Ridgecrest Health And Rehabilitation

bBased on observation, record review and facility policy, review of medication pass on 7/30/2024, and 7/31/2024 it was determined the facility failed to ensure physician orders were followed to maintain a medication rate of less than 5% to prevent complications for 2 (Residents # 31, and #28) of 3 residents observed during medication pass resulting in medication errors. The findings are: 1. Resident #31's admission Record dated 4/3/2024 noted a diagnoses of Asthma, Chronic Obstructive Pulmonary Disease (COPD), Emphysema, Wheezing, and Chronic Cough. a. Resident #31's physician orders dated 4/23/2024 documented, Advair HFA Inhalation Aerosol 115-21 mcg/ ACT (Fluticason-Salmeterol) 2 puff inhale orally two times a day related to Chronic Obstructive Pulmonary Disease(COPD). Wait 1 minute between puffs. Rinse and spit after administration. Montelukast Sodium oral tablet 10 mg (Montelukast Sodium) give 10 mg by mouth one time a day for COPD/ Asthma. b. On 7/30/2024 at 8:39 AM, during observation of medication administration for 600 hallway with Registered Nurse (RN) #25, resident #31 did…

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, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written quantified recipe and menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 2 residents who received pureed diets and 10 residents who received enhanced food diets from 1 of 1 kitchen. The findings are: 1. The menu for breakfast documented the residents who received pureed diets were to receive 1 #8 scoop (1/2 cup) of hot cereal. a. On 07/31/24 at 7:50 AM, Dietary [NAME] (DC) #7 used a #16 scoop (1/4 cup) to a serve a single serving of pureed oatmeal to the residents on pureed diets, instead of a #8 scoop (1/2 cup) as specified on the facility menu. b. 07/31/24 at 8:16 AM, the surveyor asked DC #7 what scoop size she used to serve pureed oatmeal and how many servings she gave to each resident. She stated, I used the blue scoop #16 and gave a serving each. 2. On 7/31/24 a facility breakfast recipe for super cereal documented for 10 residents use 8 ounces margarine solid…

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, record review, and interview, the facility failed to ensure food was prepared by methods that maintained flavor, appearance; hot foods were served hot and cold foods were served cold to maintain palatability and encourage adequate nutritional intake for 1 of 1 meal observed on the 400 Hall, 600 Hall, and 700 Hall. The failed practice had the potential to affect 9 residents who received meal trays in their room on 100 Hall 9 residents who received meal trays in their rooms on 200 Hall, 8 residents who received meal trays in their rooms on 300 Hall, 26 residents who received meal trays in their rooms on 400 Hall, 13 residents who received meal trays in their rooms on 500 [NAME]. 29 residents who received meal trays in their rooms on 600 Hall and 9 residents who received meal trays in their rooms on 700 Hall. as documented on a list provided by Dietary manager on 07/31/2024 at 9:30 AM. The findings are: 1. Resident #90 Minimum Data Set with an assessment reference date of 7/3/24 indicated…

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, record review, interview, and facility policy, the facility failed to ensure a resident who is on contact isolation does not have a roommate and that staff wear appropriate personal protective equipment (PPE) while entering the room for 1 (Resident #31) of 1 sample mix resident reviewed for contact isolation; ensure staff while providing care to a resident in an enhanced barrier precautions room wore appropriate personal protective equipment (PPE) for 4 (Resident #363, #366, #367, #371) of 4 residents reviewed for enhanced barrier precautions; ensure staff while providing percutaneous endoscopic gastrostomy (PEG) medication administration and tube feeding wore appropriate personal protective equipment (PPE) and sanitized hands for 1 (Resident #28) of 1 sample mix residents reviewed for medication pass; to ensure staff maintained aseptic technique during an ordered wound care treatment for 1 (Resident #367) of 1 resident reviewed for wound care treatment; to ensure continuous positive airway pressure (CPAP) face masks were contained in a storage bag when not in…

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 and interview the facility failed to ensure accommodation needs were met by not ensuring the call light was within reach for one (Resident #366) of one sampled resident. The findings include: A review of the Order Summary revealed Resident #366 had diagnoses of paralytic syndrome affecting right side with a stroke, anxiety disorder and major depressive disorder, and that Resident #366 had an order for Treatment to skin tear to L forearm: Cleanse with wound cleanser or sterile water apply xeroform to wound bed. Cover with 4 x 4 bordered foam on MWF (Monday, Wednesday, and Friday) and PRN (as needed) until resolved. Active order as of 07/29/2024. A review of the Care Plan revealed Resident #366 Interventions/Task: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs a prompt response to all requests for assistance. On 07/29/2024 at 6:35 AM, the surveyor observed Certified Nursing Assistant (CNA) #21 and #22 entered Resident #366's room. The surveyor observed CNA #22 state that they will…

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 record review and interview, the facility failed to ensure an admission Minimum Data Set (MDS) was completed in a timely manner for one (Resident #371) of one sampled resident. On 07/29/2024, an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/2024 was reviewed. The admission MDS was started on 07/08/2024 and was currently 18 days overdue for completion. A review of the policy Resident Assessment Instrument revealed l. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct(s) timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident's admission to the facility; On 08/01/2024 at 11:15 AM, during an interview MDS Coordinator #19 stated that usually total life respite is done by MDS Coordinator #20, but she is not really aware of that and has been training on and off. We both have been working six days a week, on the floor for up to 120 hours. We have not been…

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, record review, interview, and facility policy review, the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 1 (Resident #103) of 1 sample mix residents. The findings are: 1. Review of Resident #103's admission Record dated 05/23/2024 revealed a diagnosis of sleep apnea. a. On 07/29/24 at 10:29 AM, the Surveyor observed a Continuous Positive Airway Pressure (CPAP) mask at Resident #103's bedside with CPAP mask sitting on bedside table not in a bag. Resident #103 stated, I have sleep apnea. b. Review of Resident #103's Order Summary Report, active as of 07/29/2024, did not document CPAP usage. c. On 08/01/24 at 8:26 AM, the Surveyor observed Resident #103's CPAP mask at the bedside not in a storage bag. No storage bag was present. d. Review of Resident #103's Care Plan did not reveal CPAP usage. e. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/2024 revealed Section O0110. Special Treatments, Procedures, and Programs documented the resident does not…

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 interviews, record review, and facility policy review, the facility failed to update person-centered care plans to reflect the residents needs for three Residents (Residents #45, #23, and #462) of four residents reviewed for care plans. The facility failed to accurately document code status on the care plan which could result in a negative outcome as staff could provide lifesaving measures contradictory to the residents' choice. The facility failed to develop and implement any interventions for the moderate hearing loss for Resident #45. The facility failed to update the care plan to include elopement interventions for one (Residents #462) who had attempted to elope from the facility as documented in the progress notes. The findings are: On 07/29/24 at 8:45 AM, attempted to interview resident and found the resident to be non-interview able due to her cognitive state and hearing deficit. During an interview with Advanced Practice Nurse (APRN) #30, she confirmed resident #45 had a moderate hearing deficit. When asked if there was a hearing deficit, MDS nurse #19 stated, I…

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, record review and interview, the facility failed to ensure necessary foot/toenail treatment and care was provided to keep toenails trimmed and dry and to prevent flaky skin to decrease the potential for foot complications for 1 (Resident #22) of 1 sampled resident who were dependent on staff for foot/toenail care. The findings are: 1. Review of a facility policy titled Foot Care, dated 2001, indicated that Residents will receive appropriate care and treatment in order to maintain mobility and foot health. A review of an admission Record indicated Resident # 22 was admitted on [DATE] with a diagnosis of Acute and Chronic Respiratory Failure and Chronic Obstructive Pulmonary Disease with exacerbation and Type 2 Diabetes Mellitus with foot ulcer. The annual Minimum Data Set (MDS) with an assessment Reference Date (ARD) of 11/10/2023 revealed Resident # 22 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated Resident #22 was moderately impaired. Review of Resident #22's…

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, record review, and interview the facility failed to ensure that Registered Dietitian recommendations were following in a timely manner for an enteral bolus feeding for one (Resident #28) of one sampled resident. The findings are: On 7/30/2024 the Director of Nursing (DON) was asked if the facility had a policy for following Registered Dietitian recommendations. The DON provided a document titled UDA-RD Recommendations. Review of an admission Record indicated the facility admitted Resident #28 with diagnosis of post traumatic seizures and traumatic brain injury on 2/11/2020. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/2020 revealed Resident #28 had a Brief Interview for Mental Status (BIMS) of 7, which indicated the resident had severe cognitive impairment. Review of #28 Care Plan initiated 2/25/2020 revealed the resident was at risk for nutritional problems or potential for nutritional problems related to diagnosis. The interventions included Registered Dietitian (RD) to evaluate quarterly and as needed (PRN). Monitor…

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 facility policy review, it was determined the facility failed to ensure enteral water flush was administered per physicians' orders for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube during medication administration based on professional standards of care for 1 (Resident #28) of 1 sample mix resident. The findings are: 1. Review of Resident #28's admission Record dated 02/11/2020 revealed diagnoses of dysphagia and gastrostomy status. a. Review of Resident #28's Physician orders dated 01/23/2023 documented, Enteral feed order every shift Enteral Water Flush; with 60 (cubic centimeter) cc water before and after meds and feedings. Enteral feed order four times a day 300 milliliters (mL) enteral water flush four times per day (QID). b. On 07/31/24 at 8:53 AM, the Surveyor observed Resident #28 and Assistant Director of Nursing (ADON) #16 during medication pass. Resident #28 received a total of 330 milliliters (mL) water flush. Resident 28 received 40 mL water flush prior to medication administration through PEG tube,…

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 interview, record review, and facility policy review, it was determined the facility's Quality Assurance Performance Improvement Program (QAPI) failed to maintain records of their program that developed and implemented effective improvement plans to correct identified areas of concern. The facility failed to ensure the facility was able to provide its QAPI plan to the State surveyors during recertification survey or upon request. On 8/2/24 10:30 AM, Administrator states he is unable to provide records of the QA (Quality Assurance) committee meetings when requested. The administrator states, We can't find them, I've been here a week, and I don't have them.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and facility policy review, it was determined the facility failed to knock on doors prior to entering resident rooms for 4 resident rooms (Rooms 609, 610, 612, and 613) viewed for protecting and valuing the resident's private space. Findings include: A review of a facility policy titled, Resident Rights, revised December 2016 indicated per policy statement, Employees shall treat all residents with kindness, respect, and dignity. A. a dignified existence; b. be treated with respect, kindness, and dignity; and t. privacy and confidentiality. During an observation on 07/02/2024 at 6:43 AM, Certified Nursing Assistant (CNA) #4 entered room [ROOM NUMBER] without knocking on the resident's door and walked into the room, donned gloves and turned on the overhead light. CNA #4 turned back the covers on the resident without explaining what she was about to do, after checking the resident, covered the resident, took off gloves and walked out of the room without sanitizing her hands. During…

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 observations, interviews, record review, and facility document review, the facility failed to ensure licensed nurses have the knowledge, competencies, and skill sets to provide care and respond to each resident's individualized needs as identified in resident assessment, care plans, and physician orders for 2 (Resident #6 and Resident #7) of 2 residents reviewed for assessments, care plans, and competent staff. Specifically, the facility: 1. Failed to ensure Minimum Data Set (MDS)was completed in accordance with guidelines set forth in the Resident Assessment Instrument for Resident #6. 2. Failed to ensure that care plans were revised and updated according to the resident's current physician orders, assessments, and resident's current individualized needs for Resident #6 and Resident #7. 3. Failed to ensure that Medicare Manager, Long Term Care MDS Nurse and Treatment nurse were skilled and knowledgeable in their job responsibilities with care planning for Resident #6 and Resident #7. 4. Failure to update physician orders when changes were needed and 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 observation interview and record review, the facility failed to ensure infection prevention and control practices were implemented to prevent the development of communicable diseases and infections as evidenced by failure to perform hand hygiene between residents, during perineal care and wound care to prevent cross contamination. The findings are: During an observation on 07/02/2024 at 6:43 AM, Certified Nursing Assistant (CNA) #4 entered room [ROOM NUMBER], donned gloves, and turned on the overhead light. CNA #4 turned back the covers on the resident without explaining what was about to occur. After checking the resident, CNA #4 covered the resident, took off gloves and walked out of the room without sanitizing hands. During an observation on 07/02/2024 at 6:47 AM, CNA #4 and CNA #5 entered room [ROOM NUMBER]. CNA #4 did not sanitize hands before applying new gloves. An explanation was given to the resident prior to uncovering resident to check their brief. During an observation on 07/02/2024 at 6:50…

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, record review, and interview the facility failed to ensure a comfortable, sanitary, clean, and homelike environment was provided in facility hallways and in room [ROOM NUMBER]. The findings are: On 07/01/2024 at 10:01 AM, surveyor observed in room [ROOM NUMBER], the right wall near the bathroom has missing paint and drywall in a horizontal line along the length of the wall. The floor near the baseboard is covered in a black substance. Surveyor observed on the right side of the room, the back wall is missing dry wall in three vertical lines and several white dots are scattered on the wall. Near the light above the entrance, the ceiling is cracked and bubbled. On 07/01/2024 at 10:43 AM, the surveyor observed an open bag sitting in a chair against the wall by room [ROOM NUMBER]. On 07/01/2024 at 10:44 AM, the surveyor observed a large pink cup with a lid and a straw setting on the handrail by room [ROOM NUMBER], and a small clear cup, empty with a fork inside, setting on the handrail by room…

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 and record review, the facility failed to ensure incontinent care was provided is a safe manner to prevent a resident from sliding out of the bed resulting in the resident receiving a fracture of the femur for 1 (Resident #2) of 1 sampled resident. The findings are: Resident #2 was admitted to facility on 4/18/22 with diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. A Care Plan initiated on 4/18/22 documented, .The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t [related to] left sided paralysis, hx [history] of polio .The resident is at risk for falls. Resident had fall with major injury on 11/14/2023 . On 11/14/23 at 5:10 am, the Incident and Accident report documented, cnas (Certified Nursing Assistants) were turning resident and she rolled out of bed. she did not hit her head and complained of left knee and hip pain. x-rays ordered. Immediate Intervention: educated cnas on resident safety when changing residents and rolling them side to side while in 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 record review the facility failed to provide appropriate care to include, completing admission assessment, completing initial body audit and failed to ensure treatment and services were in place to prevent pressure ulcers for 1 resident. R#1. The findings are: The facility did not complete an admission assessment on the resident admitted to the facility on [DATE]. Per the resident's record, there was no admission assessment or skin audit completed on the day of admission. The first skin audit completed for Resident #1 was on 10/2/23 per the resident's record review. The 9/21/23 admission Minimum Data Set (MDS) did not document any skin conditions upon admission. The current plan of care was revised on 10/26/23 to reflect DTI (Deep Tissue Injury) to right heel. Wound care orders were implemented on 10/5/23 according to record review of the physician orders for the DTI on the right heel for Resident #1. An interview was conducted with Resident #1 on 10/26/23 at approximately…

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 observations, interview, and record review, the facility failed to ensure the call light was answered in a timely manner for 1 (Resident #5) and fingers were clean and trimmed for 4 (Residents #6, #7, #8 and #9) of 16 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) sampled residents who required assistance with activities of daily living. The findings are: 1. Resident #5: a. On 10/02/23 at 12:28 PM, Resident #5 was lying in bed. The Surveyor the care she was receiving. Resident #5 replied, They are a little slow. Sometimes it takes a while to get my medications to me and give me a bath, but they are shorthanded, so I try to work with them. The Surveyor asked if she had to wait a long time when she uses the call light. Resident #5 responded, A lot of the time. The Surveyor asked if she had ever urinated or soiled herself while waiting on assistance. Resident #5 responded, I've wet myself a couple of times while waiting for help. b. A Care Plan with an initiated date of 05/15/23 noted Resident #5 required assistance of 1 staff for…

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 interview and record review, the facility failed to ensure sufficient nursing staff were available to meet the needs of residents who required assistance with activities of daily living. This failed practice had the potential to affect all 111 residents who resided in the facility. The findings included: 1. During an interview on 09/12/23 at 11:38 AM, Certified Nursing Assistant (CNA) #2 confirmed Resident #57 is scheduled for showers on Mondays and Thursdays, and confirmed they were not charted for yesterday or today and could not identify when the last bath or shower was documented. CNA #2 said the CNAs are overwhelmed and it's hard to chart on so many people, and further stated it is usually just one CNA on the hall. CNA #2 said the staff struggles to get everyone showered and changed. CNA #2 said Resident #57 probably got a bath on 9/7/23. 2. During an interview on 09/12/23 at 3:10 PM, Licensed Practical Nurse (LPN) #1 said the nurses and CNAs work 12-hour shifts. LPN #1 said there is usually only one CNA per hall on the day shift and the night shift has 2 CNAs per…

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 and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practice had the potential to affect 109 residents who received meals from the kitchen, (total census: 111), as documented on a list provided by Dietary Supervisor #1 on 09/13/23 at 11:55 PM. The findings are: 1. On 09/12/23 at 12:08 PM, Dietary Employee (DE) #1 opened the door to the Storage Room and went in. DE #1 unzipped a bag that contained slices of cheese, without washing her hands, she removed slices of cheese from the bag and bagged them individually to be served to the residents for snack. 2. On 09/12/23 at 12:10 PM, DE #2 removed serving spoons from the drawer and placed them on the steam table. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents for the lunch meal. 3. On 09/12/23 at 12:14 PM DE #2 picked up a pot that…

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 record review, the facility failed to ensure resident rooms were maintained in a clean and homelike manner for 6 (Rooms 401, 408, 413, 508, 601 and 610) of 41 (Rooms 401, 402, 403, 404, 405, 406, 407, 408, 409, 410, 411, 412, 413, 414, 415, 416, 501, 502, 503, 504, 505, 506, 507, 508, 509, 601, 602, 603, 604, 605, 606, 607, 608, 609, 610, 611, 612, 613, 614, 615 and 616) resident rooms on the 400 Hall, 500 Hall and 600 Hall. The findings are: On 09/11/23 at 2:40 PM, the floor in Resident room [ROOM NUMBER] contained dirt and debris. The area around the oxygen concentrator contained food particles of a variety of colors, shapes, and sizes. The floor under the trash can and the bedside table was littered with dirt and food particles. Across the floor and under an accent table were large pieces of dirt, lint, and dead insects, extending up to the corner of the wall. On 09/13/23 at 9:30 AM, the floor in Resident room [ROOM NUMBER] contained the same areas of dirt and debris that…

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 record review and interview, the facility failed to ensure quarterly resident assessments were completed no later than the Assessment Reference Date (ARD) plus 14 calendar days and were submitted within 14 days after completion to meet the requirements for the Centers for Medicare & Medicaid Services for 4 (Residents #66, #84, #67 and #90) of 4 sampled residents whose Quarterly Assessments were reviewed. The findings are: 1. Resident #66's Quarterly Minimum Data Set (MDS) with an ARD of 08/09/23 had a completion date of 09/12/23. 2. Resident #84's Quarterly MDS with an ARD of 08/02/23 had a completion date of 09/13/23. 3. Resident #67's Quarterly MDS with an ARD of 08/05/23 had a completion date of 09/13/23. 4. Resident #90's Quarterly MDS with an ARD of 08/02/23 had a completion date 09/13/23. 5. On 09/15/23 at 2:25 PM, the Surveyor asked the MDS Coordinator how long from the assessment reference date do you have to submit an update. The MDS Coordinator stated, Two weeks. The Surveyor asked what guidelines were followed in relation to submitting. The MDS Coordinator…

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, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance and at temperatures that were acceptable to the residents during 1 of 1 meal observed. This failed practice had the potential to affect 10 residents who received meal trays in their rooms on the 100 Hall, 10 residents who received meal trays on the 200 Hall, 14 residents who received meal trays in their room on the 300 Hall, 24 residents who received meal trays in their room on 400 Hall, 13 residents who received meal trays in their room on the 500 hall, 24 residents who received meal trays in their room on the 600 Hall, and 11 residents who received meal trays in their room on the 700 hall as documented on a list provided by Dietary Supervisor #1 on 09/13/23 at 9:36 AM. The findings are: 1. On 09/11/23 at 1:30 PM, the Surveyor asked Resident #94 if the hot food stays hot and the cold food is cold. Resident #94 stated, The Food here is always cold. Lunch arrived while the Surveyor was in the room. Resident #94 did not eat the mixed vegetables.…

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 interview and record review, the facility failed to ensure residents with a trust account had access to their personal funds after business hours and on weekends for 2 (Residents #32 and #73) of 2 (Residents #32, #73,) sampled residents. The findings are: On 09/12/23 at 8:58 AM, the Surveyor asked Resident #32 who handled his money. Resident #32 indicated that his money is handled by the facility. The Surveyor asked if he was able to get his money on the weekends. Resident #32 said he was unable to retrieve personal funds on the weekends. On 09/14/23 at 1:00 PM, during the Residential Council Meeting, the Surveyor asked Resident #73 who handled his money. Resident #73 indicated that his money is handled by the facility. The Surveyor asked if he was able to get his money on the weekends. Resident #73 said, There is usually a nurse that has some that she will let me have till Monday. On 09/14/23 at 3:05 PM, the Surveyor asked the Business Office Manager if the residents have access to their money on weekends. The Business Office Manager stated, We just got approved, where we…

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, and record review, the facility failed to ensure Activities of daily living (ADL) care was provided for 4 (Residents #26, #59, #75 and #81) of 13 (Residents #4, #14, #26, #37, #48, #49, #59, #73, #75, #81, #83, #94 and #307) sampled residents who were dependent or required assistance with ADL care. The findings are: 1. Resident #81: a. On 09/11/23 at 12:03 PM, Resident #81's fingernails were jagged and extended ¼ inch past the tips of the fingers. b. On 09/12/23 at 2:38 PM, Resident #81's fingernails had uneven, jagged edges and extended ¼ inch past the tips of the fingers. c. On 09/12/23 at 9:20 AM, Resident #81's fingernails had uneven, jagged edges and extended ¼ inch past the tips of the fingers. d. On 09/14/2023 at 09:30 AM, Resident #81's fingernails had uneven, jagged edges and extended ¼ inch past the tips of the fingers. e. On 09/14/23 at 9:45 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1, How often is nailcare performed? CNA #1 replied, There is a list on specific days and nailcare is completed on shower days. f. On 09/14/23…

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 and record review, the facility failed to ensure a medication administered by a family member was ordered by the attending physician for 1 (Resident #357) of 1 sampled resident. The findings are: On 09/13/23 at 11:42 AM, Resident #357's family member was at the Nurses Station requesting to give resident a medication brought from home. Licensed Practical Nurse (LPN) #6 authorized the family member to give the ophthalmic solution to the resident stated, Just don't leave it in the room. During an interview on 09/13/23 at 12:00 PM, LPN #6, said the resident had an order for artificial tears, which had not been given, and said it is not a regular practice to allow families to bring medications in from home. A review of Resident #357 physician orders failed to reveal an order for artificial tears. During an interview on 09/13/23 at 12:06 PM, the Director of The DON confirmed Resident #357 did not have an order for artificial tears.

Based on observations, record review, and interview, the facility failed to ensure medications were not left unattended in resident rooms for 2 (Resident #14, #48) of 2 sampled residents. The findings are: 1. On 09/11/23 at 11:06 AM, observed a bottle of prescription nasal spray for allergies on Resident #14's bedside table. No staff were noted in the area. b. On 09/12/23 at 9:00 AM, Resident #14 revealed the nurses leave her medications on her bedside table when she is in the bathroom. The Surveyor asked if her allergy nasal spray was left for her on 09/11/23. Resident #14 replied, They left it for me when I was in the restroom because they knew they can trust me to do it. c. During an interview on 09/13/23 at 9:30 AM, Registered Nurse (RN) #1, said Resident #14 can administer allergy nasal spray with the nurse present and confirmed the medication should not be left at the bedside. RN #1 further said she might have accidentally left the allergy nasal spray in Resident #14's room. 2. On 09/11/23 at 11:04 AM, Resident #48 had an opened bottle of Artificial Tears and an opened bottle…

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, and record review, the facility failed to administer Oxygen at the Physician ordered flow rate for 1 (Residents #57) and failed to ensure the nebulizer mouthpiece was stored in a bag for 1 (Resident #48) of 14 (Residents #4, #32, #33, #41, #42, #48, #49, #52, #57, #59, #75, #81, #90 and #357) sampled residents who received respiratory therapy. The findings are: 1. On 09/11/23 at 2:58 PM, Resident #57 was lying in bed with oxygen at 2.5 liters per minute via nasal canula. a. On 09/12/23 at 9:25 AM, Resident #57 was lying in bed with oxygen at 2.5 liters per minute via nasal canula. b. On 09/12/23 at 2:30 PM, Resident #57 was sitting on the side of bed visiting with family with oxygen at 2.5 liters per minute via nasal cannula. c. On 09/13/23 at 8:10 AM, Resident #57 was lying in bed with oxygen at 2.5 liters per minute via nasal cannula. d. Review of the Order List Report for oxygen therapy showed Resident #57 had a Physicians Order, with a revision date of 10/25/22 to receive oxygen at 3 liters per minute by nasal cannula. f. Review of Resident #57's…

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 and interview, the facility failed to ensure opened vials of insulin were dated, medication carts were locked, and medications were not left on top of the medication carts when out of the line of the nurse's sight. The findings included: 1. On 09/13/23 at 11:00 AM, observed on the 600 Hall Medication Cart an opened vial of Insulin with a resident's name. There was no open or use by date written on the vial. a. During an interview on 09/15/23 at 8:50 AM, LPN #5 confirmed the insulin should be dated when opened and is typically good for 28 to 30 days. b. During an interview on 09/15/23 at 8:55 AM, the Director of Nursing (DON), confirmed the insulin vials should be dated when opened and are good for 28-30 days. c. An Insert for the opened insulin provided by the Administrator on 09/15/23 at 11:50 AM indicated the Insulin was to be used within 42 days after opened. 2. On 09/13/23 at 11:07 AM, observed Registered Nurse (RN) #1 leave a bottle of allergy nasal spray on the medication cart, then enter Resident #408's room and shut the door. At 11:08 AM, RN #1 opened…

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 record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with maintaining a clean, comfortable homelike environment, with distributing and serving food in a sanitary manner, preventing accidents and hazards, and providing respiratory care. These failed practices had the potential to affect all 111 residents who resided in the facility. The findings are: 1. A Recertification survey was conducted on 07/01/22. During the survey, the team identified concerns with housekeeping, providing fingernail care to dependent residents, preventing accidents and hazards, providing respiratory care, and preparing and serving food in a sanitary manner. a. A review of the facility's Plan of Correction for maintaining a homelike environment, with a completion date of 08/01/22 included: a. Housekeeping/Laundry Supervisor ensured all other bed linens in the facility were free and clean from stains and in acceptable condition for use on 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 observations, interview and record review, the facility failed to ensure staff changed gloves and washed hands during wound care for 1 (Resident #307), failed to maintain a bath table free of cracks, staff failed to perfume hand hygiene during medication administration, and laundry staff used Personal Protective Equipment (PPE) and clean technique when providing laundry services. These failed practices have the potential to affect 31 residents who received wound care, 24 residents who used the bath table, and all 111 residents who resided in the facility. The findings are: The following observations were made on 09/13/2023. a. At 9:55 AM, the Surveyor observed wound care performed for Resident #307. LPN #2 removed the old dressing and placed it in a red bag. She then handled the cotton tipped applicator with ungloved hands, laid the applicator back on the table, and left the room without washing or sanitizing her hands to get more gloves from the wound cart in the hallway. LPN #2 returned to Resident #307's room and did not sanitize or wash her hands. She placed extra…

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.