S.P.J.S.T. Rest Home No 2

In the surveyor’s words

From the most serious findings on record at S.P.J.S.T. Rest Home No 2, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Jul 28, 2023

  Based on observation, interview, and record review, the facility failed to ensure 1 resident (CR #84) of 5 residents reviewed for medication administration was free of a significant medication error. -Resident #84 was administered 60 units of long-lasting insulin. -Resident #84 exhibited a blood sugar of 22 mg/dl. -Resident #84 required hospitalization . The failure placed residents at risk for complications and possible death from receiving the wrong or excessive dosage of medication. An Immediate Jeopardy (IJ) was identified on [DATE] at 10:38 a.m. The noncompliance was identified as Past Noncompliance. The IJ began on [DATE] and ended on [DATE]. […]

• No harm, potential for more than minimal, patternF812Sep 19, 2024

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the kitchen in that: 1. The facility failed to ensure unlabeled foods were not stored in the refrigerator. 2. The facility failed to ensure unsealed foods were not stored in the dry good storage. This failure had the potential to place residents at risk of serious complications from foodborne illness as a result of their compromised health status. Findings include: Interviews and observation s on [DATE] at 8:15 AM with the [NAME] revealed while in the dry food storage there was a bag cereal that was opened which the [NAME] identified as corn flakes. There was also a bag of potato chips unsealed. […]

• No harm, potential for more than minimal, patternF761Jun 9, 2022

  Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured in locked compartments, labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts ( Hall C medication cart and Hall C PRN medication cart) reviewed for drug labeling and storage. - LVN A failed to ensure all medications were secured in locked carts when not in use and unattended. - The facility failed to ensure the Hall C PRN Medication cart did not contain multidose containers with no open dates. These failures could place residents at risk of adverse medication reactions and drug diversions. […]

• No harm, potential for more than minimal, patternF812Jun 9, 2021

  Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure: -Food was not stored on the floor and dated in the dry storage area. -Fruit in open containers had mold and mildew on outside and not dated. -Food in containers not labeled with use by date. -Outdated food was discarded. These failures placed residents at risk of food borne illness and cross contamination. Findings included: Observations on 06/09/21 at 10:55 AM in the kitchen revealed: Dry storage area - Large bag of cornmeal on the floor. Large open bag of all-purpose flour on the floor not dated. Dead insect on floor near door. […]

• No harm, potential for more than minimal, patternF921Jun 9, 2021

  Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment for residents, staff and the public, as evidenced by; The facility failed to ensure: -Multiple leaks in the activity room were contained, -Keep floors dry in the activity room water puddles were on the floor, -The sink and garbage disposal were working properly in the kitchen, and -Dead bugs and grease, and broken crates were not on the floor in the kitchen. These failures placed residents at risk of harm and unsafe and sanitary conditions. Findings included: Observation on 06/09/21 at 9:50 AM revealed 4 water spots in the activity room coming from the ceiling leaks. Vents in activity room have black and brown substances on them. […]