Eaton Creek Post Acute

Inspectors wroteBased on facility policy review, a nourishment room posted note, observations, and interviews, the facility failed to maintain dietary equipment in a sanitary manner and failed to ensure food was stored and labeled in a manner to prevent the spread of infection when foods were found uncovered, unlabeled, and undated, in a refrigerator in the kitchen and in the nourishment room refrigerator. This facility had a census of 99, with 94 residents receiving a tray from the kitchen.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to provide an environment free of hazardous materials for 7 of 99 (Resident #19, #55, #66, #73, #83, #93, and #98) sampled residents for accident hazards.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to store medication in accordance with facility policy when medication was found unsecured in the resident's room for 1 of 99 (Resident #33) sampled residents.

Inspectors wroteBased on facility policy review, medical record review, facility investigation review, hospital record review, and interview, the facility failed to provide adequate supervision and assistance to prevent a fall accident for 1 of 3 residents (Resident #1) reviewed for accidents. On 1/21/25, Certified Nursing Assistant (CNA) V attempted to transfer Resident #1 from a shower bed to Resident #1's bed without assistance from another staff member and failed to lock all the shower bed wheels properly. [...]

Inspectors wroteBased on facility policy review, Facility #1 medical record review, facility investigation review, Hospital #2 medical record review, Facility #2 medical record review, Emergency Medical Services (EMS) report review, police report review, and interview the facility failed to provide an environment free from all types of abuse including, deprivation of goods and services by staff, sexual abuse by a resident, physical abuse by a family member, and verbal abuse by a staff member for 7 of 21 sampled residents (Resident #4, #5, #2, #3, #35, #19, and #49) reviewed for abuse. On 7/7/2024, Certified Nursing Assistant (CNA) O entered Resident #5's room and saw Resident #4 with her face leaning over the groin area of Resident #5, who quickly pulled up his pants when the CNA entered the room. CNA O failed to immediately intervene and left the two residents alone. [...]

Inspectors wroteBased on the Board of Examiners of Nursing Home Administrators (BENHA) review, list of Director of Nursing (DON) staff, job description review, facility policy review, Quality Assurance Performance Improvement (QAPI) Plan, Licensed Independent Practitioner Scope of Services, and interview, the facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of vulnerable residents in the facility. The facility Administration failed to provide oversight of clinical staff and follow-up on a resident with a recent long and severe history of illicit/street drug abuse. [...]

Inspectors wroteBased on facility policy review, Quality Assurance Performance Improvement (QAPI) meeting minutes review, and interview, the facility ' s Governing Body consisting of the present Administrator, Senior [NAME] President of Operations, Regional Director of Operations, Assistant [NAME] President of Clinical Operations, Regional Nurse Manager, Assistant Director of Nursing, and the Director of Nursing failed to provide oversight for the QAPI Program to ensure an effective QAPI plan was established and implemented to address, timely report, and thoroughly investigate allegations of sexual abuse, physical abuse, and neglect. The Governing Body failed to ensure the QAPI Program established and implemented effective interventions to address nutritional needs for vulnerable residents that resulted in significant weight loss. [...]

Inspectors wroteBased on policy review, job description review, Quality Assurance and Performance Improvement (QAPI) Minutes review, QAPI sign-in sheets, facility investigation, and interview, the QAPI Committee failed to ensure an effective QAPI program that systematically identified, reported, tracked, investigated, analyzed and used data and information related to all types of abuse and nutritional status in the facility. The QAPI committee failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently. [...]

Inspectors wroteBased on facility policy review, medical record review, facility investigation review, and interview, the facility failed to timely report allegations of abuse and neglect for 5 of 21 (Resident #2, #3, #19, #4, and #5) sampled residents reviewed for abuse. The facility failed to report an allegation of sexual abuse to the State Survey Agency within 2 hours when Resident #2 reported/alleged to staff on 5/8/2024 at approximately 11:00 PM that Resident #3 assaulted her through anal penetration. The facility failed to report Resident #19 ' s cocaine overdose in the facility on 11/8/2023 at approximately 8:30 PM, within 2 hours to the State Survey Agency. The facility ' s failure to ensure all allegations of abuse and neglect were reported immediately resulted in an Immediate Jeopardy (IJ) for Resident #2, #3, and #19. [...]

Inspectors wroteBased on facility policy review, facility investigation review, medical record review, and interview, the facility failed to conduct a thorough investigation and take appropriate corrective actions for 6 of 21 (Resident #4, #5, #2, #3, #7 and #19) sampled residents reviewed for abuse. The facility failed to conduct a thorough investigation into an allegation of sexual abuse between Resident #4, a vulnerable, cognitively impaired resident with a diagnosis of dementia, and Resident #5 on 7/7/2024. The facility failed to conduct a thorough investigation into Resident #2's allegation that Resident #3 sexually assaulted her through anal penetration on 5/8/2024, which resulted in psychosocial harm and delayed incontinence care for the victim. The facility failed to conduct a thorough investigation into Resident #19's cocaine overdose in the facility on 11/8/2023. [...]

Inspectors wroteBased on facility job description, facility policy review, ADL (Activities of Daily Living) Verification Worksheet, Patient Weight Reports, Weight (wt) Loss Documentation Report, medical record review, observation and interview, the facility failed to recognize repeated, systemic failures to assess and address a resident ' s nutritional status and to implement pertinent interventions that resulted in continued significant weight loss for 5 of 9 (Residents #67, #65, #63, #45 and #46) sampled residents reviewed for nutritional needs. Resident #45 experienced a significant weight loss of 10% (percent) in 6 months. Resident #67 suffered a significant and severe weight loss of approximately 9.0% over 2 months from 8/15/2024 to 10/14/2024. Resident #65 suffered a significant and severe weight loss of approximately 8.5% over 1 month from 8/9/2024 to 9/13/2024. [...]

Inspectors wroteBased on policy review, record review, medical record review, observation, and interview, the facility failed to ensure a safe, secure environment for a vulnerable and high-risk resident with wandering behaviors for 1 of 5 sampled residents (Resident #1) reviewed for elopement/wandering. The facility's failure to ensure a safe, secure environment resulted in Immediate Jeopardy (IJ) when Resident #1 exited the facility through the window in his room. Resident #1's sister called the facility around 5:30 AM to notify the facility that Resident #1 was found sitting on her front porch which was approximately 3 miles from the facility, along highly trafficked city streets and in a heavily populated area. Facility staff were unaware Resident #1 had exited the facility for approximately 8 and a half hours. [...]

Inspectors wroteBased on facility policy review, facility investigation summary review, medical record review, and interview, the facility failed to ensure 1 (Resident #26) of 3 residents reviewed were free from misappropriation.

Inspectors wroteBased on facility policy review, medical record reviews, and interviews, the facility failed to ensure transfer/discharge information was documented in the medical record and communicated to the receiving provider for 6 of 6 residents (Resident #44, #43, #52, #53, #54 and #51) reviewed for transfer/discharge.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to provide a bed-hold notice to the resident or resident representative at the time of transfer for 5 of 6 residents (Resident #43, #52, #53, #54, #51) reviewed for discharge.

Inspectors wroteBased on facility policy review, medical record review, and interviews, the facility failed to update the care plan for 2 (Resident #45and #56) of 70 sampled residents reviewed for care plans.

Inspectors wroteBased on the facility policy review, medical record review, and interviews, the facility failed to provide a resident who was unable to carry out activities of daily living (ADL) the necessary services to maintain personal hygiene for 1 of 5 (Resident #33) residents reviewed for bathing.

Inspectors wroteBased on facility policy review, medical record reviews, and interviews, the facility failed to provide a physician order to administer medication for 2 of 7 residents (Resident #43 and Resident #8) reviewed for physician orders.

Inspectors wroteBased on the facility policy review, medical record review, and interviews, revealed the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcer for 2 (Resident #31 and Resident #33) of 9 residents reviewed for wound care.

Inspectors wroteBased on review of the facility assessment, review of employee time sheets, review of the nursing home licensure check list and interview the facility failed to have sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with the facility assessment. Failure to assure the facility had sufficient nursing staff had the potential to affect all residents residing in the facility. The Census on entrance was 109.

Inspectors wroteBased on facility assessment, nursing home licensure checklist, employee time sheets, and interview, the facility failed to ensure Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week for 2 days in June of 2024.

Inspectors wroteBased on facility policy review, facility document review, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision for 1 (Resident #29) of 7 sampled residents reviewed for wandering/elopement. The facility's failure to supervise and prevent Resident #29, with a known history of exit seeking behaviors and who was actively exhibiting delusions and auditory hallucinations from eloping to an unsafe environment, resulted in Immediate Jeopardy (IJ) when Resident #29 was found outside of the facility in the parking lot at 9:15 PM on 9/24/2022. According to staff statements, the resident was last seen in her wheelchair ambulating through the facility hallways around 8:30 PM. [...]

Inspectors wroteAmended from F-865 to F-867 Based on facility policy review, facility document review, medical record review, and interview, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to develop an effective QAPI program that recognized concerns related to exit seeking behavior when a resident exited the facility without staff knowledge, and failed to provide adequate supervision to prevent elopement and failed to ensure a safe environment for 1 (Resident #29) of 7 sampled residents. Failure of the QAPI Committee to provide adequate supervision to prevent elopement placed Resident #29 in Immediate Jeopardy. Resident #29 (a resident who was experiencing auditory hallucinations and delusions, with known wandering and exit seeking behaviors) was able to exit the facility to the parking lot at night on 9/24/2022. [...]

Inspectors wroteBased on facility policy review, medical record review, documentation, and interview, the facility failed to conduct and document Resident Council meetings.

Inspectors wroteBased on observation, and interview the facility failed to ensure a safe, homelike environment for 1 of 62 (room [ROOM NUMBER]) rooms observed.

Inspectors wroteBased on facility policy review, Facility Reported Investigation, medical record review, and interview, the facility failed to thoroughly investigate the allegation of abuse for 3 of 6 sampled residents (Resident #83, #90, and #361) reviewed.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to send a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 33 (Resident #2) residents reviewed.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to provide written information regarding the bed hold policy for 1 of 33 (Resident #2) residents reviewed.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to obtain a physician's order for a condom catheter for 1 of 2 (Resident #58) residents reviewed.

Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to label and cover graduate urine measurement containers and bedpans in 2 of 62 (room [ROOM NUMBER] and room [ROOM NUMBER]) resident rooms observed. The facility to failed to keep oxygen cannulas off the floor, and cover nebulizer masks for 3 of 33 sampled residents (Resident #19, Resident #58, and Resident #60) reviewed.

Inspectors wroteBased on facility policy review, observation and interview, the facility failed to secure the personal privacy and confidentiality of medical records for 1 resident (#21) of 45 residents reviewed.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to coordinate the timely completion of a Level II Pre-admission Screening and Resident Review (PASRR) for 1 Resident (#24) of 45 residents reviewed.

Inspectors wroteBased on facility policy review, medical record review and interview the facility failed to complete a baseline care plan within 48 hours of admission to the facility for 2 residents (#59 and #67) of 45 residents reviewed.

Inspectors wroteBased on facilty policy review, medical record review, observation and Interview, the facility failed to revise/update comprehensive care plans for 2 residents (#6 and #72) of 45 resident care plans reviewed.

Inspectors wroteBased on facility policy review, observation and interview the facility failed to store medications properly related to medications being left unattended in a medication cup on top of a medication cart.

Inspectors wroteBased on facility policy review, observation and interview, the facility failed to maintain 1 of 2 ice machines in a clean and sanitary condition to prevent cross contamination of the ice and failed to store foods in safe and sanitary manner to prevent cross contamination.