Vermilion Health Care Center

Based on observation and interview, the provider failed to ensure the most recent survey results for the facility were posted in a place readily accessible to residents, family members, and legal representatives of residents. The facility's census was 94 residents. Findings: On 09/23/2024 at 1:30 p.m., an observation was made of a blue binder labeled Survey Results was located in a clear plastic document holder mounted to the wall across from the Nurses station near the main entrance just outside of the Minimum Data Nurses (MDS) office. A review of the Survey Results binder revealed the results and the plans of correction from the last annual survey dated 08/02/2023 and a complaint survey that was conducted 04/04/2023. The results of the most recent complaint survey conducted 10/04/2023 were not in the binder. On 09/24/2024 at 12:44 p.m., an interview was conducted with S6Adm (Administrator) who stated all recent survey results were available in the blue binder in a wall pocket just outside of the MDS Nurse Station Office. S6Adm then reviewed the contents of the binder and confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations and interviews, the facility failed to develop an/or implement a comprehensive person-centered plan of care for 3 (#10, #49 and #88) out of 31 sampled residents as evidenced by failing to: 1. follow the plan of care to address Resident #49's elevated blood sugar; 2. develop a person-centered plan of care to address hearing deficits for Resident #88; and 3. follow the plan of care for Resident #10 for ensuring the chair alarm was functioning properly. 1. Resident #49 Review of Resident #49's electronic medical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included in part: Type 2 Diabetes Mellitus. Review of the resident's physician's orders revealed in part .Novolin R (regular) Injection Solution 100 UNIT/ML (milliliter), inject as per sliding scale: >400=15U (units) recheck in 1 hour, then if >400 (greater than) =15U and call MD/NP, subcutaneously four times a day. Review of the resident's MARs (Medication Administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to provide appropriate and sufficient services, treatment and care according to standards of professional practice for 1 (#49) of 2 (#49, and #64) residents that were reviewed for urinary catheter or UTI (urinary tract infection). The facility failed to ensure Resident #49's urinary catheter drainage tubing was properly secured off of the floor. Findings: Resident #49 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Urinary Tract Infection, Acute Cystitis without Hematuria. A review of Resident #49's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/19/2024 section H revealed yes for indwelling catheter. On 09/23/2024 at 9:07 a.m., an observation was conducted of Resident #49 in her room. The resident had a urinary catheter, the catheter bag was covered and placed underneath the wheelchair, and the drainage tubing part was under her wheelchair touching the floor. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the resident's Minimum Data Set (MDS) accurately reflected the resident's status by failing to accurately code the resident for serious mental illness for 1 (#3) of 3 (#1, #2, and #3) sampled residents. Findings: A review of Resident #3's electronic record revealed he was admitted to the facility with diagnoses including Paranoid Schizophrenia. A review of Resident #3's admission MDS (Minimum Data Set) dated 08/28/2023 revealed he had a BIMS (Basic Interview for Mental Status) of 3, indicating he had severe cognitive impairment. Further review revealed Resident #3 had behavioral symptoms that interfered with resident care, social activities, and intruded on privacy of others. Section A1510A which asked if he had a serious mental illness was blank. A review of Resident #3's Social Services' Progress Notes revealed in part, 08/21/2023 at 10:38 a.m., S1SSD (Social Service Director) wrote: His Dx (Diagnoses) are as follows: Paranoid Schizophrenia . On 10/24/2023 at 08:36 a.m., an interview was conducted with S6MDS who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to refer a resident with a possible serious mental disorder for a Level II PASARR (Pre-admission Screening and Resident Review) evaluation to the appropriate state-designated authority after the resident was readmitted to the facility following an inpatient psychiatric stay for 1(#3) out of 3 (#1, #2 and #3) sampled residents. This deficient practice placed Resident #3 at risk of not receiving or benefiting from specialized services the resident may have needed. Findings: A review of the facility's policy titled Resident Assessment-Coordination with PASARR Program read in part, Policy Explanation and Compliance Guidelines: .6. The Social Services Director or designee shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority .9. Any resident who exhibits a newly evident possible serious mental disorder intellectual disability, or a related condition will be referred promptly to the state…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the accuracy of a Level I PASARR (Pre-admission Screening and Resident Review) for a resident with a diagnosis of Paranoid Schizophrenia upon admission to the facility for 1(#3) out of 3 (#1, #2 and #3) sampled residents. This deficient practice placed Resident #3 at risk of not receiving or benefiting from specialized services the resident may have needed. Findings: A review of the facility's policy titled Resident Assessment-Coordination with PASARR Program read in part, Policy Explanation and Compliance Guidelines: .1. All applicants to this facility will be screened for serious mental disorders .in accordance with the State's Medicaid rules for screening. a. PASSAR Level I - initial screening that is completed prior to admission . 6. The Social Service Director or designee shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority . A review of Resident #3's electronic record revealed he was admitted to the facility from a rehabilitation facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #23 Review of the facility's policy, Laryngectomy Care and Suctioning read in part: It is the policy of this facility to ensure that a resident with a laryngectomy stoma receives care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Review of the facility's policy, Personal Protective Equipment read in part: Personal Protective Equipment or PPE refers to a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with pathogens. It includes gloves, gowns, face protection (facemasks, goggles, and face shields) .PPE will be utilized as part of standard precautions regardless of a resident's suspected or confirmed infection status .Indications/considerations for PPE use: Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene .Change gloves and perform hand hygiene between clean and dirty tasks .Wear a mask to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on records review, interviews, and observations, the facility failed to ensure the resident's care plan and physician's order(s), were followed for 2 (#45, #67) out of 35 sampled residents. This was evidenced when: 1. Facility staff failed to monitor for bleeding or bruising for an anticoagulant (blood thinner) for Resident #45 2. Facility staff failed to place a left elbow extension brace on Resident #67 to prevent further contractures. Findings: Review of policy: Anticoagulants Purpose: This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility's collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety. Policy Explanation and Compliance Guidelines: .3. The resident's plan of care shall alert staff to monitor for adverse consequences. 1.Review of Resident #45's electronic clinical record revealed an admit date of 05/22/2019 with diagnoses that included Hypertension, Schizoaffective Disorder Bipolar Type,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide a charge nurse other than the DON (Director of Nursing) when the facility had an average daily census of greater than 60 residents. This had the potential to affect a current census of 91 residents. Findings: Review of facility assessment, dated 07/27/2023, revealed in part . 1.2 Indicate your daily average census (enter a range): 92. Review of timesheets revealed: -S3RNAIT (Registered Nurse) (Administrator in Training) clocked in as the DON and functioned as the charge nurse on the following dates: 06/06/2023, 06/07/2023, 06/08/2023, 06/09/2023, 06/12/2023, 06/13/2023, 06/14/2023, 06/15/2023, 06/16/2023, 06/19/2023, 06/20/2023, 06/21/2023, 06/22/2023, and 06/23/2023. -S4DON clocked in as the DON and functioned as the charge nurse on the following dates: 07/17/2023, 07/18/2023, 07/19/2023, 07/20/2023, 07/24/2023, 07/25/2023, 07/26/2023, and 07/27/2023. On 08/02/2023 at 9:01 a.m., an interview was conducted with S4DON, S1ADM, and S3RNAIT. S4DON stated she started 06/26/2023 as the full time DON. S1ADM stated S3RNAIT…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure its medication rate was not 5 percent or greater as evidenced by a calculated medication error rate of 18.75 percent. Findings: Review of the facility's policy titled Medications- Administering read in part .3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. On 08/02/2023 at 8:19 a.m., S6LPN (Licensed Practical Nurse) was observed as she administered medications. Resident #76 Resident #76 was admitted to the facility on 0 2/13/2023 with diagnoses in part: Heart Failure, Hypertension, and Coronary Artery Disease. 08/02/2023 at 8:20 a.m., an observation was made of S6LPN administering the following medication to Resident #76 that was due at 7:00 a.m.: -Carvedilol 12.5 mg (milligram) tablet - 1 tablet by mouth twice daily On 08/02/23 8:22 a.m , an interview was conducted with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to ensure quality of care in accordance with professional standards of practice, for 1(#6) of 35 sampled residents. This was evidenced when 72 hours of neuro-checks were not completed after Resident #6 had an unwitnessed fall and hit her head. Findings: A review of the facility's policy titled, Head Injuries read in part: 1. Residents who have sustained a head injury will be monitored according to current standards of nursing practice. 2. When a resident sustains a head injury, he or she will be assessed by a licensed nurse according to the following schedule as a minimum: -Every 15 minutes for 1 hour -Every 30 minutes for 1 hour -Every hour for 4 hours -Every 4 hours for the next 20 hours -Every 8 hours for the next 24 hours -And once 24 hours later . Resident #6 was admitted to the facility on [DATE] with diagnoses: Generalized Anxiety Disorder, Malignant Neoplasm of Right Main Bronchus, Other Deficiency Anemias, Diabetes Mellitus, Personal History of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide respiratory care in accordance with professional standards of practice and the facility's policies and procedures evidenced by: 1. failing to follow the physician's order and care plan for oxygen administration for 2 (#6, #22) of 2 residents investigated for oxygen therapy and 2. failing to assure the resident had a portable supply of oxygen to take along when outside the room/ambulating on the unit for Resident #22. Findings: Review of the facility's policy Oxygen Administration revealed in part: Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident .Equipment and Supplies 1. portable oxygen cylinder (strapped to the stand); .No smoking/oxygen in use signs .Place an oxygen in use sign in a designated place on or over the resident's bed. Adjust the oxygen delivery device so that it is the proper flow of oxygen being administered.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.