Grove of Lagrange Park, the

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide adequate supervision to residents at high risk for falls due to poor cognition, poor safety awareness, impulsiveness, and a history of repeated falls. This failure applies to one of three residents (R4) reviewed for accidents and supervision and resulted in R4 sustaining multiple fractures.

Inspectors wroteBased on interview and record review the facility failed to provide care and services to a resident that had a change of condition for 1 of 4 residents (R2) reviewed for change of condition in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received timely and adequate incontinence care and hygiene assistance. This failure applies to 4 of 4 residents (R1, R4, R5, and R6) reviewed for incontinence care.

Inspectors wroteBased on observations, interviews and record review the facility failed to follow interventions to prevent falls and use equipment as per policy and procedures. This applies to 2 (R1 and R3) of 7 residents reviewed for falls and safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail care for 2 of 3 residents (R2, R3) reviewed for activities of daily living in the sample of 5.

Inspectors wroteBased on observations, interview and record review, the facility failed to maintain sanitizer in dish machine during dish washing and failed to ensure that cold foods are stored properly per facility policy guidelines. This applies to 114 residents who receives meals prepared in the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and grooming. This applies to 7 of 7 residents (R19, R26, R30, R57, R71, R97 and R259) reviewed for ADLs (activities of daily living) in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide perineum and indwelling urinary catheter care in a manner that would prevent urinary tract infection. This applies to 4 of 6 residents (R15, R30, R65, R85) reviewed for perineum and urinary catheter care in the sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare pureed consistency hamburger beef steaks to residents on pureed diet. This applies 6 of 6 residents (R1, R4, R24, R25, R50, R319) reviewed for pureed diets in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices during provisions of incontinence and catheter care related to hand hygiene and gloving. The facility also failed to sanitize glucometer machine during blood glucose monitoring. This applies to 6 of 24 residents (R9, R15, R30, R65, R85, R105) reviewed for infection control in the sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to request a re-evaluation for a PASARR II (Pre-admission Screening and Resident Review) screening for a resident with an SMI (serious mental illness) diagnosis within the required timeframe. This applies to 1 of 1 resident (R96) reviewed for PASARR in the sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide staff supervision during meal times to a resident with difficulty swallowing and staff failed to use a gait belt/transfer belt when assisting and transferring a resident. This applies to 2 of 4 residents (R75 and R98) reviewed for accidents and supervision in the sample of 24.

Inspectors wroteBased on observation, interview and record review the facility failed to implement fall interventions. This applies to 4 of 4 residents R3, R4, R5 and R6 reviewed for falls in a sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to immediately notify residents' families of a change of condition. This applies to 2 of 3 residents (R1 and R2) reviewed for policy and procedure in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to handle and store bulk bin scoops in a sanitary manner. This failure has the potential to effect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff performed hand hygiene after direct care, failed to ensure enhanced barrier precautions were in place and failed to ensure staff wore PPE (Personal Protective Equipment) during direct care for residents on isolation to prevent cross contamination. This applies to 7 of 24 residents (R23, R1, R14, R76, R109, R270 & R267) reviewed for infection control in the sample of 24.

Inspectors wroteBased on observation, interview and record review the facility failed to provide assistance to residents that needed extensive assist with activities of daily living (ADL's) to 5 of 24 residents (R70, R22,R23, R19, R65) reviewed for ADLs in the sample of 24.

Inspectors wroteBased on observation and interview the facility failed to ensure a residents dirty linens were changed which applies to 1 of 24 residents (R54) reviewed for homelike environment in a sample of 24.

Inspectors wroteBased on interview and record review the facility failed to complete a comprehensive assessment after a hospice admission. This applies to 1 of 24 (R33) residents reviewed for comprehensive assessments in the sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the prescribed treatment order was in place for a resident with unstageable sacral pressure ulcer. This applies to 1 of 7 residents (R14) reviewed for pressure ulcers in the sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the safety of a resident by not having interventions in place while eating for a resident with a diagnosis of dysphagia which applies to 2 of 24 (R27, R24) residents reviewed for safety in a sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy for residents during administration of medications. This applies to 2 of 2 residents (R22 and R74) reviewed for privacy in a sample of 26.

Inspectors wroteBased on observation and interview the facility failed to ensure that a resident who required assistance in mobility and transfer was transferred from her bed to chair. This applies to one of one residents (R66) reviewed for mobility and transfer in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two residents who required assistance with grooming and personal hygiene received staff assistance, including shaving and rendering nail care. This applies to 2 of 26 resident (R25, R43) reviewed for activities of daily living in the sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to put heel protector boots on residents with a history of pressure sores and with a physician order for the same. This applies to 2 of 7 residents (R43 and R46) reviewed for pressure sores in the sample of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide instruction and personal protective equipment for a family member of a resident in isolation. This applies to 1 of 5 residents (R76) reviewed for Transmission Based Precautions in the total sample of 26.