Jeffrey & Susan Brudnick Center for Living

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) for one Resident, (#123), out of a total of 25 sampled Residents. Specifically, the facility failed to ensure Certified Nursing Assistants (CNAs) donned gowns and gloves while providing care to Resident #123, who was on enhanced barrier precautions related to a catheter.

Inspectors wroteBased on observation, record review and interview, the facility failed to develop and implement a person- centered comprehensive care plan for three Residents (#335, #29 and #18) out of a total sample of 30 residents. Specifically, 1. For Resident #335, the facility failed to develop orders or a care plan for the use of ACE wrap bandages. 2. For Resident #29, the facility failed to devlop a care plan for alcohol use disorder when a resident, with known history of alcohol use disorder was found with alcohol bottles in his/her room. 3. For Resident #18, the facility failed to develop a pain management care plan.

Inspectors wroteBased on observation, chart review and interview the facility failed to provide a dignified existence for one Resident (#23) out of a total sample of 30 Residents. Specifically, for Resident #23 the facility staff stood over the Resident while providing meal assistance.

Inspectors wroteBased on record review and interview, the facility failed to accurately reflect the status of one Resident (#27) out of a total sample of 30 residents, when the Minimum Data Set (MDS) assessment indicated that the Resident was receiving an anticoagulant Resident #27 was admitted to the facility in October 2023 with diagnoses that include diabetes, anemia and hematuria. Review of Resident # 27's most recent Minimum Data Set (MDS) Assessment, dated 11/16/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the Resident is cognitively intact. The MDS further indicates that the Resident is taking an anticoagulant medication. Review of Physician's orders failed to indicate any orders for anticoagulant medications. [...]

Inspectors wroteBased on record review and interview, the facility failed to follow eye doctor recommendations for one Resident (#16) out of a total sample of 30 residents.

Inspectors wroteBased on observations, record reviews, policy review and interviews, the facility failed to prevent a fall with major injury for 1 Resident (#43) out of a total sample of 34 residents. Specifically, the facility failed to complete the admission fall risk assessment and implement fall prevention interventions for a Resident with a history of recurrent falls and Traumatic Brain Injury, resulting in a fall with acute facial fractures.

Inspectors wroteBased on interview and record review the facility failed to accurately code the Minimum Data Set (MDS) assessment for four Residents (#123, #52, #140, and #61) out of a total sample of 34 Residents.

Inspectors wroteBased on observations, record reviews, policy reviews and interviews, the facility failed to follow recommendations for the treatment of pressure ulcers for three Residents (#65, #6, and #52) out of a total sample of 34 residents. Specifically, the facility 1) failed to follow a recommendation to offload a wound for Resident #65 and 2) failed to maintain the correct air mattress setting for two Residents #6 and #52.

Inspectors wroteBased on observations, records reviewed, policy review and interviews, the facility failed to ensure it was free of a medication error rate of five percent or greater when 2 of 4 nurses, made 6 errors in 28 opportunities, totaling a medication error rate of 21.43%. These errors impacted 2 Residents (Resident #291 and #114) out of 4 residents observed.

Inspectors wroteBased on record review and interviews for one Resident (#123) of 34 sampled residents, the facility failed to ensure staff adequately identified a significant change in the Resident's status and completed a comprehensive Significant Change of Status Assessment Minimum Data Set (MDS) as required. Specifically, the facility failed to identify and complete Significant Change in Status MDS when Resident #123 sustained a fall resulting in a right hip fracture, experienced significant weight loss, worsening dysphagia (difficulty swallowing), and developed two new pressure wounds.

Inspectors wroteBased on record review and interview, the facility failed to follow the plan of care and implement physician's orders to perform weekly skin assessments for one Resident (#66) out of a total sample of 34 Residents.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide care in accordance with professional standards of practice for one Resident (#64) out of a total sample of 34 Residents. Specifically, for Resident #64, the facility failed to implement the physician's orders to free float heels while in bed. Review of facility policy, titled Pressure Ulcer Prevention, undated, indicates immobility as a risk factor for pressure ulcers and when in bed, every attempt should be made to float heels (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by clinical staff or by the physician. [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to administer parenteral fluids (delivery of fluids or medications through an intravenous route) consistent with professional standards of practice for one Resident (#130) out of a total sample of 34 residents. Specifically, the facility failed to: 1. Change the Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV]) dressing per facility policy; 2. Obtain a baseline measurement for the external length of Resident #130's PICC from when it was placed to ensure the PICC had not migrated (moved from the heart to another area, which could have a significant impact on treatment, or cause serious harm) per facility policy.

Inspectors wroteBased on observations, interview, and record review the facility failed to provide respiratory care services consistent with professional standards of practice for one Resident (#8) out of a total sample of 34 residents. Specifically, for Resident #8, the facility failed to a). follow physician's orders to administer supplemental oxygen at night, and b). failed to change and label oxygen tubing per physician's orders. Review of the facility policy, Oxygen Administration, undated, indicates in part to Review the physician's orders or facility protocol for oxygen administration, and to assess oxygen saturation (the measure of how much oxygen is traveling through your body in your red blood cells) before and while the resident is receiving oxygen therapy. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a plan of care was developed for Trauma-Informed Care for one Resident (#129), who was admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total sample of 34 residents.

Inspectors wroteBased on observations, interviews and policy review the facility failed to ensure 1. medication carts were locked on two of nine nursing units and 2. failed to ensure medications were stored properly on one of nine nursing units.

Inspectors wroteBased on observations, record review, policy review, and interviews, the facility failed to provide adaptive equipment for one Resident (#93) of 34 sampled residents. Specifically, the facility failed to ensure Resident #93 was provided with built up utensils for use during his/her meals to maximize food intake.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to maintain accurate medical records for two Residents (#119 and #86) out of a total sample of 34 residents. Specifically, the facility 1) inaccurately completed a skin assessment for Resident #119 and 2) inaccurately documented the presence of an air mattress for Resident #86.

Inspectors wroteBased on observations, policy review and interviews the facility failed to ensure infection control standards of practice for the prevention of infections were implemented. Specifically, the facility failed to ensure nursing staff performed hand hygiene appropriately during the medication administration task.