Presbyterian Village North Special Care Ctr

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the interdisciplinary team determined self-administration of medication was safe for 1 (Resident # 1) of 8 resident's reviewed for medication self-administration. The facility failed to prevent Resident #1 from possessing and administering an inhaler without an assessment to determine if she could safely self-administer the medication. This failure could place all residents who self-administer medications at risk of not receiving the therapeutic dose of their medication as ordered.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 1 of 5 facility shower room and hallway (MU) were reviewed for environment. 1. The facility failed to ensure shower chairs and shower curtains were thoroughly cleaned and stored away from Memory care residents, staff, and visitors. 2. The facility failed to discard used water bottles located on shower chair on the memory unit. These failures could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. An observation on 07/02/2025 at 12:06 PM the facility hydration cart was left open unattended with the ice exposed and the metal scoop. After waiting for approximately 4 minutes, CNA-M was observed coming out of a resident’s room [ROOM NUMBER] minutes later. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 5 residents (Residents #21 and #33) reviewed for respiratory care. 1. The facility failed to change and date Residents #21, bag nasal Cannula and CPAP mask when not in use and date and change oxygen and nasal cannula tubing and humidifier bottle every week.2. The facility failed to bag and date Residents #33's bag and date CPAP mask when not in use to prevent infection prevention. These failures could place residents at risk for respiratory infections. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #147), reviewed for pharmaceutical services. MA A failed to dispose of Resident #147's used Fentanyl Transdermal Patch, 12 micrograms/hour (applied to the skin to treat moderate to severe chronic pain around the clock. Fentanyl is extremely potent. 2 to 3 milligrams of this drug can lead to death due to decreased breathing which can quickly lead to coma and death.) per facility policy. This failure could place residents at risk for obtaining Fentanyl patches out of the trash and overdosing on them.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide coffee that was palatable to meet the needs of each resident for 2 of 2 residents (Resident #187 and confidential resident), reviewed for Dining services. The facility did not serve beverages that was palatable. Resident #187 and an anonymous resident said the coffee tasted bad. This failure could place residents who drank beverages from the kitchen at risk of a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for one of six residents (Resident #1) reviewed for accidents and supervision. CNA A failed to transfer Resident #1 in accordance with her care plan and facility protocol when she independently transferred Resident #1 via mechanical lift (a mechanical device used to safely transfer individuals with limited mobility, typically those who are unable to bear weight or have difficulty moving independently, from one place to another, such as a bed, chair, or wheelchair). As a result, Resident #1 fell from the mechanical lift and sustained a head laceration that required staples. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 02/21/25 and ended on 03/04/25. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive for 1 (Resident #71) of 10 residents reviewed for advanced directives. Resident #71 was administered CPR by LVN H on [DATE], in not honoring the resident's advance directives. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:48PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of more than minimal harm that is not immediate jeopardy and a severity level of isolated because the facility was continuing to implement their Plan of Removal. This failure could affect residents with an accessible DNR and could result in residents not getting their Do Not Resuscitate wishes honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions for 2 (Resident #22 and Resident # 323) of 8 residents reviewed for storage of drugs and Biologicals. The facility failed to ensure that MA D secured Resident # 22's medication before walking away from the medication cart. The facility failed to ensure that Resident #323's self-administration medications were secured and not left on the bedside table after administration. These failures could cause accidental ingestion of medication by a resident not prescribed the medication and could cause access, loss, and diversion of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Residents #30) of 8 residents reviewed for dignity. The facility failed to ensure Residents #30 had the right to a dignified existence when staff stood over the resident while feeding the resident. This failure could affect the residents by placing them at risk for a loss of dignity, decreased self-worth and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 1 (Resident #5) of 8 residents reviewed for refrigerators in the rooms. The facility failed to monitor Resident #5's refrigerator temperature and to clean out undated foods. These failures could affect residents by placing them at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food was properly stored in the facility's dry storage room. 2. The facility failed to ensure expired foods were discarded. These failures could place all residents at risk for food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #48) observed for infection control. CNA A failed to perform hand hygiene while providing incontinence care to Resident # 48. This failure could place the residents at risk for infection.