Patewood Post Acute

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure a resident was not served their meals on disposable tableware to protect their dignity, which affected 1 (Resident (R)42) of 2 residents reviewed for dignity concerns.

Inspectors wroteBased on facility policy review, interview, and record review, the facility failed to ensure residents who self-administered medications were assessed as safe to self-administer medications, which affected 2 (Resident (R)134 and R26) of 3 sampled residents who had medications in their room.

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure medications were administered by only licensed staff and with a physician's order for 1 (Resident(R)26) of 3 sampled residents who had medications in their room.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff followed physician's orders for the use of supplemental oxygen for 2 (Resident (R)26 and R114) of 2 sampled residents reviewed for oxygen therapy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure safe insulin administration for 1 (Resident (R)88) of 2 residents reviewed for insulin administration. Specifically, Licensed Practical Nurse (LPN)30 failed to verify R88's insulin order prior to preparing insulin for administration and failed to immediately document the insulin administration. The facility also failed to follow a procedure to ensure staff accurately acquired, received, and administered medicated eye drops for 1 (R72) of 25 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents were free from significant medication errors, which affected 1 (Resident (R)72) of 25 sampled residents. Specifically, the facility failed to provide prescription eye drops per the physician orders for R72.

Inspectors wroteBased on facility policy review, record review, observation, and interview, the facility failed to ensure medications were stored safely and securely for 2 (Resident (R)3 and R119) of 8 residents reviewed during the medication administration task and 1 (R120) of 3 sampled residents who had medications in their room.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to properly label and date food items that had been opened or prepared in the kitchen, and failed to discard expired items. These failures had the potential to affect all 116 residents who consumed food from the kitchen.

Inspectors wroteBased on review of review of facility policy, observation, interview, and record review, the facility failed to ensure an ongoing and meaningful program of activities was provided for two (Residents (R) R3 and R67) of four residents reviewed for activities out of a total of 25 residents were reviewed in the sample. This had the potential for the residents to have a decreased quality of life.

Inspectors wroteBased on review of facility policy, observation, interview, and record review, the facility failed to ensure a palm guard was applied to one (Resident (R) R3) of four residents reviewed for positioning/mobility. A total of 25 residents were reviewed in the sample. This had the potential for the resident to experience a decline in ROM.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure respiratory care equipment was maintained in a clean and sanitary manner for one (Resident (R) 413) of four residents reviewed for respiratory care out of a total sample of 25 residents. This failure had the potential to lead to respiratory infections.

Inspectors wroteBased on observation, review of facility policy, and interview, the facility failed to ensure proper hand hygiene was completed, and proper personal protective equipment (PPE) was worn during direct contact/care for two residents (Resident (R)49 and R313) out of two residents observed during direct contact who were on enhanced barrier precautions (EBP) out of a total sample of 25 residents. This failure had the potential to cause cross contamination to the residents.

Inspectors wroteBased on record review, interview, document review, and facility policy review, the facility failed to ensure the McGeer criteria was used when an antibiotic was ordered and administered to one resident (Resident (R)45) of five residents reviewed for unnecessary medications out of a total sample of 25 resident. This had the potential for the resident to have unnecessary adverse reactions to a potentially unnecessary antibiotic administered.

Inspectors wroteBased on observation, interviews, and policy review, the facility failed to ensure one Resident (R)80 was provided with an adapted call light control (referred to as a soft touch), to be able to request assistance from the staff when he was in need.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure personal privacy by covering an indwelling urinary catheter collection bag for one Resident (R)13 of four residents reviewed for catheter care in a total sample of 32 residents. This failure resulted in the potential for an undignified appearance for the resident.

Inspectors wroteBased on record review, observation, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure two residents (Resident (R)39 and R58) out of 29 sampled residents had an accurate Minimum Data Set (MDS) assessment.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to properly label enteral feeding bag and properly sanitize the reusable enteral feeding syringes for one Resident (R)63 from a sampled 39 residents.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure that two (Residents (R)44 and R60) from a sampled 39 residents were receiving oxygen therapy according to physicians' orders. The failure has the potential for residents to receive inadequate oxygen therapy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain an indwelling urinary catheter off the floor for one Resident (R)37 of four residents reviewed for catheter use, in a total sample of 32 residents. This failure resulted in the potential for increased infections to occur.