Evenglow Lodge

Inspectors wroteBased on observation, interview, and record review the facility failed to store resident's medications separately from food, failed to maintain a pharmacy label on medications and failed to discard/return medication for someone who was not a resident in the facility. This failure affects four residents (R11, R6, R8, R18) with medication in the medication room refrigerator in the sample list of 24.

Inspectors wroteBased on interview and record review the facility failed to report a fall to the physician and resident representative for one (R12) of five residents reviewed for falls in the sample list of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide personal hygiene assistance for one (R3) of one resident reviewed for Activities of Daily Living in the sample list of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall prevention interventions, failed to obtain an ordered X-ray in a timely manner, and failed to document fall and post fall assessment for two residents (R13, R12) of five residents reviewed for falls in a sample list of 24 residents. Findings Include: 1. R13's Current Diagnoses list includes the following diagnoses: Fractured Right Hip, Alzheimer's Dementia, Unsteadiness on Feet, Difficulty Walking, and Instability of Left Hip. R13's Fall Risk assessment dated [DATE] documents R13 is at moderate risk for falls. R13's Progress note dated 7/30/24 at 6:25AM by V11 (Licensed Practical Nurse/LPN) documents (R13) slid off edge of bed and was sitting next to bed. Denies any injury but complained of usual arthritic pain. Ambulated to bathroom and then out to breakfast. Narcotic pain reliever given as ordered. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label and properly store nebulizer mask and tubing. The facility also failed label oxygen tubing when changed for two of two residents (R16, R3) reviewed for respiratory care in the sample list of 24.

Inspectors wroteBased on interview and record review the facility failed to complete an initial assessment prior to starting an antipsychotic medication for one of five residents (R28) reviewed for unnecessary medications in the sample list of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food is handled in a sanitary manner for one (R12) of 16 residents reviewed for dining in the sample of 24. The facility's undated policy titled Handwashing, Glove Use, and Personal Standards for (facility) Foodservice, documents wear gloves when handling ready-to-eat foods. On 09/03/24 at 11:39 AM The noon meal was distributed on the second floor. V12 (Volunteer/R22's Family) was assisting staff in serving resident meal trays. R12 requested ketchup for his turkey burger. V12 touched R12's turkey burger bun with V12's bare hands and applied ketchup. On 9/03/24 at 12:00 PM V12 confirmed he volunteers at the facility and assists in serving meal trays. V12 stated V12 only wears gloves when prepping chicken on the bone. V12 confirmed V12 did not wear gloves when he touched R12's turkey burger. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to post daily staffing and include total hours worked as part of the posted daily staffing. This failure affects all 30 residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper food storage by failing to label foods with a date, ensure the walk-in cooler contained a thermometer, and ensure foods were not expired prior to serving. These failures have the potential affect all 32 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to implement their infection control program by failing to complete infection control logs and by failing to track, trend, and analyze infection data within the facility. This failure has the potential to affect all 32 residents that reside within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a self-administration of medication assessment for residents to administer their own medication/treatments and ensure residents had an active order for the treatment for two of two residents reviewed (R1, R3) for self-administration of medications on the sample list of 25. Findings Include: The facility's Medication Administration Policy dated March 2022 documents after checking labels against the MAR (Medication Administration Record), select the appropriate medication for administration, identify the resident and observe the resident as they take the medication. 1. On 11/27/23 at 12:29 PM, R3 was sitting up in a wheelchair at the dining room table with V16 (R3's family) next to R3. R3 had a medication cup with 10 ml (milliliters) of a red liquid in the cup, without a nurse present. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a level II PASARR (Preadmission Screening & Resident Review) was completed for one (R23) of one residents reviewed for PASARR screenings in the sample list of 25.

Inspectors wroteBased on interview and record review the facility failed to update a care plan to include interventions to prevent reoccurring Urinary Tract Infections (UTIs) and address an active infection for one (R16) of one resident reviewed for UTIs in the sample list of 25.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview and record review, the facility failed to complete weekly wound assessments, complete a wound treatment as ordered and prevent potential cross contamination of the wound for one of two residents (R4) reviewed for skin alterations/wounds on the sample list of 25. B. Based on interview and record review the facility failed to ensure the hospice plan of care and visit notes were part of a resident's medical record to ensure coordination of care for one (R16) of one resident reviewed for hospice in the sample list of 25. Findings Include: A.) R4's November 2023 POS (Physician Order Sheet) documents the following orders: 11/15/23 - Skin prep to the right second toe every shift for two weeks at the previous gout site which is now a resolving blister. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement physician ordered hand splints and implement restorative nursing services for range of motion and splint application following discharge from therapy services for one (R23) of one resident reviewed for range of motion in the sample list of 25.

Inspectors wroteBased on observation, interview and record review, the facility failed to date oxygen tubing and humidifier bottles. The facility also failed to secure and store portable oxygen cylinders appropriately for one of one resident (R4) reviewed for oxygen on the sample list of 25. Findings Include: R4's November 2023 POS (Physician Order Sheet) documents the following orders: Check R4 after meals to ensure R4's oxygen is in use, change oxygen tubing weekly and check humidification bottle daily. On 11/27/23 at 9:21 AM, R4's oxygen tubing was draped over the top of oxygen concentrator, not covered. There was no label with a date on the tubing or humidifier. On 11/28/23 at 1:21 PM, R4 was reclined back in R4's recliner with R4's oxygen tubing lying next to R4 and the oxygen concentrator on at three liters per minute. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor and record fluid intake for a physician ordered fluid restriction for one (R5) of one resident reviewed for dialysis in the sample list of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to document behaviors and implement nonpharmacological interventions prior to administering psychotropic medications, failed to document clinical rational to extend an order for PRN (as needed) antianxiety medication, and failed to ensure appropriate justification for use of an antipsychotic for one (R12) of five residents reviewed for unnecessary medications in the sample list of 25.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications according to Physician Orders and Manufacture's Recommendations for two of six residents (R11, R34) reviewed for medication administration on the sample list of 25. The facility had two errors out of 33 opportunities for a medication error rate of 6.06%. Findings Include: 1. R11's November 2023 POS (Physician Order Sheet) documents an order for Carafate (Antiulcer) 1 gm (gram) - administer one tablet before meals and at bedtime. On 11/28/23 at 11:45 am, R11 was sitting at the dining room table eating lunch and stopped V17 (Registered Nurse/RN) stating, I (R11) haven't had my Carafate yet and I'm supposed to have it 30 minutes before I eat. R11 explained R11 was served lunch around 11:30 am and has been eating since that time. [...]

Inspectors wroteBased on interview and record review the facility failed to implement its Antibiotic Stewardship Program for one (R23) of three residents reviewed for antibiotic use in the sample list of 25.