Lake Taylor Hosp

Inspectors wroteNumber of residents sampled: 47Number of residents cited: 2 Based on record review, interview, and policy review, the facility failed to ensure residents' safety for two (Resident (R) 11 and R195) of two residents reviewed for accident hazards in the sample of 47 residents. Specifically, R11 fell to the floor during an assisted transfer by nursing staff from the commode to the bed, which resulted in a femur fracture and R195 rolled out of bed when nursing staff were providing incontinence care and fell to the floor which resulted in a femur fracture. This had the potential to affect residents who required staff assistance during care.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide appropriate meal assistance for two of two residents (Resident (R)9 and R85) reviewed for activities of daily living (ADLs) in a sample of 47 residents. This failure could cause residents to become malnourished, aspirate, or an exacerbation of health conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility for one resident (Residents (R)11) reviewed for dialysis out of a total sample of 47. This had the potential to effect the continuity of care for residents who receive dialysis treatment.

Inspectors wroteNumber of residents sampled: 47Number of residents cited: 1Based on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails; documented discussion related to risk versus benefits; and signed informed consent prior to bed rail use for one of four residents (Resident (R)89 reviewed for side rails out of 47 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment.

Inspectors wroteBased on observation, interview, record review, and review of the manufacturer's manual, the facility failed to maintain air loss mattresses at the proper setting for two of three residents (Resident (R)9 and R15) observed for patient care equipment. This failure could lead to increased risk of skin breakdown.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure that one (Resident (R) 59) of eight residents reviewed for pressure ulcers out of a sample of 31 residents did not develop a pressure ulcer unless their clinical condition showed that it was unavoidable. R59, who had been wearing a splint for a fracture, developed a facility-acquired Stage IV pressure after the facility failed to follow physician orders for daily skin checks and wound care.

Inspectors wroteBased on observation and interview, the facility failed to ensure food, dishware, and cookware used for food preparation/service was stored in a sanitary manner. Food items were not labeled, dated when opened, and/or sealed closed. Dirty industrial fans were blowing on dishware which were clean and ready for use. Cookware was stacked wet. These failures had the potential to affect all 145 residents in the facility who were served food from the facility kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure there was a sufficient supply of bath linens available on two of four units ([NAME] and Dogwood). This failure had the potential to affect 101 residents living on these two units, out of the total census of 145 residents.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure the appropriate use of side rails for four cognitively impaired residents (Resident (R) 96, R125, R3, and R89) out of 31 sampled residents. The facility failed to ensure that prior to the installation of side rails (also known as bed rails), alternatives were attempted. The facility failed to assess each resident for the use of side rails, including a review of risks including entrapment; or obtained informed consent for the use of side rails from the resident and/or the resident representative. In addition, the facility failed to ensure that the bed was appropriate for the residents and that the side rails were routinely monitored for hazards and maintained in accordance with manufacturer specifications.

Inspectors wroteBased on observation, interview, record review, and review of facility program documents, the facility failed to ensure that a paid feeding assistant provided dining assistance only for residents who had no complicated feeding problems. In addition, the facility failed to ensure appropriateness for the paid feeding assistance program was reflected in the care plan. The facility's failure affected one of four units, potentially affecting the 53 residents residing on the Dogwood Unit, out of a total of 145 residents.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure that the resident and/or the resident's representative (RP) for two (Resident (R) 118, and R288) of 31 sampled residents were provided with a summary of the baseline care plan. The facility failed to provide written summaries of the baseline care plan that included, at a minimum, the initial goals of the resident; medications and dietary instructions; and services and treatments to be administered by the facility and personnel.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure the care plan for one (Resident (R) 103) of 31 sampled residents was revised as needed. R103's care plan was not reviewed and updated when the resident developed a facility-acquired Stage II pressure ulcer.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that one (Resident (R) 50) of 29 current sampled residents received activities in accordance with the resident's assessed preferences. The facility failed to assist R50 so the resident could attend a religious activity, per the resident's choice.

Inspectors wroteBased on observation, interview, and document review, the facility failed to post all required nurse staffing data, including both total number and actual hours worked for each shift. In addition, the required data was not posted on two of four units ([NAME] and Beechwood) or in a common area to which all residents and visitors had access.

Inspectors wroteBased on clinical record review, staff interviews, and facility document review, the facility staff failed to notify the office of the State Long-Term Care Ombudsman in writing of applicable discharges for 4 of 48 residents (Residents #164, #163, #147 and #164 B) in the survey sample. 1. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #164's discharges to the hospital on 1/12/18 and 8/15/18. 2. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #163's discharge to the hospital on 4/18/18. 3. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #147's discharges to the hospital on 6/26/18 and 8/30/18. 4. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #164B's discharge to the hospital on [DATE].

Inspectors wroteBased on observations during medication pour and pass, resident statement, staff interviews, clinical record review, and review of the facility's policy, the facility staff failed to ensure the medication error rates was not 5 percent or greater for 3 of 48 residents (Resident #152, #314 and #27), in the survey sample. During the medication pour and pass observation conducted with several staff over different shifts. Twenty-six (26) medication opportunities were observed; five (5) medication errors occurred resulting in a 19.23% medication error rate. 1. The facility staff crushed Resident #152's Alfuzosin Hydrochloric (a medication to decrease urinary retention) (Hcl) Extended Release (ER) 24 hours, which is a do not crush medication. 2. The facility staff crushed Resident #314's Potassium Chloride Extended Release (ER), which is a do not crush medication. 3. [...]

Inspectors wroteBased on observation, staff interviews and facility document review the facility staff failed to store food in accordance with professional standards for food service safety. The food service staff failed to ensure foods stored in the freezer and dry storage were sealed, labeled and dated when opened.

Inspectors wroteBased on on observations and staff interviews the facility staff failed to provide a safe functional sanitary and comfortable environment for residents, staff and the public.

Inspectors wroteBased on observations, record review and staff interview, he facility staff failed to maintain an effective pest control program.

Inspectors wroteBased on clinical record review and staff interviews the facility staff failed to complete a comprehensive resident assessment for 1 of 48 residents (Resident #119), in the survey sample. The facility's staff failed to complete Resident #119's admission Minimum Data Set (MDS) assessment within 14 calendar days after admission to the facility.

Inspectors wroteBased on observations during medication pour and pass, staff interviews, clinical record review, and review of the facility's policy the facility staff failed to ensure services met professional standards of quality for 2 of 48 residents (Resident #149 and #315 ), in the survey sample. 1. The facility's staff failed to assess and/or consult with the physician prior to holding Resident #149's blood pressure medication. 2. The facility staff failed to assess Resident #315 prior to offering and administering an opioid pain medication (Percocet) and failed to ensure Resident #315's Percocet order clearly defined when to administer one tablet and when to administer two tablets

Inspectors wroteBased on observation, staff interviews and clinical record review the facility staff failed to ensure 2 of 48 residents (Resident #111 and 71) in the survey sample who were unable to carry out activities of daily living received the necessary services to maintain fingernail care. 1. The facility staff failed to provide fingernail care for Resident #111. 2. The facility staff failed to ensure Resident #71 was provided ADL care to include removal of long discolored fingernails to both hands.

Inspectors wroteBased on observations, record review and staff interviews, the facility staff failed to have a smoking assessment for 2 residents (Resident #45 and Resident #111) in the survey sample of 45 residents. 1. The facility staff failed to assess Resident #45 for smoking. 2. The facility staff failed to assess Resident #111 for smoking.

Inspectors wroteBased on the Resident Group Interview, observations, staff interviews and facility documentation review, the facility staff failed to ensure that the most recent facility survey results were readily accessible to residents, family members and legal representatives of residents. The facility staff failed to ensure that the most recent facility survey results were readily accessible to residents, family members and legal representatives of residents without having to ask for them.