River Ridge Rehabilitation And Care Center

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 1 resident who received a pureed diet. The findings are: 1. On 05/28/2024 at 11:44 AM, Dietary [NAME] (DC) #1 placed two servings of meatloaf into the blender, then used a 4 ounce spoon to add tap water twice and pureed. DC #1 poured the pureed meatloaf into a pan and placed it on the steam the steam. The consistency of the pureed meat loaf was lumpy and was not smooth. At 01:26 PM the surveyor asked the Activity Director to describe the consistency of the pureed meatloaf served to the resident on a puree diet. She stated, It looks chunky. 2. On 05/29/2024 at 12:49 PM, puree cubed steak, served to the resident on a pureed at lunch, contained clumps. The cabbage was not smooth and contained clumps. The surveyor asked the Activity Director to describe the consistency of the pureed food…

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, facility document review, and facility policy review, it was determined the facility failed to perform proper incontinent care for 1 (Resident #9) of 1 resident reviewed for incontinent care. Findings include: A review of the Order Summary Report, indicated the facility admitted Resident #9 with diagnoses that included morbid (severe) obesity due to excess calories, dysuria, urinary tract Infection. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/2024 revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The MDS indicated the resident was substantial/maximal assistance with toileting hygiene. A review of Resident #9's Care Plan, revised 04/19/2024, revealed the resident is at risk for impaired skin integrity r/t (related to) incontinence, impaired mobility, obesity, circulatory issues associated with atherosclerotic heart disease, scoliosis, and DM (diabetes mellitus). Interventions included provide…

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, interviews, and record review, the facility failed to ensure assistance in positioning/repositioning were provided for 1 (Resident #26) of 1 sampled resident who required assistance. Findings include: 1. A review of the Order Summary indicated Resident # 26 had diagnoses of cerebral infarction, retention of urine, and obstructive and reflux uropathy. a. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/15/2024 indicated a Brief Interview for Mental Status (BIMS) score of 9 (8-12 indicated moderately impaired). b. The Care Plan dated 03/24/2024 included, Bed Mobility: Substantial/maximal assistance - Helper does MORE THAN HALF the effort. The helper lifts or holds trunk or limbs and provides more than half the effort. c. On 05/29/2024 at 12:49 PM, a lunch tray was provided for Resident #26. Resident #26 was lying with the head of the bed elevated and was not positioned high enough in the bed to be able to reach the meal tray. The meal tray was on the bedside table to the left side of the resident's bed, not across the bed.…

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 a leg strap was in place to prevent trauma from the indwelling catheter for 1 (Resident #26) of 2 (Resident #26 and #54) sampled residents who were dependent on staff for indwelling catheter care. The findings are: 1. Resident #26 had diagnoses of retention of urine and reflux uropathy. a. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/15/2024 indicated a Brief Interview for Mental Status (BIMS) score of 9 (8-12 indicated moderately impaired) and Resident #26 was admitted with an indwelling catheter. b. A review of the Physician Orders (dated, 05/23/24) revealed Resident #26 had an indwelling catheter, which was inserted through the urethra and left in the bladder to drain urine. c. A review of Resident #26's Care Plan with a revision date of 04/18/2024 revealed .The resident has foley catheter related to DX [diagnosis] of obstructive uropathy .position catheter bag and tubing below the level of the bladder, secure catheter tubing to leg with applicable device. d.…

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.

Through observation, record review, and interview, the facility failed to ensure expired medications were removed and placed into an area for destruction to prevent potential administration to residents. The findings are: 1. On 05/30/2024 at 1:40 PM, the following medicines or equipment were found expired in an area of the medication storage room used to store medications and supplies in active use: a. One hypodermic needle, 22-gauge x 1, expired on 03/31/2022. b. One 16 fluid ounce liquid multivitamin/mineral supplement expired 04/2024. c. 30 syringes - 1 milligram (mg) per 0.5 mL (milliliter) Lorazepam (Ativan) Intensol (benzodiazepines), expired on 05/04/2024. 2. On 05/30/2024 at 1:53 PM, Licensed Practical Nurse (LPN) #9 confirmed the expiration dates and stated neither the hypodermic needle nor the liquid multivitamin/mineral supplement should have been on the shelves. LPN #9 placed the items in the medication discard box. 3. On 05/30/2024 at 1:57 PM, LPN #10 confirmed the expiration date and the number of expired unused benzodiazepine oral syringes. LPN #9 and LPN #10 gave 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, interviews, record review, facility document review, and facility policy review, the facility failed to perform hand hygiene during resident care to prevent the spread of bacteria for 1 (Resident #9) of 1 resident reviewed for incontinent care. Findings include: A review of the Order Summary Report, indicated Resident #9 had diagnoses that included morbid (severe) obesity due to excess calories, dysuria, and urinary tract infection. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/2024 revealed Resident #9 had a Brief Interview of Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The MDS indicated the resident was substantial/maximal assistance with toileting hygiene. A review of Resident #9's Care Plan, revised 04/19/2024, revealed the resident is at risk for impaired skin integrity r/t (related to) incontinence, impaired mobility, obesity, circulatory issues associated with atherosclerotic heart disease, scoliosis, and DM (diabetes mellitus). Interventions included provide…

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, facility document review, and facility policy review, the facility failed to perform wound care treatments as ordered by the physician to prevent worsening of an identified pressure ulcer for 1 (Resident #465) of 1 resident reviewed for pressure ulcers. Findings include: A review of the Order Summary Report indicated Resident #465 had diagnoses that included immunodeficiency, extended spectrum beta lactamase (ESBL) resistance, peripheral vascular disease, pressure ulcer of sacral region, stage 4, local infection of the skin and subcutaneous tissue, unspecified, pain, unspecified, type 2 diabetes mellitus without complications, and elevated white blood cell count. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/16/2024, revealed Resident #465 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact, and had one stage 4 pressure ulcer present at time of assessment (Stage 4…

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 staff sat at eye level while assisting residents with meals for 1 (Resident #1) of 3 case mix residents. The findings are: Resident #1 was admitted to the facility on [DATE] with a diagnosis of Hydrocephalus. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/23 documented Resident #1 was rarely/never understood and required setup or cleanup assistance with eating. A Care Plan with an initiated date of 12/4/23 documented, .[Resident name] has an ADL [activities of daily living] self-care performance deficit due to Confusion, Encephalopathy, Dementia . On 2/29/24 at 1:01 pm, Resident #1 was served a lunch meal tray. On 2/29/24 at 1:02 pm, Licensed Practical Nurse (LPN) #1 began feeding Resident #1 while standing to the left side of the resident. On 2/29/24 at 1:08 pm, the Activity Director walked by LPN #1 and instructed her to sit down. LPN #1 slid a chair next to Resident #1 and sat down to…

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 hands were washed between clean and dirty tasks to prevent cross contamination. The findings are: On 2/29/24 at 12:40 pm, Dietary [NAME] (DC) #1 walked out of the kitchen and sat down at a dining table with one resident. DC #1 began sorting through meal tickets. When the sorting was completed, DC #1 entered the kitchen and went to the serving line and began serving food. DC #1 did not wash hands prior to serving food. On 2/29/24 at 3:05 pm, during an interview, DC #1 confirmed he/she did not wash her hands upon returning to the kitchen and began serving lunch, and should have washed his/her hands to prevent cross contamination. On 2/29/24 at 3:10 pm, during interview, the Dietary Manager confirmed DC #1 did not wash her hands when returning to the meal service food line and began serving food, that there was a potential for cross contamination, and has educated DC #1 on hand washing. On 2/29/24 at 2:44 pm, the Administrator provided a policy titled, Handwashing and Glove Usage in Food service, 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 and interview, the facility failed to ensure that the kitchen vents were cleaned to provide a sanitary environment for food preparation, floors, dish washer and kitchen walls, the door frames and baseboards were free of rotten wood, chipped floor tiles, debris, dirt, grease, rust, stains, wall tiles were replaced, food item stored in the refrigerator were covered or sealed, expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of I kitchen; ice machine and ice scoop holder were maintained in clean and sanitary condition and 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. These failed practices had the potential to affect 54 residents who received meals from the kitchen (total census: 58) as documented on a list provided by the Dietary Supervisor on 05/31/23 at 11:58 AM. The findings are: 1. On 05/30/23 at 10:19 AM, the following observations were made 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 and interview, the facility failed to ensure that alternate dietary choices were made known and available to 4 (Residents #8, #20, #27, #33) of 24 (# 2, #6, #8, #9, #10, #14, #16, #17, #19, #20, #24, #25, #27, #33, #42, #45, #47, #50, #55, #59, #61, #64, #65, #116) sampled residents who relied on the facility to meet their dietary needs. The findings are: a. On 05/30/23 at 12:51 PM, Resident #33 was sitting in her room with her uneaten lunch on the bedside table. The Surveyor asked if she had been offered an alternative if they didn't find the offered meal appetizing. Resident #33 stated, No, they've never offered me anything else. b. On 05/30/23 at 12:55 PM, the Surveyor observed Resident #20 in the hallway and asked if she had a good lunch. She shook their head and stated, I didn't like it. The Surveyor asked if an alternative option had been offered. She stated, No, I wasn't offered anything. I didn't know there was anything different ever available. c. On 05/30/23 at 1:09 PM, the Surveyor observed Resident #8 having only eaten a small portion 10% (percent)…

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 resident funds were refunded promptly after the resident's discharged /expired for 10 (Residents #366, #368, #369, #370, #371, #372, #373, #374, #375, #376) of 10 case mix residents who had been discharged /expired and had a remaining balance in the resident trust fund account at 1 of 1 facility according to the list provided by the Business Office Manager (BOM) on [DATE]. The findings are: a. The admission Packet received on [DATE] from the BOM documented, Beneficiary Designation Form: Be it known to all, that I [space for resident's name], a resident of [Facility's Name], hereby declare and designate that [space for Beneficiary's Name], who lives at [space for Beneficiary's Address], shall receive all monies held in my personal trust account held at said facility, if any, at the time of my death. If the above-named beneficiary predeceases me in death, I declare and designate that [Second Beneficiary's Name] who lives at [Second Beneficiary'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 privacy and confidentiality of resident's personal and medical records was maintained for 1 resident (Resident #249) of 4 sampled residents (#49, #247, #249, and #351) during medication pass by not locking the laptop screen when not in use, and not ensuring confidential information on a notepad such as names, diagnoses, and medications were not visible to passersby. The findings are: a. On 05/31/23 from 9:15-9:17 AM, the Surveyor observed an unattended Medication Cart on Hall C. There were 5 medication blister packs containing Resident #47's Personal Health and Medication Information left out in the open. The Surveyor asked Licensed Practical Nurse (LPN) #1 if it was safe to leave medications out in the open unattended on the Medication Cart. LPN #1 answered, Oh shoot, I didn't even think about it. This is only my third day here and I'm just trying to get everything done on time. b. On 06/02/23 at 1:20 PM, the Surveyor asked the Director of Nursing (DON), Who was responsible for protecting Resident Health Information?…

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 fingernails were trimmed and clean for a resident to maintain good hygiene and prevent complications for 1 (Resident #7) of 14 (#2, #6, #7, #8, #9, #10, #14, #16, #18, #20, #27, #45, #55, #61) sampled residents who require assistance with Activities of Daily Living (ADL's). The findings are: 1. Resident #7 was admitted on [DATE] with a diagnosis of Dementia with Psychotic Disturbance. The Minimum Data Set (MDS) with an Assessment Reference Date of 04/27/23 documented the resident scored 00 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS) and required extensive assistance for personal hygiene. a. On 06/01/23 at 10:38 AM, Resident #7 was sitting in her room in her wheelchair. Her fingernails on her right hand were approximately 1/4 to 1/2 inch in length from the fingertips. Her right hand's fourth fingernail was split. Half of the fingernail was missing, and there was a sharp pointed edge on part 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.

Based on observation, interview, and record review, the facility failed to follow care planned interventions intended to prevent falls for 1 (Resident #25) of 5 (#10, #16, #25, #33, #42) sampled residents identified as having a high risk of falls as documented by a list titled High Fall Risk provided by the Administrator on 06/02/23 at 10:50 AM. The findings are: a. The Care Plan with the initiation date of 10/26/21 documented, .Resident #25 is at risk for falls r/t [related to] generalized muscle weakness. He has a personal history of falls . Observe Resident #25 for appropriate footwear when ambulating or mobilizing in w/c [wheelchair] . b. The Fall Risk Assessment for Resident #25 dated 04/10/23 documented a score of 13. If the total score is 12 or greater, then the resident is considered to be at High risk for falls. c. On 05/30/23 at 12:45 PM, Resident #25 was seated on a bench in his room by the window. He was wearing loose fitting white socks that were not pulled up completely on his feet. d. On 05/30/23 at 1:10 PM, the Surveyor heard Resident #25 cry out for help from his…

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 provide assessment and intervention intended to prevent severe weight loss for 1 (Resident #16) of 24 (Residents #2, #6, #8, #9, #10, #14, #16, #17, #19, #20, #24, #25, #27, #33, #42, #45, #47, #50, #55, #59, #61, #64, #65, #116) sampled residents who relied on the facility to meet their dietary needs. The findings are: a. The Physician's Order with a start date of 08/28/19 documented, Regular diet, Regular texture .Give extra protein with all meals related to Type 1 Diabetes Mellitus Without Complications. b. On 11/21/22, Resident #16 weighed 240.6 pounds. On 05/23/23, the resident weighed 194.5 pounds which is a -19.16 % [percent] Loss. c. On 04/27/23, Resident #16 weighed 208.6 pounds. On 05/23/23, the resident weighed 194.5 pounds which is a -6.76 % Loss in a one-month time span. d. The Care Plan had no goals or interventions documented related to Resident #16's weight loss. e. On 06/01/23 11:50 AM, the Surveyor asked the Dietary Supervisor if she was aware of any dietary interventions put in place for Resident #16.…

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 obtain a Physician's Order before administering supplemental oxygen to 1 (Resident #6) of 4 (#6, #20, #27, #50) sampled residents receiving supplemental oxygen in the facility. The findings are: a. The Physician's Orders for Resident #6 did not include an order for supplemental oxygen. b. On 05/30/23 at 12:40 PM, Resident #6 was lying in her bed resting. She received supplemental oxygen from a nasal cannula that was connected to an oxygen concentrator at her bedside. The flow gauge on the oxygen concentrator displayed that it was providing 6 liters per minute (lpm) of oxygen. c. On 05/31/23 at 3:20 PM, Resident #6 was receiving 6 lpm of oxygen from the bedside oxygen concentrator via nasal cannula. d. On 05/31/23 at 3:29 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 to navigate to Physician's Orders for Resident #6 and identify if there was an order for supplemental oxygen. LPN #1 stated, No, I don't see it in there. The Surveyor asked if an order was required for administering supplemental oxygen.…

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 medication error rate was less than 5% (percent). The medication error rate was 7.41 %. The findings are: 1. Resident #47's Physician Order with an order date of 05/14/23 documented, Acetaminophen 325mg [milligram] Give 2 tablet by mouth every 6 hours as needed for pain. 2. The Physician Order with an order date of 05/14/23 documented, Myrbetriq oral tablet ER [Extended Release] 24-hour 25mg (Merabegron) Give 1 tablet by mouth one time a day for bladder spasms. 3. The Physician Order with an order date of 05/14/23 documented, Crush and administer all meds concurrently unless clinically contraindicated. This applies to crushed meds given orally or per tube. 4. On 05/31/23 at 9:02 am, LPN #3 administered 1 500 mg tab of Acetaminophen to Resident #47. 5. On 05/31/23 at 9:20 am, LPN #3 crushed 1 Myrbetriq 25 mg ER tablet, then administered to Resident #47. 6. On 06/02/23 at 10:20 am, the Surveyor asked the Assistant Director of Nursing (ADON) if crushing the Extended-Release tablets was appropriate. 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 1 meal observed. This failed practice had the potential to affect 15 residents who received mechanical soft diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 05/31/23 at 11:58 AM. The findings are: 1. The Menu for lunch documented the residents on Mechanical soft diets were to receive 8 ounces of spaghetti with meat sauce. a. On 05/30/23 at 11:35 AM, Dietary Employee (DE) #1 used a 4 ounce spoon and placed 11 servings of spaghetti into a pan, used a 6 ounce spoon and placed 12 servings of meat sauce on the spaghetti, poured the mixture into a blender and grounded it. On 05/30/23 11:38 AM, she poured the ground spaghetti with meat sauce into a pan and placed it on the steam table. b. On 05/30/23 at 12:16 PM, DE #3 used a #8 scoop (1/2 cup) to serve a single portion of spaghetti with meat sauce to the residents that required 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, record review, and interview, the facility failed to ensure the meals were served in a method that maintained the appearance of cold product and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 9 residents who receive meal trays in their rooms on the A-Hall, 13 residents who receive meal trays in their room on the B-Hall, 10 residents who receive meal trays on the C-Hall, and 14 residents who receive meal trays in their room on the D-Hall, as documented on a list provided by Dietary Supervisor on 05/31/23 at 11:58 PM. The findings are: 1. On 05/31/23 at 7:23 AM, an unheated cart that contained 14 breakfast trays was delivered to the D-Hall by Certified Nursing Assistant (CNA) #1. At 7:39 AM immediately after the last residents received their trays in their rooms on D-Hall, the temperatures of food items on the test tray were checked and read by CNA #2 with the following results: a. Milk at 50.7 degrees Fahrenheit. b.…

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 hand hygiene was preformed, failed to ensure the stethoscope was disinfected between residents, and failed to ensure a multi-resident use glucometer was disinfected before and after use to decrease the potential for spread of infection for 1 (Resident #47) of 1 sampled resident who had Physician Orders for Capillary Blood Glucose (CBG) monitoring and resided on the 200 Hall according to a list provided by the Director of Nursing (DON) on 06/02/23 at 10:30 am. The findings are: a. On 05/31/23 at 8:34 am, Licensed Practical Nurse (LPN) #3 did not wear gloves when administering eye drops and did not sanitize or wash hands between resident rooms during medication administration. b. On 05/31/23 at 9:02 am, LPN #3 did not clean the glucometer, or disinfect the glucometer before or after using the glucometer when performing a CBG test for Resident #47 and returned it to the medication Cart drawer. c. On 05/31/23 at 9:17 am, the Surveyor asked LPN #3 if he had hand sanitizer on the medication cart. LPN #3…

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.