Chesterton Manor

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were held per blood sugar parameters for 1 of 1 resident reviewed for insulin. The facility also failed to ensure areas of discoloration and dry flaky skin were assessed and monitored for 4 of 4 residents reviewed for skin conditions non-pressure related and signs and symptoms of constipation were monitored and treated for 2 of 2 residents reviewed for constipation. (Residents 53, 3, 69, 58, 176, 13, and 226)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fall interventions were in place for residents with a history of falls related to floor mats, bed position, and call lights in reach for 2 of 2 residents reviewed for falls. (Residents 46 and 13) The facility also failed to ensure hot water temperatures were below 120 degrees Fahrenheit on 3 of 4 halls throughout the facility. (100, 300 and 400 halls) This had the potential to affect 53 of the 75 residents who resided in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to protect a resident's right to be free from misappropriation of property related to bank fraud by Agency CNA 1, for 1 of 1 resident reviewed for misappropriation of property. (Resident 25) The deficient practice was corrected by [DATE], prior to the start of the survey, and was therefore past noncompliance. The facility thoroughly investigated the incident related to the bank fraud once being notified by the police. A report was initiated by the police department and a detective was assigned to the case. The Staffing Agency was notified as soon as the Administrator was made aware and the Agency CNA had not worked at the facility since [DATE].

Inspectors wroteBased on record review and interview, the facility failed to ensure a care plan meeting was conducted at least quarterly for 1 of 5 residents reviewed for care planning. (Resident 4)

Inspectors wroteBased on record review and interview, the facility failed to ensure pressure ulcer treatments were completed as ordered by the physician for 1 of 4 residents reviewed for pressure ulcers. (Resident 10)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an orthotic device was in place for a resident with a limited range of motion to the hand for 1 of 2 residents reviewed for range of motion. (Resident 10)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 2 of 2 residents reviewed for nutrition. (Residents 6 and 176)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was at the correct flow rate for 2 of 3 residents reviewed for oxygen. (Residents 7 and 58)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was free from pain related to pain medications and transportation to the pain clinic not being available for 1 of 1 resident reviewed for pain. (Resident 36)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure proper medication storage related to medicated creams not stored securely for 2 of 2 residents randomly observed. (Residents 58 and 13)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control practices were in place and implemented related to not donning personal protective equipment (PPE) for residents in enhanced barrier precautions (EBP) for 3 of 3 wound care treatments observed. (Residents 3, 6, and 226)

Inspectors wroteBased on observation and interview, the facility failed to ensure the call light system in a resident's room and the call light system at the nurses' station was properly functioning during random call light observations. (Residents 38 & 18)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents received timely assistance with ADL's (activities of daily living) related to incontinence care for 2 of 4 residents reviewed for ADL's. (Residents C and F)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff member (CNA 3) when providing care to a resident (Resident E) who was in Enhanced Barrier Precautions (EBP) and failed to ensure hand hygiene was completed by a staff member (CNA 2) after the care had been completed, for one random observation for infection control.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours in the facility on any given day. This had the potential to affect 67 of 67 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure areas of bruising were assessed and monitored, for 3 of 4 residents reviewed for skin conditions (non-pressure related), and signs and symptoms of constipation were monitored, for 1 of 1 residents reviewed for constipation. (Residents 56, 22, 166, and 217)

Inspectors wroteBased on observation and interview, the facility failed to keep the resident's environment in good repair, related to marred walls, doors, and door frames, gouged walls, missing baseboards, and non-skid strips peeling off the floor, for 2 of 4 units in the facility. (100 and 200 Hall).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications, and an assessment to self-administer their own medications, for 3 of 3 residents reviewed for self-administration of medication. (Residents 56, 22, and 54)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a suprapubic foley catheter received foley catheter care, and catheter bags and tubing were kept off the floor, for 2 of 3 residents reviewed for catheters. (Residents B and D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to care for a PICC line (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) in accordance with professional standards of practice, related to not flushing the PICC line with the correct amount of saline, and a lack of documentation the saline and heparin flushes were administered as ordered, for 1 of 1 residents observed with a PICC line during medication pass. (Resident 62)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was administered as ordered, and set at the correct flow rate, for 1 of 1 residents reviewed for respiratory care. (Resident 54)

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were properly stored, related to loose pills inside the medication drawers, for 2 of 4 medication carts observed. (Hall 100 and 200).

Inspectors wroteBased on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented, related to clarification orders for as needed (PRN) pain medications, and documentation of meal consumption, for 2 of 21 records reviewed. (Residents 13 and 22)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders and an assessment to self-administer their own medications for 3 residents randomly reviewed for self-administration of medication. (Residents 31, 55, and 57)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide ADL (activities of daily living) assistance to dependant residents related to completing scheduled showers and shaving male residents for 3 of 7 residents reviewed for ADL care. (Residents 55, 45, and 15)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure skin excoriation and bruising was assessed, monitored, and treated for 2 of 7 residents reviewed for skin conditions non-pressure related. (Residents 55 and 32)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents with impaired hearing received the necessary services related to ear wax removal for 1 of 2 residents reviewed for vision and hearing. (Resident 55)

Inspectors wroteBased on record review and interview, the facility failed to ensure acceptable parameters of nutrition were maintained related to documenting food consumption for a resident with a history of weight loss for 1 of 1 residents reviewed for nutrition. (Resident 59)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate and functioning for 3 of 3 residents reviewed for oxygen. (Residents 59, 58, and 15)

Inspectors wroteBased on record review and interview, the facility failed to manage medications appropriately related to not monitoring the side effects of opioid medication and administering blood pressure medication outside of the parameters for 2 of 5 residents reviewed for unnecessary medication. (Residents 59 and 23)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form to meet individual needs related to not following a recipe for pureed food. This had the potential to affect 3 residents who received a pureed diet. (Main Kitchen)

Inspectors wroteBased on record review and interview, the facility failed to promote antibiotic stewardship related to unnecessary antibiotic use for 1 of 1 residents reviewed for antibiotic use. (Resident 4)

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to marred doors and door frames, chipped floor tile, and broken shower heads on 2 of 4 units and 1 of 2 shower rooms. (The 200 and 300 Units and the Women's Shower Room)