Parsons Presbyterian Manor

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a stop date for an as needed (PRN) antianxiety medication for Resident (R)2 and R5's lorazepam (an antianxiety medication).

Inspectors wroteBased on interview and record review, the facility failed to provide Resident (R) 31 with a written notification of transfer to the resident and/or his representative as soon as practicable and failed to send a copy of that notification to the ombudsman.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide grooming opportunities related to shaving of facial hair to maintain good personal hygiene and dignity for Resident (R)3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform restorative care for Resident (R) 6 who had a contracture (abnormal permanent fixation of a joint or muscle) to her right hand.

Inspectors wroteThe facility reported a census of 29 residents. The sample included three residents reviewed for medications. Based on observation, interview, and record review, the facility failed to prevent the significant medication error of cognitively impaired Resident (R) 1. On 09/12/24 Certified Medication Aide (CMA) R incorrectly administered another resident's (R2's) medications to R1, which included Crestor (anti-hyperlipidemic) 20 milligram (mg) and Coreg (anti-hypertensive) 25 mg, as well as R1's scheduled mirtazapine (anti-depressant) 15 mg. The health care provider advised (HCP) to transport the resident to the Emergency Department (ED) via Emergency Medical Services (EMS) due to R1's life-threatening hypotension (low blood pressure) which occurred within an hour and a half hour of the medication error. [...]

Inspectors wroteThe facility reported a census of 28 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests.

Inspectors wroteThe facility reported a census of 28 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 12 dates between 07/01/23 and 09/30/23 and 10 dates between 01/01/24 and 03/31/24. Findings Included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for Fiscal year (FY), Quarter 4, 2023 (07/01/23 and 09/30/23) revealed a lack of License Nurse (LN) for 24 hours/seven days a week 24 hour/day on the following dates: [...]

Inspectors wroteThe facility reported a census of 28 residents with 13 residents sampled, which included one resident sampled for abuse. Based on observation, interview, and record review, the facility staff failed to report an allegation of staff to resident, verbal abuse (the use of oral, language that willfully includes disparaging and derogatory terms to residents or within their hearing distance regardless of their age ability to comprehend, or disability) related to calling Resident (R)4 lazy in the presence of another resident.

Inspectors wroteThe facility reported a census of 28 residents, with 13 residents sampled which included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to complete a thorough investigation to determine causes and contributing factors related to a skin tear and failed to implement appropriate immediate interventions to prevent further skin tear for Resident (R)18.

Inspectors wroteThe facility reported a census of 28 residents with 13 selected for review, which included four residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure pressure relieving device was in working order for one Resident (R)21, of the four residents reviewed for pressure ulcers.

Inspectors wroteThe facility reported a census of 28 residents, with 13 residents sampled which included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to complete a safe transfer for dependent (R)18 using a sit to stand lift related to the lack of use of the sling's safety belt to ensure the resident's safe transfer.

Inspectors wroteThe facility reported a census of 25 residents with 14 selected for review, which included 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 ensure Resident (R)76 and R4 received timely interventions for pressure ulcer prevention, which resulted in R76's development of an unstageable pressure ulcer (unable to determine depth of the ulcer due to overlying slough (dead tissue usually yellow or white) or eschar (dried dead tissue).

Inspectors wroteThe facility reported a census of 26 residents. Based on interview and record review the facility failed to complete an annual performance review at least once every 12 months for five of five Certified Nurse Aides (CNA) and Certified Medication Aides (CMA) reviewed, including CNA O, P and CNA Q and CMA T and RR.

Inspectors wroteThe facility reported a census of 26 residents with 14 selected for review. Based on observation, interview and record review, the facility failed to ensure the development of a Baseline Care Plan for two of the 14 residents (R) R4 and 76 for pressure ulcer preventive interventions.

Inspectors wroteThe facility reported a census of 26 residents with 14 selected for review which included two residents reviewed for Activities of Daily Living (ADL). Based on observation, interview and record review, the facility failed to offer bathing and grooming opportunities to one of the two residents (R)76 reviewed for ADLs.

Inspectors wroteThe facility reported a census of 26 residents, with 14 residents sampled. Based on observations, interviews, and record review, the facility failed to ensure that one sampled Resident (81), received care and services in accordance with professional standards of practice, when the facility waited over 13 days to implement the physician ordered neurostimulator (an implanted device that sends low levels of electricity directly into the spinal cord to relieve pain), following surgery to the resident.

Inspectors wroteThe facility reported a census of 26 residents with 14 residents sampled, including two residents reviewed for restorative services. Based on observation, interview, and record review, the facility failed to provide restorative services for one of the two sampled, Resident (R)14 to maintain or prevent decline in range of motion (ROM) ability.

Inspectors wroteThe facility reported a census of 26 residents with 14 residents sampled, that included two residents sampled for urinary catheter care. Based on observations, interviews, and record review, the facility failed to provide appropriate and sufficient services, treatment, and care based upon current standards of practice to ensure that Resident (R) 176 received appropriate treatment and services to prevent urinary tract infections to the extent possible.

Inspectors wroteThe facility reported a census of 26 residents with 14 selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure two of the five residents reviewed were monitored for extrapyramidal (abnormal involuntary body movements caused by medications) symptoms for Resident (R) 12 and R 76.