Lawrence Street Health Care Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #1) reviewed for parenteral fluids. The facility failed to flush Resident #1's PICC line every shift, obtain orders for the PICC line, and change the dressing every 7 days, from 5/27/26 to 6/16/26. These failures could place residents at risk for infection, blood clot formation, and pain.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (CR #1) reviewed for accidents and supervision. The facility failed to ensure CR #1 did not elope from the facility on 11/19/24, after being let out by staff to the patio area to smoke unsupervised. CR #1 was found by the previous Social Worker approximately 30 minutes later by a gas station. The non-compliance was identified as PNC. The IJ began on 11/19/24 and ended on 11/19/24. The facility had corrected the non-compliance before the survey. This failure could place residents at risk of elopement or injury.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal Laws, drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 19 residents (Resident #4) reviewed for drug labeling and storage. The facility failed to ensure Resident #4's medication was not stored on the resident's nightstand. This failure could place residents at risk of adverse reactions and drug diversions.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure all drugs and biologicals were stored securely for one (Nurse Cart for B Hall/D Hall) of three medication carts reviewed for storage of medications. The Nurse Cart for B Hall/D Hall contained medications without resident identifiers. The Nurse Cart for B Hall/D Hall contained a narcotic medication blister pill card with a punctured protective seal. The failures could place all residents at risk of not receiving the therapeutic benefit of medications, infection, adverse reactions to medications and drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpster reviewed for food and nutrition services. -The facility failed to ensure the dumpster door was closed at all times when no one was dumping garbage . This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1 received the correct dose of Vitamin D3 (a dietary supplement to help maintain bone health and for vitamin deficiency) as written by the physician. LVN A failed to confirm the correct dose of Vitamin D3 prior to administration. This failure could place residents at risk of not receiving the intended therapeutic benefits of the medications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened/preparation discarded after 96 Hours (4 days) per facility policy 2. The facility failed to keep food off the floor. These failures could place residents at risk of food borne illness and disease. Findings Include: Observation of the facility kitchen on 08/20/24 at 8:15 AM revealed the following. 1. 5 chicken sandwiches in the walk in cooler had use by date 8/19/24. 2. A Plastic container of deli sliced ham in the walk-in cooler had no label/ no date 3. A plastic container - of shredded lettuce dated 8/12/24 and no use by date. 4. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 (Resident #1) of 6 residents reviewed for changes of condition. The facility failed to notify Resident #1's physician when she experienced a change of condition, including developing a small bump on the back of the head after she fell out of her wheelchair and hit her head on [DATE]. This failure placed residents at risk experiencing a delay in medical treatment and worsening of condition/symptoms. Record review of Resident #1 ' s face sheet dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses of Alzheimer ' s Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks); [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices based on the comprehensive assessment for 1 (Resident #1) of 6 residents reviewed for quality of care. -The facility failed to complete an appropriate assessment for Resident #1 after she fell out of her wheelchair and a small bump to the back of the head was sustained. -The facility failed to send Resident #1 to the hospital after she fell out of her wheelchair, hit her head and developed a small bump on the back of her head. These failures could place residents at risk of not receiving needed care and services to meet their physical, mental, and psychosocial needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and the facility failed to determine that drug records were in order and that an account of all controlled drugs were maintained periodically reconciled for 1 of 7 residents (Resident #15) reviewed for medication administration and 1 of 2 medication carts (B Hall medication cart) reviewed for accounting. 1. The facility failed to ensure an accurate recordkeeping of liquid Lorazepam (a controlled substance) from the B Hall medication cart. 2. The facility failed to check Resident #15's blood pressure prior to administering Metoprolol used to treat high blood pressure. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for two of two medication carts (B Hall medication cart and medication cart in the secure unit) reviewed for storage of medications. 1. The facility failed to ensure B Hall medication cart and the medication cart in the secure unit did not contain torn protective seals on the back of narcotic medication blister pill cards. 2. The facility failed to ensure the B Hall medication cart did not have loose pills. 3. The facility failed to ensure eye drops were labeled and medications had the expiration dates in the B Hall medication cart. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #44) reviewed for care plans. The facility failed to implement Resident #44's care plan by failing to ensure bed rails were installed on the resident's bed frame. This deficient practice could place residents at risk for not receiving appropriate care and services. Findings Include: Record review of Resident #44's face sheet, dated 07/12/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessment for 1 of 17 residents (Resident #7) reviewed for care plans. The facility failed to ensure Resident #7's care plan was revised to include interventions for falls to help prevent injuries. This failure could place residents at risk of not having their needs addressed and inconsistency of care.