Premier At The Springs

Based on record review and interviews the facility failed to accurately assess the comprehensive assessment for 2 (Resident #52, #90) sampled residents. The findings are: 1. Resident 52 had a diagnosis of bi-polar, depression, and anxiety disorder. a. A Significant Change Minimum Data Set with the Assessment Referenced Date of 08/24/23 documented that Resident #52 scored 03 (indicating severe cognitive impairment) on the Brief Interview of Mental Status (BIMS), and Resident was not currently considered by the state level II Pre-admission Screening and Resident Review (PASRR) process to have serious mental illness and/or intellectual disability or a related condition. b. A Care Plan for Resident #52, with the revision date of 06/19/2023, documented Resident had mood problem related to (r/t) bipolar disorder. c. On 05/08/24 at 08:15 AM, the Minimum Data Set (MDS) Coordinator was not aware that Resident 52 was considered by the state as PASSAR level II. MDS Coordinator voiced that the electronic records did not reflect that information. 2. Resident #90 had a diagnosis of depression,…

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 and record review, the facility failed to ensure 1 Resident #104 of 3 (Resident #54, #91, and #104) sampled residents reviewed for Activities of Daily Living (AD)s nails were clean and that they received a shave. The findings are: Resident #104 had diagnosis of Pressure Ulcer Sacral Region Stage 4. The Medicare-5 Day Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 4/08/24 documented resident scored 04 (00-07 indicates severe impairment) on a Brief Interview for Mental Status (BIMs) and required substantial/maximal assistance with bathing. A review of a facility policy titled, Shaving the Resident, dated 05/08/2024, indicated, The purpose of this procedure is to promote cleanliness and to provide skin care. A review of a facility policy titled, Fingernails/Toenails, Care of, dated 05/08/2024, indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . A care initiated 3/08/24 documented, .Check nail length and trim and clean as necessary . On 5/05/24 at 11:45 AM, Resident…

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 hydration was available at all times for 1(Resident #69) of 2 (Resident #69 and Resident #214) sampled residents reviewed for hydration. The findings are: A review of the Physician Order indicated Resident #69 had a diagnosis of constipation. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/24 revealed Resident #69 had a Brief Interview of Mental Status (BIMS) of 15 (13-15 indicates cognitively intact). A review of Resident #69's care plan initiated on 10/02/21 documented, .Encourage and assist with fluid intake to promote hydration . On 5/05/24 at 11:58 AM Resident #69 asked the surveyor to get some water. The surveyor asked, How long have you been out of water? Resident stated, I haven't had any all day. The surveyor asked, How often are you out of water? Resident stated, Mostly on weekends. On 5/05/24 at 12:30 PM, Resident #69 doesn't have any water available. On 5/05/24 at 1:40 PM Certified Nurse Aide #11 was asked, Can you tell me why Resident #69 doesn't have any water…

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 provide a clean oxygen tubing to 1 Resident #97 of 2 (Resident #32 and #97) sampled residents on oxygen therapy, and the facility failed to ensure oxygen tubing was placed in a storage bag for 1 Resident #32 of 2 (Resident #32, and Resident #97) sampled residents on oxygen. The findings are: 1. On 5/05/2024 at 9:02 AM, surveyor entered Resident #32's room to find oxygen tubing lying on the floor. a. On 5/07/2024 at 8:54 AM, surveyor asked Certified Nursing Assistant (CNA) #1 what should a staff person do when a resident's oxygen tubing is found lying in the floor? CNA #1 said go get the nurse. b. On 5/08/2024 at 10:40 AM, surveyor asked Director of Nursing (DON) what should a staff person do when they find oxygen tubing lying on the floor? DON said the tubing would need to be immediately replaced. c. Oxygen administration policy and services were provided by DON. 2. Resident #97 had diagnosis of Moderate Persistent Asthma. The 5-Day Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 5/03/24 documented 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 ensure bed rails were not used for 1 Resident #104 of 2 (Resident #90 and Resident #104) sampled residents reviewed for accidents without a side rail assessment to prevent the potential for accidents. The findings are: Resident #104 had a diagnosis of Pressure Ulcer Sacral Region Stage 4. The Medicare-5 Day Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 4/08/24 did not indicate that Resident #104 used side rails. A review of a side rail assessment dated [DATE], indicated Resident #104 did not use bed rails. On 5/05/24 at 11:45 AM, Resident #104 indicated he needed to be repositioned in bed. His bed rails were up x 2. On 5/05/24 at 11:48 AM, Certified Nurse Aide (CNA) #11 was asked, How long has Resident #104 used side rails? She stated, He's had them since he's been here. On 5/06/24 at 8:54 AM, Resident #104 was in bed. His side rails were up x 2. On 5/07/24 at 3:14 PM, Resident #104 was in bed. His side rails were up x…

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 a dose reduction was implemented for 1 (Resident #82) of 5 (Resident #10, #30, #37, 79, and #82) sampled residents reviewed for unnecessary medication administration. The findings are: A review of a Physician Order, indicated Resident #82 had a diagnosis of Major Depressive Disorder. A Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 5/28/24 documented the Resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMs). A review of a care plan initiated 9/26/22 documented, .Administer antidepressant medications as ordered by physicians . A review of Pharmacy Medication Regimen Review, dated 3/14/24 documented, .Please consider a gradual dose reduction or tapering the dose of this medication in an effort to determine optimal dose or if it may be unnecessary for this resident . It revealed Resident #82 original start date for Sertraline 125 milligrams was on 6/15/2023. The physician recommended reducing the Sertraline to 100 milligrams daily effective…

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 menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 27 residents who had mechanical soft diets. 7 residents received pureed diet from 1 of 1 kitchen. The findings are: 1. The menu for lunch documented the residents on mechanical soft diets and pureed diets were to receive ¾ cup of pork chili Verde. 2. On 05/07/24 at 11:31 AM, Dietary Employee (DE) #1 used a 6-ounce spoon to place 8 servings of boiled seasoned pork cubes into a blender, ground and poured into a pan. 3. On 05/07/24 at 12:10 PM, the following observations were made on the steam table. a. A 4- Ounce spoon was (1/2) cup was in a pan of ground meat. b. A #8 scoop was in a pan of pureed pork chili Verde. c. On 05/08/24 at 10:57 AM, the surveyor asked the Dietary Supervisor if they ran out of mechanical soft meat when serving lunch meal. She stated, Yes, we did. I did extra 4 more servings. d. On 05/08/24…

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 an effective pest control program was maintained to keep the facility free of pests. The findings are: On 05/07/2410:50 AM, the following observations were made in the kitchen areas during the noon meal preparation and meal serving. a. There were 2 flies at the edges of a cart by the food preparation sink that contained clean scoops. b. One fly was on the wall leading to the dishwashing machine. c. Two flies were on the wall by the plate warmer. d. Two flies were flying around the food preparation area. On 05/07/24 11: 26 AM, there were 4 flies on the corners of a clean dish rack where clean scoops were kept. There was a fly on top of a box of iodized salt. On 05/07/24 11:53 AM, there were 3 flies on the window by the food preparation counter. One was on the menu, one on top of the microwave and one on the right side of the 2-door refrigerator. The surveyor asked the Dietary Supervisor to count the flies that were not moving. She did so and stated, I counted 10 flies, excluding the ones flying. 05/08/24…

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 complete a Self-administration safety screen for 1 (Resident #27) sampled resident to ensure that the resident could safely administer medication, there were no drug interactions between prescribed medication and medication at the bedside, Resident did not over/under dose, and/or the medications did not have a negative effect on any medical illness the Resident ise currently was diagnosed with. The findings are: Resident #27 had a diagnosis the following diagnosis: (Primary) Hypertension and Chronic Kidney disease, stage 4 (severe), old Myocardial Infarction (heart attack), Chronic Obstructive Pulmonary Disease (condition that affects breathing), and Atrial Fibrillation (condition that affects the heart), Benign Prostatic Hyperplasia with lower Urinary Tract symptoms. The Physician's orders did not document any of the over the counter (OTC) medications found in the Resident's room. A Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 04/18/24 documented that Resident #27 scored 11…

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 Care Plan for 1 (Resident #9) sampled resident was revised to reflect that the resident had an indwelling catheter. The findings are: According to list of diagnosis in the electronic records Resident #9 had a diagnosis of Personal history of urinary tract infection, overactive bladder, retention of urine, and acute cystitis. According to the Physician's order in the electronic records there was an order for an indwelling urinary catheter 16 French (FR) with 10 Cubic Centimeter (CC) balloon. According to Significant Change Minimum Data Set (MDS) with the Assessment Reference Date of 4/15/24 Resident 9 scored 07 (indicates severely impaired cognition) on the Brief Interview of Mental Status (BIMS), and that the Resident had an indwelling catheter, and always incontinent of bowel. A Care Plan, with the revision date 4/30/24, documented that Resident has an indwelling urinary Catheter 16 French/10 Cubic Centimeter (cc) for urinary incontinence. There were 2 interventions in place (catheterize 4x a day…

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 proper incontinence care was provided to 1 (Resident #9) sampled resident with an indwelling urinary catheter and the catheter was placed in a manner to prevent possible dislodging and/or trauma to the resident. This failed practice had the potential to affect 2 (Resident #9, #13) sample of 4 Residents on 300 hall with indwelling catheters. The findings are: According to a list of diagnosis in the electronic records Resident #9 had a diagnosis of personal history of urinary tract infection, overactive bladder, retention of urine, and acute cystitis. According to the Physician's order in the electronic records, there was an order for indwelling urinary catheter 16 French (FR) with 10 Cubic Centimeter (CC) balloon. According to Significant Change Minimum Data Set (MDS) with the Assessment Reference Date of 4/15/24 Resident #9 scored 07 (indicates severely impaired cognition) on the Brief Interview of Mental Status (BIMS), and the Resident had an indwelling urinary catheter, and always incontinent of…

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 call light was within reach for 4 (Resident #19, #32, #45, and #82) of 5 (Resident #32, #45, #82, #17, and #19) sampled residents reviewed for call lights. The findings are: On 5/05/2024 at 9:30 AM, during initial rounds, surveyor observed Resident #19 did not have a call light within reach. On 5/05/2024 at 1:26 PM, surveyor observed Resident #32 did not have a call light within reach. The call light was on the floor near the foot of the bed. On 5/06/2024 at 8:33 AM, surveyor observed Resident #19 did not have a call light within reached. On 5/08/2024 at 8:08 AM, surveyor asked CNA #2 what is important to do before exiting the resident's room. CNA said to make sure the residents have their call light. On 5/08/2024 at 8:30 AM, surveyor asked CNA #3 what is one of the last things a person needs to do before leaving a resident's room. CNA said to make sure residents have their call light. On 5/08/2024 at 8:34 AM, surveyor asked CNA #4 what is one of the most important things to do when exiting a…

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 food items stored in the refrigerator/freezer were covered, sealed and dated; ceiling vents and lights were maintained in clean, sanitary conditions for food preparation and to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed/discarded by the expiration or use by dates; foods were dated when received to ensure first in, first out usage to prevent potential for food bone illness; leftover foods were used to maintain food quality; 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; and failed to ensure 2 of 3 ice machine scoop holders were maintained in a clean and sanitary condition to prevent potential contamination of the residents' beverages and ice from the ice machines on the 200 Hall and 300 Hall. The failed practices had the potential to affect 39 residents who received ice from the ice machine on the 200 Hall,…

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 the call light was placed within reach to ensure the resident could call for assistance when needed for 1 (Resident #68) of 21 (Residents #6, #17, #24, #31, #40, #43, #45, #50, #53, #68, #72, #73, #77, #79, #83, #84, #88, #94, #97, #104 #518) sampled residents who were able to use the call light to call for staff assistance. This failed practice had the potential to affect 48 residents who were able to use the call light as documented on a list provided by the Administrator on 03/02/23. The findings are: 1. Resident #68 had diagnoses of Quadriplegia, C (cervical) 1-C4 Incomplete and Contracture of Muscle, Multiple Sites. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (MRD) of 01/04/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS) and was totally dependent on two plus persons physical assistance for bed mobility, transfer, and toilet use, dressing and personal hygiene and required extensive physical assistance…

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 complete a Significant Change Minimum Data Set (MDS) within 14 days of the identification of a decline in two or more activities of daily living for 2 (Residents #45 and #49) of 27 (Residents #12, #17, #22, #26, #27, #31, #45, #49, #50, #53, #56, #59, #72, #73, #77, #80, #83, #88, #94, #95, #97, #104, #116, #118, #268, #271 and #518) sampled residents whose MDSs were reviewed. This failed practice had the potential to affect all 103 residents who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the Administrator on 02/27/23 at 1:15PM. The findings are: 1. Resident #45 had a diagnosis of Cellulitis of Right Upper Limb and End Stage Renal Disease. The Medicare 5-Day MDS with an Assessment Reference Date (ARD) of 01/27/23 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required supervision of one person ' s physical assistance with bed mobility and toilet use and supervision…

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 a Preadmission Screening and Resident Review (PASRR) was completed prior to admission to ensure the resident received the needed care and services in the most appropriate setting for 2 (Residents #12 and #26) of 14 (Residents #2, #5, #12, #26, #27, #31, #45, #49, #50, #64, #72, #77, #97 and #104) sampled residents who had a diagnosis of mental illness. The findings are: 1. Resident #12 had diagnoses of Bipolar Disorder, Unspecified and Depression, Unspecified. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/23 documented the resident scored 8 (8-12 indicates moderately cognitively impaired) on Brief Interview for Mental Status (BIMS) and received an antipsychotic medication 7 days of the 7 day look back period. a. The Physicians Orders documented, .Duloxetine HCI [Hydrochloride] capsule delayed release particles 30 mg Give one capsule by mouth one time a day for depression . Order Date 10/13/22 . Rexulti tablet 2 mg[milligrams] (Brexpiprazole) Give one tablet by mouth one time…

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 the Care Plan for residents who had a decline in activities of daily living (ADL) was reviewed and revised for 2 (Residents #45 and #49) of 27 (Residents #12, #17, #22, #26, #27, #31, #45, #49, #50, #53, #56, #59, #72, #73, #77, #80, #83, #88, #94, #95, #97, #104, #116, #118, #268, #271 and #518) sampled residents whose Care Plans were reviewed. This failed practice had the potential to affect all 103 residents who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the Administrator on 02/27/23 at 1:15 PM. The findings are: 1. Resident #45 had diagnoses of Cellulitis of Right Upper Limb and End Stage Renal Disease. The Medicare 5-Day MDS with an Assessment Reference Date (ARD) of 01/27/23 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required supervision of one person's physical assistance with bed mobility…

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 the transparent semipermeable membrane dressing on a Peripherally Inserted Central Catheter (PICC) line was changed according to professional standards of practice for 1 (Resident #271) of 2 (Residents #26 and #271) sampled residents who had Physician Orders for a PICC line as documented on a list provided by the Administrator on 02/28/23 at 3:59 p.m. The findings are: 1. Resident #271 had diagnoses of Cerebral Infarction, Unspecified, Sepsis and Acute on Chronic Systolic Heart Failure. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/23 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and received 1 injection and 7 days of antibiotics during the 7 day lookback period. a. The Physician Orders dated 02/15/23 documented, .CHANGE MIDLINE DRESSING TO RIGHT ARM Q [every] WEEK ON THURSDAY . b. On 02/27/23 at 10:45 AM, Resident #271 was lying in bed with a PICC line in his right upper arm. 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 of the 8:00 AM medication pass on 02/28/23, interview, and record review, the facility failed to ensure a medication error rate of less than 5% was maintained to prevent potential complications for 1 (Resident #5) of 3 residents observed during the 8:00 AM medication pass. The medication error rate was 7.41% based on observation of 27 medications, and a total of 2 errors detected. This failed practice had the potential to affect 103 residents in the facility as documented on the Resident Census and Conditions of Residents provided by the Administrator on 02/27/23 at 1:15 PM. The findings are: 1. Resident #5 had a diagnosis of Vitamin Deficiency, Unspecified. a. The Physician Orders documented, .Cetirizine HCl [hydrochloride] Tablet 10 MG [milligrams] Give 1 tablet by mouth one time a day for allergies . Order Date 01/26/21 . Multivitamin Tablet (Multiple Vitamin) Give 1 tablet by mouth one time a day related to VITAMIN DEFICIENCY, UNSPECIFIED . Order Date 06/02/22 . 2. LPN #5 was observed by two Surveyors as she performed the medication pass on 02/28/23 at 8:15…

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 medications were stored and labeled properly for 2 (Residents #4 and #40) of 20 sampled residents who resided on the 300 Hall. This failed practice had the potential to affect 46 residents who resided on the 300 Hall as documented on a list provided by the Chief Nursing Officer on 03/01/23 at 11:34 AM. The findings are: 1. Resident #4 had a diagnosis of Alzheimer's Disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/14/23 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. On 2/27/23 at 10:40 AM, Resident # 4 was lying in bed with a bed side table next to bed. On the bedside table was a see-through medication cup with 6.5 medications in it. The Surveyor turned on the call light for a licensed nurse. A Certified Nurse Assistant (CNA) answered the call light in 4 minutes 29 seconds. The Surveyor asked the CNA to go get the nurse. Licensed practical Nurse (LPN) #5 came to the door, and 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, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. This failed practice had the potential to affect 65 residents' who received regular diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 02/28/23. The findings are: 1. On 2/27/23, the menu for the lunch meal documented residents who received regular diets, mechanical soft diets and pureed diets were to receive one cup of chicken rice casserole, residents on regular diets and mechanical soft diets were to receive 1/2 cup of broccoli with cheese sauce and residents on pureed diets were to receive 3/8 cup of pureed broccoli with cheese sauce. 2. On 02/27/23 at 11:53 AM, the following observations were made during the lunch meal: a. Dietary Employee (DE) #2 used a #8 scoop (gray scoop), which is equivalent 1/2 cup (4 ounces), to serve a single portion of chicken rice casserole to the residents on regular diets, mechanical soft diets,…

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 pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets, as documented on the Diet List provided by the Dietary Supervisor on 2/27/2023. The findings are: 1. On 2/27/2023 At10:35 AM, Dietary Employee #1 used 6-ounce spoon to place 6 servings of chicken rice casserole into a blender, added 2 cartons of whole milk and pureed. At 10:38 AM She poured the pureed chicken rice casserole into a pan. She covered the pan with saran wrap and placed it in the oven. The consistency of the pureed rice was lumpy and was not smooth. The rice was not completely pureed. 2. On 2/27/23 At 10:55 AM, Dietary Employee #1 placed 6 dinner rolls into a blender, added ¼ cup of thickener, 2 cartons of whole milk and pureed. At 10:57 AM She poured the pureed bread into a pan. She covered the pan with saran wrap and placed it 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.

Based on observation, record review, and interview, the facility failed to ensure a nurse changed contaminated gloves and performed hand hygiene during administration of medication via an enteral tube for 1 (Resident #59) of 3 (Residents #59, #95 and #268) sampled residents who receive medication via an enteral tube as documented on a list provided by the Chief Nursing Officer on 03/01/23 at 11:34 AM. The findings are: 1. Resident #59 had diagnoses of Nontraumatic Intracerebral Hemorrhage, Cerebral Infarction, and Obstructive and Reflux Uropathy. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/22 documented the resident was moderately impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and had a feeding tube while a resident. a. The Care Plan with a revision date of 12/05/22 documented, .I require tube feeding via Gastrostomy tube r/t [related to] Dysphagia . b. The February 2023 Physicians Orders documented, .NPO [nothing by mouth] diet, NPO texture for PEG TUBE . Order Date 06/29/2021 .…

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.