Newton Presbyterian Manor

Inspectors wroteThe facility identified a census of 53 residents, with 14 residents sampled, including two residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to identify and implement pressure ulcer preventative measures, consistent with professional standards of practice, to prevent the development of a facility acquired stage three pressure ulcer to Resident (R)53's left heel after R53 returned from the hospital, due to surgical repair of her left hip fracture.

Inspectors wroteThe facility had a census of 53 residents and the sample included 14 residents. Based on observations, record review and interview, the facility failed to ensure an environment free of accident hazards for Resident R 53 who obtained ahip fracture during a fall and R23 when a Certified Nurse Aide transferred her without a gait belt causing a fall.

Inspectors wroteThe facility reported a census of 53 residents with 14 residents included in the sample. Based on observation, interview, and record review the facility failed to effectively utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high care) and failed to follow established infection control practices related to hand hygiene, peri-care, medication administration, and cleaning of resident nebulizers. The facility further failed to cover resident clean clothing while transporting it through the hallway.

Inspectors wroteThe facility reported a census of 53 residents with 14 included in the sample. Based on interview and record review the facility failed to ensure staff adhered to the principles of antibiotic stewardship through the lack of monitoring for the appropriate use of prescribed antibiotics to prevent antibiotic resistance and the spread of multidrug resistant organisms within the facility.

Inspectors wroteThe facility reported a census of 53 residents. The sample included 14 residents. Based on interview and record review, the facility failed to provide Resident (R)1 who had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition, care in a dignified manner during administration of medication.

Inspectors wroteThe facility identified a census of 53 residents, with 14 residents sampled. Based on observation, interview, and record review the facility failed to identify a significant change and complete an assessment for one resident reviewed for significant change assessments. Resident (R) 53 had a decline with ambulation, toileting hygiene, transfers, and bed mobility.

Inspectors wroteThe facility reported a census of 53 residents; there were 14 residents in the sample. Based on observation, record review and interview, the facility failed to update Resident (R) 36's Care Plan with interventions for R36's right hand positioning device to prevent contractions (abnormal fixations of a joint or muscle) indwelling urinary catheter (a device inserted into the bladder that drains urine into a collection bag).

Inspectors wroteThe facility identified a census of 53 residents, with 14 residents sampled, including two residents reviewed for quality of care. Based on observation, interview, and record review, the facility failed to provide a mechanical lift transfer for Resident (R) 53 which resulted in an injury.

Inspectors wroteThe facility identified a census of 53 residents. The sample included 14 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1's hypoglycemic (medication used to lower blood glucose levels) medication levels were monitored to determine the effectiveness of her ordered hypoglycemic medication.

Inspectors wroteThe facility reported a census of 53 residents. Based on observation, interview and record review the facility failed to ensure the posted daily nurse staffing sheets were posted daily as required.

Inspectors wroteThe facility reported a census of 53 residents. Based on observation and interview, the facility failed to maintain and or dispose of kitchen garbage refuse properly.

Inspectors wroteThe facility reported a census of 49 residents. The sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to prevent an injury to dependent Resident (R) 1 when staff failed to transfer the resident according to the resident's plan of care with two staff present. This failure resulted in R1 obtaining a 2-to-3-centimeter (cm) laceration (a cut in body skin) on her left lower extremity, which required transport to the Emergency Department and 10 sutures to treat the wound.

Inspectors wroteThe facility had a census of 55 residents. The sample included 14 residents, with six reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 40 remained free from avoidable falls when staff failed to provide R40 with the necessary equipment to ensure safety, including a call light and mobility devices, on two separate occasions which resulted in falls on both occasions. This placed the resident at risk for avoidable injury.

Inspectors wroteThe facility had a census of 55 residents. The sample included 14 residents, with one reviewed for hydration. Based on observation, record review, and interview, the facility failed to establish the physician-ordered fluid restriction for one resident, Resident (R) 40. This placed the resident at risk for dehydration (a harmful reduction in the amount of water in the body) or fluid overload (too much fluid in the body).

Inspectors wroteThe facility had a census of 55 residents. The sample included 14 residents, with seven reviewed for behaviors. Based on observation, record review, and interview, the facility failed to complete a trauma-informed care assessment and failed to develop a comprehensive trauma-informed care plan for Resident (R) 35, who had a diagnosis of post-traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). This placed R35 at risk for unmet behavioral and mental health needs and retraumatization.

Inspectors wroteThe facility reported a census of 55 residents with 22 selected for review which included 12 residents reviewed for medications. Based on observation, interview and record review, staff failed to follow physician orders for ten of the 12 residents(R)4, R10, R11, R18, R20, R29, R35, R31, R38, and R 50 reviewed for medications.

Inspectors wroteThe facility reported a census of 55 residents with 22 selected for review. Based on observation, interview and record review, the facility failed to review and revise the plan of care for one resident (R)2's with a pressure ulcer.

Inspectors wroteThe facility reported a census of 55 residents with 22 selected for review which included two residents reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to ensure staff provided care and interventions to prevent pressure ulcers for one of two sampled at risk residents (R)2 in which staff identified a blood blister on her foot and subsequently developed an unstageable pressure ulcer (coverage of a wound by slough and/or eschar) on the same area of the foot.

Inspectors wroteThe facility reported a census of 55 residents with 22 selected for review including six residents reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to follow and implement care plan interventions following a fall for Resident (R)7 and failed to ensure the oxygen tubing for R14 was off the floor to reduce a tripping hazard.

Inspectors wroteThe facility reported a census of 55 residents with 22 selected for review including 12 residents reviewed for unnecessary medications. Based on record review and interview, the facility failed to act upon the pharmacy recommendation for one of the residents, Resident (R)20.

Inspectors wroteThe facility reported a census of 55 residents with 22 residents selected for review including 12 residents reviewed for unnecessary medications. Based on record review and interview the facility failed to provide adequate monitoring for Lasix, Potassium, and Metoprolol medications for one of the sampled residents, Resident (R)20, to ensure no unnecessary medication usage.