Pathstone Living

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer long-acting insulin at consistent times for 2 of 3 residents (R1, R4), failed to appropriately respond to abnormal blood glucose levels, and failed to ensure monitoring and follow-up after interventions for hypoglycemia for 1 of 3 residents (R1) reviewed for diabetic management. R1's face sheet dated 3/5/26, identified a diagnosis type 2 diabetes mellitus. R1's comprehensive Minimum Data Set (MDS) dated [DATE], identified R1 had no cognition issues. R1 was on a therapeutic diet and received insulin injections seven days per week. R1's care plan revised on 3/4/25, identified a focus of risk for complications related to altered glucose metabolism. Diagnosis of diabetes mellitus with retinopathy (damage to retina of the eye). [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure 7 of 7 residents (R4, R7, R10, R11, R14, R18, and R46) reviewed for adequate staffing received timely assistance with incontinence care, hydration, and prompt call light responses. The deficient practice had the potential to affect all 61 residents who resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure nursing staff had specific competencies and skill sets necessary to care for resident needs as identified through resident assessments and plan; failed to ensure accuracy of wound assessments for 2 of 3 residents (R12 and R13) reviewed for pressure wounds. In addition, failed to provide services to maintain and/or prevent loss of range of motion (ROM) for 1 of 3 residents (R4) reviewed for limited range of motion and ensure a hand splint was properly applied to ensure palmar protection. In addition, the facility failed to develop a comprehensive care plan for 1 of 1 resident (R46) reviewed for colostomy care. Additionally, the facility failed to ensure staff competent in cleaning mechanical lift equipment. This had potential to affect all 61 residents who resided in the facility. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure dietary staff adhered to basic infection control practices, specifically hand-hygiene, when serving residents in the dining room. This had the potential to affect all residents who ate meals in the dining room.

Inspectors wroteBased on observation, interview, and document review, administration failed to exercise effective oversight and ensure corrective action of multiple, ongoing deficient practices across departments. The administration had knowledge of these issues through staffing data, QAPI activities, staff reports, and prior monitoring, yet failed to implement timely and effective interventions, resulting in continued noncompliance. The deficient practice had the potential to affect all 61 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to conduct ongoing quality assessment (QA) and assurance activities and develop and implement action plans in order to correct quality deficiencies identified during the survey that the facility was aware of or should have been aware of. This had the potential to affect all 61 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to sanitize and/or replace resident water mugs on a daily basis for 7 of 7 residents (R10, R4, R7, R30, R39, R54, R17), reviewed for infection control practices, to ensure a safe and sanitary vessel from which residents consumed water. This had the potential to affect all 61 residents residing in the facility. In addition, the facility failed to ensure basic infection control practices were followed when 3 of 3 residents (R13, R3, R43) urinary drainage bags were observed resting on the floor.

Inspectors wroteBased on observation and interview, the facility failed to provide a comfortable and sanitary environment for 1 of 1 resident (R4) reviewed for environment, when a bedside commode was observed overfilled and a soiled brief was observed in a wastebasket. In addition, the facility failed to maintain a clean and sanitary environment in the kitchen food preparation and service areas, this had the potential to affect all 61 residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a skin injury had a timely assessment and documentation for 1 of 1 resident (R30), reviewed for non-pressure wounds; failed to ensure accuracy of wound assessments for 2 of 3 residents (R12 and R13) reviewed for pressure wound; failed to ensure an accurate, new, comprehensive assessment was completed for newly identified facility acquired toe wounds for 1 of 1 resident (R3) reviewed for non-pressure wounds.

Inspectors wroteBased on observation and interview, the facility failed to provide fresh drinking water to 7 of 7 residents (R10, R4, R30, R7, R49, R54, R17) on a daily basis who were reviewed for hydration.

Inspectors wroteBased on observation, interview and document review, the facility failed to notify the provider of a choking episode for 1 of 2 residents (R11) reviewed for accidents and skin injury for 2 of 2 residents (R30, R3) reviewed for skin.

Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of missing money were reported timely to the State Agency for 1 of 1 resident (R55) reviewed missing property. In addition, the facility to report choking incident with care plan not being followed for 1 of 2 residents (R5) reviewed for accidents. R55's 5-day Minimum Data Set (MDS) assessment dated [DATE], indicated R55 initial admit date was [DATE], makes self-understood, ability to understand others, adequate hearing, severely impaired vision, moderately impaired cognition, no hallucinations or delusions, no rejection of care, utilized a manual wheelchair, required substantial/maximal assistance with eating, showers, upper body dressing; dependent on toileting, lower body dressing, putting on footwear, and transfers; [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure actions were taken to prevent further misappropriation of funds for 1 of 1 and resident (R55) reviewed for missing property and prevent further neglect due to lack of following the care plan for 1 of 2 residents (R5) reviewed for accidents. Further the facility failed to fully investigate these allegations or take actions to protect other residents.

Inspectors wroteBased on interview and document review, the facility failed to ensure the resident and/or legal representative received a bed hold notice and written notice of transfer for 2 of 2 residents (R13 and R4), reviewed for hospitalization, who were transferred to the hospital for overnight stays.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for 1 of 1 resident (R13) reviewed for MDS accuracy and 1 of 1 resident (R55) reviewed for dialysis.

Inspectors wroteBased on interview and document review, the facility failed to develop a comprehensive care plan for 1 of 1 resident (R46) reviewed for colostomy care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents received assistance with meals for 1 of 2 resident (R5) reviewed for nutrition who required staff assistance and/or supervision with meals.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide incontinence care for 1 of 1 resident (R12) reviewed who was dependent upon staff for assistance with activities of daily living (ADL).

Inspectors wroteBased on observation, interview and document review, the facility failed to provide services to maintain and/or prevent loss of range of motion (ROM) for 1 of 3 residents (R4) reviewed for limited range of motion. In addition, the facility failed to ensure a hand splint was properly applied to ensure palmar protection.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure required nursing staffing information was posted for residents, staff and visitors. This had the potential to affect all 61 residents residing in the facility and their visitors.

Inspectors wroteBased on interview, observation, and document review the facility failed to ensure the infection control program included ongoing surveillance, trending and analysis of resident infections, and failed to ensure enhanced barrier precautions (EBP) were implemented for 1 of 1 residents (R38) reviewed for nephrostomy tube. This had potential to affect all 64 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to implement a process for antibiotic review in order to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect any residents who had infections requiring antibiotic use.

Inspectors wroteBased on interview and document review, the facility failed to ensure a care plan included cultural aspects for 1 of 2 residents (R20) reviewed for food.

Inspectors wroteBased on observation and interview, the facility failed to ensure 3 of 7 (R16, R54, R226) resident ceiling vents in the 3400 wing were clean when they had a black substance present on the vents. This deficient practice had the potential to affect all residents, staff, and visitors on the 3400 wings.

Inspectors wroteBased on interview and record review, the facility failed to recognize a sudden change of condition which resulted in a delay of treatment for 1 of 3 resident (R1) reviewed with change condition. As a result R1 experienced chest pain was hospitalized and died. The immediate jeopardy (IJ) began on [DATE] when licensed nursing staff failed to comprehensively assess and monitor R1 after he voiced he was having chest pain. The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 4:30 p.m. The IJ was removed on [DATE] but non-compliance remained at the lower scope and severity level 2 (D), which indicated no actual harm with potential for more than minimal harm that is not IJ.

Inspectors wroteBased on interview, observation, and document review the facility failed to ensure the infection control program included ongoing surveillance, trending and analysis of resident infections, staff doffed (removed) personal protective equipment (PPE) incorrectly for 1 of 1 resident (R16), failed to ensure PPE was stored in a manner to prevent transmission of bacteria when PPE was observed stored directly on the floor for 18 of 18 residents (R12, R52, R218, R3, R20, R36, R41, R10, R27, R15, R16, R6, R8, R17, R57, R46, R21, and R219) placed on enhanced barrier precautions (EBP) and the staff placed a meal tray on the floor for 1 of 1 resident (R27). This had the potential to affect all 56 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to implement a process for antibiotic review in order to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect any of the 56 residents who had infections requiring antibiotic use.

Inspectors wroteBased on interview and document review, the facility failed to ensure an allegation of misappropriation of property was reported to the state agency (SA) within 24 hours, in accordance with established policies and procedures, for 1 of 1 resident (R1) reviewed for allegation of money theft.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident status was accurately identified in the Minimum Data Set (MDS) assessment for 2 of 2 resident (R52, R21) reviewed for hospice and pressure ulcers.

Inspectors wroteBased on interview and document review, the facility failed to offer/provide a summary of the baseline care plan to the resident and/or resident representative for 3 of 3 residents (R29, R57, R112 ) reviewed who were newly admitted .

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure individualized activities were provided for 1 of 1 resident (R29) reviewed for activities.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure services were coordinated with the hospice agency for 1 of 1 resident (R52) reviewed who received hospice services.

Inspectors wroteBased on observation, interview and document the facility failed to ensure a range of motion program for upper extremities was implemented, wrist brace was applied correctly, and edema glove was on for 1 of 2 residents (R14) who had limited range of motion to prevent contractures.

Inspectors wroteBased on observation, interview and document review, the facility failed to properly assess disposing of cigarettes for 1 of 1 resident (R57) reviewed for smoking.

Inspectors wroteBased on observation and interview, the facility failed to provide a sanitary environment in the kitchen serving food preparation area and drying pots/pans area. This had the potential to affect all 56 residents currently residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure insulin was administered per physician orders for 1 of 3 residents (R1) reviewed for medication administration.

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess, implement interventions, and provide timely notification for change in condition to a provider for 1 of 1 resident (R1) who was found unresponsive which delayed care resulting in death from acute respiratory distress. The facility's failures resulted in an immediate jeopardy for R1. The immediate jeopardy (IJ) began on 3/3/24, when licensed nursing staff failed to comprehensively assess and monitor R1 after being notified by several nursing assistants of R1's change in condition which included decreased appetite, facial pallor, blue lips, increased fatigue, lethargy, and decreased responsiveness. The Administrator and Director of Nursing were notified of the IJ on 3/7/24 at 5:25 p.m. The immediate jeopardy was removed on 3/8/24 at 2:40 p.m. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure safe mechanical lift transfers were completed along with following manufacturer guidelines on how to apply slings,harness, and checking strap before using them for 4 of 4 residents (R1, R2, R3, R4), who utilized a mechanical lift. This resulted in immediate jeopardy (IJ) for R1, R2, R3, R4 when staff were not implementing recent retraining resulting in residents sliding through the lift sling, pain and anxiety when transferred with the lift causing the likelihood for serious harm, impairment or death if they fell from the lift. The immediate jeopardy began on 10/6/23 when nursing assistant (NA)-F transferred R1, not in accordance with the care plan, which resulted in a fall from lift. This same practice resulted in a fall from a lift on 10/8/23 with R2. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure 7 of 7 nursing assistant students (NA-F, NA-J, NA-K, NA-L, NA-M, NA-N and NA-O) involved in the facility's nursing assistant student training program included a system to ensure return demonstration competency for mechanical lift transfers were evaluated by qualified staff to ensure students were adequately trained to safely operate mechanical lifts. This had the potential to affect all 44 of 65 residents who used mechanical lifts in the facility.