Inspection Reports for
Ecumen North Branch

F0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies: The facility did not ensure the most recent survey results were available to residents/visitors; the binder contained results dated 9/27/23 and was missing the 8/9/24 recertification and two complaint surveys.

F0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: The facility stored clean steam table pans with visible moisture (5 of 9 pans) instead of ensuring items were completely dry before storage, increasing risk for bacterial growth.

F0880 Provide and implement an infection prevention and control program: Staff routinely started wash loads of mop heads and cleaning cloths at the end of a shift and left them damp in the washing machines overnight instead of ensuring they were dried, posing infection risk to residents.

F0554 Allow residents to self-administer drugs if determined clinically appropriate: The facility failed to assess and document self-administration (SAM) for resident R26; staff set up nebulizer treatments without a SAM order or assessment and records/care plan did not identify SAM.

F0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: R198's baseline care plan was blank after admission on 7/31/24 and was not completed within 48 hours.

F0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.: The facility failed to ensure care plan interventions for R26's pressure ulcer risk were reviewed and revised as needed; offloading interventions (Prevalon boots/elevation) were frequently not in place and refusals were not consistently documented to maintain updated interventions.

F0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.: The facility did not perform ordered weekly skin assessments and failed to administer PRN furosemide for weight gains for R26 (weight gains on 7/13 and 7/31 were not treated) and had multiple lapses in required skin checks.

F0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.: The facility lacked clinical documentation justifying a PRN oxycodone order for R11; the consultant pharmacist recommended review/discontinuation because the medication had not been used and no provider justification was found.

F0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.: Unit refrigerators contained resident food without open dates and items stored beyond the facility's three-day policy (example: a meal dated 7/25/24 found in a unit fridge).

F0880 Provide and implement an infection prevention and control program.: During a COVID-19 outbreak the facility failed to implement/ensure infection control measures — including appropriate cohorting or moving COVID-negative roommates, broad-based staff testing, and enforcement of posted enhanced respiratory precaution signage and PPE use — with observations of doors left open and staff entering/exiting isolation rooms without required PPE.

F0636 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months: The facility failed to ensure a comprehensive care plan and resident-specific fall interventions for 1 of 3 residents (R2), as evidenced by missing fall interventions on R2's care plan and nursing assistant care sheet and documentation of R2 found on the bathroom floor.

F0695 Provide safe and appropriate respiratory care for a resident when needed: The facility failed to maintain oxygen equipment by not routinely changing a resident's nasal cannula (R12), evidenced by tubing dated 9/4/23 while in use.

F0880 Provide and implement an infection prevention and control program: The facility failed to ensure shared glucometers were sanitized after use, staff did not perform required hand hygiene during medication passes and wound care, and contact-precautions signage was not in place for R15.

F0881 Implement a program that monitors antibiotic use: The facility failed to utilize antibiotic stewardship protocols before initiating antibiotics for R15 (vancomycin) and did not obtain stool testing for C. difficile prior to treatment.