Paoli Health and Living Community

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 3 of 4 resident halls observed. Resident rooms contained used towels/washcloths on the floors, resident bed pans were stored uncovered in shared restrooms, resident toothbrushes were stored uncovered and unlabeled in shared restrooms, and odors were present 2 of 2 days during the survey. (100 hall, 200 hall, 300 hall, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER])

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents reviewed for pharmaceutical services. A resident received an incorrect dose of an ordered medication for three days for a total of four doses due to incorrectly transcribed physician's order. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during 3 of 4 observations of resident care. Staff failed to change gloves when completing a dirty task and prior to starting a clean task, failed to perform hand hygiene between glove uses, and failed to implement enhanced barrier precautions for a resident per the physician's order. (Resident C, Resident D, Resident F)

Inspectors wroteBased on interview and record review, the facility failed to ensure a notice of transfer or discharge was given to residents or resident representatives for 3 of 5 residents reviewed for hospitalizations, and the ombudsman was not notified for 5 of 5 residents reviewed for hospitalizations. The transfer discharge form was not completed. There was no documentation of a resident, representative, and the ombudsman receiving a notice of transfer or discharge at the time of hospitalization. (Resident 15, Resident 56, Resident 48, Resident 41, Resident 231)

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for 2 of 5 residents reviewed for unnecessary medications, 1 of 2 residents reviewed for skin conditions, and 1 of 4 residents reviewed for accidents. Residents were taking an anticoagulant, antiplatelet, and anticonvulsant medications and a resident had falls that were not listed on the MDS assessments. (Resident 231, Resident 57, Resident 15, Resident 56)

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records on residents that are complete and accurate for 2 of 2 residents reviewed for self administration of medications, and 2 of 4 residents reviewed for activities of daily living. Two residents who self-administered medication did not have assessments documented. Ancillary services were not documented accurately for two residents. (Resident 10, Resident 66, Resident 44, Resident 64)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity for 2 of 3 residents reviewed for dignity concerns and one random observation. Staff leaned over a resident to provide care and remove a fitted sheet, a resident's hair was disheveled, food was observed on a resident's face, blood ran down a resident's neck and staff failed to wipe it off, a resident had a gauze dressing on her forehead that was not covered, water was observed on the bedside table of a (nothing by mouth) NPO resident, and staff indicated they would provide water with a mouth sponge to a resident and failed to provide it. (Resident 57, Resident 44, Resident 64)

Inspectors wroteBased on interview and record review, the facility failed to ensure a bed hold policy was given to residents or resident representatives for 2 of 5 residents reviewed for hospitalizations. The bed hold form was not completed. There was no documentation of a resident or representative receiving a bed hold at the time of hospitalization. (Resident 15, Resident 41)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents requiring assistance with Activities of Daily Living (ADLs) received adequate assistance with bathing, nail care and oral care for 3 of 3 residents reviewed for ADL care. (Resident 44, Resident 64, Resident 14)

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided to a resident with an open skin area for 1 of 3 residents reviewed with skin conditions. Assessments including measurements and description of the area were not completed for an open skin area. (Resident 60)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 1 residents reviewed for behavioral health. A resident's clinical record lacked documentation of behavior monitoring. (Resident 64)

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain proper infection control practices and provide a safe and sanitary environment for 1 of 2 residents observed for incontinence care and 1 of 1 residents reviewed for feeding tube care. Staff did not sanitize their hands between glove changes, wash cloths were laid on the side of the bathroom sink and then used for wiping the resident during incontinence care, clean linens and a resident's bare skin were touched with soiled gloves, and a bed sheet with blood on it was not changed. (Resident 64, Resident 281)

Inspectors wroteBased on interview and record review, the facility failed to ensure a sufficient and competent behavioral and mental health training program for all staff was implemented, as determined by staff needs and the facility assessment. Resident clinical records lacked documentation of behavior monitoring and staff were unaware of a resident's diagnosis. (Resident 64)

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from sexual abuse by staff for 1 of 3 residents reviewed for abuse allegations. (Resident C) This deficient practice resulted in an alert and oriented female resident alleging staff to resident sexual abuse on 12/28/24 when Resident C indicated that Certified Nurse Aide (CNA) 13 lifted her gown during care and licked or sucked on her breast a week prior. CNA 13 indicated to a police detective on 12/21/24 that, she asked me to do it, so I done it, to shut her up. This Immediate Jeopardy began on 12/18/24 at approximately 4:00 P.M. when Resident C alleged that CNA 13 had lifted her gown and placed his mouth on her breasts. Resident C was tearful during staff interviews and indicated that she did not want the staff member to place his mouth on her breasts. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from accidents for 1 of 3 residents reviewed for the use of a mechanical lift. A resident was in the process of transferring in a mechanical lift while the lift pad was wrapped under the resident's legs rather than through the resident's legs. The resident did not possess the required stability to transfer safely with the lift pad wrapped under her legs. The resident slid feet first out of the lift pad which resulted in multiple lower extremity fractures and a laceration to the back of her head. The resident was transferred to a local Emergency Department (ED) where she expired. (Resident D) This Immediate Jeopardy began on [DATE] at approximately 7:50 A.M., when Resident D fell 3.5 to 4 feet from a mechanical lift while being transferred by Certified Nurse Aide (CNA) 6 and CNA 7. [...]

Inspectors wroteBased on interview and record review, the facility failed to completely and accurately report an allegation of sexual abuse to the state agency for 1 of 3 allegations of abuse reviewed. (Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the plan of care was implemented for 1 of 3 residents reviewed for resident abuse. A resident was not assisted by two staff members during a transfer according to the resident's plan of care. (Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's right to privacy was protected for 1 of 3 residents reviewed for privacy. Two photographs of a resident, taken by facility staff, were shared to the facility's social media website without the resident's consent. (Resident F)

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident in order to meet medical needs that were identified in the comprehensive assessment. Staff did not follow orders and implement care plan interventions for 6 of 8 residents reviewed for falls and nutrition. (Resident 38, Resident 53, Resident 68, Resident 2, Resident 64, Resident 80)

Inspectors wroteBased on interview and record review, the facility failed to ensure services of an RN (Registered Nurse) were available at least 8 consecutive hours a day, 7 days a week for 1 of 27 days reviewed from the PBJ (Payroll Based Journal) Staffing Data Report during Quarter 4 of 2023 (weekends from July 1, 2023 through September 30, 2023).

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were completed with the CNA training program and evaluation within 4 months of their hire date for 4 of 4 staff that completed the CNA training program at the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure safe and sanitary infection control practices to help prevent the development and transmission of communicable diseases and infections for 4 of 5 residents observed for incontinence care, wound care, glucometer use. Gloves were not changed between dirty and clean tasks and the glucometer was cleaned with an alcohol wipe. (Resident 80, Resident 65, Resident 26, Resident 40)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity for 1 of 2 residents reviewed for dignity and 1 random interview during the resident council meeting. A resident was not given oral care after vomiting and a resident's stained linens were not changed. (Resident 66, Resident 96)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 1 of 4 residents observed during a medication pass. (Resident 58)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents received the necessary respiratory care and services in accordance with the professional standards of practice for 2 of 2 residents reviewed for respiratory care. The facility failed to have a physician's order for oxygen and follow physician's order for oxygen. (Resident 15, Resident 88)

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurate documentation of resident records for 1 of 4 residents reviewed for hospitalizations. A resident's allergy list was not updated. (Resident 2)

Inspectors wroteBased on record review and interview, the facility failed to notify the physician when a resident experienced changes in a level of consciousness, swallowing ability, wound condition, and the need to continue antibiotics for 1 of 19 residents reviewed for physician notification. (Resident 71)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure proper catheter care was provided for 2 of 3 residents reviewed related to indwelling urinary catheters. (Residents 35 and 40)