Restoracy of Goshen, the

Inspectors wroteBased on record review and interview, the facility failed to follow physician orders for the administration of blood pressure medication and failed to follow the orders regarding medication parameters for blood pressure medication for 3 of 6 residents reviewed for quality of care. (Residents C, D & F)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 5 staff observed administering medication met professional standards regarding ensuring a resident consumed medication for 1 of 8 residents observed during medications pass. (Resident 26)

Inspectors wroteBased on observation, record review and interview, the facility failed to to notify the physician and obtain treatment orders timely for an unstageable pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident 19)

Inspectors wroteBased on record review and interview, the facility failed to follow physician orders by not obtaining ordered laboratory tests for 1 of 5 residents reviewed for unnecessary medications. (Resident 6)

Inspectors wroteBased on interview and record review, the facility failed to ensure lab results were obtained in a timely manner and antibiotic treatment for a UTI was initiated in a timely manner for 1 of 1 residents reviewed for UTI (Resident 12).

Inspectors wroteBased on observation, record review and interview, the facility failed to follow enhanced barrier precautions for a resident with a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident 19)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's family member/Power of Attorney (POA) was notified when a medication was discontinued for 1 of 3 resident's reviewed for medication changes. (Resident B)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a care plan regarding self care deficits and fall risk was implemented for 1 of 3 residents reviewed for staff assisted transfers. (Resident D)

Inspectors wroteBased on observation and record review, the facility failed to ensure staff members were present when 3 residents were observed at the dining room table, eating and drinking who required supervision with meals. (Resident M, Resident J and Resident K)

Inspectors wroteBased on interview and record review, the facility failed to ensure a Care Plan had been updated timely for 1 of 3 residents reviewed for care plans. (Resident 9)

Inspectors wrote3. On 6/19/2024 at 3:30 P.M., a review of the clinical record was completed for Resident 18. The resident's diagnoses included, but were not limited to, congestive heart failure, hypertension, and sinus bradycardia. A Quarterly Minimum Data Set (MDS), dated [DATE] indicated the resident's cognition was intact. The Physician's Orders for medications indicated the resient was to receive Carvedilol 6.25mg by mouth, twice per day, hold if heart rate is less than 50. A review of the resident's Medication Administration Record (MAR) indicated Carvedilol 6.25 mg was documented as given on the following dates and shifts, with the corresponding heart rates: Morning shift: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain a physician's order for an indwelling urinary ( Foley) catheter for 1 of 2 residents reviewed for catheters. (Resident 35)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure respiratory equipment was stored properly for 1 of 2 residents reviewed for respiratory care. (Resident 26)

Inspectors wroteBased on record review and interview, the facility failed to ensure the appropriate antibiotic was prescribed at the appropriate time for the appropriate duration for a skin infection for 1 of 4 residents reviewed for antibiotic stewardship. (Resident 26)

Inspectors wroteBased on observation and interview, the facility failed to ensure the current ombudsman's name was listed on their Resident Right's poster, in 4 of 4 houses. (Strawberry Fields, Blueberry Hill, [NAME] and Penny Lane) This deficient practice had the potential to affect all 46 residents and/or their family members and visitors.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide nail and hand hygiene and grooming assistance to a resident unable to complete care for themselves for 1 of 2 residents reviewed for activities of daily living. (Resident B).

Inspectors wroteBased on record review and interview, the facility failed to notify a resident's physician, responsible party, and the Director of Nursing timely of a fall with injury, for 1 of 3 residents reviewed for falls. (Resident B).

Inspectors wroteBased on record review and interview, the facility failed to provide adequate care and treatment related to lack of an assessment and neurological checks after a resident fell out of bed and sustained a head injury, for 1 of 3 resident reviewed for falls. (Resident B).

Inspectors wroteBased on observation and interview, the facility failed to provide the posting of nursing staff hours in 4 of 4 homes reviewed for nurse staffing information.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean environment for 23 of 37 rooms reviewed for environmental services.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean environment for 11 of 39 rooms reviewed for environmental services.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure food was stored, prepared and served in a sanitary manner for 4 of 4 kitchens observed. (Green Gabels, Penny Lane, Strawberry and Blueberry Houses) This deficient practice affected 41 of 42 residents in the building who consumed food.

Inspectors wroteBased on record review and interview, the facility failed to obtain a physician's order for cardiopulmonary resuscitation (CPR) as indicated by the residents POA (power of attorney) upon admission for 1 of 2 residents reviewed for advanced directives. (Resident 28)

Inspectors wroteBased on interviews and record reviews the facility failed to include the resident, and/or resident's representative, in care plan meetings for 1 out of 22 residents whose care plans were reviewed. (Resident 4)

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide resident centered activities that incorporate the residents' interests and hobbies for 2 of 3 residents reviewed for activities. (Residents 4 and 26)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure placement of a gastrostomy tube was assessed prior to the administration of tube feeding for 1 of 1 residents observed for gastrostomy tube care.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure physician orders for oxygen therapy were obtained and respiratory equipment was stored properly for 1 of 1 residents observed for respiratory care. (Resident 91)

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the menu was followed for pureed food. This deficient practice affected 2 of 2 residents receiving pureed food in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to comply with infection control measures for glucometer sanitation for 2 of 2 residents observed for blood sugar monitoring. (Resident 13 & 31).