Lantern Park Specialty Care

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, the facility failed to educate a resident and/or a resident representative and obtain an informed consent prior to two changes in psychotropic medications for 1 of 3 residents (Resident #60) reviewed. The facility reported a census of 86 residents.

Inspectors wroteBased on clinical record review, Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated October 2023 (RAI) review and staff interview the facility failed to complete a Minimum Data Set for a significant change after a hospice admission for 1 of 4 residents (Resident #2) reviewed for hospice. The facility reported a census of 86 residents.

Inspectors wroteBased on clinical record review, Resident Assessment Instrument (RAI) manual review, and staff interviews the facility failed to complete quarterly Minimum Data Set assessments in a timely manner for 3 of 3 residents (Resident #49, Resident #51, Resident #84) in the sample. The facility reported a census of 86 residents.

Inspectors wroteBased on clinical record review, resident interview and staff interview the facility failed to provide at least 2 baths per week for 2 of 3 residents (Residents #13 and Resident #61) reviewed. The facility reported a census of 86 residents.

Inspectors wroteBased on observation, clinical record review, staff and resident interviews, and policy review the facility failed to ensure respiratory care devices are on and operational for 2 of 3 residents reviewed (Residents #1 and #18) and failed to maintain oxygen tubing in a clean and sanitary manner for 1 of 3 residents reviewed (Resident #1) for respiratory care. The facility reported a census of 86.

Inspectors wroteBased on observation, clinical record review, interviews, and policy review the facility failed to provide trauma informed care for 1 of 3 residents reviewed (Resident #60). Resident #60 experienced suicidal ideations that were not addressed in their care plan, staff did not adequately monitor mental health behavior for patterns and medication changes, and staff were not able to articulate resident behavior triggers. The facility reported a census of 86 residents.

Inspectors wroteBased on observation, resident interview and staff interview the facility failed to answer call lights in 15 minutes or less for 3 of 3 observations for call light response. The facility reported a census of 86 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to ensure residents were free from significant medication errors for six of ten residents reviewed for medication administration (Resident #3, Resident #4, Resident #12, Resident #13, Resident #14, and Resident #15). The facility reported a census of 84 residents.

Inspectors wroteBased on interview, clinical review review, and facility policy review, the facility failed to thoroughly investigate an allegation of physical abuse for 1 of 3 residents reviewed for dignity. The facility reported a census of 84 residents.

Inspectors wroteBased on resident and staff interview, clinical record review, and facility policy review, the facility failed to obtain physician orders when utilizing supplemental oxygen or transcribe verbal order for supplemental oxygen for 1 of 3 residents (Resident #2) reviewed for assessment/intervention. The facility additionally failed to administer medications as ordered when multiple morning and afternoon medication doses were omitted on 10/08/24 for 1 of 10 residents (Resident #6) reviewed for medication administration. The facility reported a census of 84 residents.

Inspectors wroteBased on record review and staff interview the facility failed to provide baths for 1 out of 3 residents reviewed (Resident #1) The facility identified a census of 85 residents.

Inspectors wroteBased on clinical record review, observation, staff interviews, and facility policy review the facility failed to provide appropriate supervision with ambulation that resulted in injury for one of four residents reviewed. (Resident #4). The facility reported a census of 85.

Inspectors wroteBased on clinical record review, staff and resident interviews and observations the facility failed to update residents care plans to reflect their current level of functioning for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 85.

Inspectors wroteBased on clinical record review, observation, staff interview and facility policy, the facility failed to transfer a resident who required a mechanical lift in a safe manner for one of three residents reviewed. (Resident #2). The facility reported a census of 85 residents.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and facility policy review the facility staff failed to treat residents with respect and dignity for 4 out of 4 residents reviewed (Residents #4, #13, #78, and #86). The facility reported a census of 84 residents.

Inspectors wroteBased on resident interview, record review, staff interview, and policy review the facility failed to ensure residents were informed of new medications and participated in their own treatment plan for 1 of 3 residents reviewed (Resident #41). The facility reported a census of 84 residents.

Inspectors wroteBased on Payroll Based Journal (PBJ) Data, schedule review, staff interview, and policy review the facility failed to submit payroll data for agency staff during the second quarter of the current fiscal year. The facility reported a census of 84 residents.

Inspectors wroteBased on Minimum Data Set (MDS) review, Pre-admission Screening and Resident Review (PASRR), staff interview, and policy review the facility failed to complete an updated PASRR evaluation for a resident with a new diagnosis for 1 of 1 residents reviewed (Resident #13). The facility reported a census of 84 residents.

Inspectors wroteBased on clinical record review, policy review and staff interview the facility failed to provide appropriate supervision to ensure the safety for 1 of 3 residents (Resident #4) reviewed. The facility reported a census of 83 residents.

Inspectors wroteBased on clinical record review, policy review and staff interview the facility failed to complete an accurate assessment and provide intervention based on that assessment after a fall for 1 of 4 residents (Resident #4) reviewed. The facility reported a census of 83 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to provide resident meals under sanitary conditions for 2 of 2 kitchen observations. The facility reported a census of 84 residents.

Inspectors wroteBased on observation, interview, clinical record review, narcotic book records, and policy review the facility failed to identify situations as an alleged drug diversion and to report allegations within the required regulatory timeframe for 1 of 3 residents reviewed (Resident #18). The facility reported a census of 84 residents.

Inspectors wroteBased on observation, interview, clinical record review, narcotic book records, and policy review the facility failed to complete a thorough investigation of alleged violations, maintain documentation, and prevent further incidents for 1 of 3 residents reviewed (Resident #18). The facility reported a census of 84 residents.

Inspectors wroteBased on clinical record review, policy review, staff interviews, and resident interviews, the facility failed to provide an adequate amount of bathing assistance for 2 of 8 residents reviewed for bathing assistance (Residents #1 and #2). The facility reported a census of 84 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to carry out wound treatment orders for 1 of 4 residents reviewed for wounds (Resident #1). The facility reported a census of 84 residents.

Inspectors wroteBased on clinical record review, policy review, and resident and staff interviews, the facility failed to ensure staff emptied a urinary catheter (a drainage system which emptied urine from the bladder into a drainage bag via a tube) in a timely manner for 1 of 3 residents reviewed with catheter (Resident #1). The facility reported a census of 84 residents.

Inspectors wroteBased on observation, staff interview, record review, and policy review the facility failed to have safeguards in place to protect and account for pro re nata (PRN, as needed) medications for 2 of 4 residents reviewed (Resident #5 and Resident #18). The facility reported a census of 84.

Inspectors wroteBased on clinical record review, observations, staff interview, and policy review, the facility failed to conduct accurate Skin assessments, report the development of a pressure ulcer, and notify the Physician of pressure ulcer development for one of three sampled residents with pressure ulcers (Resident #171). This failure to conduct accurate Skin Assessments, report the development of a pressure ulcer, and notify the physician of pressure ulcers resulted in an Immediate Jeopardy (IJ) at F686-J; Pressure Ulcers due to the increased likelihood of serious, severe, systemic infection and serious pain. On 05/16/23 at 8:57 PM, the Administrator and Director of Nursing (DON) were notified of the IJ at F686 Pressure Ulcers. [...]

Inspectors wroteBased on clinical record review, observations, staff interviews, and review of the facility assessment, the facility failed to ensure one of five Certified Nursing Assistants (CNA's) (CNA 2) was competently trained to report changes in one resident's skin immediately (Resident #171) to the Charge Nurse. In addition, the facility failed to ensure the Director of Nursing (DON) completed a Skin Assessment using basic competencies, including observing all areas of the resident's skin. These failures resulted in the resident experiencing actual harm (delay in treatment to a newly acquired wound.). (Cross Reference F686). The facility reported a census of 82 residents. Findings Include: 1. [...]

Inspectors wroteBased on clinical record review, observation, resident and staff interviews, and facility policy review, the facility failed to follow Physician Orders when the failed to administer lacosamide, a controlled substance anti-seizure medication, and/or Toradol, a pain medication, as ordered by the Physician for 2 of 35 sampled residents (Resident #170 and #15). Resident #170 had a recent seizure history requiring the use of Keppra (an anti-seizure medication) and lacosamide to control the seizures, and the facility failed to administer four doses of the lacosamide. Resident #15 had been prescribed Toradol to help with an uncontrolled migraine headache, and the facility failed to administer the medication for two days. The facility reported a census of 82 residents. Findings Include: 1. [...]

Inspectors wroteBased on observation, staff interviews, and policy review the facility failed to ensure that the kitchen was maintained in a sanitary manner for 82 out of 82 residents. Specifically, food items in the kitchen and storage areas were unlabeled or expired, dietary equipment had a white residue and Dietary Staff were seen in the kitchen not wearing appropriate hair coverings. The facility reoprted a census of 82 residents. Findings Include: 1. The initial kitchen inspection was conducted on 05/15/23 at 09:13 AM through 10:00 AM with the Dietary Manager (DM). The following concerns were noted: a. In the Dry Storage area, an opened bag of corn flakes, removed from the manufacturer's packaging was observed to be dated 04/22/23, which the DM stated was the opened date. There was no use by date. [...]

Inspectors wroteBased on clinical record review, staff interview and review of facility policy, the facility failed to act on a Pharmacy recommendation for one of five residents reviewed for unnecessary medications (Resident #44). The facility failed to act on the Consultant Pharmacist's recommendation that Resident #44, who was prescribed an antianxiety medication (Lorazepam), received a gradual dose reduction. The failure to act on this recommendation had the potential for the resident to experience adverse medication effects such as impaired memory, judgement, and an increased risk of falls. The facility reported a census of 82 residents. Findings Include: Review of Resident #44's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included anxiety disorder and difficulty walking. [...]

Inspectors wroteBased on staff interview and review of facility documentation, the facility failed to ensure the facility's Quality Assurance Performance Improvement (QAPI) policy and procedure addressed feedback; data collection systems; the development, monitoring, and evaluation of performance indicators; or corrective actions. This failure had the potential to affect all 82 residents who currently lived in the facility. Findings Include: A review of the facility's Quality Assurance and Performance Improvement (QAPI) Program, dated 03/2020, indicated the facility's QAPI policy and procedure failed to: a. Describe how it obtained and used feedback from residents, representatives, and staff to identify high-risk, high-volume, or problem prone issues. b. Describe how the committee would ensure data was collected, used, and monitored. c. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to establish and maintain an Infection Prevention and Control Program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility. As part of this failure, the facility did not have an effective Antibiotic Stewardship Program, which had the potential to affect all residents of the facility (Cross Reference F881). In addition, the facility failed to have an adequate water management program. [...]

Inspectors wroteBased on review of facility policy, facility document review and staff interview, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included a functional Antibiotic Stewardship Program. The failure to have a system in place that monitors antibiotic use in accordance with established protocols has the potential to affect all 82 residents of the facility. Findings Include: Review of a policy provided by the facility titled Antibiotic Stewardship dated 04/2018 revealed, This protocol will meet the CDC [Centers for Disease Control and Prevention] elements of Antibiotic Stewardship and will be followed by all Care Initiatives Employee. [...]

Inspectors wroteBased on clinical record review, staff interview and review of facility documents, the facility failed to ensure six residents (Residents #12, #21, #27, #30, #53, and #124) were afforded privacy out of a sample of 35 residents. The facility failed to protect these six residents' medical diagnoses from non-clinical facility staff, and potential public consumers, by placing the residents' names and mental health diagnoses in the Facility Assessment. The facility reported a census of 82 residents. Findings Include: During review of the admission Records for residents, the following concerns noted: a. Review of Resident #12's admission Record, located in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE]. b. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain permanently affixed compartments for storage of controlled drugs for three of three narcotic storage lock boxes observed. The facility reported a census of 82 residents. Findings Include: On 05/18/23 at 10:52 AM, the small medication refrigerator in the medication room was observed with the Interim Director of Nursing (IDON). Three small lock boxes, which were not permanently affixed to the refrigerator, were noted in the refrigerator. The IDON confirmed the boxes were for storage of narcotic medications and that the boxes were not permanently affixed to the refrigerator. Upon further review of the narcotic medication storage boxes the following noted: a. On 05/18/23 at 10:55 AM, Licensed Practical Nurse (LPN) 2 unlocked the lock box for halls 100 and 200. [...]

Inspectors wroteBased on personnel record review and staff interview, the facility failed to ensure five Certified Nursing Assistants (CNA) of five random CNA's reviewed for staffing were trained in the facility's Quality Assurance Performance Improvement (QAPI) Program (CNA 2, CNA 5, CNA 6, CNA 7, and CNA 8). The facility reported a census of 82 residents. Findings Include: Review of documents provided by the facility titled Relias [an on-line training program] revealed the following: 1. CNA 2's date of hire was 11/03/06 and his training failed to address the facility's QAPI program. 2. CNA 5's date of hire was 07/20/18 and her training failed to address the facility's QAPI program. 3. CNA 6's date of hire was 01/03/17 and her training failed to address the facility's QAPI program. 4. CNA 7's date of hire was 05/25/12 and her training failed to address the facility's QAPI program. 5. [...]

Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to ensure that residents and/or their representatives received written information about and assistance with formulating Advance Directives for three of three sampled residents reviewed for Advance Directives (Resident #14, #51, and #52). The facility reported a census of 82 residents.

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to ensure written notice was sent to the resident and/or the resident's representatives after emergent transfers from the facility to the hospital for two residents who were reviewed for hospitalizations (Residents #69 and #67). The failure to provide the required written notices, containing all required information, places the residents at risk of involuntary transfer, and/or not being informed of their rights, including how to appeal, their transfer. The facility reported a census of 82 residents. Findings Include: 1. Review of Resident #69's Electronic Medical Record (EMR) revealed an admission Record, which indicated the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews and facility policy review, the facility failed to ensure one out of a survey sample of 35 residents (Resident #20) received services to maintain or improve the resident's activities of daily living related to mobility. Resident #20 was not provided restorative services, as directed by Skilled Therapy for a walk-to-dine program. The facility reported a census of 82 residents. Findings Include: Review of Resident #20's admission Record in the Electronic Medical Record (EMR) indicated the resident was admitted to the facility on [DATE] with muscle weakness. Review of Resident #20's Quarterly Minimum Data Set, with an Assessment Reference Date of 04/07/23, revealed the resident had a Brief Interview for Mental Status score of 15 out of 15 which revealed the resident was cognitively intact. [...]

Inspectors wroteBased on clinical record review, observations, family member and staff interviews and policy review, the facility failed to provide activities designed to meet the individualized needs for one of two residents reviewed for activities out of 35 sampled residents (Resident #50). Specifically, the facility failed to provide a resident with dementia with consistent, resident-appropriate Activities Program to enhance her quality of life. The facility reported a census of 82 residents. Findings Include: Review of Resident #50's admission Record, located under the Profile tab of the Electronic Medical Record (EMR) indicated Resident #50 was admitted on [DATE] and had diagnoses that included unspecified dementia, without behavioral disturbance. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews and facility policy review, the facility failed to ensure one of three residents reviewed for accident hazards received adequate assistance and supervision to prevent injuries (Resident #37). Resident #37 required assistance from staff to be fed. On 05/09/23 the resident attempted to feed herself, spilled hot food on her right chest, and sustained a first-degree burn on her chest. After this accident, the facility failed to conduct a comprehensive root cause analysis which contained all components per facility policy. The facility also failed to implement measures identified to prevent further accidents, including an Occupational Therapy assessment and the need for total dependence on staff for feeding to reduce the chance of another potential injury. The facility reported a census of 82 residents.

Inspectors wroteBased on facility document review, staff interview and policy review, the facility failed to ensure three Certified Nursing Assistants (CNA's) of five reviewed were provided Annual Performance Reviews (CNA #2, CNA #8, and CNA #5). This failure has the potential for decreased quality of life or quality of care for the residents. The facility reported a census of 82 residents. Findings Include: 1. Review of a document provided by the facility titled Annual Review, signed as dated 11/22/21, indicated CNA #2 completed an Annual Review at that time. 2. Review of a document provided by the facility titled Annual Review, signed as dated 03/28/22, indicated CNA #8 completed an Annual Review at that time. 3. Review of a document provided by the facility titled Annual Review, signed as dated 11/07/21, indicated CNA #5 completed an Annual Review at that time. [...]

Inspectors wroteBased on clinical record review, staff interview and review of facility policy, the facility failed to act on a Pharmacy Recommendation for one of five residents reviewed for unnecessary medications (Resident #44). The facility failed to act on the Consultant Pharmacist's recommendation that Resident #44, who was prescribed an antianxiety medication (Lorazepam), received a gradual dose reduction. The failure to act on this recommendation had the potential for the resident to experience adverse medication effects such as impaired memory, judgement, and an increased risk of falls. The facility reported a census of 82 residents. Findings Include: Review of Resident #44's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included anxiety disorder and difficulty walking. [...]

Inspectors wroteBased on clinical record review, observation, and staff interview, the facility failed to ensure a medication error rate of less than 5% for one of five sampled residents observed receiving medications (Resident #170. There were two errors in 30 opportunities, resulting in a medication error rate of 6.67%. The facility reported a census of 82 residents. Findings Include: Review of Resident #170's Clinical Census, located under the Census tab of the Electronic Medical Record (EMR) revealed Resident #170 was admitted to the facility on [DATE] with diagnoses that included seizure like activity and dermatosis. On 05/16/23 at 9:22 AM, Licensed Practical Nurse (LPN)2 was observed preparing medications for Resident #170. LPN 2 stated Resident #170 did not have two medications available that he was supposed to receive. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to conduct and document a comprehensive facility-wide assessment to determine what resources were necessary to care for its residents competently during day-to-day operations. The lack of an adequate Facility Assessment had the potential for residents' needs to go unmet and/or result in a lack of services provided by the facility to competently care for 82 residents who resided at the facility at the time of the survey. Findings Include: A review of the Facility Assessment, updated 03/27/23, indicated the Facility Assessment failed to address the following pertinent characteristics affecting day-to-day operations and potential emergency situations: a. A facility-based and community-based all hazards approach Risk Assessment. b. Staffing requirements based on resident acuity levels. c. [...]