Balmoral Home

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders were followed for one resident (R1). This failures affected one of three residents reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standards of practice by not performing a proper nursing assessment of a resident's wound/skin condition, after a certified nursing assistant (C.N.A) notified the nurse of the existence of the wound/skin condition for 1 resident (R5) out of 3 residents reviewed for a skin assessments. This failure resulted in the delay of R5's wound treatment, for a wound that was septic, necrotic, infected with Fournier's gangrene, and required wound debridement. Findings Include:R5's face sheet documents that R5's diagnosis is not limited to peripheral vascular disease, type 2 diabetes mellitus, malignant neoplasm of overlapping sites of bladder, hypertensive heart disease without heart attack, hyperlipemia. [...]

Inspectors wroteBased on staff interviews and record review, the facility failed to protect the right of the resident to access their personal funds without restriction by placing a resident on a money management program as a form of behavioral punishment. This failure affected 1 resident (R4) out of 4 residents reviewed for resident funds.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were free of abuse/physical assault. This failure affected three residents (R3, R4, and R5) of five residents reviewed for resident-to-resident abuse in the facility.

Inspectors wroteBased on interview and record review, the facility failed to supervise and prevent a resident who repeatedly stated she did not want to be in the facility from eloping from the facility. This failure affects one (R6) out of three residents reviewed for supervision in a total sample of three residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide wheelchairs to residents that were in safe and working condition to 3 (R12, R13 and R14) of 3 residents reviewed for concerns on properly functioning wheelchairs. This failure had the potential to result in accidents and safety hazards. Findings Include:R12's Face Sheet documents that R12 was admitted to the facility on [DATE] with a diagnosis of nontraumatic intracerebral hemorrhage, traumatic subdural hemorrhage epileptic seizures related to external causes, chronic kidney disease, and hypertensive heart disease without heart failure aneurysm of the descending thoracic aorta. R12's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact with little to no impairment. [...]

Inspectors wroteBased on review of records, interviews and observations facility failed to follow preventive measures to address sacral pressure ulcer care for 1(R2) out of 3 residents for a total of 3 residents reviewed for skin care. This failure resulted to one resident (R2) sustaining pressure ulcer deterioration.

Inspectors wroteBased on review or records and interview the facility failed to provide accurate treatment administration record for 1(R2) out of 5 residents for a total of 5 residents reviewed. This failure resulted to inaccurately representing one (1) resident (R2) treatment of pressure ulcer care in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to supervise and monitor a cognitively impaired resident with known behaviors of ingesting non-edible, toxic items from obtaining those items. This failure affects one of three residents (R2) reviewed for supervision in a total sample of three residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess a resident for safe self-administration of medications. This failure affected one resident (R148) and has the potential to affect all 56-residents residing on the second floor. Findings Include: The (12/03/2024 email correspondence with V10 (Assistant Administrator documented that there were 56 residents on the second floor. R148's admission diagnoses include but not limited to dermatitis, atrial fibrillation, congestive heart failure, and dementia. R148's Brief Interview of Mental Status (BIMS) score is 11 which indicates R148 has moderate cognitive impairment. On 12/1/24 at 10:30 am, observation of Zinc oxide 20% ointment in a long white tube on R148's nightstand. On 12/2/24 at 1:10 pm observation of Zinc oxide 20% ointment and triamcinolone acetonide 0.5% ointment in long white tubes on R148's nightstand. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that medications were signed out when administered for four residents (R8, R43, R81, and R97). This failure affected four residents in the sample of 57 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident (R120) smoke at a designated smoking area; and failed to ensure that environment was free from hazards (razors) for three residents (R36, R116 and R148). These failures have the potential to affect all 47 residents on the first floor, and all 56 residents on the second floor at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy of reconciling controlled substances at the end of each shift. This failure has a potential to affect all 4 residents receiving controlled substances on the 1st floor.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored at proper temperatures in two of three medication refrigerators reviewed for medication storage; failed to secure Schedule II controlled drugs and other controlled drugs subject to abuse in a separately locked compartment separate from non- controlled drugs; and failed to ensure medications including controlled drugs of two of two residents (R159 and R262) that expired are disposed timely. These failures have the potential to affect 47 residents residing on first floor and 56 residents residing on third floor of the facility.

Inspectors wroteBased on interview and record review the facility failed to refer one resident (R126) for rescreening to the state agency for Preadmission Screening and Resident Review (PASRR). This deficient practice affected one resident (R126) in a total sample size of 57 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date oxygen equipment (oxygen tubing and nebulizer mask per the facility's policy. These failures affected two residents (R54 and R126) reviewed for oxygen equipment, in a total sample of 57 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that medication that fell on the floor was not administered to a resident (R55). This failure affected one resident (R55) in the sample of 57 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a comfortable environment to one resident (R162). This failure affected one resident in a total sample size of 57 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Daily Nursing Staffing was posted daily and failed to ensure the Daily Nursing Staffing was completed appropriately. These failures have the potential to affect all 159 residents residing at the facility.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their fall policy to study fall causations, provide corrective actions to prevent reoccurrences, failed to provide adequate supervision and failed to develop specific fall interventions for 1 [R1] of 3 residents reviewed for falls. This failure resulted in R1 sustaining traumatic subarachnoid hemorrhage. Findings Include: R1's clinical record documents in part; [...]

Inspectors wroteBased on observations, interviews and records review, the facility failed to properly label, store and discard expired medications in a medication cart that serves 21 residents on the second floor. This deficiency has the potential to affect R12, R18, R76, R37, and 21 residents receiving medications from the second floor, team two medication cart, in a sample of 30 residents reviewed.

Inspectors wroteBased on review of records and interviews the facility failed to follow pain management policy related to documentation of pain, assessment of pain, and following physician order in giving pain medication for 1 out of 4 residents (R2) reviewed for pain management.

Inspectors wroteFailures resulted in two deficient practice statements. A. Based on observation, interview, and record review, the facility failed to follow their Aspiration Precautions policy and follow speech therapy recommendations for 2 (R12 and R66) of 29 residents reviewed for improper nursing care. B. Based on observation, interview, and record review, the facility failed to follow policy and procedure on glucometer cleaning to prevent cross contamination for 2 (R110, R143) of 3 residents observed for blood glucose monitoring during medication administration. The facility also failed to follow its Enhanced Barrier Precautions policy for one resident (R122) by not sanitizing hands prior to and after entering resident's room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure low air loss mattress devices were properly working and on the correct setting for 2 (R11, R146) of 2 residents identified as at risk for developing pressure ulcers in a sample of 29 residents reviewed for skin preventative measures.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adaptive devices were applied to residents' hands to prevent further contracture or deformities. This failure applies to 2 (R22, R35) residents out of 4 residents reviewed for limited range of motion in the final sample of 29 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow smoking safety policy to provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. This failure applies to 1 (R85) resident who is on supervised smoking out of 5 residents reviewed for smoking in the final sample of 29 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food trays were distributed in a sanitary manner to prevent contamination for 1 (R130) resident being served food on the first floor in a sample of 29. Findings Include: On 03/07/23 at 11:27 AM dietary staff were observed on the first floor with the steam table in hallway in front of the men's shower room serving food trays. On 03/07/23 at 11:34 AM V11 (Activity Aide) placed a used plate cover on the overbed table next to two pitchers of red juice. On 03/07/23 at 11:36 AM V9 (Agency Certified Nurse Assistant) removed the used plate cover that was placed on the overbed table by V11 (Activity Aide), placed the plate cover over R130's food then proceeded down the hallway and delivered the food tray to R130's room. V9 returned to the steam table. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives or goals and interventions to meet the residents' needs for 6 (R90, R103, R52, R22, R85, R134) residents reviewed for advance directives. This has the potential to affect all 142 residents per the census on [DATE].