Plum Tree Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to follow their policy and procedure (P&P) for answering the call light for one of five sampled resident rooms when:1 .Resident 1 stated call light response time was more than 20 minutes at times;2. Resident 2 stated call light response time was more than 10 minutes at times;3. Observation of call light response time was five minutes for Resident room [ROOM NUMBER]. This failure had the potential to affect residents' care, health conditions and well-being of residents in sampled resident rooms.

Inspectors wroteBased on interview and record review, the facility failed to address the residents' discharge needs when Resident 1's durable medical equipment (DME, medically necessary devices prescribed for everyday use to manage illnesses, injuries, or disabilities at home) was not available upon discharge. This failure had the potential for compromising the resident's well-being and safety. Review of Resident 1's record indicated he was admitted on [DATE] and had diagnoses including cerebral infarction (the death of brain tissue caused by a blocked or severely restricted blood supply) and abnormalities of gait and mobility. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/4/26, indicated his Brief Interview for Mental Status (BIMS) was 10, indicating he had moderate cognitive impairment in daily decision-making skills. [...]

Inspectors wroteBased on interview and record review the facility failed to follow it's policy titled, Release of Information, for one of 3 sampled residents (Resident 1), when the facility failed to comply with a medical records request for Resident 1's Medical Record within the 2 day time period stated in the policy. This failure resulted in Resident 1's family to receive the medical records outside the mandated time period. During an interview on 7/30/35, at 9:12 a.m., with Medical Records (MR), MR stated, she received a medical records request signed by Resident 1's family on 4/30/25 via email. MR stated she sent the medical records via email to the requestee on 5/9/25. During a review of emails to MR dated 4/30/25-5/9/25 indicated, a medical record request was emailed to the facility on 4/30/25 for Resident 1. [...]

Inspectors wroteBased on interview and record review the facility failed to document reason to withheld medications and failed to notify primary care physician (PCP) when withheld medications for one of three sampled resident (Resident 2) to meet professional standards. This failure had the potential to affect Resident 2's medical condition and well-being. Review of Resident 2's face sheet (FS: a documenta that gives resident's information at a quick glance) indicated Resident 2 was admitted to facility on 4/30/2025 and discharged home on 5/21/2025. Resident 2 was self-responsible for daily decision making. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure to notify blood work results to primary care physician (PCP) and resident's responsible party (RP: individual person designated to make decisions and receive information on behalf of a resident) for one of three sampled resident (Resident 1). This failure had the potential to compromise to address Resident 1's medical condition and well-being. Review of Resident 1's face sheet (FS: a document that provides resident's information at a quick glance) indicated Resident 1 was admitted to facility on 4/3/2024. Review of Resident 1's diagnoses included diabetes type 2 (DM 2: high sugar levels in blood) and congestive heart failure (CHF: chronic condition in which heart does not pump blood as well as it should). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards of practice were followed for three out of six sampled residents (Resident 5, 11, and 39) when: 1. [NAME] color particles (solid particles settle out of urine), and cloudy color urine (urine appears hazy or white color particles) in urinary catheter (U/C-a thin, flexible tube inserted into urethra [urinary opening] to drain urine from bladder [body organ that stores urine] into a collection bag) in U/C drain tube were not assessed and reported to medical doctor (MD) for Resident 5; 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to provide proper oxygen (a colorless, odorless gas) care and treatment services for three of 15 sampled residents (Residents 16, 20, and 53) when: 1. Resident 16 had room air concentrator (RAC- a medical device take in air from room and filter out nitrogen [a colorless, odorless and nontoxic gas, humans do not breath directly] to provide enriched oxygen [O2-a colorless, odorless, and tasteless gas essential to living organisms])and there was no oxygen signage posted on the door; 2. Residents 20 had an oxygen concentrator (a portable device that provides oxygen) at the bedside, but there was no oxygen signage posted on the door. 3. Residents 53 had an oxygen concentrator at the bedside, but there was no oxygen signage posted on the door. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper medication storage and labeling of medications and supplies when: 1. An opened multi use eye drop medication with no opened date for Resident 175; 2. Expired over the counter (OTC- medication that can be purchased without a prescription) laxative (medication that helps to promote bowel movement) stored in supply cabinet in medication room [ROOM NUMBER]; 3. Expired suction machine (a medical device that is used for removing obstructions from resident's airway [the path that air follows to get into and out of the lungs]) tubing stored in supply area in medication room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented proper infection control practices when: 1. Uncovered feeding tube (a thin, flexible tube one end attached to feeding formula bottle and other end attached to gastrostomy tube [GT-a thin, flexible tube inserted into the stomach to provide nutrition and medications to resident who cannot eat or drink by mouth]) when feeding was not in use; 2. Resident 39's nephrostomy (a surgery to make an opening from the outside of the body to the renal pelvis [part of the kidney that collects urine]) collection bag was laying in the floor; 3. Nebulizer (a small machine that turns liquid medicine into a mist, allowing you to breathe it in directly into your lungs through a mouthpiece or mask) kit was not properly stored after use for Resident 32. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for one of four sampled residents (Residents 39) when staff failed to provide privacy bag for above residents' nephrostomy (a surgery to make an opening from the outside of the body to the renal pelvis [part of the kidney that collects urine]) collection bag. This failure had the potential to affect the emotional and psychosocial well-being of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident 58) out of 15 sampled residents was free from physical restraint not required to treat medical symptoms when Resident 58 was restrained to a wheelchair. This failure resulted in Resident 58 being restricted from moving out of the wheelchair which had the potential for distress and physical injury.

Inspectors wroteBased on interview and record review the facility failed to follow their policy and procedure (P&P) for pre-admission screening and resident review (PASRR- screening for residents with mental disorder and residents with intellectual disability) screening was completed and submitted for one of two sample resident (Resident 24) with significant change in mental illness (MI-a wide range of conditions that affect resident's mood, thinking, and behavior). This failure had the potential for mentally ill sample resident not to receive benefit from specialized health care and services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was stored and/or prepared under sanitary conditions when an opened bag of hamburger buns past their used-by date was found in the kitchen pantry. This failure had the potential to cause food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to provide assistance to prevent an accident for one of three sampled residents (Resident 1). Resident 1's functional ability for bending and picking up objects on the floor was not assessed to determine the ability to bend and Rehab Aide A (RAA) did not provide assistance by holding the gait belt (a device that helps caregivers safely move and support patients who have mobility issues) during therapy exercise. This failure resulted in Resident 1 having a fall and was sent to the hospital with a forehead laceration (a cut in the skin or underlying tissue that's usually caused by blunt trauma).

Inspectors wroteBased on interview and record review, the facility failed to provide services according to professional standards of practice for 1 of 2 sampled residents (Resident 1). When staff failed to: 1. Document to keep Resident 1's oxygen saturation (a measure of how much hemoglobin: protein responsible for transporting oxygen, is currently bound to oxygen) greater 90% as prescribed by the physician; 2. Notify the physician regarding Resident 1's change of condition and there was no physician order for transfer to the acute care hospital. These failures had the potential to affect his medical condition and address the residents needs during the transfer to the acute care hospital.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement proper infection control practices for 1 of 2 sampled residents (Resident 2) when Resident 2 ' s oxygen tubing and humidifier was not replaced and labeled according to facility policy. This failure had the potential for Resident 2 to develop an infectious disease from old oxygen tubing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standard of practice for four out of five sampled residents (Resident 24, 34, 4, and 3) who had a pacemaker (implanted device for a heart condition, a battery-powered device implanted inside the heart to restore a normal heartbeat) when: 1. Resident 24 had no documentation of apical pulse checks and no pacemaker malfunction monitoring, no pacemaker-related information in the medical records, no medical identification card regarding pacemaker, and no care plan regarding the pacemaker management, 2. Resident 34 had no care plan to manage the pacemaker care; 3. Resident 4 had no medical identification card regarding pacemaker; and 4. Resident 3 had no documentation of pacemaker information. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. three personal water bottles were kept in the medication room; 2. unlabeled used medication in the refrigerator; 3. discontinued medications were not discarded. These deficient practices had the potential for unsafe, ineffective and risk the misuse of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the kitchen when: 1. Undated and unrefrigerated bottle of sauce in the dry storage area; 2. Dented can in the dry storage area; 3. Two kitchen staffs did not completely cover their hair while handling food; 4. Ice machine had a black substance inside; and 5. Food prep sink drain was too close to the floor drain. These failures had the potential to cause food contamination and spread food-borne illness to residents who received their food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, infection control practices were implemented when: 1. Licensed Vocational Nurse (LVN) B did not remove gloves, sanitize (to reduce or remove pathogenic agents) hands and put on new gloves, after she fixed the plastic liner of the trash can before handing the inhaler to Resident 115, 2. Registered nurse (RN) C did not change gloves, sanitize hands and put on new gloves, after she picked up the pills of Resident 7 that fell on the floor, then discarded them, and administer the new medication pills, 3. Foley catheter bag (bag that is connected to the foley catheter, where the urine that drains through the catheter is collected) of Resident 265 was touching the floor, and; 4. The maintenance supervisor (MS) did not do hand washing upon entering the kitchen. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident the items and services included in the nursing facility for one of four sampled residents (Resident 45) when Resident 45's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, notice that transfers potential financial liability) was not provided. This failure had the potential in Resident 45 not being informed of his payment responsibilities to the facility after Medicare Part A services ended.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standard of practice for two of 15 sampled residents when: 1. Resident 57 refused her medications and the doctor was not notified and; 2. Resident 111 refused her medication and the doctor was not notified. These failures had the potential to jeopardize the residents' health. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of 19 sampled residents (Resident 44) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: Resident 44 received Seroquel (an antipsychotic medication) without adequate indication and evaluation for its use. The failure resulted in unnecessary medications for the resident, which had the potential for increased risks associated with psychotropic medication use that include, but not limited to, sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss.

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 6.45% when two medication errors occurred out of thirty-one opportunities during the medication administration, for one out of eight residents, (Resident 115). These deficient practices resulted in medications not given in accordance with the prescriber's orders, which resulted in the resident, not receiving the full therapeutic effects of the medications and may cause preventable side effects for the resident.

Inspectors wroteBased on interview and record review the facility failed to ensure for safe discharge plan to address resident's health and safety needs for one of two sampled residents (Resident 1) when Resident 1's blood glucose monitoring (using a device to automatically estimate blood glucose levels) and insulin (insulin: a hormone controls blood sugars) administration was not address upon discharge to the board and care home (B&C home: a residential house that provides care for a small group of seniors). This failure could potentially affect the Resident 1's health and wellness upon discharge from the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement resident-specific and person-centered care plans for six of 12 sampled residents (Residents 11, 15, 16, 25, 23, and 31). Care plans are the basis for resident care and treatment. Failure to develop and implement resident care plans could contribute to residents' compromised care and complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of residents when: 1. Two of five E kit (emergency kit, a limited supply of medications in the facility for use during emergency or after-hours situations) were opened and were not replaced in a timely manner for a census of 46 residents. This failure had the potential for residents not receiving emergency medications in a timely manner, thereby adversely affecting resident's condition. 2. There were multiple missing entries of licensed nurses' signatures in the change of shift narcotics reconciliation Narcotic Report records for two out of the four medication carts. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed properly dispose multiple discontinued medications of discharged residents, opened and expired medications, opened/undated medications in three of four medications carts. This failure had the potential of administering expired medications, and/or incorrectly administering the medications to other residents.

Inspectors wrote3. During the kitchen tour with dietary supervisor (DS) on 2/9/2022 at 10:13 a.m., the kitchen reach-in refrigerator had the following food items: a. One whipped ricotta cheese and one sour cream in 5 pound plastic containers opened and unlabeled; b. One unlabeled personal drinking bottle; c. One open tomato juice in 1.36 liter carton, prepared date: 1/7/2021. d. One open preserved cherry halves in 4 pound plastic container jar. Prepared date: 4/18/2021. During a concurrent interview with DS, she confirmed the above observation and stated the shelf life for the above food items was thirty days from the time they were opened. She also stated the unlabeled personal drinking bottle belonged to one of her staff. All food items should be labeled to keep track of the expiration date. She acknowledged routine inspection should be done to make sure all food items were current and labeled. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the dignity for two of 12 residents (Residents 11 and 26) when staff did not close the door and draw the privacy curtains that exposed to public view: 1. Resident 11's bare upper and lower body while lying in bed, and 2. Resident 26's left upper body and chest during rehabilitation treatment. These failures violated the residents' right to dignity and privacy. Findings 1. During the initial tour on 2/7/2022 at 12:45 p.m., Resident 11's door and privacy curtain were open. Resident 11 was lying in bed with no body covering on except her incontinent pad. Resident 11's upper and lower body parts were bare and exposed to staff and visitors who were passing by. This observation was validated by restorative nursing assistant A (RNA A) who came inside Resident 11's room and pulled the curtain to provide privacy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards for two of 12 sampled residents (Residents 11 and 25) when: 1. Staff did not implement Resident 11's care plan to elevate heels off the bed to help prevent possible skin problems. 2. Staff did not accurately code Resident 25's minimum data set (MDS, an assessment tool) regarding the presence of functional limitation in range of motion on the resident's right lower leg. These failures had the potential for Resident 11 to develop pressure injury and/or skin problems. Accuracy in Resident 25's assessments was important in the development of a care plan with appropriate interventions.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure fall management were implemented for three of 12 sampled residents (Residents 11, 16, and 25) when: 1. Staff did not implement the fall care plan to keep the call light within reach, complete a Fall Risk Review after each fall incident, and ensure Neurological/Vital Signs check were accurately done for Resident 11. 2. Staff did not accurately code the minimum data set (MDS, an assessment tool), implement the post fall care plan for pharmacy consult, and complete a Fall Risk Review after each fall incident for Resident 16. 3. Staff did not ensure the call light was within reach, complete Fall Risk Review after fall incident, develop, update, and implement person-centered and resident-specific fall care plans, and ensure Neurological/Vital sign check was accurately documented for Resident 25. [...]

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure a resident receiving hemodialysis (medical procedure of removing waste products and excess fluid from the blood through an artificial kidney) treatment received care consistent with professional standards for one of 12 sampled residents (Resident 17). For Resident 17, a person-centered and resident specific care plan for the access site was not developed and implemented. Also, the licensed nurse did not follow-up and complete the post-hemodialysis assessment and report upon Resident 17's return to the facility and did not report/call the dialysis unit when Resident 17's central catheter (surgically-placed dialysis access inserted in the neck, chest or groin area) was not marked with precautions and had no dressing applied. These failures had the risk of causing Resident 17's health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 12 sampled residents (Residents 16, 29 and 22) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. For Resident 16, there were missing informed consents for the use of sertraline (an antidepressant medication) and increased dose of olanzapine (an antipsychotic medication), manifested behaviors were not monitored consistently, and the behaviors monitored by the nurses were not consistent with the resident's behaviors indicated in the care plan. 2. For Resident 29, there was no risks and benefits statement for continued use of Haldol (an antipsychotic medication) and manifested behaviors were not monitored consistently. 3. [...]