Casey's Pond Senior Living

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from chemical restraints for two (#58 and #45) of six residents out of 25 sample residents. Specifically, the facility failed to: -Ensure Resident #58 and Resident #45 were offered non-pharmacological interventions prior to administering as-needed (PRN) antipsychotic medications; and, -Ensure Resident #58's representative consented to increasing the dose of an antipsychotic medication.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free from abuse for one (#26) of two residents reviewed for abuse out of 25 sample residents. Specifically, the facility failed to protect Resident #22 from sexual abuse by Resident #26.

Inspectors wroteBased on observations and interviews, the facility failed to provide services in accordance with currently accepted professional principles. Specifically, the facility failed to follow accepted standards of practice for medication administration by pre-pouring medications prior to confirming the resident was ready and available for medication administration.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#7 and #49) of four residents out of 25 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility failed to: -Ensure Resident #7's portable oxygen concentrator was turned on while she was out of the building at an appointment; and, -Ensure Resident #49 was assisted with removing her cervical collar (c-collar) during meal times.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards for one of one medication refrigerators. Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently affixed to the refrigerator.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure food was prepared, stored and served under safe and sanitary conditions in one of one facility production kitchen. Specifically, the facility failed to minimize the risk for potential foodborne illness in an at risk population. The facility failed to ensure: -Appropriate hand washing; -Safe storage of cold foods; and -Food and non-food contact surfaces were maintained in a clean and sanitary manner.

Inspectors wroteBased on observation and interviews, the facility failed to treat one (#27) of two residents reviewed for dignity of 39 sample residents with respect and dignity and provide care for the resident in a manner that enhanced her quality of life. Specifically, the facility failed to: -Assist Resident #27 with dining while being seated at the resident's eye level; and -Interact with Resident #27 while assisting the resident with dining.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to administer medications according to professional standards of quality for two (#39 and #30) of 11 residents reviewed for medication administration of 39 sample residents. Specifically, the facility failed to ensure: -Resident #39's and Resident #30's medications were not left at the bedside; -Residents #39 and #30 were evaluated and assessed to self-administer their own medications in a timely manner; and -Physician orders were in place in a timely manner that allowed Residents #39 and #30 to self-administer their own medications.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (#36) of one resident reviewed for bathing and grooming received the necessary assistance with activities of daily living (ADLs) of 39 sample residents. Specifically, the facility failed to ensure Resident #36 received timely assistance with eye and facial cleanliness.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure infection control standards of practice for three (#15, #5 and #13) of three residents reviewed for blood glucose monitoring of 34 sample residents. Specifically, the facility failed to: -Properly disinfect and store personal blood glucose monitoring devices after use for Residents #15, #5, and #13; -Dispose of contaminated materials properly after blood glucose testing; and -Wear appropriate personal protective equipment (PPE) while performing blood glucose testing.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure food was prepared, stored and served under safe and sanitary conditions in one of one facility kitchen and one of three resident dining room refrigerators. Specifically, the facility failed to minimize potential risks for foodborne illness in a highly susceptible population as evidenced by: -Inadequate hand washing; -Insufficient sanitation of work surfaces; and -Failure to monitor, identify and correct improper refrigerator temperatures in the Creekside dining area.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide oxygen services as prescribed by the physician. Specifically, the facility failed to ensure oxygen therapy was administered as ordered by the physician for four (#2, #12, #13 and #35) of four residents reviewed for oxygen therapy of 35 sample residents.

Inspectors wroteBased on resident, family and staff interviews and record review, the facility failed to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 17 (#1, #2, #3, #9, #16, #22, #24, #25, #28, #31, #35, #41, #44, #47, #50, #51, #52) of 35 sample residents. Resident and staff interviews revealed the facility failed to consistently provide adequate nursing staff resulting in delayed call light response, assistance with activities of daily living, assistance to and from the toilet, and prolonged wait times before and after meals in the dining room.

Inspectors wroteBased on interviews, observations and record review, the facility failed to employ sufficient dietary support staff to carry out the functions of the food and nutrition services department in two of two facility dining rooms. Specifically, insufficient numbers of adequately trained food and nutrition staff contributed to prolonged wait times for meals and overall decreased resident satisfaction with dining.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure the resident's call light system was functioning in its entirety. Specifically, the facility failed to ensure call light requests for assistance were not dismissed prior to the resident receiving the help they needed. Cross-reference F725 sufficient nursing staff

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure one (#17) of one resident reviewed for dignity of 35 sample residents was treated with respect and dignity. Specifically, the facility failed to: -Assess needs and provide dignified care while Resident #17 was visibly upset; -Verbally interact with Resident #17 while providing care; and -Provide dignified care to Resident #17 by honoring the resident's request to be transferred to a recliner.

Inspectors wroteBased on record review and interviews, the facility failed to inform two (#500 and #46) of three residents reviewed for beneficiary notices of 35 sample residents in a timely manner of changes in their services covered by Medicare. Specifically, the residents were not provided notice of Medicare provider non-coverage, including all required information, in a timely manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the accuracy of minimum data set (MDS) assessments regarding personal alarms for two (#43 and #51) of two residents reviewed for personal alarms of 35 sample residents. Specifically, Residents #43 and #51 had personal alarms but their MDS assessments documented alarms were not used.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide person-centered dementia care services to one (#43) of two residents reviewed for dementia with antipsychotics and dementia care services of 35 sample residents. Specifically, Resident #43 had diagnoses of dementia with Lewy bodies and dementia with behavioral disturbance, but no psychiatric diagnoses. Resident #43 was administered antipsychotic medications and personal alarms were applied to his wheelchair and bed. However, the facility failed to comprehensively assess, develop and implement person-centered, non-pharmaceutical interventions for dementia care to enhance Resident #43's highest practicable quality of life and well-being.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#9) of five residents reviewed for medications of 35 sample residents was free from unnecessary medications. Specifically, the facility failed to: -Ensure documentation related to Resident #9's level of psychosis was consistent between the diagnosis list, minimum data set (MDS), computerized physician orders (CPOs), progress notes and care plan; and -Consistently document Resident #9's reaction to psychotropic medications, including effectiveness, potential side effects and any non-pharmacological interventions attempted in lieu of psychotropic use.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure infection control standards of practice for one (#8) of five residents reviewed for blood glucose monitoring of 35 sample residents. Specifically, the facility failed to properly disinfect and store blood glucose monitoring devices after use for Resident #8.