Health Central Park

Inspectors wroteBased on interview, and record review, the facility failed to provide activities in resident rooms on the weekends for 3 of 4 residents reviewed for activities, of a total sample of 53 residents, (#142, #65, #66).

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer hand hygiene prior to meals for 35 residents, at 3 different dining locations and failed to follow evidence based practice for implementation of enhanced barrier precautions for 1 of 1 residents reviewed for enhanced barrier precautions, (#65); of a total sample of 53 residents.

Inspectors wroteBased on interview, and record review, the facility failed to timely accommodate a resident's preference to obtain individualized diabetic shoes for 1 of 1 residents sampled for specialized durable medical equipment, of a total sample of 53 residents, (#46).

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor implementation of a fall prevention intervention for 1 of 1 residents sampled regarding fall care plan interventions, of a total sample of 53 residents, (#95).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Activities of Daily Living (ADLs) were maintained for nail care of 1 of 1 residents reviewed for ADLs, of a total sample of 53 residents, (#141) .

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services to prevent reduction in range of motion by failing to apply bilateral palm guards per the plan of care for 1 of 1 residents reviewed for positioning, of a total sample of 53 residents, (#66).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the appropriate assistive device for fluids (two-handled cup) during the lunch meal for 1 of 2 residents reviewed for assistive devices while dining on the 500 unit, of a total sample of 53 residents, (#128).

Inspectors wroteBased on interview, and record review, the facility failed to maintain an accurate medical record for 1 of 2 residents reviewed for respiratory care, of a total sample of 53 residents, (#107).

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from neglect by their failure to provide care and maintenance for a central line intravenous catheter (CVC) per standards of care for 1 of 1 resident reviewed for CVCs, of a total sample of 42 residents, (#65). Resident #65, was readmitted to the facility from the hospital on [DATE] with a central venous line intravenous catheter to the right side of his chest. The admitting nurse noted a treatment was ordered or required in the admission documentation, but only a weekly dressing change was ordered on 11/23/22 for 3 weeks. On 12/09/22, resident #65 was again hospitalized and re-admitted back to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and assessment of a central line intravenous catheter (CVC) for 1 of 1 resident reviewed for CVCs of a total sample of 42 residents, (#65). Resident #65, was readmitted to the facility from the hospital on [DATE] with a central venous line intravenous catheter to the right side of his chest. The admitting nurse noted a treatment was ordered or required in the admission documentation, but only a weekly dressing change was ordered on 11/23/22 for 3 weeks. On 12/09/22, resident #65 was again hospitalized and re-admitted back to the facility on [DATE]. Resident #65 remained at the facility for the next 38 weeks and 5 days including 7 hospitalizations and re-admittances without receiving care and services to maintain and prevent infection of the CVC. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses were knowledgeable and demonstrated competency to provide care and services for a central line intravenous catheter (CVC) for 1 of 1 residents reviewed for CVCs of a total sample of 42 residents, (#65). Resident #65, was readmitted to the facility from the hospital on [DATE] with a CVC to the right side of his chest. The admitting nurse noted a treatment was ordered or required in the admission documentation, but only a weekly dressing change was ordered on 11/23/22 for 3 weeks. On 12/09/22, resident #65 was again hospitalized and re-admitted back to the facility on [DATE]. Resident #65 remained at the facility for the next 38 weeks and 5 days including 7 hospitalizations and re-admittances without receiving care and services to maintain and prevent infection of the CVC. [...]

Inspectors wroteBased on interview, and record review, the facility failed to timely follow procedures to ensure a resident's wishes related to health care treatments and procedures at the end of life were accurately recorded and available to nursing staff, and failed to honor an advance directive that reflected the decision to withhold Cardiopulmonary Resuscitation (CPR) for 1 of 1 resident reviewed for Death, of a total sample of 42 residents, (#108). These failures contributed to resident #108 receiving CPR against her explicit wish for a natural, dignified death. There was likelihood resident #108 experienced severe pain, and could have suffered broken bones, organ damage and a prolonged dying process. On Friday, [DATE], at approximately 2:00 PM, resident #108 and her physician signed a Do Not Resuscitate Order (DNRO) form. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain sufficient nurse staffing on the night shift to promote the highest practicable level of well-being for residents on 2 of 2 units; and failed to provide necessary care and services and ensure safety according to the plans of care for 7 of 16 residents reviewed for staffing concerns, (#2, #3, #10, #12, #45, #62, and #79).

Inspectors wroteBased on interview and record review, the facility failed to utilize its resources effectively to develop and implement a plan that ensured sufficient staffing on the night shift to meet residents' care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain oxygen flow rate as ordered by the physician for 1 resident (#60); and failed to ensure oxygen concentrators were in clean and safe condition for 6 residents (#60, #83, #49, #32, #13, and #83), out of 7 residents reviewed for respiratory care, of 16 residents receiving oxygen therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain safe and sanitary conditions for food storage in 1 of 2 nutrition rooms, (400-unit).

Inspectors wroteBased on interview and record review, the facility failed to provide showers according to preferences for 3 of 8 residents reviewed for choices of a total sample of 54 residents, (#20, #65, #75).

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized care plan for 1 of 5 residents reviewed for oxygen therapy of a total sample of 54 residents, (#51).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide non-surgical site treatment according to a physician's order for 1 of 2 residents reviewed for non-pressure skin condition out of a sampled of 54 residents, (#83).

Inspectors wroteBased on interview and record review, the facility failed to post daily nurse staffing information that included hours worked from 1/01/21 to 2/21/22.