Elmwood Care Center

Based on observation, interview, and facility document review, the facility failed to ensure: 1. Residents had a location to safely store perishable food brought into the facility by family/visitors; and 2. A policy described the safe storage of food brought in by family members. This failure had the potential to result in foodborne illness from unsafe food storage, decreased food intake, and did not create a homelike environment for 65 residents who took food by mouth out of a census of 68. Findings: During an interview on 7/16/24 at 2:40 p.m., Certified Nursing Assistant (CNA) 1 stated sometimes food brought in by family/visitors was stored for residents in the staff refrigerator. CNA 1 stated she thought perishable food could be stored up to 24 hours in the staff refrigerator. During an interview on 7/16/24 at 2:48 p.m., CNA 2 stated sometimes family and visitors brought in food for residents, but the facility did not store residents' perishable food because there was not a refrigerator for this purpose. CNA 2 stated if milk was at a resident's bedside during her shift, she would…

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 the menu was followed for 6 residents on Renal diets (diet that promotes kidney health) and Renal Consistent Carbohydrate (CCHO; a diet typically prescribed to control blood sugar) out of 65 residents who received food from the kitchen. This failure had the potential to result in providing residents on a Renal diet and Renal CCHO diets with an inadequate and/or a harmful amount of nutrients, further compromising residents' medical status. Findings: Review of tray tickets for lunch dated 7/15/24 and used for the lunch trayline on 7/15/24, showed 3 residents received a Renal diet and 3 residents received a Renal CCHO diet. During concurrent tray line observation and record review on 7/15/24 at 12:00 p.m., lunch trays were prepared for residents. The trays included desserts which were placed on the tray by Dietary Aide (DA) 1. The trays with a tray ticket that specified the resident was on a Renal diet or Renal CCHO, had a cup of cappuccino chocolate mousse. Review of the cook's spreadsheet titled Summer…

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 provide the appropriate food texture for mechanical soft diets. This deficient practice had the potential to cause difficulty with eating, chewing, and/or swallowing leading to an increased risk of choking for 10 of 10 residents who received prescribed mechanical soft diets. Findings: Review of the Cooks spreadsheet titled Summer Menus dated 7/15/24, showed residents prescribed a Mechanical Soft diet received ground French Dip-Roast Beef moistened with broth, and chopped corn coleslaw. During an observation of trayline food service and concurrent interviews with [NAME] 1 and the Certified Dietary Manager (CDM) 1 on 7/15/24 starting at 12:00 p.m., residents who's tray ticket indicated a physician prescribed Mechanical Soft diet were served dry, shredded roast beef on a bun, with no added au jus (a light broth or gravy usually made with the meat's natural juices). In addition, Mechanical Soft diets were served a bowl of dry coleslaw (shredded cabbage salad). [NAME] 1 confirmed she did not moisten the mechanical…

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 facility document review, the facility failed to fortify resident food according to physician orders. This failure had the potential to result in decreased calorie intake for two (Residents 9 and 14) out of seven residents who had physician prescribed fortified diets. Findings: An observation of trayline food service on 7/15/24 at 12 p.m., showed resident diets printed on tray tickets, and fortified was included in seven resident diets. [NAME] 2 called out diets according to the tray ticket to [NAME] 1. Then [NAME] 1 placed hot food on plates according to the diet called out. [NAME] 2 did not call out fortified when she called out diets with fortified printed on the tray ticket. When the surveyor asked how diets were fortified, [NAME] 1 stated residents with fortified diets received margarine on the sweet potato fries. [NAME] 1 informed [NAME] 2, she had to call out fortified when it was printed on the ticket in order for her to know to place margarine on the sweet potato fries. [NAME] 1 confirmed she did not call out fortified printed on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a patient to signal his or her needs for assistance) was functioning for 13 of 68 sampled residents (Resident 32, 168, 40, 174, 26, 51, 20, 31, 41, 2, 4, 5, and 53). This deficient practice had the potential to result in the delay of care and services. Findings: 1. a. During a review of Resident 32's admission Record, dated 7/17/24, indicated Resident 32 was admitted to the facility on [DATE] with multiple diagnoses that included Parkinson's Disease (a progressive disorder that affects nervous system and parts of the body controlled by the nerves), absence of right and left legs below knees. During a review of Resident 32's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 4/21/24, indicated Resident 32 had a Brief Interview for Mental Status (BIMS - a tool used to assess mental function) score of 14. Meaning Resident 32 was able to understand and understood others. 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 and interview, the facility failed to provide a comfortable, temperature-controlled environment for one of six residents (Resident 319) when Resident 319's window was in a fixed open position and found to be non-functional due to a missing crank. This failure prevented Resident 319 from opening or closing the window at the resident's discretion to control the room's temperature. Findings: During a review of Resident 319's Minimum Data Set (MDS - an assessment tool used to guide care) assessment dated [DATE], Section C showed a Brief Interview for Mental Status (BIMS - an assessment tool used to evaluate mental status) score of 12 out of 15, indicating the resident had moderately impaired mental status but could communicate needs. During a concurrent observation and interview on 7/15/2024 at 10:00 am with Resident 319 in her room, the window was missing a crank handle and could not be closed. Resident 319 stated she was unable to close the window adjacent to the foot of the bed resulting in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medication error rate did not exceed five percent. There were four medication errors out of 26 opportunities for errors, which resulted in an error rate of 15.38 percent (%). 1. For Resident 39, Licensed Vocational Nurse (LVN) 2 administered insulin (a medication that helps people control their blood sugar) that was expired for 13 days. 2. For Resident 220, LVN 3 administered Senna (a medication used to relieve constipation) . and Divalproex (a medication used to treat seizures) 2hrs (hours) over their appropriate scheduled timeframe, and Levetiracetam (a drug used to treat seizures) 3hrs over it's appropriate scheduled timeframe. These failures had the potential to jeopardize resident 39 and 220's health due to unsafe medication administration practices not being followed. Findings: 1. A review of Resident 39's admission Record printed [DATE], indicated Resident 39 was admitted to the facility in 2024 with multiple diagnoses,…

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 infection control practices for two of two sampled residents (Residents 5 and 39), when the following was observed: 1. Licensed Vocational Nurse 3 (LVN) did not clean and sanitize the glucose monitor (a device for measuring the concentration of glucose in the blood) in between finger stick blood sugar tests (a test that measures blood glucose levels by pricking a fingertip with a lancet and applying a drop of blood to a test strip in a glucose monitor) for resident 5 and 39. 2. LVN 3 disposed Resident 5 and 39's contaminated blood sugar lancets in residents 5 and 39's trash cans. 3. LVN 3 did not perform hand hygiene in between resident 5 and 39's finger stick blood sugar tests. These failures placed Residents 5 and 39 at risk for injury, cross contamination, and infection. Findings: A review of Resident 5's admission Record printed 7/17/24, indicated Resident 5 was admitted to the facility in 2021 with multiple diagnoses, which included Unspecified Sequelae (an aftereffect of a disease) of Unspecified…

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 safe infection control practices to prevent spread of infection when: 1a. The glucometer (device used to measure the blood sugar level) was not sanitized per manufacturer specifications in-between resident care use on two residents (Resident 28 and Resident 10) out of a census of 63. 1b. The Blood Pressure device (or BP device, included a cuff that wraps around the arm, a rubber squeeze bulb, and a gauge that measured the blood pressure flow in the body), medication tray (a small shared tray used to carry the medication to resident's room) and the Pulse-oximeter device ( or Pulse-ox, a device placed on fingertip to measure blood oxygen level) were not sanitized in-between resident care use on two residents (Resident 258 and Resident 214) out of a census of 63. 2. The IV (Intravenous- into the vein) line cover dressing was not changed and cleaned for more than one week in one resident (Resident 256) out of 21 sampled residents.…

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 provide care with dignity for one of three sampled residents (Resident 8) when two licensed nurses did not provide privacy for Resident 8 during nursing care. This deficient practice resulted in not ensuring resident 8's rights to be treated with dignity and respect. Findings: During a review of Resident 8's face sheet, dated 7/26/22, the face sheet indicated, Resident 8 was admitted to the facility in 2020 with multiple diagnoses that included weakness. During a review of Resident 8's Brief Interview for Mental Status (BIMS, a tool used to assess mental function) in the Minimum Data Set (MDS, an assessment tool used to guide care), dated 1/20/22, indicated the resident's score was 10, meaning Resident 8's cognitive ability was mildly impaired. Resident 8's MDS also indicated Resident 8 required extensive assistance with bed mobility from one or more staff members. During a concurrent observation and interview on 7/26/22, at 10:44 a.m., in Resident 8's room, Registered Nurse (RN) 1 and Licensed Vocational…

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 self-administered medications kept at bedside were reviewed and approved by medical doctor in one resident (Resident 260) out of 21 sampled residents. This failure could result in unsafe medication use in the facility. Findings: During a medication pass observation in facility's Unit #2, with Licensed Nurse 3 (LN 3), on 7/26/22, at 9:45 a.m., LN 3 entered Resident 260's room and asked if he used his inhalers (means medication devices used to treat asthma or breathing problems). Resident 260 responded that he used it a while ago. Further observation indicated Resident 260 shared the room with another resident and the two medication inhalers were inside a Ziplock bag at bedside table. Review of the Resident 260's electronic medical record titled Medication Administration Record (or MAR, a legal document showing doctor's order, instructions, and the nurse's administration record), dated 7/2022, the MAR indicated doctor orders for the two inhalers as follow: Spiriva Respimat . (an inhalation medicine used…

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 food preference for one of one sampled resident (Resident 15) was honored, when the facility served food Resident 15 disliked. This deficient practice had a negative impact on Resident 15's overall health when Resident 15 did not eat his food. Findings: During a review of Resident 15's admission Minimum Data Set (MDS - an assessment tool used to guide care), dated 1/23/22, the MDS showed, Resident 15 was admitted to the facility in 2022. During a concurrent observation and interview on 7/25/22, at 12:45 p.m., with Resident 15, Resident 15 pushed aside a plate with uneaten meat covered in gravy sauce. Resident 15 indicated, he disliked gravy but was served food covered in gravy sauce. Resident 15 further stated, they always do this (serve gravy and sauces), I don't like gravy, I can't eat that (pointing to uneaten food). During a concurrent interview and record review, on 7/26/22, at 12:35 p.m., with Dietary Manager (DM), DM confirmed Resident 15 disliked gravy sauce but was given in yesterday's lunch.…

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 range of motion (ROM) exercises were provided according to the physician's order, for three of three sampled residents (Resident 33, 41, and 29) with limited ROM. This failure had the potential to result in decline in the Resident 33, Resident 41, and Resident 29's ROM and functioning. Findings: 1. During a review of Resident 33's admission record, dated 7/28/22, the admission record indicated, Resident 33 was admitted to the facility in 2014. According to Resident 33's Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/7/21, Resident 33 had a Brief Interview for Mental Status (BIMS) score of 05, meaning Resident 05 had severe cognitive impairment. The MDS also indicated, Resident 33 had multiple diagnoses which included muscle weakness. During a review of Resident 33's Order Summary, dated 5/31/22, the order summary indicated a physician order for RNA (Restorative Nurse Aide) to perform functional mobility and…

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

Based on interview, observation, and record review the facility failed to ensure safe and accountable medication handling with census of 63 when: 1. The unused or discontinued medication were disposed of without double signature of the two licensed staff. 2. Narcotic medication (medications with high potential for abuse or unlawful use) removal from the Controlled Drug Record (or CDR, a paper record that tracked narcotic medication use) were not documented in the Medication Administration Record (or MAR- a legal document for medications given to a residents) when given to the Resident 9 and Resident 55. 3. Medication orders in the MAR did not have monitoring parameter for vital signs such as Blood Pressure (or BP, the force of the blood against the artery walls), or heart rate (same as heart beat) in Resident 30, Resident 31. 4. Medication orders in the MAR did not have an indication (medical reason to use) consistent with resident's diagnosis (doctor's medical assessment) or the manufacturer approved indication for use on Resident 34. These failures could contribute to unsafe…

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

Based on interview, and record review the facility failed to ensure one resident (Resident 30) out of 21 sampled residents, was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when the indication for use was not addressed by medical providers consistently. The failure had potential for unsafe medication use in the facility. Findings: During a review of Resident 30's electronic medical record (records in the computer) and the paper chart, on 7/27/22, in the doctor's note section (a section where doctors document,on regular basis, their visit or assess resident's medical condition), the record did not show doctor's note or assessment. During a review of Resident 30's electronic medical record, titled Medication Administration Record (or MAR- a legal document showing doctor's order, how to give the medicine and what is used for), dated 7/2022, the record indicated a medication used to control behavior as follow: QUEtiapine . 25 mg (mind altering medication; mg is unit of measure), Give 0.5 tablet by…

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 the medication error rate was below 5% during the medication administration observation with census of 63. The facility had a total of nine errors out of 51 opportunities which resulted in a facility wide medication error rate of 17.65 % (% or percent, a fraction of the 100th). Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. These failures may result in unsafe medications use and not following the doctor's orders. Findings: During a medication administration observation, in Station 2 of the facility, with Licensed Nurse 3 (LN 3), on 7/26/22, from 8:45 AM to 10:30 AM, the following observation were noted with medication administration to Resident 9, Resident 258, Resident 46, Resident 260, and Resident 21 as follow: a. Resident 9's order for Vitamin D Tablet ., Give 2000 unit (vitamin supplement;units, and mcg measure of dosage), by mouth one time a day for supplement -Start Date- 4 4/07/2022 was instead administered…

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

Based on interview, and record review the facility failed to ensure safe and accurate transcription of doctor's order in the electronic medical record in one out of 21 sampled residents (Resident 41), when a high risk injectable (a shot) medication called insulin (medication given as a shot under the skin to treat blood sugar disease) was transcribed with a dangerous dosage and duplicate orders were transcribed in the Medication Administration Record (or MAR, a legal document showing doctor's order, how and how much medicine to give). This failure had potential to cause adverse health outcomes. Findings: During a review of Resident 41's electronic medical record, titled Medication Administration Record (MAR), dated 7/22, the record indicated an order for insulin as follow: Insulin Aspart Solution 100 UNIT/ML (type of Insulin medication that lowers blood sugar; Units/mL strength of the medicine- means 100 unit in every ML or CC, a measure of volume.) Inject 2 cc (cc or mL was amount or volume to be given) subcutaneously (shot under the skin) before meals related to TYPE 2 DIABETES…

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, observation, and record review the facility failed to ensure safe medication storage practices in the main medication room (a locked room used to store medications and supplies) and one out of three medication carts (a mobile cart stored medication and supplies for immediate use) when: 1. Expired (outdated) medication were stored in the active storage areas in the medication room and the refrigerator. 2. Unlabeled prescription medications were stored in the active storage areas in the medication room and the medication cart. 3. Undated multidose containers were stored in active storage areas in the refrigerator, medication cart and medication room. 4. Discontinued medication stored in the active storage areas in the refrigerator and the medication room. These failed practices could contribute to unsafe medication use in the facility. Findings: During a concurrent observation and inspection of the facility's main medication room, in facility's Unit #1, on 7/25/22, at 11:25 AM, accompanied by Registered Nurse 1 (RN 1), the medication room was crowded, unorganized…

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 the kitchen was free from food being stored past their use-by date and keeping the toaster clean after use as evidenced by 1. Multiple unlabeled, undated pre-made sandwiches, fruits and vegetables were stored and used by their use-by date in the kitchen refrigerator. 2. Toaster containing black debris matter This failure has the potential to cause foodborne illnesses to any resident who consumes them which can result in illness or hospitalization. Findings: 1. During a concurrent observation and interview on 7/25/22, at 10:26 a.m., with [NAME] 1 in the kitchen at Refrigerator 1, seven 16-oz packages of strawberries dated 7/21/22, four unlabeled pre-made sandwiches, one unopened large package of salad mix with brown lettuce leaves dated 7/14/22 were found in Refrigerator 1. [NAME] 1 stated strawberries were allowed to be kept up to one week. [NAME] 1 further stated that pre-made sandwiches should be labeled before being stored in the refrigerator and the package of salad mix is bad and should be thrown…

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 garbage and refuse were properly stored in dumpster when the lid of one of two dumpsters was broken and did not securely cover the bin. This failure had the potential for pest infestations and spread of diseases in the facility. Findings: During a concurrent observation and interview on 7/26/22, at 10:10 a.m. with IADM (Interim Administrator), one large garbage dumpster in the rear building was propped open with broken lids. IADM stated, she was not aware dumpster lid was broken. During an interview on 7/27/22, at 1:10 p.m., with House Keeping (HK) 1, HK 1 stated, dumpster lid was broken two months ago. HK 1 further added, leadership member was aware dumpster lid was broken.

Based on observation, interview, and record review, the facility failed to store, distribute, and serve food under sanitary conditions when refrigerated food items were not dated, when a scoop was stored in a food bin, a dented can was stored along with other undented cans in the dry food storage area, dirty plates were stored as clean, kitchen swamp cooler vents were unclean and dietary staff had uncovered hair. These deficient practices had the potential to place residents at risk for foodborne illnesses. Findings: During an initial kitchen observation on 12/9/19 from 8:50 a.m. to 9:30 a.m.: The Food and Nutrition Service Director (FNSD) wore a cap style hairnet with her bangs uncovered. Refrigerator #2 contained seventeen four ounce undated cups including thirteen teas, one orange juice and three milks. A scoop was stored in a bin containing lentils. One dented six pound can of corn was stored on a shelf in the dry food storage area with undented cans. During an observation of the kitchen on 12/11/19 at 12:01 p.m. to 12:25 p.m. with Cook, small black particles were on six…

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 one Registered Nurse (RN 2) failed to wash her hands according to facility guidelines for Handwashing/Hand Hygiene when performing a dressing change on one Resident's (Resident 56) pressure ulcer. This had the potential to transfer germs from RN 2's unwashed hands after cleaning Resident 56's wound to the cleansed wound, which could increase the risk of infection. Findings: Review of a Skin and Wound Evaluation dated 12/9/19 indicated the Resident 56 has a Stage III pressure ulcer (sore that has gone through the second layer of skin) to the coccyx (lower back) with an area of 7.1 cm, and a length of 3.9 cm and a width of 2.2 cm. During an observation on 12/12/19 at 10:00 a.m., Wound Treatment Nurse (RN 2) was observed doing the dressing change to Resident 56's coccyx. After the dressing was removed and the wound was cleansed with normal saline, RN 2 washed her hands and donned a new pair of clean gloves. Then RN 2 wiped Resident's skin surrounding the pressure ulcer and removed and donned new gloves twice without sanitizing her…

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 interior temperature were within comfortable level when rooms [ROOM NUMBERS]'s temperature were below comfortable level. This failure had the potential to result in uncomfortable interior temperature. Findings: During an interview with Resident 42 on 12/10/19 at 8:42 a.m., Resident 42 stated the room was always cold. Resident 42 stated the vent was blowing cold air even in winter. Resident 42 shared the room with another resident. Review of Resident 42's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 11/16/19 indicated Brief Interview for Mental Status score of 15 (BIMS, an assessment tool for resident's orientation to time and capacity to remember, BIMS score range is from 0-15, with zero as the most impaired). During an observation and concurrent interview with Maintenance Supervisor (MS) on 12/11/19 at 11:49 a.m., MS stated the rooms would be slightly colder that the hallways because the Certified…

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, for one of two sampled residents (Resident 41), facility failed to develop and implement a comprehensive care plan to address Resident 41's self-administration of an eye medication. This failure had the potential to result in improper use of eye medication. Findings: Review of Resident 41's admission Record indicated Resident 41 had been known to the facility since 6/27/18. During an observation and concurrent interview with Resident 41 on 12/10/19 at 9:42 a.m., Resident 41's over-bed table had an opened box of eye medication. Resident 41 stated it was an eye drop medication to treat dry eyes. During an interview with Resident 41 on 12/10/19 at 10:34 a.m., Resident 41 stated to apply one to two drops of the eye medication in his left eye every two hours making sure that the tip did not touch his eye. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 12/10/19 at 10:38 a.m., LVN 2 stated Resident 41 had been doing self-administration of an eye medication for awhile. LVN 2 stated they had Resident 41's eye 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 and record review, for one of 21 sampled residents (Resident 10), the facility failed to provide nail care. This failure had the potential to result in skin infections around the nail bed. Findings: Review of Resident 10's admission Record indicated Resident 10 had been known to the facility since 3/24/17 with diagnoses that included intracerebral hemorrhage (bleeding in the brain). During review of Resident 10's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 9/13/19 indicated Resident 10 had moderate impairment in cognitive skills for making daily life decisions. Resident 10 required extensive staff assistance during activities of daily living that included personal hygiene (how resident maintains personal hygiene like combing hair, brushing teeth, washing/drying face and hands). During an observation and concurrent interview with Director of Staff Development (DSD) on 12/10/19 at 9:44 a.m., DSD stated Resident 10's fingernails were long and curled up. DSD stated, if residents' fingernails were not dirty, staff did not…

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

Based on observation, interview and record review, for one of two sampled residents (Resident 10), who were investigated for accident hazards, the facility failed to ensure the environment was free from accident hazards when Resident 10's low air loss mattress was not secured to the bed frame. This failure had the potential to result in avoidable falls. Findings: Review of Resident 10's admission Record indicated Resident 10 had been known to the facility since 3/24/17 with diagnoses that included intracerebral hemorrhage (bleeding in the brain). During review of Resident 10's Morse Fall Scale dated 9/12/19, Resident 10's score was 75, which indicated Resident 10 was at high risk for falling. During review of Resident 10's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 9/13/19 indicated Resident 10 had moderate impairment in cognitive skills for making daily life decisions. Resident 10 required extensive assistance from two staff during activities of daily living that included bed mobility (how resident moves to and from lying position turning from…

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.