Lindsay Gardens Nursing & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure financial abuse was reported to the state agency for one of three sampled residents (Resident 1). This failure resulted in an incomplete investigation.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure when physician orders were not entered correctly in the electronic medical record (EMR) and wound treatments were not being documented on the Treatment Administration Record (TAR) for one of three sampled residents (Resident 1). This failure resulted in the medical record being inaccurate.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement and revise a comprehensive care plan (CP) for three of 33 sampled residents (Resident 61, Resident 81 and Resident 36). This failure had the potential to result in Resident 61, Resident 81, and Resident 36 having an unrecognized change in condition and adverse health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Obtain a physician's order for two of six sampled residents (Resident 36 and Resident 84) prior to oxygen use. This failure had the potential for Resident 84 and Resident 36 to have serious health outcomes, including hypoxia (lack of oxygen) or oxygen toxicity (too much oxygen) causing lung damage and confusion. 2. Follow physician's orders for one of six sampled resident (Resident 84) when oxygen saturation levels were not monitored. This failure had the potential to result in missed early signs of low blood oxygen levels which could lead to potential organ damage, especially to the heart and brain.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled to work in the facility for at least eight consecutive hours a day, seven day per week. This failure had the potential to adversely affect resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:1. The facility's 3-compartment procedure for manual dishwashing was followed by one of one sampled dietary aide (DA) 1 who washed one piece of foodservice equipment via the 3-compartment sink.2. One of five observed dietary employees (DA 2) washed their hands after a cross-contamination incident during the lunch tray line meal service for residents. These failures had the potential to place residents at risk of foodborne illness who received meals from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control standards when:1. A Water Management Program (WMP) was not implemented, for 32 of 32 sampled residents, when risk for growth of opportunistic waterborne pathogens (germs that grow well in water) was not assessed, areas for growth were not identified, and measures to prevent and monitor growth were not identified within the facility's water system. This failure had the potential to result in serious illness or death of residents, visitors and staff.2. Licensed Vocational Nurse (LVN) 4 failed to use aseptic technique for one of four sampled residents (Resident 5) when she introduced a syringe in Resident 5's mouth and then reintroduced the used syringe into the clean medication container. This failure had the potential to contaminate the medication container with bacteria and microorganisms.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 7) was provided dignified care when Resident 7's urine collection bag was not covered and was visible to other residents, staff and visitors. This failure had the potential to result in emotional distress for Resident 7.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two sampled residents (Resident 99 and Resident 87) were provided privacy when 24 hour video surveillance was used to monitor Resident 99 and Resident 87 without written consent. This failure resulted in the violation of Resident 99 and Resident 87's right to privacy and confidentiality and the potential to result in emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 33 sampled residents (Resident 61) IDT (interdisciplinary team, group of health care professionals that meet to discuss resident care) comprehensive plan of care was updated and revised to reflect Resident 61's current health status, care needs and interventions. This failure had the potential for Resident 61 not to receive care that could negatively impact the quality of life/care.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Telephone Orders, when one of 33 sampled resident (Resident 10) physician telephone orders were not recorded in Resident 10's medical record. This failure resulted in Resident 10 not receiving recommended treatments and had the potential for skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 33 sampled residents (Resident 5) received treatment and services to bilateral feet. This failure resulted in Resident 5 having dry, flaky skin around toes, and feet, and long thickened untrimmed toenails and had the potential to cause skin breakdown and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled resident (Resident 68) head of bed (HOB) was elevated during G-tube feeding (gastrostomy tube, a small flexible tube surgical inserted through the abdomen and placed into the stomach to deliver nutrition, fluids, and medication directly into stomach). This failure had the potential to cause aspiration (liquid or food enters into the lungs instead of the stomach) for Resident 68.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its policy and procedure (P&P) titled, Foods Brought by Family/Visitors provided sufficient guidance on safe refrigerated food storage and was followed for labeling resident's outside food brought into the facility. These failures had the potential to place residents storing outside food in the employees' breakroom refrigerator at risk of foodborne illness.

Inspectors wroteBased on interview and record review the facility failed to develop a base line care for one of four sample resident (Resident 1) who was admitted with a left arm cast (a medical treatment used to support bone during healing process). This failure has the potential for Resident 1's left-ham cast to develop complications without staff awareness and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure a follow-up visit with orthopedic doctor (treats injuries and disease affecting bones, muscle, and etc.) was made for one for four sampled residents (Resident 1). This failure resulted in Resident 1 not being seen by an orthopedic doctor and potential for increased risk of complications, prolonged recovery, and worsening pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure when restraint removal was not documented every 2 hours for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 ' s motion and exercise to be limited.

Inspectors wroteBased on observation, interview, record review, facility policy review, and review of manufacturer's information, the facility failed to ensure the medication error rate was less than 5 percent (%). Observation of medication administration revealed there were 2 errors out of 35 opportunities, which resulted in a medication error rate of 5.71 %, affecting 2 (Resident #46 and Resident #77) of 5 residents observed during medication administration.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the status of 1 (Resident #57) of 21 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #38) of 2 residents reviewed for Preadmission Screening and Resident Review (PASARR or PASRR) was referred for a Level II PASARR assessment when the resident was newly diagnosed with a serious mental illness.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to follow physician's orders for 2 (Resident #33 and Resident #84) of 5 residents reviewed for unnecessary medications. Specifically, the facility staff failed to administer insulin as ordered by the physician to Resident #33, and the facility failed to administer metoprolol and insulin as ordered by the physician to Resident #84.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to provide routine pharmaceutical services to ensure medications were available for administration for 1 (Resident #33) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) for three of 26 sampled residents (Resident 50, Resident 27, and Resident 74) when: 1. Resident 50 was permitted to have cigarettes and lighter in his room and to smoke without supervision. 2. Resident 27 was permitted to have a cigarette lighter in her room and to smoke without supervision. 3. Resident 74 was permitted to have cigarettes and lighter. These failures had the potential to result in an avoidable smoking accident.

Inspectors wroteBased on interview and record review, the facility failed to ensure a distinct population was included in the facility assessment. This failure had the potential to lead to unmet care needs for the facility's smoking residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three housekeepers (HK) 1 cleaned high touch surfaces according to the facility's COVID-19 (A highly contagious respiratory illness in humans that is spread from person to person when an infected person coughs, sneezes, or talks. It may also be spread by touching a surface with the virus on it and then touching one's nose, mouth, or eyes) mitigation plan. This failure had the potential to facilitate the spread of COVID-19 to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a policy and procedure(P&P) was developed and implemented to ensure the residents had a safe smoking environment. This failure had the potential to result to an unsafe smoking area and possible exposure to second hand smoke for non-smoking residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of 26 sampled residents (Resident 30) call light was within reach. This failure had the potential for Resident 30's needs to go unmet.

Inspectors wroteBased on interview and record review, the facility failed to ensure the SNFABN form (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage, a form that provides information to the beneficiary so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility) was completed for one of three sampled residents (Resident 9). This failure resulted in Resident 9 not being informed of the three options available.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for two of 26 sampled residents (Resident 43 and Resident 28). This failure had the potential for unmet care needs and adverse outcomes for Resident 43 and Resident 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise one of 26 sampled residents (Resident 30) care plan timely. This failure had the potential for Resident 30's needs to go unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 26 sampled residents (Resident 38) continuous tube feeding (a liquid food mixture given through a tube into the stomach to provide nutrients to people who cannot eat or drink safely) container and tubing were changed according to manufacturer's guidelines. This failure had the potential to result in Resident 38's tube feeding becoming contaminated with harmful bacterial growth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were labeled appropriately and expired medications were removed from active supply. These failures had the potential for the residents to receive ineffective medications.