George Ade Memorial Health Care Center

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's dignity was maintained related to an uncovered urinary catheter bag and a resident's choice was honored for bathing for 2 of 2 residents reviewed for dignity. (Residents G and 57)

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to a Wanderguard alarm (wearable device that alarms when approaching a restricted area) not documented for a resident with history of wandering for 1 of 21 MDS assessments reviewed. (Resident 37)

Inspectors wroteBased on observation, record review and interview, the facility failed to update care plans to reflect the resident's transfer status for 1 of 19 resident care plans reviewed. (Resident 16)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide activities to support the psychosocial well-being of cognitively impaired, dependent residents for 1 of 1 resident reviewed for activities. (Resident H)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to not notifying the physician when a resident was having frequent diarrhea for 1 of 1 resident reviewed for constipation/diarrhea. (Resident 16) The facility also failed to ensure physician's orders were followed related to a resident's catheter securement device for 1 of 1 resident reviewed for catheters. (Resident 52)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide treatment for limited range of motion related to splints not in place for 2 of 3 residents reviewed for range of motion (ROM). (Residents G and H)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were provided with adequate equipment to prevent falls for 1 of 5 residents reviewed for accidents. (Resident D)

Inspectors wroteBased on record review and interview, the facility failed to ensure physician's orders were followed related to a fluid restriction for 1 of 1 resident reviewed for hydration. (Resident 52)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received proper treatment and care related to oxygen administration, implementing physician's orders, and testing for a resident with respiratory symptoms for 2 of 3 residents reviewed for respiratory care. (Residents 32 and 12)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received adequate supervision and assistance to prevent accidents, related to one staff member (CNA 1) assisting a resident with a shower who was care planned for two staff assistance for activities of daily living (ADL's) resulting in the resident falling in the shower and receiving an abrasion to the right knee and a laceration to the right eyebrow that required four sutures. The resident also had a decline in normal functioning related to ambulation after the fall and was diagnosed eight days later with a fractured right hip for 1 of 3 residents reviewed for accidents and supervision. (Resident D)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received care in accordance with professional standards of practice related to a lack of assessments with changes in condition after a fall including pain, weight bearing, and ambulation status which delayed treatment for a fractured right hip for 1 of 3 residents reviewed for quality of care. (Resident D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing related to a treatment not implemented timely for 1 of 3 residents reviewed for pressure ulcers. (Resident 30)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fall precautions were in place for a resident with a history of falls for 1 of 3 residents reviewed for accidents. (Resident 52)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received proper treatment and care related to oxygen administration for 1 of 2 residents reviewed for respiratory care. (Resident 4)

Inspectors wroteBased on observation, record review and interview, the facility failed to attempt alternative measures and assess the necessity for bed rails for 1 of 1 resident reviewed for bed rails. (Resident 52)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were treated with dignity, related to urinary drainage bags not covered, for 2 or 4 residents reviewed for dignity. (Residents C and D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents who required assistance with activities of daily living (ADL's) received oral care and assistance with placement of eyeglasses for 2 of 3 residents reviewed for ADL's. (Residents B and D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a urinary catheter and history of urinary tract infections received proper care and services related to improper placement of the urinary catheter drainage bag and tubing, catheter care not completed, and the outlet tube was not disinfected after emptying the urinary drainage bag, for 1 of 2 residents reviewed for urinary catheters. (Resident D)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff members (CNA 1 and CNA 6) when providing care to residents (Residents D and C) who were in Enhanced Barrier Precautions (EBP) for two random observations for infection control.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a care plan was reviewed and revised to include changes related to splint use for a resident with contractures for 1 of 16 resident care plans reviewed. (Resident 35)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the lack of monitoring and assessments of skin discolorations for 1 of 1 residents reviewed for non-pressure skin conditions. (Resident 43)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received the necessary treatment to prevent a decrease in range of motion related to a hand splint not in place as recommended and no Physician's order for splints for 1 of 1 residents reviewed for positioning and mobility. (Resident 35)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident's pain was managed and monitored for 1 of 1 residents reviewed for pain. (Resident 19)

Inspectors wroteBased on record review and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy to reduce antibiotic resistance related to hospice prescribing antibiotics for a urinary tract infection without a urinalysis and culture completed for 1 of 3 residents reviewed for antibiotic use. (Resident 43)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident equipment was safe and functional related to torn and ripped armrests on a resident's wheelchair for 1 of 1 random observations of resident equipment. (Resident 108)

Inspectors wroteBased on record review and interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment timely for 6 of 19 residents whose MDS assessments were reviewed. (Residents 8, 25, 29, 17, 19, and 42)