Balanced Healthcare

Inspectors wroteThe facility failed to report sexual abuse between two residents (#1 and #2), out of six residents sampled for abuse allegations, within the required timeframes.

Inspectors wroteBased on record reviews, observations, and interviews the facility failed to provide adequate supervision to two (#4 and #5) of two residents which resulted in an physical altercation perpetrated by one resident (#4).

Inspectors wroteBased on observations and interviews, the facility did not ensure a clean, sanitary, and homelike environment for three (1 [NAME] [also known as the secured unit], 1East, and Lifestyle 2) out of six Wings.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure Enhanced Barrier Precautions (EBP) were initiated for three (#163, #138, and #237) of four residents sampled.

Inspectors wroteBased on observation, record review and interview the facility did not implement a comprehensive person-centered care plan consistent with resident rights for one resident (#51) out of eight residents sampled.

Inspectors wroteBased on record review and interview, the facility did not honor the wishes for Activities of Daily Living (ADL) related to bathing of body and hair for two residents (#51 and #100) out of eight residents sampled.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide quality care and services related to wound care management and treatment for two (#377 and #378) out of three sampled residents.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure smoking adaptive equipment was provided for one (#42) of 11 residents sampled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide enteral nutrition according to standards of practice related to expired nutritional formula for one resident (#246) out of one resident sampled.

Inspectors wroteBased on observation, interview, facility record review, hospital record review, and policy review the facility failed to protect residents' right to be free from physical, verbal, psychological, psychosocial and sexual abuse to one (Resident #1) of three residents reviewed, by failing to provide medication and supervision to an unsafe resident. On 1/20/2024 at approximately 3:35 AM Resident #1 was punched repeatedly in the face and sexually assaulted by Resident #2 in Resident #1's room. The facility failed to provide supervision of Resident #2, who was exhibiting poor impulse control, combativeness, erratic behavior, aggressive behavior and was difficult to redirect. Resident #2 required two psychiatric medication changes in the first five days of his stay in the facility and four days later he assaulted Resident #1. [...]

Inspectors wroteBased on observation, interview, facility record review, hospital record review, and policy review the facility failed to ensure adequate supervision to prevent physical and psychosocial harm to one (Resident #1) of three residents reviewed. On 1/20/2024 at approximately 3:35 AM Resident #1 was punched repeatedly in the face and sexually assaulted by Resident #2 in Resident #1's room. The facility failed to provide supervision of Resident #2, who was exhibiting poor impulse control, combativeness, erratic behavior, aggressive behavior and was difficult to redirect. This failure created a situation that resulted in serious injury to Resident #1 and resulted in the determination of Immediate Jeopardy on 1/17/2024. The findings of Immediate Jeopardy were determined to be removed on 1/29/2024 and the severity and scope was reduced to a D after verification of removal of immediacy of harm.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide written notification of Transfer/Discharge to Resident Representatives and the Ombudsman for five residents (#24, #161, #188, #221, and #95) of five residents sampled for hospitalization.

Inspectors wroteBased on interviews and record reviews the facility failed to provide written notification of Bed Hold Policy to Resident/Resident Representatives for five residents (#188, #24, #221, #161, and #95) of five residents sampled for hospitalization.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to 1. Adequately supervise thirty-two sampled residents to include resident (#193 and #10); and who reside in one of six units (LS1 [NAME] Secured) unit, during two of four days observed, on (6/27/2022, and 6/28/2022). It was determined Resident #193 was standing and walking out in the main hallways disrobed and not wearing any clothing on her lower part of her body, and with no staff supervision for long periods of time; 2. Failed to assure fall floor mats were placed while residents #721, #670, and #184 were in bed.

Inspectors wroteBased on observations, staff interview, and record review, the facility failed to ensure the kitchen and kitchen equipment were sanitary and maintained during four of four days observed (6/27/2022, 6/28/2022, 6/29/2022, and 6/30/2022). The kitchen was observed with peeling and chipped paint on equipment over the food preparation tables, rusted pipes and ducts that were over food preparation areas, food not stored appropriately in the walk-in refrigerator, pools of raw meat blood on the floor of the walk-in refrigerator, and refrigerator motor housing dripping rust color liquid on a vented bag of onions.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure one resident (#193) out of eleven sampled residents who had intellectual and or developmental disabilities, was dressed in a dignified manner during two days (6/27/22 and 6/28/22) of four days observed while in the LS1 [NAME] Secured unit. It was observed staff did not intervene to assist Resident #193 who disrobed and was standing out in the hallways for long periods of time.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one resident (#143) was free from the use of restraints out of one sampled resident for restraint usage.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide an activities program based on the comprehensive assessment and care plan for one resident (#212) of one sampled for activities.

Inspectors wroteBased on observation, interviews, and medical record review the facility failed to provide care and services four wound care of ulcers to one resident (#211) out of one sampled for wound care. Findings Included On 6/27/22 at 10:18 a.m. Resident #211 was observed sitting in the hallway with both of his feet wrapped with a thick white kerlix dressing. The dressing to his left foot contained bright yellow moist drainage noted to be the size of a soft ball. The yellow drainage was surrounded by a dark brown color dried drainage. The resident had no socks or shoes covering the dressing and both of his feet rested on floor surface. On 06/28/22 at 9:55 a.m. Resident #211 was observed in the hallway speaking with Staff M, Physical Therapist. She said Resident #211 had just finished his therapy session and she was going to transport him back to his bedroom. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure orders were followed related to catheter care for three residents (Resident #207, #188, and #218) out of the sampled five residents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure behavioral and side effect monitoring was conducted with the use of psychotropic medications for one resident (#188) of five resident sampled for unnecessary medications.

Inspectors wroteBased on observations, interviews, and policy reviews facility failed to 1) properly secure one of twelve medication carts, two of six narcotics boxes, and prescription medication for three residents (#14, # 47, and # 49) and one unknown resident and 2) ensure one of six refrigerators was at a proper temperature for medication storage.

Inspectors wroteBased on interview, medical record review, and facility policy review the facility failed to notify two resident representatives (# 79 and 105) by 5:00 p.m. on the calendar day once a COVID-19 positive case was confirmed by the facility out of three residents sampled for notifications. Findings Included: On 6/30/2022 at 3:15 p.m. an interview was conducted with the Director of Nursing (DON) who verbalized the last three residents that had tested positive for COVID-19 at the facility. A review of Resident #79's medical record contained a copy of a Lab Results Report which revealed a positive result of COVID-19 dated 6/22/2022. A review of Nursing Progress Notes dated 6/22/2022 at 11:46 p.m. read the resident was transferred to the isolation unit. The medical record did not reflect documentation of the emergency contact being notified of the change in condition. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to treat residents with respect and dignity for two (Residents #167 and #102) of sixty one sampled residents related to the lack of privacy for Resident #167 that was left in bed unclothed and Resident #102 that did not have a privacy cover on his urinary drainage bag.

Inspectors wroteBased on resident interviews, staff interviews, and policy review, the facility failed to honor a request for one (Resident #553) of two sampled residents to obtain copies of their medical record.

Inspectors wroteBased on observations, policy review, and staff interview, the facility failed to ensure a safe, clean, comfortable and homelike environment as evidence by, chipped paint, broken cabinet doors, a missing cabinet drawer, and dusty ceiling vents at the entrance to the kitchen and in nourishment rooms on three (1 East, 2 East, and Lifestyle 2) of five occupied units.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a care plan for three (Residents #102, #152, and #52) of 61 sampled residents related to 1). A urine catheter for Resident #102, 2). A wander alarm for Resident #152, and 3). Nutritional behaviors for Resident #52.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure behavioral monitoring for psychotropic medications was performed for one (Resident #82) of five residents reviewed.