Peak Resources- Shelby

In the surveyor’s words

From the most serious findings on record at Peak Resources- Shelby, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 5, 2022

  Based on observations, record reviews and resident, staff, Physician Assistant (PA), and Medical Doctor (MD) interviews, while under their care, the facility failed to implement an effective plan to protect the residents from accidents and injuries when smoking. Resident #34 and Resident #48 both utilized wheelchairs for mobility and had to navigate uneven pavement, with holes and cracks, to get to the side of the two-lane road which had a posted speed limit of 35 miles per hour and heavy local traffic. There were frequently cars parked across the street and during one observation a car had to go around Resident #48 as they smoked at the side of the road. The facility failed to ensure Resident #34 had a means to call for help. Both residents smoked during the day and night. […]

• Immediate jeopardy, isolatedF600May 18, 2021

  Based on record review, staff and physician interviews, the facility neglected to provide necessary care and services to a surgical wound. The resident was admitted into the hospital on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This was for 1 of 3 sampled resident's reviewed for providing care according to professional standards (Resident #166). Immediate Jeopardy began on [DATE] when Nurse #1 failed to identify the need for and provide nursing and medical interventions when Resident #166 was noted to have a foul odor with a large amount of yellow drainage coming from her surgical wound. The immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. […]

• Immediate jeopardy, isolatedF689May 18, 2021

  Based on observation, record review, resident, staff, and corporate nurse interviews, the facility failed to prevent a cognitively impaired resident who wandered and was assessed for being at risk for elopement from exiting the facility unsupervised. This affected 1 of 2 residents (Resident #167) reviewed for supervision to prevent accidents. Resident #167 was located 2 hours and 35 minutes later in the emergency room (ER) of the local hospital where he was treated for a laceration of his left lower infraorbital (the area located below the eye and lateral to the nose) area and an abrasion to his left forehead. He was treated in the ER and transferred back to the facility the same day. […]

• Immediate jeopardy, isolatedF600Mar 23, 2021

  Based on record review, staff and physician interviews, the facility failed to identify the seriousness of low oxygen saturation levels, assess the residents, provide nursing and medical interventions, identify the urgent need for medical attention or notify the physician for residents who experienced a low oxygen saturation levels. As a result, Resident #2 maintained a low oxygen saturation level ranging from 66% to 76% (normal range greater than 92%) for a 9-hour period resulting in a hospitalization . Resident #2 was confirmed to be hypoxic (deprivation of adequate oxygen supply at the tissue level) and was diagnosed with [REDACTED]. Resident #1 had a sudden onset of low oxygen saturation of 72% and oxygen therapy was initiated without ongoing assessments. […]

• Actual harm, isolatedF550Jun 23, 2021

  Based on observation, record review, resident, and staff interviews the facility failed to provide incontinence care for 1 of 3 residents sampled for incontinence (Resident #2). The resident expressed feelings of being upset. The findings included: 1. Resident #2 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and required extensive assistance of two staff members for bed mobility and transfers. She was coded as being dependent on one staff member for assistance with toileting. Resident #2 was coded as being always incontinent of bladder and frequently incontinent of bowel. […]