The Lodge at Mills River

In the surveyor’s words

From the most serious findings on record at The Lodge at Mills River, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 1, 2022

  Based on observations, record review, review of manufacturer's instructions, Nurse Practitioner, family and staff interviews, the facility failed to ensure securement was according to manufacturer recommendations for providing a safe facility van transport when a resident fell out of the wheelchair onto his side on the floor of the van resulting in minor abrasions and bruising to his face, arm and side for 1 of 2 residents reviewed for accidents (Resident #22). The findings included: Review of the manufacturer's instructions for the QRT-1 Series, which is the system used on the facility's transport van to secure residents who are seated in wheelchairs during transport, specified in part: B. Secure Passenger: 1. […]

• No harm, potential for more than minimal, patternF812Dec 1, 2022

  Based on observations and staff interviews, the facility failed to discard dry food items that were past the use by date, opened, and ready for use in 1 of 1 pantry, failed to discard fresh vegetables with visible signs of spoilage in 1 of 1 walk-in refrigerator and failed to discard frozen food items with visible signs of freezer burn and ice accumulation stored in 1 of 1 walk-in freezer. This had the potential to affect food served to residents who resided in the facility. Findings included: An initial observation of the kitchen and concurrent interview was conducted with the Dietary Manager (DM) on [DATE] at 9:32 AM that revealed the following: Stored in the pantry and available for use was a clear plastic bag containing instant chocolate pudding mix labeled with a use by date of… […]

• No harm, potential for more than minimal, isolatedF554Dec 1, 2022

  Based on record review, observations, interviews with residents and staff the facility failed to assess the capability of residents to self-administer medications for 2 of 2 residents reviewed for self-administration (Resident #9 and #17). The findings included: 1. Resident #9 was admitted to the facility on [DATE]. Review of the admission MDS dated [DATE] revealed Resident #9 was assessed as being cognitively intact. Review of the physician orders revealed none were in place for lubricating eye drops. Review of the medical records for Resident #9 revealed there was no documentation or assessment to show the resident was safe to self-administer medications. An observation and interview were conducted on 11/28/22 at 11:09 AM with Resident #9. […]

• No harm, potential for more than minimal, isolatedF641Dec 1, 2022

  Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the area of functional status for 1 of 12 sampled residents reviewed for MDS accuracy (Resident #22). Findings included: Resident #22 was admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or loss of strength on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side. The Hospice plan of care, revised 04/11/22, for Resident #22 revealed a care plan in place to address a problem of area of pain due in part to contractures in bilateral legs and arms. […]

• No harm, potential for more than minimal, isolatedF695Dec 1, 2022

  Based on observations, record review, staff and Nurse Practitioner (NP) interviews the facility failed to follow the Physician order for the use of supplemental oxygen for 1 of 2 residents reviewed for respiratory care (Resident #191). Findings included: Resident #191 was admitted to the facility 11/22/22 with diagnoses including chronic obstructive pulmonary disease (abbreviated as COPD and meaning a condition involving constriction of the airways and difficulty breathing) and respiratory failure (a condition in which the lungs have difficulty loading the blood with oxygen or removing carbon dioxide). […]