Diversicare Of Arab

Based on observations, interview, record review, and policy review the facility failed to ensure the kitchen was maintained in a sanitary manner creating the risk for foodborne illness to 75 of 78 residents (three residents received nutrition from tube feeding) residing in the facility. Kitchen flooring, surfaces, and areas were not sanitary and were in need of cleaning and repairs. Findings include: 1.The initial kitchen inspection was conducted with the Employee Identifier (EI) #27, Dietary Supervisor on 04/12/21 from 9:59 AM - 10:20 AM The following concerns were noted during the initial inspection: a. Can opener -The can opener was observed with a layer of accumulated black residue on the cutting blade. b. Large stainless-steel shelf - A large stainless-steel shelf attached to the stainless-steel table/counter (located a few inches above the floor) was observed to be completely covered in rust. A shelf liner partially covered the shelf; however, approximately 20% of the shelf was not covered by the liner. Sheet pans were stored in a rack directly on the rusted portion of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, policy review, and Center for Disease Control (CDC) guidance the facility failed to ensure infection control practices were implemented to prevent the potential spread of infection. The facility failed to enforce the practice that required staff and residents to wear a mask appropriately to cover the nose and mouth when in close contact with others and in general population areas of the facility. Resident Identifier (RI) #41, RI #5, RI #70, and RI #66 failed to follow guidance to wear a mask to cover both mouth and nose when out of their room. Eighteen of 25 Residents who resided on the secure unit ate meals in a dining room without maintaining social distance and staff failed to direct residents to wear a mask per guidance. All residents on the secure unit received the vaccine to protect them from the Coronavirus. The facility failed to maintain a catheter in a sanitary manner for one of two residents (RI #3) reviewed for catheter care. Failure to follow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review and facility policy review the facility failed to identify target behaviors, monitor for the target behaviors for antipsychotic medications, ensure a stop date for an as needed (PRN) anti-anxiety medication and provide indications for use for three of six residents (Residents (RI) #4, RI #41, and RI #131.) This failure had the potential to cause residents to receive psychotropic medications without proper indications for use or monitoring for effectiveness. Findings include: 1. RI #41 was admitted to the facility on [DATE] according to the admission Record located under the Profile tab in the electronic medical record (EMR.) According to the Diagnosis's list located on her admission Record in the Profile tab in the EMR revealed she was admitted with diagnoses including unspecified dementia with behavioral disturbance and hallucinations. Under the Orders tab in the EMR revealed RI #41 was prescribed an antipsychotic medication for bipolar or schizophrenia, quetiapine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and policy review, the facility failed to ensure the menus were followed. Ten residents prescribed pureed diets (Resident Identifiers (RI) #24, RI #75, RI #27, RI #7, RI #46, RI #38, RI #3, RI #25, RI #2, RI #43) were not served pureed bread as directed on the menu during two of two meals observed. In addition, condiments indicated on the menu such as salt, pepper, and margarine were not served to residents on the 300 Hall during two of two meals observed. Three of 22 residents who ate meals on the 300 Hall RI #67, RI#79, RI#56) stated they would like to be served salt, pepper, and/or margarine with their meals. Findings include: 1. The Week 2 Diet Spreadsheet and Week at a Glance Menu (both undated) revealed lunch on Monday (4/12/21) for residents on regular diets consisted of: swiss steak, parly (sic) potatoes, brussel sprouts, vanilla pudding, and dinner roll/margarine. According to the Week at a Glance Menu, residents on pureed diets were to be served: pureed swiss steak with gravy, pureed parly (sic) potatoes, pureed brussel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to assess and implement interventions after one of three sampled resident reviewed for falls in sample of 20 residents (Resident Identifier (RI) #54) fell on [DATE] and sustained a laceration to her forehead. The facility failed to obtain vital signs, document in nurse's notes, and complete a thorough post fall assessment to determine the root cause of the fall, and determine if new interventions were necessary, putting the resident at risk for additional falls. Findings include: Review of the facility's policy titled Falls Clinical Care System Guidelines for Falls, dated February 2017, revealed the purpose was, to establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls. After a fall occurred, the following steps were to be taken, in pertinent part: -The post fall evaluation is completed to assist in developing interventions to prevent future falls. -The fall event and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and policy review, the facility failed to store all drugs in locked compartments in one (100 Hallway) of three lockable medication carts. The facility reported 51 residents residing in the 100 and 300 hallways that had potential access to the unlocked medications. Findings include: 1. On 04/12/21 at 9:45 AM an Employee Identifier (EI)#2 Director of Nursing (DON) was escorting the survey team to the conference room when observation of the medication cart parked by the 100-hall nursing station with the unlocked drawers containing medication toward the hallway.The surveyor pointed out to EI#2 the cart was unlocked. EI#24 Licensed Practical Nurse (LPN) was present in the nurses' station with the medication cart unlocked but the unlocked cart was out of her view. EI#2 instructed EI#24 to lock the cart. EI#2 nodded her head in acknowledgement the medication cart was unlocked and out of the view of EI#24. On 04/15/21 at 9:55 AM the 100-hall medication cart was observed to be unattended and unlocked parked by the 100-hall nursing station with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of a facility policy titled Handwashing/Hand Hygiene, the facility failed to ensure a Registered Nurse (RN) washed hands and changed gloves during wound care for Resident Identfier (RI) #64, between handling dirty and clean items. This affected one of two sampled residents for whom wound care was observed. Findings include: Review of an undated facility policy titled Handwashing/Hand Hygiene, revealed the following: Policy This center considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation .5. Use an alcohol-based hand rub or, alternatively, soap . and water for the following situations: g. Before handling clean or soiled dressings, gauze pads, etc. (et cetera); .j. After handling used dressings . RI #64 was admitted to the facility on [DATE]. On 2/06/19 at 10:08 AM Employee Identifier (EI) #3, RN, was observed performing wound care for RI #64's stage three pressure ulcer. During the care, EI #3 removed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, a facility policy titled, Waste Control and the Food Code, the facility failed to ensure the top on one of two dumpsters was not broken and partially opened. This was observed on 2/28/18, and had the potential to affect all 76 residents in the facility. Findings Include: A review of a facility policy titled, Waste Control with an effective date of August 1, 2012, documented the following: .It is the policy of this facility to store garbage and trash in a sanitary manner until disposed of properly for infection control . A review of the Food Code 2013 documented the following: .5-501.13 (A) receptacles and waste handling units for REFUSE, shall be insect-and rodent-resistant .5-501.15 Outside Receptacles (A) Receptacles and waste handling units for REFUSE, .shall be designed and constructed to have tight-fitting lids, doors, or covers . 5-501.110 Storing Refuse, Recyclables, and Returnable's REFUSE, .shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents .5-501.111 Areas, Enclosures, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, medical record review and review of a facility document titled, Infection Control Guide, the facility failed to ensure licensed staff: 1. did not place a glucometer in her pocket before obtaining a fingerstick blood sugar (FSBS) for Resident Identifier (RI) #54, 2. did not place gloves on an overbed table for use during RI #54's FSBS, 3. did not place a medication cup of liquid medication inside a medication cup of pill medications for RI #27, and 4. did not touch the handle of a scoop for protein powder with her bare hand and then place the scoop back into the container during medication administration for RI #174. These deficient practices affected RI #54, RI #27 and RI #174, three of seven residents and three of five nurses observed during medication pass observation. Findings Include: A review of a facility document titled, Infection Control Guide revealed: .Standard precautions are the recommended practice for the care of all patients and residents receiving care within…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.