Gates House

The facility failed to ensure the implementation of physician orders for wound care for one resident. Specifically, the facility did not follow the prescribed daily dressing change procedures involving cleansing with normal saline and applying ABD pads as ordered by the hospice provider.

The facility failed to ensure all memory care residents have required disclosure statements and SCU pre-screens completed. An audit of business files is required to obtain missing disclosures, and all new residents must have signed disclosure statements and pre-screens finalized prior to physical move-in.

The facility failed to ensure proper wound care documentation and training. Specifically, medical assistants require in-service training on dressing changes, and bandages must be dated and initialed after each task. Additionally, weekly spot checks by management are required to ensure wound care is completed per physician orders.

The facility failed to provide adequate training on the five rights of medication administration and proper documentation. Management must provide in-service training to all medical assistants and conduct audits of documentation on scheduled wound care days to ensure progress notes are completed.

The facility failed to provide timely referral and follow-up to meet the routine healthcare needs of a resident related to a rash. Specifically, there was no documentation that prescribed Baza Protect Cream was administered for several weeks in April and early May 2023, and a reddish rash was observed during the survey.

The facility failed to provide timely medical referrals and follow-up to meet the routine healthcare needs of a resident. Specifically, a resident with a severe rash on their inner thighs was not properly managed, and there was no documentation of prescribed barrier cream administration for several weeks despite the presence of the skin condition.

The facility failed to ensure the primary care provider was notified for two sampled residents. Specifically, one resident with a scalp lesion was not referred to a dermatologist, and another resident with choking episodes and painful toenails was not referred to a gastroenterologist or podiatrist.

The facility failed to ensure the primary care provider was notified for two residents. Specifically, one resident with a scalp lesion was not referred to a dermatologist, and another resident experiencing choking episodes and overgrown toenails was not referred to a gastroenterologist or podiatrist.

The facility failed to ensure the notification of the primary care provider (PCP) for residents experiencing significant health changes. Specifically, the facility did not notify the PCP when a resident verbalized suicidal ideation and when a resident had an area of infection with drainage and odor that required antibiotic treatment.

The facility failed to ensure the primary care provider (PCP) was notified regarding a resident's suicidal ideation and an infection requiring antibiotics. While the psychiatrist was notified and safety protocols were implemented, the medication aide and resident care manager failed to follow up with the resident's PCP as required.