Prescott House

Inspectors wroteBased on record review and interview, the facility failed to report lab results to the provider timely for one Resident (#82) out of a total of 24 sampled residents. Specifically, the facility failed to notify the on call provider of Resident #82's urine culture which indicated he/she had a urinary tract infection on 1/4/26. Subsequently, antibiotic treatment was not initiated, and Resident was hospitalized and diagnosed with sepsis, (a life threatening illness that develops when an existing infection triggers an extreme immune system response in your body) secondary to a urinary tract infection on 1/6/26; approximately two days after the lab results were completed.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a change in condition for one Resident (#3) out of a total sample of 24 residents. Specifically, the facility failed to notify the physician/nurse practitioner when Resident #3's blood sugar levels went below 70 mg/dL (milligrams per deciliters) as indicated by the plan of care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow the grievance process for one Resident (#4) related to wound care, out of a total sample of 24 residents.

Inspectors wroteBased on record review and interview, the facility to ensure that services provided met professional standards for one Resident (#126), out of 24 total sampled residents. Specifically, the facility failed to obtain and implement a physician's order for Resident #126's Sinemet (carbidopa-levodopa, medication used to treat tremors with Residents who have Parkinson's disease) based on the Resident's home schedule.

Inspectors wroteBased on observation, record review, and interview, the facility failed to accurately transcribe wound recommendations and perform wound care appropriately for one Resident (#4) out of a total sample of 24 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure professional standards of practice for the care of an indwelling Foley urinary catheter (a flexible tube inserted through the urethra into the bladder to drain urine) for one Resident (#30) out of a total sample of 24 residents. Specifically, the facility failed to ensure nursing inserted the correct balloon size in accordance with physician's orders.

Inspectors wroteBased on observations, record review, and interview the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#22), out of a total sample of 24 residents. Specifically, for Resident #22, the facility failed to apply a PICC line dressing that did not have gauze obstructing the insertion site.

Inspectors wroteBased on observations, record review and interview, the facility failed to accurately document in the electronic medical record for one Residents (#30), out of a total sample of 24 residents. Specifically, the facility documented that Resident #30 was wearing an orthotic elbow edge cushion when he/she was not.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who was alert, oriented and able to make his/her needs known, the facility failed to ensure he/she was treated in a dignified and respectful manner, when a staff member told Resident #1 that his/her rang the call bell too much, then intentionally took Resident #1's call bell and placed it out of his/her reach to prevent him/her from using it.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was dependent on staff for assistance with care, the facility failed to ensure staff consistently implemented and followed their abuse policy related to the reporting of abuse allegations, when in the morning on 09/06/25, although Certified Nurse Aide (CNA) #2 witnessed CNA #1 forcefully remove that call bell cord out of Resident $#1's hand and intentionally place it out of his/her reach, CNA #2 did not immediately report the incident as required, but waited two days to report it.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Physician's Orders included the administration of an anxiolytic, and an ear drop medication, the Facility failed to ensure Resident #1 was administered the medications, consistent with physicians' orders.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had a new Physicians Order on 01/07/2025, for Blood Laboratory work to be conducted on 01/09/25, the Facility failed to ensure Resident #1 was provided with Laboratory Services consistent with his/her Physician Orders, when the laboratory tests were not ordered or obtained, as ordered.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure a home-like environment on the A Unit.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure resident centered care plans were developed and/or implemented for three Residents (#12, #91 and #13) out of a total sample of 24 residents. Specifically, 1. For Resident #12, the facility failed to a. develop a comprehensive resident centered care plan for a pacemaker and b. failed to implement the Resident's fall intervention of non skid strips on the floor next to his/her bed. 2. For Resident #91, the facility failed to implement a right hand splint and arm wedge as per the plan of care. 3. For Resident #13, the facility failed to implement a right hand roll as per the plan of care.

Inspectors wroteBased on observation, record review and interview, the facility failed to regularly inspect bed frames and mattress spacing to identify areas of potential entrapment. Specifically, the facility failed to regularly inspect and document findings regarding the seven zones of bed entrapment of Residents' beds for potential areas of entrapment as evidenced by a bed bolster (an object used to fill gaps between the mattress and headboard/footboard of a bed) that did not fit properly.

Inspectors wroteBased on policy review, interview and observation, the facility failed to ensure it provided a means for residents to communicate to staff on the A Unit.

Inspectors wroteBased on interview, record review and observation, the facility failed to ensure one Resident (#175) was able to dine in a dignified manner.

Inspectors wroteBased on record review, interview and observation, the facility failed to follow physician's orders for two Residents (#175 and #68) of 24 sampled residents. Specifically: 1. For Resident #175, the facility failed to change a soiled wound dressing for three days. 2. For Resident #68, the facility failed to change oxygen tubing for approximately three weeks because staff did not obtain a physician's treatment order for the procedure.

Inspectors wroteBased on interview, record review and observation, the facility failed to ensure it provided one Resident (#175) with the assistance required for meal setup.

Inspectors wroteBased on record review and interview, the facility failed for one Resident (#175) to communicate with the Dialysis Center nurse regarding Resident #175's care, document his/her condition after dialysis treatment, and notify the practitioner of fistula bleeds out of a total sample of 24 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an accurate medical record for three Residents (#91, #13 and #175), out of a total sample of 24 residents. Specifically: 1 For Resident #91, the nurses documented in the Treatment Administration Record (TAR) the Resident was wearing his/her right hand splint and arm wedge, when he/she was not; 2. For Resident #13, the nurses documented in the TAR the Resident was wearing his/her right hand roll, when he/she was not; 3. For Resident #175, nursing staff documented they changed a dressing when they did not. Findings Include: Review of the facility policy titled Charting and Documentation, dated July 2022, indicated the following: Policy Statement: [...]

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure that 1. Sufficient staffing levels were maintained to adequately meet residents' care needs. 2. For Resident #44, who is dependent on staff for personal hygiene and grooming, the facility failed to remove unwanted facial hair, which the staff attributed to being short staffed.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure staff did not store their drinks with resident food ingredients and that food was labeled and not kept beyond the use-by date in the main kitchen and the A unit Kitchenette.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain an accurate medical record for three Residents (#110, #67 and #76 ) out of a total sample of 28 residents. Specifically, 1. For Resident #110 the facility failed to ensure that Enteral feeding orders were not conflicting. 2. For Resident #67, who has a stage III pressure ulcer on his/her foot, the facility documented that his/her heels were offload, as ordered by the physician and wound physician, when they were not. 3. For Resident #76, the facility failed to accurately transcribe the physician order for an alternate wound dressing.

Inspectors wroteBased on observations, interviews and record review, the facility failed to 1. Perform hand hygiene before entering and exiting a room with isolation droplet/contact precautions, specifically, a room with a resident positive with COVID-19 (Coronavirus disease 2019) on the B unit. 2. Maintain monthly chlorine water testing and weekly water pressure testing as a measure to prevent the growth of Legionella and other waterborne pathogens and 3. Failed to disinfect blood pressure cuffs between residents.

Inspectors wroteBased on record review and interviews the facility failed to ensure grievances voiced in the monthly Resident Council meetings were adequately addressed or resolved.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe environment for two Residents (#18 and #21) out of a total sample of 28 residents. Specifically, 1. For Resident #18, the facility failed to ensure adequate supervision was provided, resulting in eight falls in 2023, including two that required emergency room evaluations. 2. For Resident #21, who has a diagnosis of epilepsy, the facility failed to ensure bilateral padded side rails were in place to prevent injury in the event of a seizure.

Inspectors wroteBased on facility document review and interview, the facility failed to provide Certified Nursing Assistants (CNA) in-services, for at least 12 hours in a year, based on the outcome of performance reviews for 3 out of 3 CNA inservice records reviewed.

Inspectors wroteBased on observation and interviews, the facility failed to serve food that is palatable, and at a safe and appetizing temperature, on two out of three units:

Inspectors wroteBased on record review policy review, and interview the facility failed to ensure that at least 12 hours of in-service training was completed for three of three Certified Nurse Aides (CNAs).

Inspectors wroteBased on observations, record review and interviews the facility failed to provide the right to a dignified existence for two Residents (#44 and #8) out of a total sample of 28 residents. Specifically, 1. For Resident #44, who is dependent on staff for personal hygiene and grooming, the facility failed to remove unwanted facial hair. 2. For Resident #8 the facility failed to provide a dignified dining experience.

Inspectors wroteBased on observation, record review and interview the facility failed to implement a plan of care for two Residents (#110 and #11) out of a total sample of 28 residents. Specifically: 1. For Resident #110 the facility failed to provide assistance with eating. 2. For Resident #11, the facility failed to ensure that the air mattress was set to the correct setting as ordered by the Physician.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide care in accordance with professional standards of practice for two Residents (#112 and #83) out of a total sample of 28 Residents. Specifically, 1) for Resident #112, the facility failed to follow the most current doctor's order for G-tube (gastric tube, a tube placed directly through the abdomen for the purpose of instilling nutrition) feeding and failed to label and date the tube feeding bottle and water flush bag with the date and time hung. 2) for Resident #83 the facility failed to label and date the tube feeding bottle and water flush bag with the date and time hung.

Inspectors wroteBased on observations, interviews and record review, the facility failed to assist one Resident (#90) out of a sample of 28 residents to replace lost hearing aids. Specifically, the facility failed to assist the Resident in obtaining services to replace hearing devices lost at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to implement the plan of care for one Resident (#67) out of a total sample of 28 residents. Specifically, for Resident #67 who has a Stage 3 pressure ulcer on his/her foot, the facility failed to offload his/her feet as ordered by the Physician and Wound Physician.

Inspectors wroteBased on observation, record review and interview the facility failed to address continued weight loss in a timely manner for one Resident (#110) out of a total sample of 28 residents.

Inspectors wroteBased on observations, policy review, and interview the facility failed to ensure two medication carts were locked when unattended.

Inspectors wroteBased on observations and interview, the facility failed to ensure that sufficient staffing levels were posted in a clear readable format in a prominent place, readily accessible to residents and visitors.