Ahc of Landerhaven LLC

In the surveyor’s words

From the most serious findings on record at Ahc of Landerhaven LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Aug 27, 2021

  Based on interview, record review and emergency department summary notes, the facility failed to ensure residents were free from significant medication errors when one resident (Resident #30) was not administered physician ordered medications including an anti-[CONDITION(S)] medications, a blood thinner, insulin and other medications as prescribed. This resulted in Immediate Jeopardy and serious life-threatening harm when on 08/08/21 at 9:15 A.M., Resident #30 experienced seizures and an undetectable, high blood sugar level requiring hospitalization and admission to the intensive care unit (ICU). Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one resident (Resident #30) of five residents reviewed for medication administration. […]

• Actual harm, isolatedF684Aug 27, 2021

  Based on interview and record review and emergency department summary notes, the facility failed to assess and provide medical care/treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual harm occurred when Resident #30 was found having seizures and the licensed nursing staff failed to assess her and obtain prompt medical treatment as evidenced by waiting approximately 45 minutes to call the emergency squad (911) for transport to the emergency department. Resident #30 was admitted to the intensive care unit for seizures and diabetic ketoacidosis. This affected one resident (Resident #30) of three residents reviewed for seizures. […]

• No harm, potential for more than minimal, widespreadF880Aug 27, 2021

  Based on observation, record review, interview, and policy review, the facility failed to ensure staff donned the appropriate personal protective equipment (PPE) prior to entering a resident room who was on transmission-based precautions for observation related to COVID-19. This had the potential to affect all 45 residents residing in the facility. Findings include: Review of Resident #2's medical record revealed an admission on 08/03/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were also special instructions for staff to wear PPE including a gown, gloves, a mask, and a face shield or goggles when providing care to the resident. Observation during a facility tour on 08/04/21 at approximately 10:00 A.M. […]

• No harm, potential for more than minimal, widespreadF725Jul 19, 2021

  Based on interview and record review the facility failed to provide sufficient nursing staff to provide safe and timely care and medication administration to residents. This had the potential affect all 44 residents residing in the facility. Findings include: Interview with Resident #34 on 07/07/21 at 10:28 A.M. revealed call lights are not answered timely on weekends or holidays and stated the facility is understaffed. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] aerosol inhaler 90 micrograms (mcg) per actuation, two puffs every four hours (to prevent and treat wheezing and shortness of breath caused by breathing problems such as asthma or chronic obstructive pulmonary disease): · Scheduled on 07/01/21 at 4:00 A.M. […]

• No harm, potential for more than minimal, widespreadF800Jul 19, 2021

  Based on interview and record review the facility failed to provide a diet that met the nutritional needs of the residents. This affected all but three (Resident's #7, #14 and #39) who received nothing by mouth. The facility had a census of 44. Findings include: Interview with Resident #9 on 07/07/21 at 5:02 P.M. confirmed two slices of pizza were served for lunch on 07/05/21. She stated she heard staff discussing no kitchen staff had shown up for the day. Interview with Resident #42 on 07/07/21 at 5:17 P.M. revealed he was served cereal on Monday 07/05/21 for breakfast and two slices of pizza for lunch. He stated he heard staff discussing no kitchen staff had shown up for the day. Interview with the Administrator on 07/07/21 at 3:16 P.M. […]