Tierra Rose Care Center

In the surveyor’s words

From the most serious findings on record at Tierra Rose Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 11, 2023

  1. Based on interview and record review it was determined the facility failed to ensure Resident 9 did not elope from the facility for 1 of 1 sampled residents (#9) reviewed for elopement. This failure was determined to be an immediate jeopardy situation because the facility failed to follow the residents care plan and provide supervision which resulted in Resident 9's elopement from the facility. Findings include: Resident 9 admitted to the facility in 2022 with diagnoses including symptoms involving cognitive functions following other nontraumatic intracranial hemorrhage and cataracts. Prior to admission, the resident was homeless. […]

• Immediate jeopardy, isolatedF690Jan 11, 2023

  Based on interview and record review it was determined the the facility failed to monitor and assess Resident 2 for signs of UTI (urinary tract infection) such as decreased food and fluid intake and decreased urine output and failed to notify the provider of condition changes for 1 of 3 sampled residents (#2) reviewed for change of condition. This failure was determined to be an immediate jeopardy situation because the facility failed to recognize and treat a UTI which resulted in severe sepsis and death. Findings include: Resident 2 admitted to the facility in 4/2022 with diagnoses including intellectual disabilities and neurogenic bladder. […]

• Immediate jeopardy, isolatedF867Jan 11, 2023

  Based on interview and record review it was determined the facility failed to correct and monitor a quality deficiency identified on the previous survey related to resident elopement and to respond to adverse events timely. This failure was determined to be an immediate jeopardy situation because the facility failed to prevent Resident 9's elopement from the facility three times since the 10/20/22 QAPI committee meeting. Findings Include: The 10/21/22 State Operations Manual, Appendix PP instructs facilities to create a formal action plan for identified deficiencies which included determining contribution causes of the problem; measurable goals, step by step interventions to correct the problem and achieve stable goals, and a description of how the QAPI committee would monitor the concern… […]

• Immediate jeopardy, isolatedF689Mar 28, 2022

  1. Based on observation, interview, and record review it was determined the facility failed to ensure residents with dementia did not elope from the facility and the facility failed to ensure residents who were at risk for aspiration were supervised while eating for 4 of 14 sampled residents (#s 2, 17, 18 and 158) reviewed for elopement and aspiration precautions. These failures resulted in immediate jeopardy situations and placed other residents at risk for accidents. Findings include: A. Resident 158 admitted on ,d+[DATE] with diagnoses including [CONDITION(S)], dementia and acute kidney failure. The 2/18/22 hospital discharge diet orders indicated Resident 158 required 1:1 supervision with feeding. […]

• Actual harm, isolatedF552Jan 11, 2023

  Based on interview and record review it was determined the facility failed to ensure a resident and resident's representative had the right to direct her/his own care, refuse hospice and be aware of all treatment options for 1 of 3 sampled residents (#5) reviewed for hospice. This caused Resident 5 to be admitted to hospice and sustained a distressing and diminshed quality of life prior to death. Finding include: Resident 5 admitted to the facility on [DATE] with diagnoses including heart failure and chronic pleural effusion (an excessive accumulation of fluid in the lungs pleural space). The resident died on [DATE]. On [DATE] Resident 5 admitted with a PleurX catheter (a small, flexible tube that doctors place within the patient's chest to drain fluid from the pleural space). […]