Overlook Masonic Health Center

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that respiratory care and services consistent with professional standards of practice pertaining to oxygen equipment maintenance was provided for two Residents (#9 and #23), out of a total sample of 19 residents. Specifically, for Resident #9 and Resident #23, the facility failed to maintain the Resident's oxygen concentrator (device used to deliver supplemental oxygen) air intake gross particle filter in accordance with Physician orders and manufacturer's guidelines, placing both Residents at risk for contamination, equipment malfunction, and impaired oxygen delivery.

Inspectors wroteBased on record review and interview, the facility failed to monitor adverse consequences (side effects) of an antipsychotic (psychotropic medication capable of affecting the mind, emotions, and behaviors) medication in accordance with professional standards of practice for one Resident (#38) of five applicable residents, out a total sample of 19 residents. Specifically, for Resident #38, the facility failed to: -complete an Abnormal Involuntary Movement Scale (AIMS - an assessment used to identify the existence and severity of movement side effects associated with antipsychotic drugs) within the required time frame -act upon the Pharmacist Consultant's recommendation following the Resident's monthly medication regimen review indicating a need for AIMS when Resident #38 had been prescribed and administered Clozapine (antipsychotic medication).

Inspectors wroteBased on record review, and interview, the facility failed to ensure one Resident (#86) out of a total sample of 19 residents, was free of a significant medication error. Specifically, for Resident #86, the facility failed to ensure that a daily PRN (as needed medication) Methocarbamol (central nervous system depressant - used to treat pain and muscle spasms while relaxing the brain and the spinal cord) medication was administered as ordered by the Physician.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain an effective infection control and prevention program to stop the spread of organisms and infections for one Resident (#9) out of a total sample of 19 residents. Specifically, for Resident #9, the facility failed to implement appropriate hand hygiene during wound care for Resident #9 who was on Enhanced Barrier Precautions (EBP: infection prevention practice of wearing gown and gloves to reduce transmission of multi-drug-resistant organisms [MDRO's - bacteria that are resistant to three or more types of antimicrobial drugs]) during high contact resident care).

Inspectors wroteBased on observation, interview and policy review, the facility failed to store food in accordance with professional standards for food service safety in the main kitchen and maintain a refrigerator temperature log for one out of four kitchenettes in the facility. Specifically, the facility staff failed to ensure the following: -in the main kitchen: >that expired food items were discarded. >that food items were labeled, dated, and included an expiration date after being opened. -in the Post Acute Unit ([NAME]) kitchenette: >that temperature logs were maintained for the kitchenette refrigerator. >expired food was discarded from the refrigerator by the discard date.

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to adhere to infection control practices and standards to mitigate the spread of infection during a COVID-19 outbreak and for two Residents (#70 and #102). Specifically, the facility staff failed to: 1. Implement timely outbreak testing for COVID-19 when the facility experienced an outbreak of COVID-19. 2. Adhere to infection control practices during wound dressing changes and implement Contact Precautions (gown and gloves for all interactions that may involve contact with the patient or the patient's environment) for one Resident (#70) when the Resident required wound dressing changes to his/her bilateral lower extremities and required Contact Precautions due to the presence of a wound infection. 3. [...]

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to administer parenteral fluids (delivery of fluid or medication through an intravenous [IV: within a vein] . route) according to professional standards of practice and in accordance with the Physician's order for one Resident (#70) out of a total sample of 22 residents. Specifically, the facility staff failed to verify patency (openness of an IV line, allowing medication to flow directly into one's vein) of Resident #70's midline catheter (small tube inserted into a vein in one's arm used to deliver medication and take blood samples), prior to administering an IV antibiotic (medication used to treat infection), as required per the Physician's order, increasing the Resident's risk for complications during antibiotic treatment.

Inspectors wroteBased on record and policy review, and interview, the facility failed to perform a trauma assessment on admission to the facility for one Resident (#61) out of a total sample of 22 residents. Specifically, the facility failed to assess whether Resident #61 had a past history of trauma, and/or any triggers which may cause re-traumatization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that nursing competencies (measurable patterns of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) were assessed, according to the Facility Assessment and care needed by the resident population for two Nurses (#3 and #4) out of four Nurses reviewed. Specifically, the facility failed to: 1. Assess any skill competencies for Nurse #3 since May 2022, including clean dressing (use of a clean procedure field, clean gloves, and with avoidance of direct contamination of materials and supplies) technique, when the Nurse was assigned to care for one Resident (#70) who required daily dressing changes to his/her lower extremities. 2. Assess annual competency for Nurse #4 relative to care of intravenous (IV: [...]

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure that medications and biologicals for two Resident's (#61 and #70) were appropriately managed by staff in a safe and secure manner. Specifically, the facility staff failed to: 1. For Resident #61, store and/or dispose of medications after Resident refusal. 2. For Resident #70, ensure that medications and biologicals left at the Resident's bedside were stored and secured in locked compartments and not accessible to unauthorized individuals.

Inspectors wroteBased on record and policy review, and interview, the facility failed to ensure that the required members were included in the Quality Assessment and Performance Improvement (QAPI) committee quarterly meetings. Specifically, the facility failed to provide evidence that the Infection Preventionist (IP) attended three out of the four quarterly QAPI meetings, as required.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1), who was severely cognitively impaired and dependent on staff for care, the Facility failed to ensure staff implemented and followed their Abuse Prohibition Policy, when on 10/05/23 Certified Nurse Aide (CNA) #2 witnessed an alleged incident of potential physical abuse involving CNA #1 and Resident #1, but did not immediately report the incident per facility policy, and waited until the following day to report it, therefore placing other residents at risk for potential abuse.

Inspectors wroteBased on observation, policy review and interview the facility failed to ensure that its staff stored, prepared, distributed, and served food in accordance with professional standards for food service safety. Specifically: 1) The staff failed to monitor and record food temperatures, and 2) Date refrigerated food items.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that its staff assessed two Residents (#407 and #66), out of a total sample of 23 residents for self-administration of medication, while medication was not stored safely and securely at the bedside. Specifically, the facility staff failed to determine if self-administration of medications was clinically appropriate for Residents #407 and #66.