City View Post Acute

In the surveyor’s words

From the most serious findings on record at City View Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF684Jan 9, 2024

  Based on observations, interviews, and record review the facility failed to ensure one of three sampled residents (Resident 1) was provided with the appropriate resident-centered treatment and care when: 1. Multiple skin discoloration on Resident 1's back observed on 6/28/23 did not have a follow-up assessment, evaluation, and appropriate interventions by the Wound Care Team (Clinicians who develops and implements wound prevention, skin management, and wound care). 2. The Weekly Skin Assessments (WSK, supposed to be documented on the Comprehensive Skin Evaluation/Assessment, CSEA) form were not done for the months of May and June 2023. For the month of July 2023, the WSKs were done only on 7/6/23 and on 7/14/23, not on a weekly basis, as per policy. 3. […]

• Actual harm, isolatedF600Nov 8, 2022

  Based on interviews and record review, the facility failed to ensure Residents 1, 2, and 3, three out of 16 sample residents, were protected from neglect. Resident 1 reported: a pattern of staff not providing assistance; staff telling her to defecate into her adult brief and they will clean her up later. Resident 2 reported: being left alone in the bathroom for over an hour and was unable to reach the call light; waiting for over two hours for her pain medication; Call light response time can be over an hour; waiting for four hours for staff to provide toileting care. Resident 3's family member reported: long wait of at least 40 minutes for staff to answer the call light. The facility failed to protect Residents 1, 2, and 3 from neglect. […]

• Actual harm, isolatedF600Nov 8, 2022

  Based on interview and record review the facility failed to implement an effective plan of correction. 1. The facility failed to follow up on Resident 1, 2, and 3's allegations of neglect according to facility policies. 2. The facility implemented a room round program asking residents to rate call light response time on a scale of 1-5 (1= poor and 5= excellent). Part of the facility's plan of correction was to follow up on responses that were rated 3 or lower. There were 28 responses for call light that were rated 2 or lower and there were no documented evidence of a follow up. 3. The facility failed to implement clear precise metrics to track interventions regarding call lights response. […]

• Actual harm, isolatedF600May 23, 2022

  Based on observation, interviews, and record review, staff neglected to attend to four of four sampled resident ' s needs in a timely manner (Resident 1, 2, 3, and 4). Residents 2 and 3 expressed anger and frustration when they had to wait for a prolong period of time for staff to meet their needs. Residents 1 and 4 were not interviewed due to their medical conditions. However, a reasonable person would feel anger, lack of respect when staff failed to attend to a dislodged Foley catheter (a tube to drain urine from the bladder) for at least two hours for Resident 1. […]

• Actual harm, isolatedF684Jan 6, 2022

  Based on interview and record review, the facility failed to assess one of three sampled residents (Resident 1), for skin [CONDITION(S)]. This failure to assess Resident 1's lower abdominal skin folds resulted to delayed treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Definition: Blister- a pocket of body fluid within the upper layers of the skin, a type of skin lesion. [CONDITION(S)]- swelling of the skin and subcutaneous tissues (layer below the skin), most often caused by an infection. Findings: During a review of Resident 1's admission summary dated 9/23/21, admission summary indicated, Resident 1 was admitted with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]