Senior Citizens Home

Inspectors wroteBased on observations and staff interviews, the facility failed to keep food service equipment free of debris and corrosion by failing to clean 2 of 3 HVAC (heating and air conditioning system) filters observed. This practice had the potential to affect food served to the residents who resided in the facility.

Inspectors wroteBased on record review, and interviews with staff, Director of Nursing, Nurse Practitioner, Pharmacy Technician, and Pharmacist, the facility failed to provide services to ensure the acquiring, dispensing, and administration of medications for 1 of 5 sampled residents whose medications were reviewed (Resident #59). The facility failed to have an anticonvulsant, antipsychotic, and a triple-therapy bronchodilator available for administration to Resident #59.

Inspectors wroteBased on record review, and interviews with staff, Nurse Practitioner, Pharmacist, Assistant Director of Nursing, and Director of Nursing, the facility failed to prevent a significant medication error for 1 of 5 residents whose medications were reviewed (Resident #59). The facility failed to administer prescribed antipsychotic medication, anticonvulsant medication and triple therapy bronchodilator to Resident #59.

Inspectors wroteBased on staff interview and review of the Facility Assessment the facility failed to ensure the required parties were involved in developing the Facility Assessment, failed to evaluate contracted services utilized by the facility to provide necessary care for its residents during normal operations and emergencies, and failed to ensure the staffing plan considered specific staffing needs for each unit and shift as required, which had the potential to affect 49 of 49 residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours and licensed nursing coverage 24-hours per day. This was for 1 of 3 quarters reviewed for sufficient nurse staffing (Quarter 3 2024).

Inspectors wroteBased on record review and staff interviews, the facility failed to conduct quarterly reviews of resident care plans for 5 of 23 resident care plans that were reviewed (Resident #23, Resident #6, Resident #9, Resident #8, and Resident #45).

Inspectors wroteBased on observations, record reviews, resident interview, and staff interviews the facility failed to correctly code the Minimum Data Set (MDS) assessment in the areas of falls and restraints for 2 of 23 residents whose MDS assessments were reviewed for accuracy (Residents #45 and #23).

Inspectors wroteBased on record review and staff interviews, the facility failed to have a physician order for dialysis in the medical record for 1 of 1 resident reviewed for dialysis (Resident #204).

Inspectors wroteBased on record review and staff interviews, the facility failed to post accurate licensed nurse staffing data for 18 of 30 days reviewed for sufficient staffing (11/02/24, 11/03/24, 11/05/24, 11/06/24, 11/09/24, 11/10/24, 11/13/24, 11/15/24, 11/16/24, 11/17/24, 11/18/24, 11/22/24, 11/23/24, 11/24/24, 11/25/24, 11/27/24, 11/28/24, 11/30/24).

Inspectors wroteBased on record review, staff interview, pharmacy director interview, physician assistant interview, and resident interview the facility failed to provide medications upon admission for 18 hours for 1 (Resident #1) of 3 residents reviewed for provision of medication upon admission.

Inspectors wroteBased on record review, staff interview, Physician Assistant interview, Pharmacy Director interview, Surgical Physician interview and resident interview the facility failed to provide antibiotic, diabetic, hypertension, antiepileptic, and pain medication as ordered resulting in significant errors by omission of high alert medications for one (Resident #1) of one resident reviewed for significant medication errors. Antibiotic medications were delayed after admission to the facility due to a transcription error for Resident #1. Diabetic, hypertension, antiepileptic, and pain medication were omitted initially upon admission due to a delay obtaining required medications from the pharmacy for Resident #1.

Inspectors wroteBased on record review, observations, staff, and Physician interview, the facility failed to safely transfer a dependent resident from wheelchair to bed which resulted in the fracture of the right humeral head (shoulder joint) and injury to the toenail of the right great toe with bleeding for 1 of 1 Residents (Resident #27) reviewed for accidents

Inspectors wroteBased on observations, record review and Physician, resident, Responsible Party (RP), and staff interviews the facility failed to provide a pest free living environment for 1 of 1 resident residing in the facility (Resident #42). The facility's failure contributed to Resident #42 sustaining a rash to her arms and legs due to ant bites resulting in itching and discomfort.

Inspectors wroteBased on record review and staff interviews, the facility failed designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program.

Inspectors wroteBased on staff interviews and record review, the facility failed to have a Registered Nurse (RN) for at least eight consecutive hours a day, 7 days week for 8 of 62 days reviewed (7/15/23, 7/16/23, 7/22/23, 7/23/23, 7/29/23, 7/30/23, 8/6/23 and 8/13/23).

Inspectors wroteBased on a lunch meal tray line observation, staff interviews and record review the facility failed to provide pureed food items with a smooth consistency. This failure had the potential to affect 7 of 45 residents with diet orders for a pureed diet texture.

Inspectors wroteBased on observation and staff interviews, the facility failed to 1) maintain the temperature of potentially hazardous cold foods at 41 degrees Fahrenheit or below (yogurt and milk) prior to delivery 2) label/date, store, and discard perishable foods beyond the use date in one of two kitchen refrigerators and failed to 3) allow plates to air dry prior to assemblage and stacking for one of two observations. These practices had the potential to affect all residents.

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation survey of 5/12/22. This was for two deficiencies cited in the areas of food procurement store/prepare/serve sanitation (F812) and infection prevention/control (F880). The continued failure during 2 federal surveys of record showed a pattern of the facility's inability to sustain an effective QAA program. Findings Included: This tag was cross-referenced to: 1. F812: [...]

Inspectors wroteBased on record review, resident, and staff interviews the facility failed to invite the resident to participate in the development of care planning for 1 of 14 Residents care plans reviewed (Resident #41).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to provide nail care to 1 of 3 dependent residents reviewed for activities of daily living (ADL) (Resident #27).

Inspectors wroteBased on record reviews, staff interviews, Physician interview, and Pharmacy Consultant interview, the facility failed to ensure Physician's orders for PRN (as needed) psychotropic medications were time limited in duration for 1 of 7 Residents (Resident #24) reviewed for unnecessary medications.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure 1 of 1 wound treatment carts and 1 of 2 medication carts (Hall 2) were not secured while unattended.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement their infection control policy and policy for handling soiled linen. Laundry Aide #1 was observed having soiled linens come in contact with her clothing while sorting them into the washing machine and transporting soiled linens from a resident hall to the laundry room in a wire laundry basket with no lid for 1 of 2 laundry aides observed (Laundry Aide #1).

Inspectors wroteBased on record review and staff interviews, the facility failed to assess residents for eligibility and ensure residents were offered the pneumococcal vaccine upon admittance to the facility for 2 of 5 residents reviewed for immunizations (Resident #12 and Resident #33).

Inspectors wroteBased on resident and staff interviews, the facility failed to provide mail delivery to the residents on Saturdays. This had the potential to affect all 45 of 45 residents residing in the facility.

Inspectors wroteBased on observations and staff interviews the facility failed to post nurse staffing in a location that was readily accessible to residents and visitors on 3 of 4 days during the survey (9/24/23, 9/25/23, and 9/26/23).