Legacy Health and Rehabilitation of Pleasant Grove

In the surveyor’s words

From the most serious findings on record at Legacy Health and Rehabilitation of Pleasant Grove, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF814Feb 11, 2022

  Based on observations, interviews, and review of the facility policies titled, Sanitation Principles and Garbage and Refuse, the facility failed to dispose of garbage and refuse in a sanitary method and in accordance with their policy. This deficient practice had the potential to affect all residents and staff in the facility. Findings include: A review of the dietary policy titled, Sanitation Principles, dated 08/10/2018, revealed: .Refuse containers and dumpsters outside the nursing facility should have tight fitting lids and should be kept covered when not actually being loaded. The areas around the dumpster should be kept free of debris . […]

• No harm, potential for more than minimal, patternF584Feb 11, 2022

  Based on record review, interviews, and observations, the facility failed to ensure: 1. Resident Identifier (RI) #107's electrical outlet was repaired, which had detached from the wall and was hanging by electrical wire approximately one to two feet from the resident while in bed; and 2. a handrail between a resident room and the linen room was securely affixed to the wall. This deficient practice affected one of 42 sampled residents and was observed with handrails located on one of four units in the facility. Findings include: 1. Resident Identifier (RI) #107 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], revealed the Staff Assessment for Mental Status indicated the resident had severely impaired decision-making skills. […]

• No harm, potential for more than minimal, patternF759Feb 11, 2022

  Based on observations, interviews, record review, and review of a facility policy titled, Medication Administration - General Guidelines, the facility failed to maintain a medication error rate less than 5%. There were 3 errors in 26 opportunities, which resulted in a 11.54% medication error rate involving Resident Identifier (RI) #59 and RI #93 during medication pass. Specifically, the facility failed to ensure: 1. RI #59 received a multivitamin and chewable aspirin as ordered by the physician; and 2. RI #93 received the correct dilution of an intravenous medication. This deficient practice affected RI #59 and RI #93, two of seven residents observed during medication pass. […]

• No harm, potential for more than minimal, patternF886Feb 11, 2022

  Based on observations, interviews, and review of an Abbott BinaxNOW COVID-19 Ag procedure card, the facility failed to ensure proper administration of the COVID-19 test for Employee Identifier (EI) # 27, the Maintenance and Environmental Services Director, on 02/08/2022, when the result of his COVID-19 testing card was interpreted as negative before completion of the 15 minute required testing time-frame. This was observed during one of three observations of staff performing COVID-19 testing. Findings include: A review of an Abbott BinaxNOW COVID-19 Ag procedure card directed the user, in part, to Peel off adhesive liner from the right edge of the test card. Close and securely seal the card. Read result in the window 15 minutes after closing the card. […]

• No harm, potential for more than minimal, isolatedF656May 26, 2022

  Based on interviews, medical record review and a review of the facility policy titled, Person Centered Care Plans, the facility failed to ensure a person centered care plan was developed for Resident Identifier (RI) #1, when newly identified pressure ulcer/injuries were found on 3/7/22. This affected RI #1, one of three residents sampled for pressure ulcer/injury. Findings include: A review of the facility policy titled, Person Centered Care Plans, with an effective date of August 15, 2018 revealed, . PURPOSE: Person centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident/guest, consistent with the resident/guest(s) rights. STANDARD: . […]