Freedom Plaza Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure a scheduled blood pressure medication was consistently administered to one resident (#5). The sample size was 5. The deficient practice could result in medications not being administered to residents. Findings include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris, hypertension, atrial fibrillation, presence of cardiac pacemaker and long-term use of anticoagulants. During a medication administration observation conducted on November 10, 2021 at 8:53 a.m. with a Registered Nurse (RN/staff #35), the RN stated that she had not received Nifedipine (antihypertensive) ER (extended release) tablet from the pharmacy for resident #5. At 8:56 a.m., staff #35 asked a Licensed Practical Nurse (LPN/staff #3) to look for the medication in the Omnicell Pyxis. On November 10, 2021 around 9:12 a.m., staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Observations conducted of the dining room for hall 400: -On November 8, 2021 at 12:25 p.m., the Licensed Practical Nurse (LPN/staff #43) from hall 400 brought a resident into the dining room, placed the resident at the table and locked the wheelchair. Staff #43 then went to assist another resident. The LPN touched the resident on the shoulder, sat down at that residents table, touched the table cloth and one resident's silverware. The LPN was not observed to perform hand hygiene. -On November 9, 2021 at 1:15 p.m. during the lunch service, a Certified Nursing Assistant (CNA/staff #71) was observed to move from table to table delivering plates and beverages in the dining room. The CNA assisted residents in cutting food, touched silverware for several residents including two residents who subsequently used the same utensils. The CNA was not observed to perform hand hygiene. Following these observations, staff #71 left the dining room to deliver room trays. Staff #71 was observed to deliver a room meal tray from the dining room to a resident on hall 400, returned to the dining room,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, staff interview, policy review, the Centers for Disease Control and Prevention (CDC) guidance, and the Centers for Medicare and Medicaid Services (CMS) Interim Final Rule, the facility failed to ensure three residents (#2, #9, and #10), their representatives, and families were informed of new COVID-19 cases occurring in the facility within the required time frame. The deficient practice would result in residents, their representatives and families not being aware of new COVID-19 cases and the actions implemented to reduce the risk of transmission. The census was 39. Findings include: Review of documentation provided by the facility included the five most recent confirmed COVID-19 cases in the facility were staff members. Two cases on January 22, 2021, one case on January 26, 2021, one case on February 2, 2021, and one case on February 16, 2021. -Resident #2 was admitted to the facility on [DATE]. Review of the resident's progress notes did not reveal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure the physician was consistently notified when a scheduled blood pressure medication was unavailable and not administered to one resident (#5). The sample size was 5. The deficient practice could result in residents not receiving necessary blood pressure medications. Findings include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris, hypertension, atrial fibrillation, presence of cardiac pacemaker and long-term use of anticoagulants. A physician order dated February 28, 2021 included for Nifedipine (antihypertensive) ER (extended release) 60 milligrams (mg) by mouth one time a day for hypertension. Review of the care plan initiated on March 1, 2021 revealed the resident had hypertension. The goal was that the resident would be free of complication related to hypertension. Interventions included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review, staff interviews, and policy review, the facility failed to report an allegation of verbal abuse for one sampled resident (#120) to the State Survey Agency and to Adult Protective Services (APS). The deficient practice could result in further allegations of resident abuse not being reported. Findings include: Resident #120 was admitted to the facility on [DATE] with diagnoses that included traumatic subarachnoid hemorrhage without loss of consciousness, unspecified occipital condyle fracture, and unspecified dementia with behavioral disturbance. Review of the admission Minimum Data Set assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance with most activities of daily living. Review of a nursing progress note dated 12/7/2019 at 08:56 revealed the resident's spouse arrived to the facility at 08:55, dragged the resident on a wheelchair from the TV room where the resident was watching holiday movies after eating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, staff interviews, and review of policy and procedure, the facility failed to notify one resident (#4) and the resident's representative of the transfer or discharge and the reasons for the move in writing, and send a copy of the notice to the Office of the State Long Term Care Ombudsman. The sample size was 3. The deficient practice could result in the resident/resident representative and/or the Ombudsman not being aware of the transfer and reason for transfer. Findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease with lower respiratory infection, acute and chronic respiratory failure with hypoxia, pneumonia, and heart failure. Review of a nurse progress note dated August 15, 2021 revealed the resident appeared very anxious with shortness of breath and labored respirations. Lung sounds wheezing with diminished lung sounds. Increased respirations with low oxygenation. Primary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurate for one resident (#22). The sample size was 12. The deficient practice could result in inaccurate discharge tracking information. Findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included abscess of the lung with pneumonia, pleural effusion, acute respiratory failure with hypoxia, dependence on supplemental oxygen, and chest pain. A physician order dated September 25, 2021 included to discharge the resident home with home health on September 25, 2021 with all medications. Review of a progress note dated September 25, 2021 at 10:24 AM revealed the resident was discharged home with home health and all remaining medications, prescriptions, and all belongings. The note included discharge instructions were given to the resident and the resident's spouse, the resident was transported via private…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility document, staff interviews, and facility policy and procedures, the facility failed to provide an ongoing resident centered activities program based on the comprehensive assessment, care plan, and resident's preferences for one of two sampled residents (#220). The deficient practice could result in residents not participating in activities which could impact their mental and social well-being. Findings include: Resident #220 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, urinary tract infection, and acute kidney failure. Review of the clinical record revealed a physician order dated July 19, 2021 that the resident may participate in activities as tolerated. A review of the Optimum Life Program admission Data Collection form dated July 20, 2021 revealed the resident's short-term memory and long-term memory was OK and that the resident's preferences for activities included cards/other games, arts/crafts, exercise sports,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, resident and staff interviews, and review of policy and procedures, the facility failed to ensure one sampled resident (#320) received treatment and care in accordance with professional standards of practice related to the application of Thrombo-Embolus Deterrent (TED) hose as ordered. The census was 39. The deficient practice could result in a lack of proper care being provided to residents. Findings include: Resident #320 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF), bradycardia, pneumonia, personal history of venous thrombosis and embolism, and peripheral vascular disease (PVD). The admission Minimum Data Set (MDS) assessment dated [DATE] included the resident scored 14 on the Brief Interview for Mental Status (BIMS) indicating the resident did not have cognitive deficits. The assessment also included the resident required the assistance of one person for dressing. A physician order dated November 4, 2021…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical review, staff interviews, and facility policy and procedures, the facility failed to ensure thorough pain management was consistently provided to one sampled resident (#2). The census was 39. The deficient practice could result in residents' pain not being addressed. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and Thyrotoxicosis. Review of the care plan initiated on April 6, 2016 stated the resident has the potential for chronic pain related to PVD, osteoarthritis and a history of right ankle fracture. The goals were that the resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain, and would not have an interruption in normal activities. Interventions included to administer analgesia as per orders, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions, and review for compliance,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, staff interviews, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for two of five sampled residents (#6 and #15). The medication error rate was 6.67%. The facility census was 39 residents. The deficient practice could result in additional medication errors. Findings include: -Resident #6 was admitted to the facility on [DATE] with diagnoses that included hypertensive chronic kidney disease, peripheral vascular disease (PVD) and osteoarthritis. Review of the physician's order revealed an order dated [DATE] for Aspirin 81 milligram (mg) tablet by mouth one time a day every Wednesday and Saturday for PVD (peripheral vascular disease). During a medication administration observation conducted on [DATE] at 8:44 a.m., a RN (Registered Nurse/staff #35) was observed to administer one tablet of Aspirin Enteric Coated (EC) 81 mg to resident #6 instead of one tablet of Aspirin 81…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.