Tucker Park Crossing of Journey LLC

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled, Infection Prevention and Control Program F880, F880 Multidrug-Resistant Organisms (MDRO) and Enhanced Barrier Precautions (EBP), and Wound Care Guidelines the facility failed to provide a Legionella water program, use aseptic technique during wound care, ensure proper use of Personal Protective Equipment (PPE) for residents who were under enhanced barrier precautions (EBP) during medication administration, identify and prevent the spread of C-Diff (clostridium difficile) colitis, and to clean and maintain respiratory equipment properly. This deficient practice had the potential to cause widespread infection, food-borne illness, and widespread C-Diff colitis and could affect all 129 residents who resided at the facility.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide a safe, functional, sanitary environment for residents, staff, and the public by not cleaning the Packaged Terminal Air Conditioner (PTAC) filter in six rooms (Room D-16, Room D-12, Room D-15, Room E-52, Room D-15, and Room E41) on five of five halls sampled. This deficient practice had the potential to cause respiratory irritation and exacerbation of conditions in residents with chronic obstructive pulmonary disease and other related lung diseases.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Exercise of Rights/Resident Rights F550 and Residents Rights, the facility failed to allow one resident (R) (38) to exercise their rights in the facility by making her own choices.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Pre-admission Screening and Resident Review (PASARR) F644, F645, F646, the facility failed to assess and refer residents whose diagnosis qualified for PASARR II evaluation for one of three residents (R) (R68) reviewed for PASARR. This deficient practice had the potential to cause R68 not receive the appropriate treatment and placement for mental illness.

Inspectors wroteBased on observation, record review, staff interviews and review of the facility policies titled, Comprehensive Care Plans and Wandering, Unsafe Resident, the facility failed to develop a care plan regarding wandering and elopement risk for one residents (R) (R62) who had been assessed for wandering upon admission. The deficient practice had the potential for R62's needs not to be met.

Inspectors wroteBased on observations, staff and family interviews, record review, and review of the facility's policy titled, Change in a Resident's Condition or Status, the facility failed to assess and report changes in condition to the provider for one of 61 sampled residents (R) (R138). The deficient practice led to R138 being hospitalized .

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policies titled, F 689 Accidents and F 689 Accidents-Elopement, the facility failed to ensure the environment remained free of accident hazards for three of 61 sampled residents (R) (R45, R78, R92) and failed to maintain a safe environment to prevent resident elopement for one of 14 R's (R62) reviewed for elopement risk. Specifically, the facility allowed over-the-counter (OTC) flu and cold medications and shaving razors to be present and accessible in resident rooms without appropriate supervision or safety controls, and failed to adequately secure and monitor exit doors, allowing a resident to leave the building unsupervised. This deficient practice had the potential to cause injury, medication misuse, adverse drug events, elopement, serious injury, or death.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policies titled, Administering Medications F 760, Administering Oral Medications, Medication Administration Schedule, and Insulin Administration, the facility failed to ensure accurate administration of medications to four residents (R ) (R47, R113, R114, and R50) for four of 25 medication opportunities observed, resulting in a medication error rate of 16% (percent). This deficient practice has the potential to negatively impact residents, leading to complications of current health status.

Inspectors wroteBased on observations, staff interviews, record review and review of the facility's policies titled, Storage of Medications F 761 and reference guide by Omnicare pharmacy titled, Guidance for Using Insulin Products, the facility failed to ensure medications were properly stored by failing to remove expired medications from one of three medication rooms, and failing to properly date and discard expired insulin pens in one of five medication carts. This deficient practice had the potential to result in residents receiving ineffective or expired medications, placing them at increased risk for adverse health outcomes.

Inspectors wroteBased on staff and family interviews, record review, and review of the facility policies titled Baseline Care Plans and Comprehensive Care Plans, the facility failed to ensure that one R (R) (R7) out of eight reviewed for participation in care plan meetings, or R7's Power of Attorney (POA), were invited to participate in the care plan meetings to ensure that the care plan was individualized to meet R7's personal goals and preferences.

Inspectors wroteBased on family and staff interviews, and record reviews, the facility failed to notify the Power of Attorney (POA)/family of a change in condition of one resident (R) (R7) of eight residents reviewed for notification of change.

Inspectors wroteBased on staff interviews, record review, and review of the facility policies titled Grievance/Complaint Log and Lost and Found, the facility failed to make a prompt effort to file a grievance for two of eight sampled residents (R) (R7 and R8) who verbally reported grievances. This deficient practice had the potential to place residents at risk of not having their grievances resolved in a timely manner.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled, Confidentiality and Privacy Information, the facility failed to ensure the privacy for one of 30 residents (R) (R98) was maintained by displaying a sign on the bedroom wall disclosing protected personal information.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, F 625 Bed Hold, the facility failed to ensure a bed-hold policy upon transfer to the hospital for one of two residents (R) (R27) reviewed for hospitalizations.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Comprehensive Care Plan, the facility failed to develop a care plan specific to the recommendations per the physician's order related to the pain scale for one resident (R) (R23), failed to develop a care plan for dialysis for R64, and failed to to follow and update the care plan for refusals on restorative care for R19. The sample size was 30 residents.

Inspectors wroteBased on observation, resident and staff interview, record review, and review of the facility's policy titled, Administering Medication the facility failed to follow the physician's orders as recommended for one of 30 residents (R)(R23).

Inspectors wroteBased on observations, interviews, record review and review of the facility's policy titled Goals and Objectives, Restorative Services and Rehabilitative Nursing Care the facility failed to provide a right-hand grip splint for up to 4.5 hours for one of one Residents (R19) reviewed for rehab and restorative.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to administer oxygen (O2) as ordered for one of two residents (R) (R9) reviewed for respiratory care.

Inspectors wrote2. During observation on 5/5/2024 at 1:15 pm in Room B-24 , it was revealed there was paint missing around the toilet paper holder in the bathroom. During observation on 5/5/2024 at 1:20 pm in Room B-30, the wall behind the bed had three holes in the sheet rock. 3. Observation on 5/05/2024 at 1:07 pm in Room A-19 revealed a bath basin and a urinal that were unlabeled and unbagged. There was a large amount of spider webs with leaves on the outside part of the window. The wall behind the B bed had a large number of dark scuff marks. The base board in the corner of the bathroom was found coming off the wall. The personal refrigerator in the room was dirty. Observation on 5/5/2024 at 1:22pm in Room A-20 revealed scuff marks on the inside of the bathroom door and on the wall in front of B bed. There was also a hole in the wall plaster behind the towel rack in the bathroom. [...]

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policy titled Administering Medications F760, the facility failed to ensure the medication error rate was less than five percent (5%). Specifically, the facility failed to obtain physician orders to crush medications prior to administration for two of four residents (R) (R37 and R90). There were 29 opportunities observed resulting in two medication errors. The medication error rate was 6.9%.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policies titled, Indwelling Urinary Catheters F690 and Handwashing/Hand Hygiene F 880, the facility failed to follow standard infection control practices for one of four residents (R) (R15) during catheter care observation. The facility also failed to ensure hand hygiene was performed during meal tray distribution. The deficient practice had the potential to affect all residents. The facility census was 115 residents.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Pre-admission Screening and Resident Review (PASARR) Program, the facility failed to ensure a Level II PASARR was conducted for one of five sampled residents (R) (R40) reviewed for PASARR.

Inspectors wroteBased on resident and staff interviews, record reviews, and review of the facility policy titled, F656, F657, F658 Comprehensive Care Plans, the facility failed to implement the care plan for one of six residents (R) (R58). This failure had the potential for R58 to not receive treatment and/or care according to their needs.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of facility policy titled, Quality of Life-Activities of Daily Living (ADL), the facility failed to provide ADL care for three of seven residents (R) (R23, R87, and R70). Specifically, the facility failed to provide nailcare for R23 and R87 and failed to provide showers as scheduled for R70.

Inspectors wroteBased on observation, staff interviews, record review, and a review of the facility policies titled, Range of Motion Exercises and Goals and Objectives, Restorative Services, the facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for one of nine Residents (R) (R22) receiving restorative care. This deficient practice had the probability to cause a further decline in range of motion for R22.

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and a review of the facility policies titled Falls and Fall Risk, Managing F689 and Oxygen Administration, the facility failed to provide interventions to prevent falls for one of six residents (R) (R58) and failed to ensure an oxygen cylinder was stored and secured for one of 15 residents receiving oxygen (R15).

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to properly check for Gastric tube (G-tube) (tube in the stomach for nutrition) placement for one of four Residents (R) (R33) receiving nutrition through a G-tube.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Oxygen, Administration, the facility failed to obtain an order for oxygen therapy for one of 15 residents (R) (R32).

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that privacy curtains provided full visual privacy for three (3) of 63 shared resident bedrooms: (B39, E 44, D5). Findings Include: Observation on 5/5/2024 at 2:15 pm revealed that room E44 privacy curtain was missing several hooks causing the curtain to hang leaving a large gap in the curtain, and not providing full privacy for the resident in the B bed. Observation on 5/6/2024 at 9:58 pm revealed room D5 privacy curtain had missing hooks and was unable to be drawn for full privacy while providing care for the resident. Observation on 5/6/2024 at 8:46 am revealed that there were hooks noted on the curtain track, but no privacy curtain observed for room B39-1 to provide privacy for the resident during care. [...]