Lanessa Extended Care

In the surveyor’s words

From the most serious findings on record at Lanessa Extended Care, in the surveyor’s own words.

• Actual harm, patternF689Sep 7, 2022

  Based on observation, interview, record review and policy review, the facility failed to ensure that its staff maintained a hazard free environment for five Residents (#5, #55, #136, #19, and #25) out of a total of 19 sampled residents and in one out of two medication rooms, resulting in an injury for one Resident (#5). Specifically, For Resident #5 the facility failed to ensure that its staff performed neurological checks, completed a comprehensive fall investigation, and developed and implemented new fall interventions after an unwitnessed fall, resulting in a subsequent fall, a hospital admission and a diagnosed impacted proximal humerus (arm) fracture. 2) For Resident #55 and #136 the facility failed to ensure that its staff provided the required supervision with eating. […]

• Actual harm, isolatedF693Nov 8, 2023

  Based on observations, interviews, record and policy reviews, the facility failed to ensure that one Resident (#79) of one applicable resident, in a total sample of 19 residents, who received enteral nutrition (method of delivering nutrition through the stomach or the small intestine) via a gastrostomy tube (G-tube: tube inserted through the abdomen into the stomach to provide nutrition) received care and services to prevent complications. Specifically, the facility failed to ensure that all pertinent Physician's orders were implemented relative to the G-tube, that fluids were administered and monitored to maintain acceptable parameters of hydration, resulting in clinical signs of dehydration and need for the administration of intravenous fluids (IV fluids: specially formulated liquids… […]

• Actual harm, isolatedF657Sep 7, 2022

  Based on record review, observation and interview, the facility failed to ensure that its staff revised the care plan for one Resident (#5) out of 19 sampled residents after he/she sustained an unwitnessed fall on 8/29/22 and had a subsequent unwitnessed fall of similar circumstances on 8/31/22 that resulted in an impacted proximal humerus fracture [A proximal humerus fracture is a break of the upper part of the bone of the arm (humerus)]. Findings include: Resident #5 was admitted to the facility in November 2015, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, dated 8/17/22, indicated Resident #5 had severe cognitive impairment as evidenced by a score of 8 out of 15 on the Brief Interview for Mental Status (BIMS). […]

• Actual harm, isolatedF656Apr 14, 2022

  Based on observations, records reviewed, and interviews, for one of five sampled residents (Resident #5), the Facility failed to ensure nursing staff implemented and followed interventions indicated in his/her comprehensive plan of care when nursing staff failed to apply his/her Juzo wrap compression stockings (leg wraps used to treat swelling), which resulted in him/her experiencing pain in his/her legs that effected his/her ability to stand and walk. Findings include: The Facility's Policy, titled, Resident Assessment and Care Plan, dated, 4/2015, indicated, the Interdisciplinary Team would develop a comprehensive Care Plan for each resident that included measurable objectives and timelines to accommodate preferences, and special need identified in the resident assessment. […]

• Actual harm, isolatedF684Apr 14, 2022

  Based on observations, records reviewed, and interviews, for four of five sampled residents, (Resident #1, #2, #3 and #5), the Facility failed to ensure treatments and services provided by nursing were conducted in accordance with professional standards of practice. 1) Resident #1, staff failed to notify his/her physician or nurse practitioner of blood laboratory work results, specifically International Ratio (INR), which is used to determine effectiveness of [MEDICATION(S)] (blood thinner) dosages, resulting in missed [MEDICATION(S)] doses and INR levels that were not within therapeutic range. […]