Eisenberg Village

Inspectors wroteBased on interview and record review, the facility failed to monitor a resident's orthostatic blood pressure (taking blood pressure measurements taken to detect a significant drop in blood pressure when moving from lying/sitting to standing) who was prescribed an antipsychotic medication (a medication used to treat psychosis [a mental condition in which thought and emotions are so affected that contact is lost with external reality]) for 2 (Resident 3 and Resident 10) out of five residents investigated for unnecessary medications. This had the potential for Resident 3 and Resident 10 to have orthostatic hypotension (sudden, severe drop in blood pressure upon standing) side effects such as lightheadedness, syncope (fainting), placing Resident 10 at risk for fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure 7 of 7 sampled residents (38, 56, 57, 58, 64, 82, 84) had the Care Area Assessment (CAA) completed within the timeframe outlined on the Resident Assessment Instrument (RAI - a mandatory assessment tool used for the Centers for Medicare and Medicaid Services (CMS)). This failure had the potential to result in inadequate, non-individualized care plans, missed identification of resident risks, and potential for decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's pain was assessed and documented on the Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) before and after pain medication administration for one (Resident 8) of one sampled resident investigated for pain. This deficient practice had the potential to result in ineffective pain management, placing the resident at risk for unrelieved pain.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the Controlled Drug Record (CDR, accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) affecting Resident 8 for one of two medication carts (First Floor Team 2 Medication Cart) inspected. This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store drugs and biologicals in accordance with accepted professional principles when the facility: 1. Failed to ensure an eye drop medication was not used past the expiration date for one (First Floor Team Two Medication Cart) of two medication carts that were inspected during the survey. 2. Failed to ensure the label in the Midodrine (given for hypotension or low blood pressure) bubble pack (a method of organizing medications into individual doses, typically sealed in compartments with protective bubbles) is consistent with the physician`s order for the same medication for one of seven residents (Resident 24) observed during the medication administration task. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the potential for cross-contamination when: 1. Dry goods (peanuts) were not stored in a sealed container. 2. Canned goods with dents and compromised seals were not inspected or discarded. 3. Residual food debris was not cleaned on vegetable dicers. 4. The disc blade for food processor machine was in disrepair 5. Personal belongings and potential contaminants were kept in are intended for sanitized and clean cookware This deficient practice has the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in all medically compromised residents and may also introduce chemical and physical contaminants in food being served to all residents.

Inspectors wroteBased on interview and record review the facility failed to ensure the binding arbitration agreement (Arbitration Agreement, a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) was explained to residents' representatives in a form and manner that he or she understands for 4 (Resident 10, Resident 16, Resident 33, Resident 68) of 4 sampled residents. This had the potential for residents' rights to not be honored.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained a resident`s dignity and respect by failing to ensure a licensed nurse knocked prior to entering a resident`s room for one of seven residents (Resident 24) observed during medication administration task. This deficient practice violated the resident's right to be treated with respect and dignity and had the potential to affect Resident 24`s sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to post reports with respect to any surveys, certifications, and complaint investigations made during the three preceding years, and any plan of correction in effect with respect to the facility, in areas of the facility that are prominent and accessible to the public. This deficient practice had the potential to impede residents' rights and can negatively affect residents' psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan that meets the resident's assessed needs for one of seven sampled residents (Resident 3) by failing to ensure orthostatic blood pressure was monitored and implemented in accordance with the physician's order. This deficient practice had the potential to have negatively impact Resident 3's health and safety, as well as the quality of care and services provided to the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 24) was free from any significant medication errors by failing to administer Midodrine (a medication that increases blood pressure; used for residents with consistently low blood pressure) within the physician's prescribed parameters (specific instructions or limits set by a physician for how a medications should be given. Parameters may include when to give the medication or when to hold it). This deficient practice had the potential to cause complications such as dizziness, syncope (fainting) and possible hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship program (coordinated effort to ensure that antibiotics are prescribed appropriately, only when needed, in the correct dose, and for the right duration) for one of two sampled residents (Resident 26) by failing to ensure the resident's physician was notified when the resident who was prescribed an antibiotic did not meet the criteria for Skin and Soft Tissue infection (SSTI- bacterial, viral, or fungal infections that occur when germs enter breaks in the skin causing pain, swelling, redness, and warmth). This deficient practice had the potential for Resident 26 developing antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident with a communication board (a device that can help patients communicate with care providers and family using symbols, photos, or illustrations) for one of two sampled residents (Resident 3) whose primary and preferred language was not English. This deficient practice has the potential to prevent the resident from communicating with the staff and had the potential to delay receiving care/treatment the resident needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their facility's policy on wheelchair use by failing to ensure staff locked residents' wheelchair brakes while residents were sitting on their wheelchair for two of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to place the residents at increased risk of sustaining an injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication cart was locked while the medication cart was left unattended for one of two sampled medication carts (Medication Cart A). This deficient practice had the potential to result in unauthorized personnel or residents accessing the medications stored in the unlocked medication cart.

Inspectors wroteBased on interview, and record review, the facility failed to ensure two (2) of five (5) sampled residents (Residents 61 and 64) were free from unnecessary use of psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure: 1. Resident 61 had a specific, measurable target behaviors (the specific, undesirable behavior that a medication is intended to reduce or manage) related to the use of Zoloft (medication to treat depression [a persistent feeling of sadness or a lack of interest in outside stimuli]). 2. Resident 64 had a specific, measurable target behaviors related to the use of Seroquel (medication used to treat mental illness). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate below 5 percent (%) by having two medication errors out of 32 opportunities contributing to an overall error rate of 6.25 % for one of nine residents (Resident 61) observed during the Medication Administration facility task. These deficient practices resulted in the omission of medications which could have resulted in severe health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from any significant medication errors for one of nine residents (Resident 61) investigated during the medication administration facility task by failing to: 1. Ensure Registered Nurse 1 (RN 1) administered the medications Sinemet (two medications combined into one medication to treat Parkinson's disease [(a nervous system disorder which leads to movement problems) and terazosin (a medication to treat benign prostatic hyperplasia (BPH, a non-cancerous condition that causes the prostate [a gland in the male reproductive system] to enlarge due to an overgrowth of cells), for one (Resident 61) of nine residents observed during the medication pass observation. 2. Ensure Licensed Vocational Nurse 4 (LVN 4) administered finasteride and Sinemet during the 3 p.m. to 11 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Store food in accordance with professional standards for food service safety by failing to: a. Label one container of oatmeal with a use by date label. b. Label one container of powdered sugar with a use by date label. c. Label one container of quinoa with a use by date label. d. Label one container of bulgur with a use by date label. e. Label one container of cream of wheat with a use by date label. f. Label one bag of lemon curd with a use by date label. g. Label one container of chicken with a use by date label. e. Label one container of ground beef with a use by date label. 2. Ensure the chlorine test strips used to check that the sanitizing solution was not expired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Observe infection control guidelines when Registered Nurse 1 (RN 1) was observed leaving a resident's room during a medication pass observation while still wearing an isolation gown for one (Resident 61) of 12 residents who were on enhanced barrier precautions (EBP-a method of using personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments] to reduce the spread of pathogens between residents in skilled nursing facilities). This deficient practice had the potential to increase the risk of spreading infection to other residents. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the physician was notified of a resident's refusal of suprapubic catheter care for one of three sampled residents reviewed under the catheter care area. This deficient practice placed the resident at increased risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Develop a care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and the prevention of worsening a condition, and current treatments) addressing a resident's refusal to wear a mask while on contact/droplet precautions (steps that healthcare staff take to prevent the spread of germs when a patient has germs that can spread through touching and coughs and sneezes) for one (Resident 40) out of five sampled residents investigated during review of the infection control task. This deficient practice had the potential to delay the provision of necessary care and services to Resident 40. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan addressing the removal of indwelling urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) for one (Resident 22) out of two sampled residents investigated during review of the catheter care area. This deficient practice had the potential to delay the provision of necessary care and services related to the resident's urinary catheter.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was provided a communication device with the language that the resident is able to understand for one of one sample resident (Resident 22) investigated under the communication care area. This deficient practice prevented the resident from communicating with the staff and had the potential to delay the appropriate care or treatment the resident needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services that promote the prevention of pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) injury for one of three sampled residents (Resident 51) as evidenced by failing to monitor the functionality of the resident's low air loss mattress (LALM-mattress designed to treat and prevent pressure ulcers) to ensure the LALM was working properly. This deficient practice had the potential for Resident 51 to develop a new pressure injury.

Inspectors wroteBased on interview, and record review, the facility failed to act upon a recommendation from the Pharmacy Consultant (PC -a healthcare specialist who provides expert advice on medications and pharmaceutical services, including patient safety) to clarify the behavior manifestation for the use of Seroquel (a psychoactive medication-any medication capable of affecting the mind, emotions, and behavior) for one of five sampled residents (Resident 64) reviewed for unnecessary medication. This deficient practice increased the risk of receiving medication that was not optimal for Resident 64's medical condition and increased the risk of adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the medication therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles in one of (Second Floor, Medication Cart 2) four medication carts inspected when Resident 10's discontinued medication, amlodipine (a medication to lower blood pressure) was not removed from the medication cart and disposed of. This deficient practice had the potential for Resident 10 to receive this medication which could have lowered the blood pressure below normal limits causing dizziness, and loss of consciousness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility had arranged provisions of hospice (a type of medical care for residents who are in the last stages of life) services by failing to: 1. Ensure hospice staff signed the hospice Interdisciplinary Team Sign-in Sheet upon arriving to the facility for one of three sampled residents (Resident 1). 2. Ensure a hospice Interdisciplinary Team Sign in Sheet was placed in the chart for one of three sampled residents (Resident 3). 3. Ensure the hospice agency provided training programs in hospice care for facility staff per contractual agreement. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure licensed nurse staff completed reconciliation (a process that validates the controlled substance [medication with a high potential for abuse] amount at the end of a shift is the amount expected) of controlled medications for two of four medication carts (Medication Team 1 Cart and Medication Team 2 Cart) observed during medication storage. 2. Ensure a resident's Controlled Medication Count Sheet (a form that is signed at the time a licensed nurse gives a controlled medication to a resident, in order to account for each medication) was signed at the time a medication was given for one of one sampled resident (Resident 65). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a blood pressure (the pressure of circulating blood against the walls of blood vessels) was checked prior to administering losartan (medication used to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) that had a hold (do not give) parameter to hold for systolic blood pressure (SBP, measures the force the heart exerts on the walls of the arteries each time it beats) less than (<) 110 mm Hg (millimeters of Mercury, a unit of measure for blood pressure) for one of five sampled residents (Resident 2). This deficient practice had the potential to result in hypotension (low blood pressure) which can result in confusion, dizziness, and fainting and require further treatment including hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to provide dignity and respect when Registered Nurse 1 (RN 1) was observed wearing gloves and standing over two of four sampled residents (Resident 40 and 64) while assisting each resident with feeding. These deficient practices had the potential to affect residents' sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of a resident's Advance Directive (a written statement of a person's wishes regarding medical treatment) was kept in the resident's chart and easily retrievable for one of three sampled residents (Resident 64) investigated for advance directive. This deficient practice has the potential to create confusion which could lead to conflict with the resident`s wishes regarding his/her health care.

Inspectors wroteBased on interview and record review, the facility failed to monitor a resident's behaviors who was prescribed an antipsychotic medication (a medication used to treat psychosis [a mental disorder characterized by a disconnection from reality]) for one of five sampled residents (Resident 123) investigated for unnecessary medications. This deficient practice had the potential to result in adverse reaction (unwanted undesirable effects related to a medication) or impairment in the resident's mental or physical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure liquids were prepared in a form designed to the meet the needs for one of two sampled residents (Resident 18) observed during the Dining Observation task by failing to ensure nectar thick liquids (a thickening agent is added to liquids for people with difficulty swallowing and at risk for aspiration [accidentally inhaling food or liquid through the vocal cords into the airway]) were prepared and served to the resident. This deficient practice had the potential to result in aspiration pneumonia (an infection of the lungs caused by inhaling saliva, food, or liquids) in Resident 18.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quarterly Minimum Data Set (MDS- an assessment and care screening tool) assessment for one of two sampled residents (Resident 51) was transmitted within 14 days after the completion date to the Centers for Medicare and Medicaid Services (CMS) system. This deficient practice resulted in a delay of resident specific information being sent to CMS for payment and quality measure monitoring.