Johnson Cntr/Falcons Landing

In the surveyor’s words

From the most serious findings on record at Johnson Cntr/Falcons Landing, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF582May 4, 2023

  Based on staff interview, clinical record review and facility documentation review, the facility staff pre-selected the option on the SNF ABN notice (Skilled Nursing Facility Advance Beneficiary Notice) issued to 2 Residents (Resident #25 and #27) in a survey sample of 3 Residents, reviewed for such notices. The findings included: On 5/3/23, the facility Administrator was asked to provide a listing of Residents who were discharged from Medicare Part A services. From this listing a sample was selected which consisted of Resident #25 and #27. The notices issued to these Residents were reviewed and revealed the following: 1. […]

• No harm, potential for more than minimal, patternF887May 4, 2023

  Based on clinical record review, staff record review, staff interview and facility documentation review, the facility staff failed to offer and/or provide up to date COVID-19 immunization for 5 residents, Residents #2, #16, #19, #39, and #96, in a survey sample of 7 residents reviewed for COVID-19 vaccination. The findings include: 1. The facility staff failed to offer and/or provide a COVID-19 bivalent booster vaccine for Residents #2, #16, #19, #39, and #96. On 5/3/23, clinical record reviews were performed and revealed the following: A. Resident #2 completed a primary COVID-19 vaccine series on 4/30/21, however there was no evidence that Resident #2 had been offered or received a COVID-19 bivalent booster dose. B. […]

• No harm, potential for more than minimal, patternF880Mar 19, 2021

  Based on observations, interviews, record review, and policy review, the facility failed to consistently implement Centers for Disease Control and Disease Prevention (CDC) infection control measures in the quarantine unit for six of six residents (Resident (R) 18, R82, R81, R78, R77, and R79) and failed to keep urinary catheter tubing off the floor for one of one resident (R15) reviewed for urinary catheters out of a sample of 16 residents. These failures increased the risk of transmission of COVID-19 to the residents on the quarantine unit and urinary tract infection to R15. The facility had one positive COVID-19 resident at time of survey. Findings include: 1. Review of CDC guidance, Preparing for COVID-19 in Nursing Homes, updated April 30, 2020, revealed, . […]

• No harm, potential for more than minimal, isolatedF689May 4, 2023

  Based on observation, interview, record review, and review of facility policy, the facility failed to ensure the environment remained free of potential accident hazards (a portable heater) for one (Resident (R) 3) out of a survey sample of two. There was no evaluation of the resident's cognition, ambulatory status, and potential risks associated with the use of a portable heater completed prior to the use of the heater. Findings include: Review of a policy provided by the facility titled Incidents & Accidents, dated 01/09/23 failed to address potential environmental or equipment hazards. […]

• No harm, potential for more than minimal, isolatedF755May 4, 2023

  Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide pharmaceutical services including procedures that assure accurate acquiring and dispensing of medications, for 1 Resident, (#95) in a survey sample of 25 Residents. The findings included: For Resident # 95 the facility staff failed to secure hard scripts for narcotic medications, and they were accessible in the Resident's chart. On 5/3/23 during clinical record review a review of the hard (paper chart) was conducted and it was found that there were prescriptions for Oxycodone (narcotic pain medication and controlled substance), as well as Lyrica (used for neuropathic pain and also a controlled substance) in the chart. […]