Parkview Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the appropriate care and services for the use of the GT for one of four sampled residents (Resident 27) reviewed for GT use. * The facility failed to ensure Resident 27's GT tubing was not touching the floor. In addition, the facility failed to clean the syringe used to flush and administer medications via GT after use. These failures posed the risk of complications related to Resident 27's GT. Findings: Medical record review for Resident 27 was initiated on 6/2/26. Resident 27 was readmitted to the facility on [DATE]. Review of Resident 27's H&P examination dated 4/18/26, showed Resident 27 had no capacity to understand and make decisions. Further review of the H&P showed diagnoses including status post GT placement. On 6/2/26 at 1615 hours, a medication administration observation was conducted with LVN 1. LVN 1 was observed administering medications to Resident 27 via GT. During the medication administration, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary pharmaceutical services to ensure accurate administration of the medications: * The facility failed to ensure three unknown pills were properly wasted. This failure posed the risk of medication diversion. * The Administrator, who was not a licensed nurse, had a key to the narcotic destruction storage cabinet. This failure resulted in unauthorized access to controlled substances. * The storage closet used to store enteral feedings did not have a thermometer or temperature log. This failure posed a risk of the enteral products not to be maintained at appropriate room temperature. * Resident 27's stool softener (docusate sulfate) was not held, when Resident 27 had episodes of loose bowel movements. This failure posed the risk of Resident 27 suffering from further loose bowel movements and dehydration.Findings: a. On 6/4/26 at 0932 hours, an inspection of the facility's medication storage room and concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's medical record was accurate for one of 14 final sampled residents (Resident 28). * Resident 28's POLST was inaccurate when it showed the resident's DPOA had designated Family Member 1 as the Health Care Agent. * The facility failed to complete a Significant Change MDS when Resident 28's hospice services were discontinued. * Resident 28's MDS assessment was incorrectly coded to show the resident received hospice services when services had already been discontinued. These failures resulted in incomplete and inaccurate medical records, which have the potential to negatively impact continuity of care and clinical decision making.Findings: Medical record review for Resident 28 was initiated on 6/2/26. Resident 28 was admitted to the facility on [DATE]. Review of Resident 28's H&P examination dated 2/26/26, showed the resident had no mental capacity to understand and make decisions. a. Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to implement the facility's antibiotic stewardship program to ensure timely physician notification for one nonsampled resident (Residents 11) who received antibiotics for infections that did not meet McGeer's criteria. * The facility failed to ensure Resident 11's symptoms met the criteria for cellulitis/soft tissue/wound infection. In addition, the facility failed to notify the physician the resident's symptoms did not meet the criteria, and to reassess the need for continued antibiotic therapy. These failures had the potential to result in unnecessary antibiotic use and contribute to the development of multidrug resistant organisms (MDROs).Findings: Review of the facility's Monthly Antibiotic Log for February 2026 showed Resident 11 received gentamicin drops and Levaquin (antibiotics) for a HAI. Medical record review for Resident 11 was initiated on 6/2/26. Resident 11 was readmitted to the facility on [DATE]. Review…

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 the residents' care equipment was maintained in a safe operating condition. * LVN 3 was observed using a Velcro wrist blood pressure (BP) cuff machine during a medication administration observation. The BP (blood pressure) machine was used on multiple residents, was not serviced or maintained as per the manufacturer's manual and was not properly cleaned according to the manual's instruction. This failure posed the risk of cross contamination and inaccurate blood pressure readings for the residents.Findings: Review of the manufacturer's instruction for the Velcro wrist BP machine showed the machine was to be cleaned with a soft dry cloth and the device was to be serviced by the manufacturer. On 6/3/26 at 0925 hours, a medication administration observation and concurrent interview was conducted with LVN 3. LVN 3 was observed using a Velcro wrist BP machine to obtain Resident 22's BP and heart rate. LVN 3 verified the Velcro BP machine was used on multiple residents. When asked for the device manual, LVN 3 stated it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the complete medical record was maintained for one of three sampled residents (Resident 1). * Resident 1's Elopement Evaluation was not completely filled out. * Resident 1's medical record failed to show documentation the resident was monitored for a change in condition on 5/3/25, for the 0700-1500 hours shift. Findings: Review of the facility P&P titled Charting and Documentation revised 7/2017 showed documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Closed medical record review for Resident 1 was initiated on 5/20/25. Resident 1 was admitted to the facility on [DATE], and discharged on 5/5/25. a. Review of Resident 1's Elopement Evaluation dated 5/2/25, showed the following areas were left blank: - Is the wandering behavior a pattern, goal-oriented (i.e. specific destination in mind, going home etc.); - Is the Resident's wandering behavior likely 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the treatment was provided to prevent the decline in the ROM functions for one of two final sampled residents (Resident 2) reviewed for ROM functions. * The physician's order to apply the bilateral AFOs to Resident 2's lower extremities was not followed. In addition, Resident 2's skin was not assessed when the AFO was applied. These failures had the potential for Resident 2 to sustain a decline in ROM functions, leading to muscle atrophy (loss of muscle mass and strength) and decrease in functioning. Findings: Review of the facility's P&P titled Restorative Nursing Care (undated) showed the restorative care will be provided to help promote optimal safety and independence. RNAs performed daily to residents by maintaining good body alignment and proper positioning. During the initial tour of the facility on 4/28/25 at 0806 hours, Resident 2 was observed in bed awake and with contractures (shortening and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of four final sampled residents (Resident 1) reviewed for the prevention of accident hazards. * The facility failed to implement the floor mat on the left side of Resident 1's bed for safety in accordance with the physician's order. This failure had the potential for the resident to be at high risk of serious injury. Findings: Review of the facility's P&P titled Falls Prevention - Potential Interventions dated 4/2012 showed the facility's fall impact reduction methods includes low position of beds and chairs, and mattress placed on floor. During the initial tour of the facility on 4/28/25 at 0833 hours, Resident 1 was observed in bed with the bed in the lowest position. However, there was no floor mat observed at the side of the bed. Medical record review for Resident 1 was initiated on 4/28/25. Resident 1 was admitted to the facility on…

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, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of 15 final sampled residents (Residents 2, 3, and 14) reviewed for oxygen therapy. * The facility failed to ensure Resident 2's nasal cannula oxygen tubing was not touching the floor. * The facility failed to follow the physician's order for Residents 3 and 14's oxygen therapy. In addition, the facility failed to ensure Residents 3 and 14's nasal cannula oxygen tubing were not touching the floor. These failures had the potential for the residents to not receive the appropriate care and may negatively impact on the residents' medical conditions. Findings: 1. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed to verify there is a physician's order for this procedure and to review the physician's orders or facility protocol for oxygen administration. On 4/28/25 at 0904 hours, during the initial tour of the facility,…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation and administration of the medications for one of 15 final sampled residents (Resident 16) and one nonsampled resident (Resident 27). * The facility failed to ensure the injection sites for the insulin medication were documented for Resident 16. * The facility failed to ensure Resident 27 had a physician's order to crush the medications when the licensed nurse crushed and administered the resident's medications orally during the medication administration observation. These failures posed the risk for medication administration errors and the potential to negatively affect the resident's well-being. Findings: Review of the facility's P&P titled Administering Medications revised on 4/2019 showed the following: - As required or indicated for a medication, the individual administering the medication records 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, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and disposal of the medications. * The facility failed to ensure Medication Storage Room A, Medication Carts A and B were maintained in a clean and sanitary manner, and the oral medications and external medications were stored separately . * The facility failed to ensure Medication Cart B was locked when left unattended. * The facility failed to ensure the medication was labeled with an opened date and dispose of the discontinued medications in Medication Cart A. These failures had the potential for the medications to lose the stability and effectiveness, cause medication errors and negatively impact the residents' well-being, Findings: Review of the facility's P&P titled Storage of Medications revised on 4/2019 showed it is the policy of the facility to store all drugs and bilogicals in a safe, secure and orderly manner. The nursing staff is responsible for maintaining medication…

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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the scoop used for food portioning and measuring cups was air dried prior to storing. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. These failures had the potential for cross contamination and foodborne illnesses for the residents consuming the food prepared in the facility's kitchen. Findings: Review of the facility's Diet Type Report dated 4/28/25, showed 30 of 35 residents consumed the foods prepared in the kitchen. 1. Review of the facility's P&P titled Sanitation dated 2023 showed all the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. Plastic ware, China, and glassware that becomes unsightly,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. A plan to maximize recruitment and retention of direct care staff; and 3. A contingency plan for staffing needs. This failure had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed. Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included a plan to maximize the recruitment and retention of direct care staff members, and a contingency plan for staffing needs for events so as not to activate the facility's emergency…

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, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the facility's monthly Infection Prevention and Control Surveillance Logs were accurate. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. * The facility failed to ensure the proper handling of clean linens. * The facility failed to perform hand hygiene while providing care to Resident 31. These failures posed the risk of not identifying the resident infections and thereby, preventing the implementation of interventions to control the potential transmission of communicable diseases to other resident in the facility. Findings: Review of the facility's P&P titled Surveillance for Infections revised 9/2017 showed the facility…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete for three of 15 final sampled residents (Residents 14, 16, and 28) and one nonsampled resident (Resident 17) reviewed for the side rail use. These failures had the potential to negatively impact the residents, resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and ssessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapment may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the IP had the knowledge of the Pneumococcal immunization update per the CDC's guidelines. In addition, the facility failed to ensure the IP had the appropriate knowledge to implement the enhanced barrier precautions with the facility's residents needed to be placed on a special precautions. These failures had the potential for the residents not to receive timely the appropriate type of pneumonia immunization placing the residents at risk for developing pneumonia (infection of the lungs that causes inflammation of air sacs in one or both lungs which may fill with fluid), and potential for spread of infection. Findings: Review of the facility's P&P titled Pneumococcal Vaccine dated October 2019 showed all the residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be offered the vaccine series within…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to offer PCV 15/PCV 20 (PCV 15 protects against two additional serotypes and PCV 20 protects against seven additional serotypes involved in cases of invasive pneumococcal disease (IPD) and pneumonia) immunizations for 20 of 20 nonsampled residents (Residents 1, 3, 4, 5, 6, 8, 13, 15, 16, 18, 19, 21, 23, 24, 25, 27, 29, 30, 31, and 33) reviewed for pneumococcal vaccination (a vaccine given to protect the resident from pneumococcal disease) in accordance with the CDC's recommendations. No tracking system was in place for pneumococcal vaccine history. These failures increased the residents' risk for being inadequately vaccinated for the pneumococcal disease and its associated complications. Findings: Review of the new CDC guideline titled (MMWR) Morbidity and Mortality Weekly Report dated 1/28/22, showed use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate Vaccine among…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to notify five of five residents reviewed for bed hold notification (Residents 10, 22, 32, 35, and 38) of their rights to a bed hold (holding or reserving a resident's bed while the resident in the acute care hospital) policy upon transfer to the acute care facility. This failure had the potential for residents or their representatives to be unaware of his or her rights to request a bed hold upon transfer. Findings: Review of the facility's P&P titled Bed-Holds and Returns revised March 2017 showed prior to transfer and therapeutic leaves, the residents or resident representatives will be informed in writing of the bed-hold and return policy. The policy interpretation and implementation states that residents may return to and resume residence in the facility after hospitalization or therapeutic leave as outlined in this policy. Prior to transfer, written information will be given to the residents and the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the MDSs for 11 of 17 reviewed residents (Residents 3, 15, 16, 18, 19, 21, 23, 25, 27, 31, and 33) were accurate. This failure posed the risk of the residents not receiving an individualized plan of care on the residents' specific needs. Findings: Review of the Long-Term Facility Resident Assessment Instrument 3.0 User's Manual v1.18.11 dated October 2023 in Chapter 3 under Section O0300: Pneumococcal Vaccine, showed Up to date in item O0300A means in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations. For up-to-date information on timing and intervals between vaccines, please refer to ACIP vaccine recommendations available at - https://www.cdc.gov/vaccines/schedules/hcp/index.html - http://www.cdc.gov/vaccines/hcp/acip-recs/index.html - https://www.cdc.gov/pneumococcal/vaccination.html Review of the new CDC guideline titled (MMWR) Morbidity and Mortality Weekly Report dated 1/28/22, showed use 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure to provide the necessary services to attain or maintain the highest practicable well-being for three of three reviewed residents (Residents 20, 22, and 36). * The facility failed to ensure Resident 22's abduction pillow and bilateral heel protectors were in place while in bed per the physician's orders. In addition, the facility failed to ensure Resident 22 did not wear the left knee immobilizer while Resident 22 was in bed per the physician's order. The facility failed to ensure Resident 22 had other bowel management medication intervention as needed. * The facility failed to ensure the hospice and facility collaborated in the hospice care for Residents 20 and 36. * The facility failed to ensure a hospice care member participated in Resident 36's Quarterly IDT meeting. Findings: 1.a. Medical record review for Resident 22 was initiated on 4/3/24. Resident 22 was readmitted to the facility on [DATE]. 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, interview, facility P&P review, and facility document review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure the cutting boards and kitchen equipment were in sanitary conditions * The facility failed to ensure the food items were discarded on or before the best by date * The facility failed to ensure the temperature of the food items were checked prior to preparing or distributing to residents * The facility failed to ensure the staff's personal belonging was not stored in the kitchen's clean utility room * The facility failed to ensure the kitchen staff maintained proper hand hygiene * The facility failed to ensure the staff covered food during transportation through the outdoor dry storage room and back inside facility * The facility failed to ensure Resident 4 received the correct diet texture as ordered These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food prepared in the kitchen Findings: Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility P&P review, and facility document review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to ensure the EBP (Enhanced Barrier Precautions) was practiced for the residents with an indwelling urinary catheter (Resident 20) and GT (Residents 2, 9, and 36). * The facility failed to ensure LVN 2 wore proper PPE when administering medication through a GT for Resident 3. * The facility failed to ensure the Yankuer Suctioning (oral suctioning tool) was stored separately with opened date for Resident 11. * The facility failed to ensure LVN 1 performed hand hygiene in between changing gloves when providing wound treatment to Resident 22. In addition, the facility failed to ensure staff practiced the enhanced based precaution for Resident 22 who had a Stage 4 pressure ulcer (full thickness tissue loss with exposed…

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, medical record review, and facility P&P review, the facility failed to ensure the staff provided care and promoted dignity and respect for three of 11 residents reviewed for dignity and respect (Residents 5, 8, and 35). * CNA 3 was observed standing over Resident 8 while assisting the resident with meals. * CNA 2 was observed standing over Resident 35 while assisting the resident with meals. * The facility failed to ensure Resident 5's body was fully covered while being transported from the shower room to her room. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Assistance with Meals revised July 2017 showed the residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: not standing over residents while assisting them with meals. 1. During the dining observation on 4/2/24 at 1233 hours, CNA 3 was observed standing over Resident 8's right side of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility P&P review, and facility document review, the facility failed to fully inform the resident or responsible party of their bed with side rails, the entrapment assessment for Zone 6, and the treatment alternatives or options for two of four sampled residents (Residents 9 and 32). This failure had the potential for Residents 9 and 32 and their responsible parties to not make the informed decisions regarding the care and treatment of bed side rail use. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot…

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, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the care needs for one nonsampled residents of 38 residents in the facility (Resident 37). * The facility failed to ensure Resident 37's call light was within the resident's reach. This failure had the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care and services to the resident. Findings: Review of the facility's P&P titled Call System, Resident revised September 2022 showed each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting and bathing facilities and from the floor. During the initial tour on 4/2/24 at 0807 hours, Resident 37's call light was observed on the floor on the right side of her bed. Medical record review for Resident 37 was initiated on 4/2/24. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's H&P examination dated…

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, medical record review, and facility P&P review, the facility failed to ensure one of one resident (Resident 26) reviewed for resident's choice and food preferences with meals was honored. This failure had the potential risk for a diminished quality of life and impact resident's well-being. Findings: Review of the facility's P&P titled Resident Food Preferences revised July 2017 showed when possible, the staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. Review of the facility's P&P titled Resident's Rights revised December 2016 showed Federal and State laws guarantee certain basic rights to all residents to this facility. These rights include the resident's right to: e. self-determination. During the dining observation on 4/2/24 at 1253 hours, Resident 26 was observed sitting up in his wheelchair in the dining room with his lunch meal tray in front of him. Resident 26's plate was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to inform and provide the written information regarding the rights to formulate the advance directives to one of three reviewed residents (Resident 35). In addition, the facility failed to ensure the copy of the advance directives was readily available in the residents' charts for two of three reviewed residents for advance directives (Residents 10 and 12). These failures had the potential for the facility to provide treatment and services against the resident's wishes. Findings: Review of the facility's P&P titled Advance Directives revised December 2016 showed upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Written information will include a description of the facility's policies to implement advance directives and applicable state law. If the resident becomes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to notify the resident and/or their representative of the transfer/discharge and reasons for the transfer in writing for one of five residents reviewed for hospitalization (Resident 32). This failure had the potential for the resident and their representative not knowing about the appeal process should the resident and their representative believe the transfer or discharge was inappropriate or involuntary. Findings: Review of the facility's P&P titled Transfer or Discharge Notice revised December 2016 showed the facility shall provide a resident and/or the resident representative with a 30 day written notice of an impending transfer or discharge. The notice will be given as soon as it is practicable but before the transfer or discharge when an immediate transfer or discharge is required by the resident urgent medical needs. Further review of the P&P showed the resident and/or representative will be notified in writing of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide a summary of the baseline care plan for one of one reviewed resident (Resident 441). This failure had the potential for inappropriate interventions and care for Resident 441. Findings: Review of the facility's P&P titled Care Plans- Baseline revised December 2016 showed the resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a. The initial goals of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information on the details of the comprehensive care plan, as necessary. During the initial tour on 4/2/24 at 0845 hours, Resident 441 stated the SSD spoke to her about the physical therapy for walking and returning home. Resident 441 stated she did not have a discussion of her plan 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to develop and implement the comprehensive plan of care to reflect the individual care needs of one of 14 sampled residents (Resident 22). The facility failed to develop a care plan problem to address Resident 22's noncompliance with a physician's order to apply her abduction pillow at all times while in bed. This failure posed the risk of not providing appropriate, consistent, and individualized care to Resident 22. Findings: Medical record review for Resident 22 was initiated on 4/3/24. Resident 22 was readmitted to the facility on [DATE]. Review of Resident 22's H&P examination dated 3/21/24, showed Resident 22 had the capacity to understand and make decisions and had diagnosis for status post repeated surgery for infection open reduction and internal fixation (ORIF, put pieces of a broken bone into place using surgery with screws, plates, sutures, or rods to hold the broken bones together). Review of Resident 22's Physician'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of one resident reviewed for activity (Resident 11). The facility failed to provide activities for Resident 11 which met his identified interests. This failure had the potential for Resident 11 to experience feelings of social isolation and frustration. Findings: Review of the facility's P&P titled Activity Program revised June 2018 showed the activity program are designed to meet the interest of and support the physical mental and psychosocial well being of each resident. Further review of the P&P showed the activities offered are based on the comprehensive resident centered assessment and the preferences of each resident. On 4/2/24 at 0942 hours, and 4/3/24 at 0801 and 1308 hours, Resident 11 was observed lying awake in bed staring at the wall. On 4/2/24 at 1024 hours, an interview was conducted with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of two residents reviewed for the use of indwelling urinary catheter (Residents 20 and 35) were provided with the necessary indwelling urinary catheter care to prevent UTI. The facility failed to ensure Resident 20's indwelling urinary catheter orders followed the CDC's guidelines. These failures had the potential to put Residents 20 and 35 at risk for UTI. Findings: Review of the facility's P&P titled Catheter Care, Urinary revised September 2014 showed the following information should be recorded in the resident's medical record: - The date and time that catheter care was given. - The name and title of the individual(s) giving the catheter care. - All assessment data obtained when giving catheter care. - Character of urine such as color (straw-colored, dark or red), clarity (cloudy, solid particles, or blood), and odor. - Any problems noted at the catheter-urethral junction during perineal care…

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 medical record review, the facility failed to ensure the nutrition needs were met for one of two residents reviewed for nutrition (Resident 32). * The facility failed to ensure Resident 32 was offered alternative when Resident 32 consumed less than 50% of his meal tray. This failure had the potential to compromise Resident 32's nutritional status. Findings. On 4/2/24 at 0802 hours, an interview was conducted with Resident 32. Resident 32 stated he had been losing weight; however, he thought the current weight was his ideal weight. Medical record review for the Resident 32 was initiated on 4/2/24. Resident 32 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 32's Vital Signs Grid dated 4/5/24, showed following weights: - 3/4/24, 174 lbs (pounds); - 2/26/24, 174 lbs; - 2/19/24, 168 lbs; - 2/12/24, 168 lbs; - 2/5/24, 168 lbs; and, - 1/5/24, 180 lbs. Review of Resident 32's MDS dated [DATE], showed Resident 32 was cognitively…

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, facility P&P review, and facility document review, the facility failed to ensure three of four sampled residents with GT (Residents 2, 9, and 36) were provided care as evidence by: * The facility failed to ensure CNA 6 worked within their scope of practice as shown on the facility's document titled Patient Care Assistant - CNA Job Description. * The facility failed to ensure Residents 2, 9, and 36's GT tubing were properly labeled. These failures posed the risk for negative outcomes for the residents with GT. Findings: Review of the facility's P&P titled Enteral Feedings - Safety Precautions revised 12/2011 showed all personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. The facility will remain current in and follow accepted best practices in enteral nutrition. The P&P further showed administration set changes include: a. Change administration sets for open-system enteral…

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, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for two of three residents reviewed for respiratory care (Residents 2 and 17). * The facility failed to provide oxygen therapy as per the physician's order for Resident 17. * The facility failed to ensure Resident 2's suction machine canister was discarded after use and failed to ensure an oxygen bag was available and suction machine bag was dated. These failure posed the risk for residents' safety and respiratory related complications including infection. Findings: Review of the facility's P&P titled Oxygen Administration revised October 2010 showed to verify that there was a physician order for the procedure and to review the physician's orders or facility protocol for oxygen administration. Medical record review for Resident 17 was initiated on 4/2/24. Resident 17 was admitted to the facility on [DATE], and readmitted on [DATE]. On 4/2/24 at 0910 hours, an…

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, facility document review, and facility P&P review, the facility failed to ensure the ongoing assessment before, during, and after dialysis treatments for one of one resident reviewed for dialysis services (Resident 10) was conducted as evidenced by: * Resident 10's dialysis communication forms dated 4/2 and 4/4/24, were incomplete. This failure had the potential of not identifying negative outcomes for the dialysis resident (Resident 10). Findings: Review of the facility's P&P titled Hemodialysis Access Care revised on 9/2010 showed documentation included: 1. Location of the catheter 2. Condition of the dressing (interventions if needed) 3. If dialysis was done during the shift 4. Any part of the report from dialysis nurse post-dialysis being given 5. Observations post-dialysis Medical record review for Resident 10 was initiated on 4/5/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's physician's order dated 2/1/24, showed Resident 10 had dialysis on…

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, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to meet the needs of residents. The emergency kit for the facility's oral medications was not replaced in a timely manner. This failure had the potential for to contribute to a decreased availability of medications in an emergency. Findings. Review of the facility's P&P titled Availability and Use of Emergency Medication Kits revised January 2020 showed the facility must notify pharmacy when an emergency kit was opened and needs replacement. Further review of the P&P showed the pharmacy will then replace the open kit on the next working day. On 4/3/24 at 1518 hours, during the inspection of Medication Storage room [ROOM NUMBER] with the IP, the emergency kit for the oral medications was observed to be locked with a white zip tie. The IP stated the emergency kit locked with white zip tie was once opened and meant to alert staff it needed to be replace. The Emergency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for two of five residents reviewed for unnecessary medications (Residents 22 and 32). * The facility failed to ensure the Pharmacy Consultant's recommendation to provide duration of the therapy for enoxaparin (its brand name, Lovenox, an anticoagulant used to decrease the clotting ability of the blood) for Resident 22 was acted upon. This failure had the potential to put Resident 22 at risk for adverse consequences related to the medication. * The failed to ensure the physician provided a rational when no action was taken for the Pharmacy Consultant's recommendation if clinically feasible to provide a duration of therapy for Lovenox for Resident 32. These failures had the potential to put Residents 22 and 32 at risk for adverse consequences related to the medication. Findings: 1. Medical record review for Resident 22 was initiated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from the unnecessary psychotropic medications (any drug that affects brain activity associated with mental processes and behavior) for two of two residents reviewed for antipsychotic medications (Residents 20 and 35). * Resident 35 had an order for olanzapine (its brand name, Zyprexa, an antipsychotic medication). The facility failed to ensure Resident 35 was assessed for Abnormal Involuntary Scale (AIMS, a rating scale that was designed in the 1970s to measure involuntary movements known as tardive dyskinesia (TD) for the use of olanzapine (Zyrexa). * Resident 20 had an order for bupropion (Wellbutrin) (antidepressant medication) and quetiapine (Seroquel) (antipsychotic medication). The facility failed to ensure Resident 20 was assessed for abnormal involuntary movement using the AIMS (The Abnormal Involuntary Movement Scale) test for the use of bupropion and quetiapine medications. These…

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, medical record review, and facility P&P review, the facility failed to ensure the medications were not left unattended on the medication cart for one of two residents reviewed for medication administration (Resident 3). This failure had the potential for medication diversion. Findings: Review of the facility's P&P titled Storage of Medication revised April 2019 showed the drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Further review of the P&P showed to not leave medications unattended on the medication cart. On 4/3/24 at 0845 hours, a medication pass observation was conducted with LVN 2. LVN 2 was observed preparing the following medications for Resident 3: - Amantadine (medication to treat Parkinson's disease) 50 mg/ml 5 ml; - Decousate sodium (stool softer) two tablets;. - Rivastigiminie 9.5 mg (medicine to treat dementia) transdermal system (a technique that provides drug absorption via the skin); - Oxybutynin 50 mg (a medicine used to treat symptoms of an…

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, facility P&P review, and facility document review, the facility failed to ensure the puree recipes and renal and CCHO menus were followed for three residents (Residents 11, 18, and 35) with puree diet, two of four residents (Residents 11 and 18) with a puree renal diet, and 10 of 32 residents (Residents 5, 10, 11, 13, 16, 17, 18, 28, 29, and 35) on CCHO diet as evidenced by: * The facility failed to ensure the puree recipes were followed. * The facility failed to ensure two residents (Residents 11 and 18) on a renal pureed diet did not receive roasted red potatoes. * The facility failed to ensure the residents with a CCHO diet (Residents 5, 10, 11, 13, 16, 17, 18, 28, 29, and 35)received plain ice cream as shown on the Spring Cycle Menu Week 1 dated for 4/3/24. These findings had the potential for the residents on special diets to not receive the adequate nutritional and caloric intake as recommended on the recipes and menus. Findings: 1. Review of the facility's P&P titled Standardized Recipes revised 4/2007 showed standardized recipes shall be…

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, facility P&P review, and facility document review, the facility failed to ensure the food test tray was prepared in an appetizing temperature as evidenced by: * Test tray temperatures were below the recommended temperature for hot meats, vegetables, and potatoes. * Three of 38 residents (Residents 12, 26, and 32) had complained the food was cold These failures posed the risk for not providing palatable and appetizing food for the residents receiving a meal tray from the kitchen. Findings: Review of the facility's P&P titled Food Preparation and Service dated 4/2019 showed fresh, frozen, or canned fruits and vegetables are cooked to a holding temperature of 135 degrees Fahrenheit. The P&P showed the danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit and the longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained below 41 degrees Fahrenheit or above 135 degrees Fahrenheit. 1. Review of the Spring Cycle Menu Week 1 dated for 4/3/24, showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for three of 14 final sampled residents (Residents 26, 32, and 35) was complete and accurate. * The facility failed to ensure an active physician's orders for Resident 26 to continue no weight bearing status to the left upper extremity and to continue to use a left arm sling for support were discontinued. * The facility failed to ensure Resident 35's physician's order for Dulcolax (laxative) medication was accurate. These failures had the potential for the resident's accurate clinical status not being available and communicated to care team. Findings: Review of the facility's P&P titled Charting and Documentation revised July 2017 showed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate…

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, facility document review, and facility P&P review, the facility failed to ensure the hospice and facility staff worked collaboratively together in the plan of care for two of three hospice residents (Residents 20 and 36) as per the hospice contract agreement. This failure had the potential of Residents 20 and 36 to not receive hospice care as per the hospice agreement. Findings: 1. Medical record review for Resident 20 was initiated on 4/2/24. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 11/7/23 showed Resident 20 had nocapacity to understand and make decisions and goals for comfort care. Review of Resident 20's Physician's Orders for April 2024 showed an order dated 11/7/23, to admit the resident to the facility under Hospice A. Review of Hospice A Contract Agreement dated 11/6/23, showed if providers schedule service specific IDT meetings, they will allow the agency personnel to participate in these and notify the agency 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to follow up when the residents' beds failed on the entrapment assessments zone for two of three residents reviewed for bed rails (Residents 9 and 32). * The facility failed to ensure Residents 9 and 32's side rails were reassessed after failed Zone 6 measurement was noted. This failure had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to ensure the head and neck support for one of five sampled residents' (Resident 1) highbacked personalized wheelchair was in the correct position when Resident 1 left the facility for an outing with her family on 12/30/23. This failure resulted in Resident 1's head being tilted to one side and incorrectly aligned in her wheelchair, causing pain, and psychological distress, which had the potential to negatively impact the resident's well-being. Findings Medical record review for Resident 1 was initiated on 1/16/24. Resident 1 was originally admitted to the facility on [DATE],and readmitted on [DATE]. Resident 1 had a diagnosis of MS. Review of Resident 1's H&P examination dated 10/3/23, showed Resident 1 had the capacity to understand and make medical decisions. Review of Residents 1's MDS dated [DATE], showed the resident was cognitively intact. Resident 1 required substantial assistance rolling side to side and was…

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, medical record review, and facility P&P review, the facility failed to ensure the proper use of bed rails for six of six sampled residents (Residents 1, 2, 3, 4, 5, and 6). * Resident 1 was observed with bilateral bed rails elevated, however, had a physician ' s order, assessment, and care plan problem for the right siderail use only. * Resident 2 was observed with bilateral bed rails elevated, with no physician ' s order, assessment, nor care plan problem in place. * Resident 3 was observed with upper and lower left ½ (half) bed rails elevated. Resident 3 did not have a physician ' s order, assessment, or care plan problem for the use of the bed rails. * Resident 4 was observed with bilateral ½ length bed rails elevated, with the right siderail padded. Resident 4 ' s physician ' s order was only for the left padded half bed rail. * Resident 5 was observed with left bed rail elevated with no physician ' s order, assessment, or care plan problem for bed rail use. * Resident 6 was…

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.