Community Pride Care Center

Licensure Reference Number 175 NAC 12-006.18Based on observation, record review and interview, the facility failed to implement their water management policy to prevent the potential growth of bacteria such as Legionella (bacteria naturally found in fresh water and can grow in man-made water systems and can cause serious lung infections) in the facility water system and failed to COVID test Resident 6 when the resident had signs and symptoms of a respiratory illness. This had the potential to affect all facility residents. The facility census was 45. Findings are: A. Review of the undated facility Legionella Management Policy revealed the following: -The facility defined the control and management of Legionella bacteria in water systems within the facility. -The Legionella management team consisted of the Administrator, Maintenance Director, Safety Officer, and Infection Control. -If staff found control limits such as temperature levels, disinfection levels or manufacturer recommendations were not met, staff took corrective actions to return conditions back to acceptable ranges.…

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.

Licensure Reference Number 175 NAC 12-006. Based on record review and interview, the facility failed to have documented duration of use for all prescribed antibiotics or documented rationale to continue antibiotics indefinitely for Residents 15, 31 and 37. The sample size was 8 and the facility census was 45. Findings are: A. Review of the facility policy Antimicrobial Stewardship Program dated November 2017 revealed the following: -The goal of the Antimicrobial Stewardship Program (ASP) was to promote the appropriate use of antimicrobials in order to maximize treatment outcomes and minimize unintended consequences of antimicrobial therapy. The ASP aimed to improve antibiotic prescribing practices through the development and implementation of antibiotic use protocols and a system to monitor antibiotic use. -An Antimicrobial Stewardship Committee had been established to provide support and oversee activities of the ASP. The ASP was part of the infection Prevention and Control Program (IPCP) and reported activity and outcomes the QAPI (Quality Assurance Performance Improvement)…

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 Licensure Reference Number 175 NAC175 12-006.(D)(vi) Based on observation, record review and interview; the facility failed to date a multi-dose medications for Resident 2 and 21 after medication was opened or accessed to ensure manufacturer recommendations and professional standards were followed. The sample size was 3 and the facility census was 45.Findings are:A. Review of the facility policy titled Labeling of Medication Containers revised [DATE], revealed all drugs and medications maintained in the facility would be properly labeled in accordance with state and federal regulations.The Policy interpretation and implementation revealed that labels for individual drug containers must include the expiration date.B. An observation on [DATE] at 7:20 AM revealed Registered Nurse (RN)-G, prepared Resident 2's Ozempic (anti-diabetic agent) 0.25 milligrams(mg). The Ozempic syringe was not dated when opened or when expired and there were 2 doses that had been administered out of the syringe. Review of Resident 2's…

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 Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, interview, and record review; the facility failed to implement the required Personal Protective Equipment (PPE-items such as gowns, gloves, face shield that are worn to protect care givers) during the provision of cares for Resident 12 for Enhanced Barrier Precautions (EBP-involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multidrug-resistant organism (MDRO-bacteria that have become resistant to certain antibiotics) as well as those at increased risk for MDRO, residents with wounds or indwelling medical device/s). The sample sizes was 4 with a census of 42. Findings are: Review of the EBP sign posted on Resident 12's room door, from the U.S. Department of Health and Human Services Center for Disease Control and Prevention revealed the following: For EBP Everyone Must: -Clean their hands, including before entering and when leaving the room. Providers and Staff Must…

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.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview the facility failed to complete a thorough investigation following a fall with injury for Resident 1. The sample size was 4 and the facility census was 44. Findings are: Review of the facility undated policy Accidents and Incidents -Investigating and Recording revealed the e Charge Nurse or Department Director would conduct an immediate investigation of accidents/incidents including the circumstances surrounding the accident/incident. Review of the facility undated policy and procedure Shower/Tub Bath revealed the staff were to stay with the resident throughout bathing and never to leave a resident unattended, however there was no indication the policy addressed making sure the safety belt was used to secure residents in the bathing chair. Review of Resident 1's Care Plan dated 1/23/24 revealed the resident was at risk for falling, needed assistance with activities of daily living and was dependent for bed mobility, grooming, dressing, bathing, toileting, and transferring. In addition, the resident…

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.

Licensure Reference Number 175 NAC 12-006.09D7 Based on record review and interview the facility failed to ensure the safety of Resident 1 during bathing resulting in an injury. The sample size was 4 and the facility census was 44. Findings are: Review of the facility undated policy and procedure Shower/Tub Bath revealed the staff were to stay with the resident throughout bathing and never to leave a resident unattended, however there was no indication the policy addressed making sure the safety belt was used to secure residents in the bathing chair. Review of Resident 1's Progress note dated 3/19/24 at 11:52 AM revealed the resident was in a bathing chair outside of the tub and as the Bathing Aide reached to grab a towel the resident reached to the side and leaned out of the bathing chair and fell to the floor hitting (gender) head on the leg of a full body mechanical lift. The Bathing Aide immediately called for a nurse to assist. The nurse responded finding the Bathing Aide on the floor supporting the resident's head. The resident's forehead was lacerated. The resident's…

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 Licensure Reference Number 175 NAC 12-006.09C Based on observation, record review, and interview the facility failed to develop comprehensive Care Plans to accurately reflect the current status for 4 of 12 sampled residents (Resident 2's infection, and use of antianxiety medications, Resident 32's skin integrity, Resident 37's edema (fluid retention of tissue), and Resident 36's Hospice (end-of life) care). The facility census was 41. Findings are: A. Review of the facility policy Care Plan-Comprehensive dated 8/15/23 revealed the following; -The facility developed a comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs. -the interdisciplinary team in coordination with the resident, his/her family or representative, developed and maintained a comprehensive care plan for each resident, -the care plan was designed to identify problem areas, initiate goals, incorporate risk factors, build on resident strengths, reflect…

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.

Licensure Reference Number NAC 12-006.02(8) Based on record review and interview, the facility failed to thoroughly investigate Resident 192's potential misappropriation related to missing money in order to prevent further incidents. The total sample size was 17 and the facility census was 41. Findings are: Review of the undated facility policy titled Abuse, Neglect, and Misappropriation of Property revealed the following; -the purpose of the policy supported a 'zero tolerance' related to resident abuse, neglect and/or misappropriation of property; and -misappropriation was defined as; the deliberate misplacement, exploitation, or use of a resident's belongings or money without the resident's consent. Record review of a facility investigation report revealed on 2/5/23, Resident 192 reported missing bingo money from the resident's dresser drawer. There had been a search of the resident's room for the money, but staff were unable to locate it. The activity staff member and resident's family member confirmed the resident had $5.10 from bingo winnings in [gender] possession. The…

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 ensure to accurately code Resident 23's Preadmission Assessment and Annual Resident Review (PASARR) status on the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) and Care Plan the results. The total sample size was 12 and the facility census was 41. Findings are: Review of the facility policy PASARR, last revised 2/12/22 revealed the following: -PASARR was a federal requirement to ensure individuals were not inappropriately placed in nursing homes, and -when a level II PASARR was found, the facility would update the individuals Care Plan. Review of Resident 23's annual MDS dated [DATE] and a quarterly MDS dated [DATE] revealed the following: -in section A, the resident not marked to have been evaluated by Level II PASARR, -the resident was not marked to have a serious mental illness, -diagnoses of anxiety, depression, and schizophrenia, and -the resident took antipsychotic medication (a type 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.