Ascension Nazarethville Place

In the surveyor’s words

From the most serious findings on record at Ascension Nazarethville Place, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 17, 2022

  Based on observation, interviews and record reviews, the facility failed to implement interventions in preventing the development of a pressure ulcer in relation to repositioning and skin monitoring for one (R12) of one resident reviewed for pressure ulcers in the sample of 26. This deficiency resulted in R12's stage III pressure ulcer in the coccyx area worsen to stage IV pressure ulcer with ongoing infection requiring antibiotic therapy. Findings include: R12 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including but not limited to Hypertensive Heart Disease with Heart Failure; Paroxysmal Atrial Fibrillation; Unspecified Osteoarthritis, Unspecified Site; Dysphasia, Oropharyngeal Phase; and Unsteadiness on Feet. […]

• Actual harm, isolatedF684May 11, 2022

  Based on interviews and record reviews, this facility failed to adequately monitor a resident receiving an anticoagulation (blood thinner) medication, recognize signs exhibited when laboratory value is critically high, implement interventions immediately to reduce risk of further bleeding, and evaluate the effectiveness of interventions. This failure affected one resident (R3) out of three residents reviewed for anticoagulation therapy in a sample of 3. This failure resulted in R3 experiencing an acute change in condition and transported to the local hospital where R3 was assessed and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the medical record notes R3 was admitted to this facility from another long term care facility on 3/25/22. […]

• Actual harm, isolatedF689Apr 3, 2022

  Based on interviews and records reviewed the facility failed to ensure that staff utilized the mechanical lift for a resident assessed to require mechanical lift for transfers. This failure affected 1 of 3 (R1) residents reviewed for safe transfers. This failure resulted in R1 suffering an acute left medial malleolus fracture (closed fracture of the left ankle). This past noncompliance occurred on 3/17/22. Finding include: R1 is [AGE] years old with diagnosis including but not limited to Alzheimer's Disease, [CONDITION(S)], Major Depressive Disorder, [CONDITION(S)], Essential Hypertension, Age Related [CONDITION(S)], Anxiety, and [CONDITION(S)]. Cognitive pattern assessment dated [DATE] notes R1 has long and short-term memory impairments and is severely cognitively impaired. […]

• Actual harm, isolatedF880Oct 25, 2021

  Based on observation, interview, and record review, the facility failed to prevent and/or contain the spread of COVID-19 by failing to follow their policy and procedures for wearing PPE's (Personal Protective Equipment) including universal mask usage and hand hygiene; failed to provide available PPE's to staff as per CDC recommendations; and failed to train all staff including agency personnel on masking and isolation procedures. This failure caused R1 to contract COVID-19 infection who was then emergently transfer to the hospital; and died due to complications related to pneumonia and the COVID-19 virus. […]

• Actual harm, isolatedF550Mar 20, 2021

  Based on observation, interview, and record review, the facility failed to follow their policies and procedures for grievances by failing to replace essential medical devices (hearing aids) in a timely manner to accommodate one (R1) of three residents reviewed for resident rights. This failure prevented R1 from hearing his immediate surroundings and caused exacerbation of R1's [MEDICAL CONDITION] and overall psychosocial well being. Findings include: R1 is an alert and oriented [AGE] year old with [DIAGNOSES REDACTED]. Facility's form dated 2/9/21 signed by V4 (Social Service Director) titled Notification of Concern/Complement states, (R1) Resident's hearing aids are missing. Actions taken: searched residents room, searched garbage, spoke to kitchen, still unable to find. […]