La Plata Nursing Home

In the surveyor’s words

From the most serious findings on record at La Plata Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Apr 24, 2023

  Based on interview and record review, the facility failed to ensure one resident, (Resident #13) of 14 sampled residents, was free from a significant medication error. Staff failed to transcribe the resident's order for prednisone (steroid) correctly following his/her discharge from the hospital and return to the facility on [DATE]. The facility administered 30 milligrams (mg) of prednisone daily for 46 days instead of the ordered three day tapered dose. As a result, the resident presented to the emergency roiagnom on [DATE] with diagnoses that included acute pulmonary edema (condition caused by excess fluid in the lungs), steroid induced hyperglycemia (excessive amount of sugar in the blood), tachycardia (heart rate that exceeds the normal resting rate; a rate over 100 beats per minute is… […]

• Actual harm, isolatedF689Nov 14, 2022

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and oversight to prevent falls for one resident, Resident #1, in a review of four sampled residents. The facility failed to implement and revise fall prevention interventions as indicated on the resident's care plan. Resident #1 had multiple falls with injuries. The facility census was 46. Review of the facility policy, revised March 2018, titled Falls - Clinical Protocol, showed the following: -The physician will help identify individuals with a history of falls and risk factors for falling: -Staff will ask the resident and the caregiver or family about a history of falling; -The staff and physician will document in the medical record a history of one or more recent falls (for example. […]

• No harm, potential for more than minimal, widespreadF812Nov 8, 2024

  Based on observation, interview, and record review , the facility failed to serve food under sanitary conditions in accordance with professional standards for food service safety, failed to follow proper hygienic practices when preparing and serving food to residents, including using hand hygiene techniques, and failed to ensure food service equipment and surfaces were appropriately cleaned and ceilings above food preparation and serving areas were maintained. The facility census was 42. […]

• No harm, potential for more than minimal, widespreadF812Apr 24, 2023

  Based on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen. The census was 44. 1. Review of the policy, Ice Machines Cleaning and Maintenance Procedure, dated 12/7/20, showed ice and ice-making machines may be contaminated through improper handling of ice by patients and/or staff, improper storage of ice, poor cleaning or maintenance of associated equipment and ice handling equipment/implements. Ice from contaminated ice machines may result in adverse events for patients. […]

• No harm, potential for more than minimal, widespreadF880Apr 24, 2023

  Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD), and failed to perform detection and surveillance of possible cases of LD. The facility failed to ensure staff washed their hands and changed soiled gloves after direct resident contact and when indicated by facility policy to prevent the spread of infection during personal care for one resident (Resident #38 ) and during medication administration for four residents (Residents #31, #38, #5, and #13), in a review of 14 sampled residents, and for two additional residents (Residents #32 and… […]