Addington Place at College Harbor

In the surveyor’s words

From the most serious findings on record at Addington Place at College Harbor, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF552Sep 5, 2024

  Based on observation, record review, and interview, the facility failed to ensure one resident (# 14) of eight residents sampled, was provided the opportunity to participate in care planning. Findings included: On 09/03/24 at 11:00 a.m., Resident #14 was observed lying down in bed with her call light in reach. She presented well-groomed with no signs of distress. She stated she was happy at this facility. She was the new council president, and the residents were very pleased with the staff. She stated she had been at the facility for a year and had never been invited to a care plan meeting. She said she would like to be informed and a part of her plan of care. On 09/04/2024 at 10: 00 a.m., Resident #14 was observed lying down in bed with her call light within reach. […]

• No harm, potential for more than minimal, isolatedF645Sep 5, 2024

  Based on observation, record review, and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed accurately for four (#1,#5,#6,#8) of 23 residents sampled for PASRR Findings include: 1. 09/03/2024 at 11:00 a.m. and at 1:00 p.m., Resident #8 was observed lying in bed with her call light in reach. She was observed with no signs of distress. Review of an Admission Record dated 09/05/2024, showed Resident #8 was admitted to the facility on [DATE] with diagnoses to include but not limited to, anxiety disorder, unspecified, unspecified mood affective disorder, and major depressive disorder, recurrent, mild. […]

• No harm, potential for more than minimal, isolatedF695Sep 5, 2024

  Based on observation, interview, and record review, the facility failed to 1. ensure oxygen administration orders were followed for two (#239, #2) of seven residents who received oxygen therapy. Findings included: 1. A review of Resident #239's Admission Record revealed he was admitted to the facility on [DATE] with diagnoses to include pneumonia and chronic obstructive pulmonary disease. A Review of Resident #239's physician's orders dated 08/20/2024 revealed Oxygen at 2 L/min (liters/minute) via NASAL CANNULA PRN (as needed) to keep O2 (oxygen) sat (saturation) greater than 90% every shift for SOB (shortness of breath). On 09/03/2024 at 9:38 a.m., Resident #239 was observed lying in bed with a nasal cannula in use. […]

• No harm, potential for more than minimal, isolatedF656Mar 2, 2022

  Based on observation, interview, and record review the facility failed to implement the comprehensive care plan related to hearing for one resident (#15) of one resident sampled for hearing. Findings included: An interview was attempted with Resident #15 on 02/28/2022 at 10:42 a.m. Resident #15 was making the bed and when asked questions she continually stated she did not understand due to hearing issues. The resident stated she did not have hearing aids. A review of Resident #15's Admission Record revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #15's care plan, initiated on 1/13/2020, revealed a communication deficit related to hearing loss and [CONDITION(S)] in the right ear. This focus area had a target date of 03/30/2022. […]

• No harm, potential for more than minimal, isolatedF759Mar 2, 2022

  Based on observation, interview and record review, the facility did not ensure the medication error rate was less than 5.00%. A total of twenty-six medications were observed administered, and four errors were identified for three residents (#14, #25 and #28) of six residents observed. These errors constituted a medication error rate of 15.38%. Findings included: On 02/28/2022 at 10:11 a.m., an observation of medication administration with Staff C, Registered Nurse (RN) was conducted with Resident #25. […]