The Springs of Park Ave

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility did not ensure incontinence care was provided in a manner that was timely and promoted cleanliness, good hygiene, and/or prevented infection for two (Resident #27 and Resident #54) of two sampled residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for one of one meal observed.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure that food items stored in the freezer were covered or sealed, that dietary staff washed their hands between handling dirty and clean equipment, and hot food items were maintained at the required temperatures for one of one meal observed.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure that staff followed Enhanced Barrier Precautions (EBP) by wearing required Personal Protection Equipment (PPE), and staff failed to change their gloves during perineal care for a resident on EBP before touching resident ' s lift pad, clean brief, clothing, and linens to prevent cross contamination and the risk for infection for 1 of 1 sampled (Resident #6) resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to report to the state survey agency when a resident, that was care planned not to leave the facility without supervision, left the facility without staff knowledge for 1 (Resident #8) of 1 sampled resident identified as an elopement risk. 1. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/2024 indicated Resident #8 had a diagnosis of non-Alzheimer's dementia, coronary artery disease, malnutrition and scored 12 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS). a. Resident #8 ' s Care Plan with an initiation date of 05/30/2024, indicated, Focus; Risk for elopement/wandering identified, Goal: The resident will not leave the facility unattended b. An Elopement Assessment dated 10/20/24, for Resident #8 indicated, 6. [...]

Inspectors wroteThrough observation, record review, and interviews, the facility failed to ensure open food packages were properly closed, ensure walls and floors were in sanitary condition, canned goods were dent free, dietary staff washed their hands between dirty and clean tasks, chemicals were kept away from serving items, food on the steam table was properly covered, and proper serving sizes were provided.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the medication error rate was less than 5%. An observation of a medication pass performed on 08/16/23 at 7:53 AM resulted in the identification of 3 errors in 25 opportunities, resulting in a medication error rate of 12.00 %.

Inspectors wroteBased on observation, record review, interview, it was determined that the facility failed to store controlled medications in a permanently affixed container, and to ensure medications were not left at the bedside.

Inspectors wroteBased on record review and interview, the facility failed to ensure an advanced directive was readily accessible in the electronic health record for 1 (Resident #24) of 1 sampled resident whose electronic health record (EHR) was reviewed for an advanced directive.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a baseline care was completed within 48 hours of a residents admission to address activities of daily living, to promote continuity of care and communication among nursing home staff for 1 (Resident #123) of 1 sampled resident whose electronic health record (EHR) was reviewed for a 48 hour baseline care plan.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plans were reviewed and revised at least annually, or when the residents care needs changed, as evidenced by failure to revise the plan of care to address the use of insulin, a high risk medication, to ensure staff were made aware of the necessary care, assessments and services required for insulin for 1 (Resident #39) of 1 sampled residents who were reviewed for care plan revisions for insulin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enteral feeding and flush bags were properly labeled with the necessary information to promote continuity of care and decrease the potential for complications for 1 (Resident #123) of 1 sampled resident who had a percutaneous endoscopic gastrostomy (PEG) tube (tube that goes through the skin into the stomach).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a linen cart was covered while on a resident hall, failed to ensure hand hygiene was performed and proper protective equipment (PPE) was used when caring for 1 (Resident #44) of 1 sampled resident with Clostridium Difficile (C-Diff) and failed to ensure Enhanced Barrier Precautions were consistently implemented for 1 (Resident #39) of 1 sampled resident who was reviewed for EBP.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the laptop with the Medication Administration Record (MAR) was closed or covered when out of the Nurse's line of vision to maintain resident privacy of personal health information. This failed practice had the potential to affect 27 residents who resided on the A Hall as documented on a list provided by the Administrator on 05/10/23 at 11:30 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Medication Cart was locked when out of the Nurse's line of vision to prevent potential accident hazards. This failed practice had the potential to affect 21 residents on the A Hall who were independent or supervised with locomotion, as documented on a list provided by the Administrator on 10/11/23 at 8:29 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an indwelling catheter tubing was secured with a stabilization device to prevent potential pulling of the catheter, pain, and injury for 1 (Resident #168) of 3 (Residents #9, #42 and #168) sampled residents who had an indwelling catheter as documented on a list provided by the Administrator on 05/10/23 at 12:43 PM.

Inspectors wroteSurveyor: [NAME] Based on observation, record review, and interview, the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice for 2 (Residents #16 and #35) of 3 (Residents #12, #16 and #35) sampled residents who had a Physician's Order for a CPAP (Continuous Positive Airway Pressure) Machine, and for 3 (Residents #16, #35 and #50) of 6 (Residents #16, #30, #35, #50, #167 and #168) sampled residents who had a Physician's Order for Oxygen as documented on lists provided by the Administrator on 05/11/23 at 10:50 AM, and the facility failed to ensure emergency tracheostomy supplies were readily available in the resident's room for 1 (Resident #167) of 2 (Residents #39 and #167) sampled residents who had a tracheostomy as documented on a list provided by the Administrator on 05/10/23 at 12:00 PM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an indwelling catheter drainage bag was not on the floor to prevent the risk of infection for 1 (Resident #42) of 3 (Residents #9, #42 and #168) sampled residents who had a Physicians Order for an indwelling catheter as documented on a list provided by the Administrator on 05/10/23 at 12:43 PM.

Inspectors wroteBased on record review, and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission to ensure the resident received the needed care and services in the most integrated setting appropriate to their needs for 1 (Resident #13) of 1 sampled resident who required a PASARR. This failed practice had the potential to affect 6 residents as documented on a list provided by the Administrator on 05/09/23 at 3:50 PM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement a Comprehensive Care Plan that included a measurable focus, goals/outcomes, and interventions for 1 (Resident #47) of 8 (Residents #1, #3, #9, #47, #59, #62 and #168) sampled residents who had physician orders to receive an anticoagulant.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement interventions in a timely manner to prevent injury from falls for 1 (Resident #10) of 10 (Residents #1, #3, #10, #34, #35, #42, #43, #47, #51, and #54) sampled residents who had a fall in the last 30 days as documented on a list provided by the Administrator on 05/10/23 at 3:48 PM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis facility for 1 (Resident #62) of 1 sampled resident reviewed for End Stage Renal Disease/Dialysis services.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure laboratory specimen collection supplies were readily available to collect a lab specimen for 1 (Resident #10) of 3 (Residents #9, #10 and #47) sampled residents who had a Physicians Order for a Urinalysis in the last 30 days as documented on a list provided by the Administrator on 05/10/23 at 3:48 PM.