Stevens County Hospital Ltcu Dba Pioneer Manor

In the surveyor’s words

From the most serious findings on record at Stevens County Hospital Ltcu Dba Pioneer Manor, in the surveyor’s own words.

• Actual harm, isolatedF677Dec 12, 2024

  The facility had a census of 73 residents, with 18 sampled, and four reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene for Resident (R)20, which placed R20 at risk for poor personal hygiene and related complications. The facility also failed to assist R72 to the dining area for meals or provide assistance with meals in her room, to help prevent the 10.75% weight loss over four months. […]

• Actual harm, isolatedF686Dec 12, 2024

  The facility identified a census of 73 residents, with 18 residents sampled, and four residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record review, the facility failed to prevent the development of pressure ulcers and failed to provide treatment to promote healing for two residents, Resident (R) 24 and R14, who both developed pressure ulcers while a resident at the facility. […]

• Actual harm, isolatedF692Dec 12, 2024

  The facility identified a census of 73 residents with 18 sampled. Based on observation, interview, and record review, the facility failed to initiate weight loss interventions for cognitively impaired Resident (R) 72, who had an identified weight loss of 10.75% in four months. This deficient practice had the potential to negatively affect the resident's physical well-being. Findings include: - Review of R72's diagnoses from the Electronic Health Record (EHR) included dementia (progressive mental disorder characterized by failing memory, confusion) and vitamin deficiency (is the condition of a long-term lack of a vitamin). The Annual Minimum Data Set (MDS) dated [DATE], documented R72 had moderately impaired cognition. […]

• No harm, potential for more than minimal, widespreadF880Dec 12, 2024

  The facility reported a census of 73 residents. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program (IPCP) to provide a safe and sanitary environment for all residents through the following: The facility failed to ensure an effective infection control surveillance program regarding the tracking of infections of Resident (R)12 and R48. The facility failed to ensure staff performed hand hygiene prior to and during care for R20, R27, and R14. […]

• No harm, potential for more than minimal, widespreadF881Dec 12, 2024

  The facility reported a census of 73 residents. Based on interview and record review the facility failed to implement an effective antibiotic stewardship program that included antibiotic use protocols, an effective system to monitor antibiotic use, and/or an effective system to track and trend infections in the building for the facility's Infection Prevention and Control Program (IPCP). This failure had the potential to affect all 73 residents. Findings included: - During an interview on 12/12/24 at 10:50 AM, Administrative Staff B revealed the facility did not have an effective infection control program, which included an Antibiotic Stewardship Program. The staff that completed the Infection Control Surveillance Logs were not trained in infection control or Antibiotic Stewardship. […]