facility had a census of 71 residents. The sample included 18 residents with one reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)42. This placed the resident at risk for inappropriate end-of-life care. […]