Senior Citizens Home

In the surveyor’s words

From the most serious findings on record at Senior Citizens Home, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 27, 2023

  Based on record review, observations, staff, and Physician interview, the facility failed to safely transfer a dependent resident from wheelchair to bed which resulted in the fracture of the right humeral head (shoulder joint) and injury to the toenail of the right great toe with bleeding for 1 of 1 Residents (Resident #27) reviewed for accidents The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses that included a history of a stroke that resulted in right sided weakness. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #27 was severely cognitively impaired. The MDS indicated the Resident was dependent on 2 staff members for transfers and was coded as having impairment on 1 side of his upper and lower extremities. […]

• Actual harm, isolatedF925Sep 27, 2023

  Based on observations, record review and Physician, resident, Responsible Party (RP), and staff interviews the facility failed to provide a pest free living environment for 1 of 1 resident residing in the facility (Resident #42). The facility's failure contributed to Resident #42 sustaining a rash to her arms and legs due to ant bites resulting in itching and discomfort. The Findings included: Resident #42 was admitted to the facility on [DATE] with diagnoses that included dementia, diabetes, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive 1-2 staff member assistance with all activities of daily living including bed mobility. […]

• No harm, potential for more than minimal, widespreadF838Dec 5, 2024

  Based on staff interview and review of the Facility Assessment the facility failed to ensure the required parties were involved in developing the Facility Assessment, failed to evaluate contracted services utilized by the facility to provide necessary care for its residents during normal operations and emergencies, and failed to ensure the staffing plan considered specific staffing needs for each unit and shift as required, which had the potential to affect 49 of 49 residents. The findings include: Review of the Facility Assessment revealed it was revised 8/13/24 and updated on 9/24/24 and 11/01/24. […]

• No harm, potential for more than minimal, widespreadF851Dec 5, 2024

  Based on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours and licensed nursing coverage 24-hours per day. This was for 1 of 3 quarters reviewed for sufficient nurse staffing (Quarter 3 2024). Findings included: Review of the PBJ for Fiscal Year Quarter 3 2024 (April 1 through June 30) revealed there were no Registered Nurse (RN) hours for 4/13/24, 4/14/24, 4/27/24, 4/28/24, and 6/15/24. The PBJ report also noted the facility failed to have licensed nursing coverage 24 hours per day for 4/13/24, 4/14/24, 4/28/24, 6/15/24, and 6/16/24. […]

• No harm, potential for more than minimal, widespreadF882Sep 27, 2023

  Based on record review and staff interviews, the facility failed designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program. The findings included: During an interview with the Interim Director of Nursing (DON) on 9/24/23 at 11:30 am she revealed the Infection Preventionist (IP) was responsible for the facility's Infection Prevention and Control Program. The DON stated the IP was new to the position and had not completed any of the required training programs for the IP position yet. The DON stated the facility did not have any staff members with specialized training to meet the qualifications for the IP role. […]