Casey's Pond Senior Living

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nutrition and Dietary Deficiencies

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Smoke Deficiencies

Properly provide smoke detection systems in areas open to corridors.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The initial comments (ID Prefix Tag #K000) are informational only and are a representation of the facility' s general characteristics.This facility is a one-story, Type V(111) structure with a complete National Fire Protection Association (NFPA) 13 automatic fire suppression system. The facility is separated from the attached Independent Living and Assisted Living building by a two-hour fire-resistive assembly. A dry pipe system protects the attic and other freeze susceptible areas.This survey was conducted on April 10, 2024, and was inspected for compliance with the 2012 edition of NFPA 101, the Life Safety Code, Chapter 19 for Existing Health Care Occupancies, and other publications as referenced.The survey concluded with a discussion of the deficiencies with the Administrator and the maintenance staff. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, and 72. This was evidenced by: 1) Fire Alarm Annual report: 6.26.23 Western States Fire Protection, report states that 9 devices are not tested, noted as N/A. All devices are required to be tested.Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarmand Signaling Code.NFPA 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72. NFPA 72 Table14.4.5 Testing FrequenciesThis deficiency has the potential to a.. Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101 and NFPA 25. This was evidenced by:1) Fire Sprinkler Annual report: 6.27.23 Western States Fire Protection, report shows that 32 Dry barrel heads are due for testing. NFPA 25 Table 5.1.1.2 Summary of Sprinkler System Inspection, Testing, and MaintenanceNFPA 25 5.3.1.1.1.6* Dry sprinklers that have been in service for 10 years shall be replaced or representative samples shall be tested and then retested at 10-year intervals.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99 and NFPA 55. This was evidenced by:1) The Oxygen Trans-filling room needs mechanical ventilation within 12" of the floor that terminates outside of the building and is connected to essential electrical systems. NFPA 55 6.15.7.26.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor.NFPA 99 11.5.2.3.1Transfilling to liquid oxygen base reservoir containers or to liquid oxygen portable containers over 344.74 kPa(50 psi) shall include the following:(1) A designated area separated from any portion of a facility where in patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction.(2) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring.(3) The area is posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.(..

A recertification survey was conducted from 3/17/24 to 3/21/24. Four deficiencies were cited. An Emergency Preparedness survey was conducted from 3/17/24 to 3/21/24. No deficiencies were cited. Based on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards for one of one medication refrigerators. Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently affixed to the refrigerator.Findings include: I. ObservationsOn 3/18/24 at 11:09 a.m., the medication refrigerator was observed with the registered nurse liaison (RNL). A vial of liquid Ativan (a benzodiazepine and a schedule IV controlled substance used to treat anxiety) was in a storage box. -The storage box was not permanently affixed to the inside of the refrige.. Based on observations and interviews, the facility failed to provide services in accordance with currently accepted professional principles.Specifically, the facility failed to follow accepted standards of practice for medication administration by pre-pouring medications prior to confirming the resident was ready and available for medication administration. Findings include:I. Professional referencesNursing rights of medication administration, updated on 9/5/22, was retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/ on 3/22/24 at 9:00 a.m. It read in pertinent part: "' Right time' -administering medications at a time that was intended by the prescriber. Often, certain .. Based on observations, record review and interviews, the facility failed to ensure two (#7 and #49) of four residents out of 25 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.Specifically, the facility failed to:-Ensure Resident #7' s portable oxygen concentrator was turned on while she was out of the building at an appointment; and,-Ensure Resident #49 was assisted with removing her cervical collar (c-collar) during meal times. Findings include:I. Resident #7 A. Resident status Resident #7, age 82, was admitted on 10/29/2013. According to the March 2.. Based on record review and interviews, the facility failed to ensure residents were free from abuse for one (#26) of two residents reviewed for abuse out of 25 sample residents.Specifically, the facility failed to protect Resident #22 from sexual abuse by Resident #26.Findings include:I. Facility policy and procedureThe Abuse Non-Tolerance policy, dated October 2022, was provided by the nursing home administrator (NHA) on 3/18/24. It read in pertinent part,"Residents and clients must be free from abuse by anyone, including associates, other residents or clients, consultants or volunteers, family members or legal guardians, friends or other individuals."Sexual abuse includes, but..