Linley Park Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Resident (R)21's Medical Director was notified of R21 chewing gum, for 1 of 3 residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Resident (R)21's, with a physician-ordered NPO (nothing by mouth) status and documented aspiration risk, held a Care Plan meeting to discuss R21's chewing gum and implemented measures to protect R21 from choking as a result of the chewing gum.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that Resident (R)21, with a physician-ordered NPO (nothing by mouth) status and documented aspiration risk, was protected from avoidable accident hazards, specifically choking. Review of the facility policy titled, Accidents and Incidents-Investigating and Reporting, revised July 2017, revealed All accidents or hazards involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Review of R21's Face Sheet revealed she was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had a means to call for staff when the call bell system was not functional in the hallway of rooms 20 - 34 for 2 out of 2 residents reviewed.

Inspectors wroteBased on review of the facility policies observations, record reviews and interviews the facility failed to ensure Resident (R)125 was free of significant medication errors when he received a blood pressure medication outside the ordered parameter. R125 received the blood pressure medication multiple times in error for 1 of 5 residents reviewed for unnecessary medications. The facility further failed to ensure insulin via a flex pen was administered correctly by nurses for 3 out of 3 residents observed during medication administration. Review of the facility policy titled, Administering Medications. states, Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 8. [...]

Inspectors wroteBased on facility policy, record reviews and interviews, the facility failed to ensure the physician and the responsible party for Resident (R)68 were notified related to refusal of insulin on multiple occasions for 1 of 1 reviewed for notification. Review of the facility's policy titled, Change in a Resident's Condition or Status, states: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g.,changes in level of care, billing/payments, resident rights, etc.). The, Policy Interpretation and Implementation, states: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): c. Adverse reaction to medication; d. Significant change in the resident's physical/emotional/mental condition; e. [...]

Inspectors wroteBased on the guidance for administering insulin via an Insulin Pen, observations and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent for 4 out 25 opportunities for error. The medication administration error rate was 16 percent. Review of the guidance titled, Insulin Administration Using an Insulin Pen, states: How to Use. 7. Wipe the tip of the pen where the needle will attach with an alcohol swab or a cotton ball moistened with alcohol. 8. Remove the protective pull tab from the needle and screw it onto the pen until snug (but not too tight). 9. Remove both the plastic outer cap and inner needle cap. 10. Look at the dose window and turn the dosage knob to 2 units. 11. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. [...]

Inspectors wroteBased on the facility policy, observations and interviews the facility failed to ensure outdated medications and biologicals were removed from storage with other medications and biologicals in use for residents in 3 of 4 medication carts and 2 of 2 treatment carts. Review of the facility policy titled, Storage of Medications, states, The facility stores all drugs and biologicals in a safe, secure and orderly manner. The Policy Interpretation and Implementation, states: 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 (Resident (R)42, R33, and R43) of 24 residents who resided on A Unit. Observations revealed the residents' rooms had areas of disrepair.

Inspectors wroteBased on observations, interviews, record reviews, and the Centers for Disease Control and Prevention (CDC) guidelines, it was determined that the facility failed to implement an infection prevention and control program (IPCP) designed to provide a safe and sanitary environment to help prevent the possible development and transmission of Coronavirus (COVID-19) as well as other communicable diseases and infections. Specifically, the facility failed to: 1. Ensure unvaccinated/or partially vaccinated newly admitted residents were quarantined to their rooms for two (Resident (R)223 and R230) of 5 residents reviewed for transmission-based precautions. 2. Ensure that during medication administration observations nursing staff wore the appropriate personal protective equipment (PPE) when they went in rooms with residents who were on quarantine for one of three units, Unit B. [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure the medication error rate was below 5%. Observations of medication administration at the facility on 09/07/22 and 09/08/22 with two nurses on two hallways revealed there were 29 opportunities for error with 3 errors leading to a medication error rate of 10.34%.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure each resident room was near a toilet and bathing facilities for 1 of 3 hallways on the A Unit. Interview with Resident (R)66, who lived on the A Unit, revealed they did not have access to a sink or toilet on their hallway, and observations and interviews with staff revealed the plumbing on the hallway was broken, leaving residents without near access to bathing or toilet facilities.