Masonic Home

Inspectors wroteCross Reference F610Based on interview and record review, the facility failed to provide a safe environment which was free from sexual abuse for Resident 1 when Resident 2 placed his hand under Resident 1's blouse. This had the potential to negatively impact Resident 1 emotionally and psychologically. During a review of the facility's policy and procedure (P&P) titled, SNF- Chapter 11- Resident Behavior & Facility Practices 001 Elder Abuse Prevention, Identification, Investigation & Reporting), the P&P indicated, Purpose: To establish an environment that is homelike as possible and creates a culture and environment that treat each resident with respect and dignity, uploading their self-worth and individuality. Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Definitions:. [...]

Inspectors wroteCross Reference F600Based on interview, record review, and facility policy and procedure (P&P) review, the facility failed to thoroughly investigate the sexual abuse allegation as per facility's P&P for Resident 1. Certified Nursing Assistant (CNA) 1 witnessed Resident 2 place his hand inside Resident 1's blouse. This had the potential to place other vulnerable residents at increased risk of abuse. During a review of the facility's policy and procedure (P&P) titled, (SNF-Chapter 11- Resident Behavior and Facility Practices 001 Elder Abuse Prevention, Identification, Investigation and Reporting, the P&P indicated, .Policy statement: .Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident .F. Investigation.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure storage of food under sanitary conditions when the following food items in the walk-in-refrigerator were not dated and labeled with received, open and use-by dates : One open package of hot dog Six opened containers of salad cream One bowl of peeled mandarin oranges Ice machine cover and surface areas were dusty; inside panel area with brownish, rusty discoloration, and dusty grayish discolored water tubing sleeves. These deficient practices had the potential to cause food borne illness.

Inspectors wroteBased on observation , interview and record review, the facility failed to ensure three of 71 sampled residents' call lights were within easy reach (Residents 3,59 and 64). This failure had the potential for the residents' inability to use the call light when in need of assistance.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow skin and wound care policy and procedure when Resident 69 's pressure ulcer dressing was not appropriately labeled with last change date and the treatment nurse's initials. This failure has the potential to result in missed monitoring and treatment, leading to delayed wound healing, increased wound size, and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices when expired medications in an emergency drug kit (a collection of medications used to treat medical emergencies) were available for use. This failure had the potential to result in residents receiving expired and ineffective medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure garbage and refuse storage area was maintained in a sanitary condition when the dumpster's surrounding area was littered with trash and used gloves. This failure had the potential of harborage and feeding of pest.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe, sanitary, and comfortable homelike environment when the hand sanitizer dispenser in one of ten resident bedrooms was non-operational for four consecutive days. This failure resulted in an unsanitary living condition and the potential for the spread of infection between residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), received treatment and care in accordance with professional standards of care when; Facility did not address Resident 1's continued weight loss and bilateral buttock redness on comprehensive care plan with appropriate interventions. Facility did not notify Resident 1's physician and representatives of continued weight loss. This failure had the potential to cause Resident 1 to not received appropriate care and services to meet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to provide palatable food when food was served bland (lacking flavor). This failure had the potential to put residents to consume less food resulting in consumption of less calories and nutrients provided by the planned menu.

Inspectors wroteBased on observation, interview and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. Dietary Staff 2 (DS2) scooped ice without gloves and touched the ice. 2. Multiple spices containers with residue on the lids stored on the kitchen shelves were unlabeled. 3. Multiple trays of uncooked meat and multiple pies placed in a speed rack, unlabeled and undated in refrigerator 1. 4. A tray of cooked meat with used by date of 7/8/23 was left in refrigerator 1. 5. Portable kitchen counter tops were dirty with food particles on the shelves. 6. Open deep fryer at the portable kitchen was dirty wit built up brown rustic looked like sticky residue particles surrounding it and on its the walls. 7. Dietary Staff 1 (DS1) did not change gloves and wash hands in between task during food preparation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent 13.51% medication error rate when there were five medication pass errors out of 37 medication pass observations. Resident 32's medications were crushed together without an order, including one medication that had enteric coating (EC - designed to pass through the stomach and dissolve in the small intestine, this will protect the stomach lining from irritation). This failure had a potential to affect Resident 32's health due to malabsorption of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food storage practices when: a. A fluffy, gray material was observed on the filters and filter covers of two ice machines; and b. A medication refrigerator temperature log was used for the Resident food refrigerator temperature log for Station #2. These deficient practices had the potential to result in foodborne.

Inspectors wroteBased on interview and record review, the facility failed to develop baseline care plans within the first 48 hours of admission which provided instructions for the provision of effective and person-centered care for four of 22 sampled residents (Residents 231, 77, 73 and 7) when: a. For Residents 231 and 77, there were no baseline care plans to address their pacemakers (devices to help control abnormal heart rhythms) htat included specific information about the pacemaker. For Residents 231 and 77, this deficient practice had the potential to result in unrecognized abnormal pacemaker function (include fainting, dizziness, palpitations, and slow or fast heart rate) and the delay of care. b. For Resident 73, there was no baseline care plan to address the administration of Lovenox (a medicine that thins the blood). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan for one of 22 (Resident 40) sampled residents when Resident 40 did not have a care plan to address him receiving Eliquis (a medication that thins the blood). For Resident 40, this deficient practice had the potential to result in delayed care for an unrecognized bleeding emergency.

Inspectors wroteBased on observation, interview, and record review, for one of 22 sampled residents (Resident 32), the facility failed to ensure supervision to prevent accidents when Resident 32's wander guard device (an alarm system for wandering or flight risk residents) was not in place. For Resident 32, this deficient practice had the potential to result in elopement from the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control practices when Registered Nurse (RN 1) and Assistant Director of Nursing (ADON) handled Resident 63's oxygen tubing while wearing gloves and did not wash their hands after removing their gloves. This deficient practice had the potential to result in the spread of infection.