Penfield Place

In the surveyor’s words

From the most serious findings on record at Penfield Place, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF689May 10, 2023

  Based on observations, interviews, and record review conducted during the Recertification Survey completed 5/4/23 to 5/10/23, it was determined that for two (north and east halls) of four resident units, the facility did not ensure that the resident environment remained free of accident hazards. Specifically, hot water temperatures exceeding 120 degrees Fahrenheit ( F) were accessible to residents at point of use. The findings are: Observations, interviews, and record review on 5/4/23 from 11:08 a.m. to 4:06 p.m. […]

• No harm, potential for more than minimal, isolatedF554Jan 31, 2025

  Based on observations, interviews, and record review conducted during the Recertification Survey from 01/27/2025 to 01/31/2025, for one (Resident #13) of five residents reviewed, the facility did not ensure a resident was clinically appropriate to self-administer medications. Specifically, Resident #13 was observed to have multiple medications left on their bedside table and there was no documented evidence their ability to self-administer medications had been assessed or care planned for. […]

• No harm, potential for more than minimal, isolatedF677May 10, 2023

  Based on observations, interviews and record review conducted during the Recertification Survey 5/4/23 to 5/10/23, it was determined for one (Resident #10) of three residents reviewed for activities of daily living (ADLs) the facility did not ensure that residents who are unable to carry out ADLs received the necessary services to maintain personal hygiene. Specifically, there were issues with incorrect use of a bathing cleanser. The findings are: Resident #10 was admitted to the facility 11/13/20 with diagnoses including knee replacement, broken femur (leg), muscle weakness, and diabetes. The Minimum Data Set Assessment, dated 1/30/23, documented that the resident was cognitively intact, and required extensive assistance with personal hygiene. […]

• No harm, potential for more than minimal, isolatedF686May 10, 2023

  Based on observations, interviews, and record review conducted during a Recertification Survey 5/4/23 to 5/10/23, it was determined that for one (Resident #26) of one resident reviewed for pressure ulcers, the facility did not ensure that the resident received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, the nurse did not change gloves or perform hand hygiene while doing dressing changes on multiple wounds including a pressure ulcer. […]

• No harm, potential for more than minimal, isolatedF759May 10, 2023

  Based on observations, interviews, and record review conducted during the Recertification Survey 5/4/23-5/10/23 it was determined that for one (Resident #32) of four residents observed during medication pass, the facility did not ensure that it was free of medication error rate of 5 percent (%) or greater. There were 2 medication errors for 26 opportunities resulting in a 7.69 % medication error rate. The issue involved not mixing a medication in the correct amount of liquid, and not using a spacer nor rinsing the mouth after administering an inhaled medication as ordered by the phusicain. […]