Easton Health Care Center

Inspectors wroteThe facility identified a census of 39 residents. The sample included 12 residents, with one resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, record review, and interview, the facility failed to prevent the development of an avoidable stage three (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer on Resident (R) 25's left heel.

Inspectors wroteThe facility had a census of 39 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organism which employ targeted gown and glove use during high contact care) were used for Resident (R) 4, who had a suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder), failed to handle and transport soiled linen in a safe and sanitary manner, failed to ensure R4's catheter bag did not drag on the floor while in his wheelchair and bed. [...]

Inspectors wroteThe facility had a census of 39 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to promote dignity and respect for one resident, Resident (R) 4, when staff did not close the door to his room before providing personal cares.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure R4's care plan had been revised to include enhanced barrier precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact cares) that needed to be worn during staff cares of his supra pubic catheter (urinary bladder catheter inserted through the abdomen into the bladder).

Inspectors wroteThe facility had a census of 39 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to prevent two superficial open areas on Resident (R) 4's scrotum (the sac of skin and muscle located outside the lower body that holds and protects the testicles).

Inspectors wroteThe facility had a census of 39 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to provide services consistent with the standard of care for one resident, Resident (R) 4, reviewed for urinary catheter (a tube inserted into the bladder to drain urine) or urinary tract infection (UTI- an infection in any part of the urinary system).

Inspectors wroteThe facility had a census of 39 residents. The sample included 12 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required.

Inspectors wroteThe facility identified a census of 34 residents with three residents reviewed for falls and accidents. Based on record review and interview, the facility failed to ensure Resident (R) 1's safety during a transfer when Certified Nurse Aide (CNA) M and Licensed Nurse (LN) G used a Hoyer lift (total body mechanical lift) to transfer R1 from her bed to her wheelchair. During the transfer, the lift tipped, and R1 hit the back of her head on a dresser. As a result, R1 sustained a laceration to the back of her head that required staples and sutures to close. This deficient practice also placed R1 at risk for pain and other avoidable injuries.

Inspectors wroteThe facility identified a census of 33 residents and 23 active resident trust fund accounts. The sample included five residents. Based on record review and interview, the facility failed to distribute quarterly statements to all residents that held trust fund accounts in the facility. This placed the residents at risk for uninformed decisions regarding their trust fund and misappropriation.

Inspectors wroteThe facility identified a census of 33 residents which included 23 residents with active trust accounts, held by the facility. Based on interviews and record review, the facility failed to provide Resident (R) 1 with an accurate accounting of her personal funds, when the facility overcharged R1's personal funds account by $347.89 . This placed R1 at risk for impaired autonomy and misappropriation.

Inspectors wroteThe facility identified a census of 33 residents and 23 active resident trust fund accounts. The sample included five residents. Based on record review and interview, the facility failed to ensure the conveyance of personal funds within 30 days of discharge and/or death for Resident (R) 3, R4, and R5. This placed the residents at risk for impaired rights and misappropriation.

Inspectors wroteThe facility identified a census of 37 residents with three residents reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 remained free from abuse and mistreatment. On 04/26/24 at approximately 04:10 AM, R1, who had a history of trauma and Huntington's disease (a rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), approached Certified Nurse Aide (CNA) M and CNA O and asked for some chocolate milk saying chocky milk. R1 attempted to retrieve the milk from the refrigerator located in the residents' dining area but CNA M and CNA O instructed R1 he was not able to get the milk from the refrigerator himself and told him staff would get him the chocolate milk if he asked for it correctly. [...]

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents and three Certified Nurse Aides (CNAs) reviewed for yearly performance evaluations. Based on record review and interview, the facility failed to ensure three CNA staff had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ), when the facility failed to submit staffing hour data for all nursing personnel by the required deadline. This deficient practice placed residents at risk for impaired care due to unidentified and ongoing staffing issues.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program including antibiotic stewardship for the residents of the facility.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents and three Certified Nurse Aides (CNAs) reviewed for in-service training. Based on record review and interview, the facility failed to ensure the four CNA staff reviewed had the required 12 hours of in-service education including the required topics per year. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to obtain consent or declinations for influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination for Resident (R) 22 and R35. The facility also failed to offer or obtain declinations for pneumococcal (type of bacterial infection) vaccination consents, declinations, or administration information for R22, R35, R17, and R32. This placed the residents at increased risk for influenza, pneumonia, and related complications.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with two residents reviewed for hospitalization. Based on record review and interviews, the facility failed to provide written notice of transfer with the required information to Resident (R) 139 and/or to their legal representative in a practicable amount of time. The facility also failed to send a notification to the Office of the State Long-Term Care Ombudsman of the facility's transfers and discharges. This deficient practice had the risk of miscommunication between the facility and the residents and possible missed opportunities for healthcare service for these residents.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with two residents reviewed for hospitalization. Based on record review and interviews, the facility failed to provide a bed hold notice when Resident (R) 139 was hospitalized . This deficient practice placed R139 at risk of uninformed choices.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with one resident reviewed for a baseline care plan. Based on record review and interviews, the facility failed to develop a person-centered baseline care plan to include pressure relieving measures to prevent pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R) 139. This deficient practice placed R139 at risk of impaired care related to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 30's comprehensive care plan was updated to reflect what services and/or equipment were provided by the hospice within the required seven days after completion og the comprehensive assessment. The facility also failed to update R22's Care Plan to address catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) use and care. This placed these residents at risk of impaired care due to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. with two residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction) Based on record review and interviews, the facility failed to ensure pressure reducing measures were in place for Resident (R) 139 who developed deep tissue injuries on her bilateral heels. This deficient practice placed R139 at risk of development of pressure ulcers, and of wound worsening.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with three residents reviewed for limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Based on observation, record review, and interviews, the facility failed to provide ROM to help maintain and prevent a potential decrease in ROM/mobility for Resident (R) 20. This deficient practice placed R20 at risk of loss of ability to perform activities of daily living (ADLs) and worsening or development of contractures (abnormal permanent fixation of a joint or muscle).

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with two residents sampled for accidents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 5's fall investigation included a root cause analysis of the fall and failed to ensure that an appropriate intervention was implemented to prevent further falls. These deficient practices placed this resident at risk for additional falls and or injuries.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with one resident reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 20's posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R20 at risk for decreased psychosocial well-being and ineffective treatment.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with two residents sampled for hospice services. Based on observation, record review, and interview, the facility failed to establish a communication process, including how the communication will be documented between the facility and the hospice provider for Resident (R) 32. The facility failed to ensure that R32's written plan of care included both the most recent hospice plan of care and a description of the services furnished by both the facility and hospice. This placed R32 at risk of decline and/or from maintaining the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThe facility identified a census of 37 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to hand hygiene during peri-care and the disinfecting of shared equipment. This deficient practice placed the residents at risk for complications related to infectious diseases.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to post the previous state inspection information in a location accessible to residents and visitors.

Inspectors wroteThe facility reported a census of 33 residents. Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for at least eight consecutive hours, seven days a week and failed to designate a full time RN as Director of Nursing to oversee the care provided to the residents. This placed the resident at risk for decreased quality of care.

Inspectors wroteThe facility identified a census of 33 residents. The sample included three residents reviewed for accidents. Based on record review and interview, the facility failed to evaluate causative factors in order to identify and implement interventions to prevent falls for Resident (R)1, who had multiple falls. This deficient practice placed R1 at risk for continued falls and fall related injury.

Inspectors wroteThe facility had a census of 38 residents. The facility had one kitchen. Based on observation, interview, and record review the facility failed to store frozen foods under sanitary conditions in the facility kitchen. This deficient practice placed the 38 residents of the facility at risk to receive foods with contamination and/or an unpleasant taste related to freezer burn.

Inspectors wroteThe facility had a census of 38 residents and no Covid (highly contagious, potentially life threatening respiratory virus) residents. The sample included 13 residents with two residents on quarantine for Covid. Based on observation, record review, and interview the facility failed to provide a sanitary and comfortable environment to help prevent the development and transmission of communicable disease and infections when staff hung a used gown from a quarantined resident's room on an isolation cart in the hall and cleaned a quarantined resident's room without changing gloves between dirty and clean tasks. The facility further failed to maintain an ongoing infection surveillance program. This placed the 38 residents who resided in the facility at increased risk for infection.

Inspectors wroteThe facility had a census of 38 residents. The sample included 13 residents. Based on record review and interview the facility failed to maintain an ongoing infection surveillance program which included antibiotic stewardship. This placed the 38 residents who resided in the facility at increased risk for receiving an infection, and/or negative effects of antibiotic use.

Inspectors wroteThe facility had a census of 38 residents, with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide the Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN), CMS form 10055, which contained the estimated cost to continue services for skilled services, to the resident or their representative for the three reviewed residents, Resident (R) 27, 30, and 20. This placed the residents at risk for uninformed decisions regarding skilled services.

Inspectors wroteThe facility had a census of 38 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to care plan Resident (R) 35's fluid restriction. This deficient practice placed R35 at risk for fluid overload (too much fluid in your body).

Inspectors wroteThe facility had a census of 38 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to invite two sampled residents', Resident (R) 5 and R34, (or their representative) to their quarterly care plan conferences and failed to update R8's care plan with a section regarding her facial skin condition. This placed R5 and R34 at risk for not having the right to participate in choosing treatment and options for their care and placed R8 at risk for unmet and/or uncommunicated care needs.

Inspectors wroteThe facility had a census of 38 residents. The sample included 13 residents with one reviewed for foot care. Based on observation, interview, and record review the facility failed to provide appropriate care and services for Resident (R) 14's feet and or toenails. This deficient practice placed R14 at risk for complication and pain related to his feet.

Inspectors wroteThe facility had a census of 38 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to monitor Resident (R) 35's fluid restriction. This deficient practice placed R35 at risk for fluid overload (too much fluid in your body) and hospitalization for treatment.

Inspectors wroteThe facility identified a census of 38 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ackowledge and follow up on the Consultant Pharmacist's (CP) medication recommendations and failed to ensrue the CP idenitfied and reported missing behavior documentation for psychotropic (medications which alters mood and thought) medications. This placed R5 at risk for ineffective medication regimen and unnecessary psychotropic medications.

Inspectors wroteThe facility had a census of 38 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to consistent behavior monitoring for Resident (R) 5 who received several psychotropic medications ( medications which alters mood or thought) including an antipsychotic (class of psychotropic medication primarily used to manage psychosis, principally in schizophrenia but also in a range of other psychotic disorders). This placed the resident at risk for unnecessary psychotropic medication use and related side effects.