Meadows Ridge Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review for one of three sampled residents (Resident 1), the facility failed to follow their policy in providing Activities of Daily Living (ADLS) when personal hygiene was not provide as needed and failing to notify responsible party (RP) of Resident 1 ' s shower refusals. This failure has potential in putting Resident 1 ' s health and safety at risk when hygiene needs were not met. Findings: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: cerebral infarction (blood blocked to brain, causing tissue death), Benign Prostatic Hyperplasia (enlarged prostate) Neurogenic Bladder (bladder retention), Urinary tract infection, schizoaffective disorder (hallucination s, delusions), hypertension (high blood pressure). During a concurrent interview and record review of Resident 1 ' s Medical Record with the Director of Nursing (DON), reviewed are as follows: 1. Task…

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 store, prepare, and serve food in accordance with professional standards for food service safety, when: 1. On October 1, 2024, two unopened one-pound bags of mini marshmallows, with an expiration date of August 8, 2024, were found stored on top of a shelf in the dry storage room and was available for use. 2. On October 1, 2024, one 4 oz (ounce- a unit for measuring liquid) cup of apple juice and one 4 oz cup of cranberry juice, with the date September 29, 2024, were found on Resident 51's bedside table and were available for consumption. These failures have the potential to compromise food safety and increase the risk of foodborne illness (caused by the ingestion of contaminated food or beverages) for 84 vulnerable residents receiving food from the facility's kitchen. Findings: 1. During a concurrent observation and interview on October 1, 2024, at 8:19 AM, with the Dietary Supervisor (DSS), in the kitchen, the dry storage room was inspected. Two unopened one-pound bags of mini marshmallows, with 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 the interview and record review, the facility failed to ensure that Significant Change of Status Assessments (SCSA- required when a resident's condition has significantly changed, either improving or declining, and the change is expected to last longer than two weeks) of the Minimum Data Set (MDS- federally mandated assessment tool) were completed within 14 days for one of three residents reviewed for pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device)(Resident 39) when Resident 39 had a significant decline in her condition due to severe weight loss and changes in the stage (a system used to classify severity) of her pressure ulcers. This failure resulted in Resident 39's care plan not being updated and revised to reflect her current status, which had the potential to delay the implementation of her care and support needs. Findings: During a review of Resident 39's admission Record (a document that contains…

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 one of eight residents reviewed for Range of Motion (ROM- full movement potential of a joint) (Resident 39) receives appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM when Resident 39's Restorative Nursing Assistant (RNA- help residents improve and maintain their physical abilities and ADLs, and prevent further decline) orders were not carried out in a timely manner. This failure could have potentially caused a delay of preventing severe contractures (a medical condition characterized by the shortening and hardening of muscles, tendons, or connective tissues, which can lead to stiffness and restricted movement in joints) of all extremities. Findings: During a review of Resident 39's admission Record (a document that contains demographic and clinical data), it indicated Resident 39 was admitted to the facility on [DATE], with diagnoses of protein-calorie malnutrition (nutritional status in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with prescriber's orders and facility policy for one resident reviewed for use of antibiotic (medication used to treat bacterial infections) (Resident 39). This failure had the potential to make the antibiotic less effective and prolong the course of treatment, placing Resident 39's health at risk. Findings: During a review of Resident 39's admission Record (a document that contains demographic and clinical data), the admission Record indicated, Resident 39 was admitted to the facility on [DATE], with the diagnoses of protein-calorie malnutrition, (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dystonia (movement disorder), and epilepsy (brain disorder that causes recurring, unprovoked seizures). During a review of Resident 39's physician order, dated August 21, 2024, it indicated, Ertapenem Sodium (Ertapenem…

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 one of six residents reviewed for nutrition (Resident 39) received a diet prescribed by their physician in a timely manner. This failure had the potential to place Resident 39 at risk for further nutrition and medical decline. Findings: During a review of Resident 39's admission Record (contains demographic and clinical data), it indicated Resident 39 was admitted to the facility on [DATE], with diagnoses of protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dystonia (movement disorder), and epilepsy (brain disorder that causes recurring, unprovoked seizures). During a review of Resident 39's Outpatient Clinic Prescription from her Primary Care Physician, dated August 8, 2024, it indicated Please d/c [discontinue] current diet and follow recommendations per Barium test result. Small quarter size chopped soft diet w/ [with] thin liquids 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control prevention were implemented among a highly vulnerable population of 86 residents, when an oxygen tubing (thin plastic tube that connects a machine, which makes extra oxygen to a person's nose) and related oxygen supplies were not replaced in accordance with the facility's policy and procedure for one of five residents reviewed for oxygen (Resident 34). This failure has the potential to cause and increased risk of infection to Resident 34 due to prolonged use of respiratory equipment without proper replacement. Findings: During a record review of Resident 34's admission Record (contains demographic and medical information), it indicated Resident 34 was admitted to the facility on [DATE], with diagnoses of cerebrovascular disease (like a stroke, where the blood flow to part of the brain is block), dementia (general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor…

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 a certified nursing assistant was able to demonstrate competency in skills and techniques for one of three sampled residents (Resident 1) when a Certified Nursing Assistant (CNA 1) did not report Resident 1's redness on the nose to a licensed nurse. This failure had the potential to result in delayed treatment and care for Resident 1, placing Resident 1 ' s health at risk. Findings: During a review of Resident 1 ' s admission Record (contains demographic and medical information), the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of malignant neoplasm of the stomach (stomach tumor), malignant neoplasm of unspecified kidney (kidney tumor) and repeated falls. During a concurrent observation and interview on September 5, 2024, at 9:58 AM, with Resident 1, in Resident 1 ' s room, Resident 1 was lying in bed. Resident 1 ' s bed was in the lowest position. Resident 1 had redness on her nose,…

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 services were provided in accordance with resident needs and safely for one of 3 Residents (Resident 1) when: 1.Resident 1 acquired an open wound to right hand pinkie finger. 2.No wound dressing as ordered noted on pinkie finger open wound. 3.No wound care treatment as per Treatment Record for September 23, 2024. This failure resulted in a clinically compromised resident, (Resident 1) health and safety at risk, when the developed in facility and wound was exposed with possibility for infection. Findings: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included: enterocolitis due to clostridium difficile (disruption of normal bacteria in colon from antibiotics causing diarrhea), mononeuropathy (compression of nerve, cause loss of movement/sensation), muscle weakness, abnormal posture, dysphagia (difficulty…

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 record review, the facility failed to ensure supervision, monitoring, and implementation of interventions were enforced for one of three sampled residents (Resident 1) when Resident 1's whereabouts were not monitored and documented in accordance with the physician's orders and care plan after Resident 1 had an altercation with another resident on June 11, 2024. This failure had the potential for Resident 1 to have an increased risk of further altercation which could place him at risk of injuries and bodily harm. Findings: During a review of Resident 1's admission Record, (contains demographic and medical information), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest task), and anxiety disorder (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 follow policy and procedure to ensure call lights were answered in timely manner to provide care and services for two of three sampled residents (Resident 1 and 2). This failure had the potential to place a clinically compromised Residents (Resident 1 and 2) safety at risk. When residents were left soiled, and their activities of daily living were not met in timely manner. Findings: During interview and Records Reviewed with (Resident 1 and 2) indicates as followed: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include osteoarthritis of left knee ( degeneration of joint cartilage, and it causes pain and stiffness), spinal stenosis (space inside the bones of the spine gets too small), Polyneuropathy ( multiple nerves outside of the brain and spinal cord becomes damage), Hemiplegia ( paralysis of one side of the body),…

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 follow policy and procedure to ensure call lights were answered in timely manner to provide care and services for six of seven sampled residents (Resident 1,2, 3,4,5, and 6). This failure had the potential to place a clinically compromised Residents (Resident 1,2, 3,4,5, and 6) health and safety at risk. When residents were left soiled, and their activities of daily living were not met in timely manner. Findings: During interview and Records Reviewed with (Resident 1,2, 3,4,5, and 6) indicates as followed: 1. During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include type 2 diabetes (condition affecting how body processes sugar), intestinal obstruction (digested material prevented from passing normally), major depressive disorder (depressed mood, loss of interest). During an interview with Resident 1, Resident 1 states, Call…

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 ensure the care plan (a summary of a resident's health conditions, specific care needs, and current treatments) was implemented for one of three sampled residents (Resident 3) when Resident 3's care plan intervention for psychology consult was not implemented after an alleged abuse was reported by Resident 3 on January 30, 2024. This failure had the potential to cause a delay in identifying Resident 3's psychological need, immediate care and support needs which could place her mental and psychosocial well-being at the higher risk. Findings: During a review of Resident 3 ' s admission Record (clinical record with demographic information), it indicated Resident 3 was admitted to the facility on [DATE], with diagnoses of hypertension (blood pressure that is higher than normal), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (a mental disorder often worried or anxious about many…

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 protect the resident's right to be free from abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), for one of three sampled residents (Resident 1), when a Certified Nursing Assistant (CNA 1) had a verbal altercation with Resident 1, pushed his wheelchair outside the facility and closed the door, leaving Resident 1 outside the facility on July 2, 2023. This failure had the potential for Resident 1 to experience psychosocial harm. Findings: During a review of Resident 1's admission Record (clinical record with demographic information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disrupted blood flow to the brain), end stage renal disease (medical condition in which kidneys cease functioning), and hyperlipidemia (elevated fat in the blood). During a concurrent observation 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 observation, interview, and record review, the facility failed to maintain professional standards for food service safety when: 1. The top of the mixer and the coffee maker were dusty, which had the potential to contaminate the food and coffee with dust. 2. The floors under the center island and behind the ice machine had food crumbs and trash, which had the potential to attract microorganism carrying pests. 3. Two plastic four-quart containers were stacked and stored wet, which had the potential for bacteria (can cause disease) growth. 4. Two metal pans, which stored clean utensils, had liners with food crumbs under the liners, which had the potential to attract microorganism carrying pests and contaminate the clean utensils 5. The ice machine had black build up in the ice chute (where ice exits the area where its formed and drops into the ice bin), which put residents who used or ingested ice from this machine, at risk for food-borne illness (illness acquired from ingesting contaminated food). 6. The dishwashing machine was not sanitizing, which led to dishes not being…

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 did not properly dispose (get rid of by throwing away) of trash when the outside dumpster area had gloves, trash, and rotten (decomposing or break down) food on the ground. This failure had the potential to attract vermin (pest or animals that spread diseases) in the facility that cares for 81 medically compromised residents. Findings: During a concurrent observation and interview, on April 4, 2022, at 9:29 AM, with the Dietary Supervisor (DS), the outdoor garbage storage area had gloves, trash, and rotten food on the ground. The DS stated that the outdoor garbage storage area should be clean and free of food or trash. During a review of the facility's policy and procedure (P&P) titled, Waste Control and Disposal, dated 2019, indicated, Outside garbage bin should be kept closed at all times and surrounding area must be kept clean. During a review of the FDA Federal Food Code, 2017, it indicates in 5-501.11 Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records review, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary, and comfortable environment to help prevent the possible development and transmission of a Coronavirus, COVID-19 (a highly contagious respiratory infection) when: 1. Resident 389 was observed not following proper personal protective equipment (PPE) guidelines when Resident was in yellow zone (Residents under isolation observation for suspected COVID-19). 2. The COVID-19 screening forms (forms that are used to screen individuals for COVID-19 symptoms prior to entry into the facility) were not completed on the visitor's COVID-19 screening forms before entering the facility. 3. One Registered Nurse (RN 1) did not perform hand hygiene or hand washing before prepping and administration of medications between three out of eight residents. (Residents 27, 56 and 11) 4. A Licensed Vocational Nurse (LVN 2) failed to wear PPE (personal protective…

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 record review, the facility failed to ensure the Advance Directives (A legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions), were completed for nine sampled residents (Residents 25, 432, 389, 77, 55, 58, 81, 61 and 75). This failure had the potential to result in a delay of treatment for the residents as related to advance directives, or for life sustaining measures to be rendered against what the resident wanted. Findings: 1.During a review of Resident 25's admission Record (clinical record with demographic information), the admission Record indicated, Resident 25 was re-admitted to the facility on [DATE], with diagnoses which includes end stage renal disease (a condition in which kidneys cease functioning), heart failure ( a chronic condition in which the heart does not pump blood as well as it should), cirrhosis of liver (condition where liver is permanently damaged), dependence on renal dialysis (a…

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

Based on observations, interviews, and record review, the facility failed to provide appropriate treatment and services to increase range of motion or to prevent further decrease in range of motion for five of 21 sampled residents (Resident 4, 9, 14, 24, 73), when range of motion exercises, splints and hand rolls were not provided as per physician orders. This failure had the potential to decrease in the range of motion and could have resulted in worsening of contractures (joint stiffness) and mobility. Findings: 1. A review of the facility document titled admission Record, (a document contains clinical and demographic data). Resident 4, admission dated January 4, 2022 (current), with the diagnoses of cerebral infarction (stroke), abnormal posture, and multiple sites contractures of muscles (joint stiffness, tightening of muscles or tendons). A review of the facility document titled, Order summary report, the active physician orders dated, January 5, 2022, indicated, Restorative Nursing Assistant (RNA) orders for range of motion exercises to bilateral lower and upper extremities…

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 maintain acceptable parameters of nutritional status for two of 81 residents (Resident 75 and Resident 58) when: 1. Resident 75 lost 16% of her body weight from January 14th, 2022, to April 2, 2022. Her gastrostomy tube (GT- a tube placed through abdominal wall through which liquid nourishment and medications are administered) feeding rate was calculated on her adjusted body weight (adj bw) (calculation used to calculate energy needs for overweight or obese people who want to lose weight) of 56.6 kilograms (equals 124.5 pounds) which was 40 pounds less than her actual body weight. 2 Resident 58 lost 13% of his body weight in 3 months from January 2022 to April 2022. Resident 58 was improperly assessed by the Registered Dietitian (RD 1) when she did not do an in-person assessment and staff did not inform her that resident was eating with his hands. Resident 58 was observed eating with his hands on a mechanical soft diet (texture-modified…

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 their daily menu for lunch when, on April 5, 2022, at 12:45 PM, the [NAME] 1 did not prepare the puree (food that is blended until it is a thick, smooth, lump-free consistency) diet lunch correctly. The [NAME] 1 pureed regular bread for the puree diets but should have pureed garlic bread. 17 Residents received the puree diet. This failure had the potential for residents to lose their appetite and compromise the nutritional status of 17 out of 78 Residents, Findings: During a concurrent observation and interview on, April 5, 2022, at 12:45 PM, a regular diet test tray and a pureed diet test tray was sampled. The cook served the regular diet and puree diet test tray from the food on the tray-line that was prepared for the residents. The puree bread did not taste similar to the regular diet bread. The Dietary Supervisory (DS) tasted the puree bread and the regular garlic bread and stated that the pureed bread did not taste the same as the garlic bread. He stated he needed to check the spreadsheet 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 observations, interviews, and record review, the facility failed to maintain an effective pest control program for two residents' rooms (room [ROOM NUMBER] bed 2, and 305 bed 2), when several small flies were observed flying in room [ROOM NUMBER] bed-2's ceiling and by bedside table, and flies observed in room [ROOM NUMBER] bed 2 on the walls and ceiling. These failures had the potential to cause irritation to residents' skin and could spread infectious bacteria to the residents. Findings: 1. During an observation and an interview on April 4, 2022, at 11:41 AM, in Resident 39's room [ROOM NUMBER] bed 2, there were several small flies (gnats) on the right side of the room next to Resident 39's bed on the bedside table, on the wall of right side of the room. When asked about the flies, the Resident 39 stated, the flies had been there for a while. During an interview on April 4, 2022, at 12:53 PM, with the Certified Nurse Assistant (CNA 2), when asked about the flies in room [ROOM NUMBER] bed 2, CNA 2…

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 dignity was maintained for one of one sampled resident (Resident 11) when Resident 11's urinary catheter (flexible tube inserted into the bladder to drain urine) bag, was not covered by a dignity bag. This failure had the potential to compromise Resident 11's dignity and violate his right to privacy, which could cause psychosocial harm and lead to low self-esteem, feeling irritated, sad, and anxious. Findings: During a review of Resident 11's admission Record (clinical record with demographic information), the admission Record indicated, Resident 11 was admitted to the facility on [DATE], with diagnoses which includes chronic obstructive pulmonary disease (a lung disease that makes it difficult to breath), type 2 diabetes mellitus (a condition where body does not produce enough insulin), left hand contractures, gastro-esophageal reflux disease (condition in which stomach acid flows back into the esophagus), schizoaffective disorder…

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 interviews and closed record review, the facility did not ensure that one of three closed record sampled residents (Resident A) had orthostatic blood pressures (Blood pressure is taken, lying, sitting, and standing to determine if there is a drop with position change) or do vital signs (temperature, pulse, respiration and blood pressure) every four hours as well as, the oxygen saturation level as ordered by the physician. This failure resulted in resident being transferred to a hospital (a higher level of care). Findings: During a closed record review for Resident A on [DATE], at 12:00 PM, the face sheet indicated Resident A as admitted on [DATE], with diagnoses which included : hemiplegia (paralysis on one side of the body), hemiparesis (weakness or inability to move on one side of the body), history of cerebrovascular accident (damage to the brain from interruption of its blood supply), Lewy Body dementia (a disease associated with abnormal deposits of a protein in the brain, which can lead 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 observations, interviews, and record review, the facility failed to ensure adequate supervision was provided for one Resident (Resident 56), when the facility did not implement intervention (floor mat) to prevent future falls as indicated in the care plan and the physician orders. This failure had the potential to result in future falls and increase the risk of injury related to falls. Findings: A review of the facility document titled admission Record, (a document contains clinical and demographic data). Resident 56 was a [AGE] year-old female, admission dated November 5, 2021, with diagnoses of diabetes mellitus (increase sugar level in the blood), hypertension (increase blood pressure), generalized muscle weakness, syncope (sudden loss of consciousness). During an observation on April 4, 2022, at 11:26 AM, Resident 56 was observed to be in bed, the bed was against the left wall and there was no floor mat on the right side of the bed. During an observation on April 7, 2022, at 3:21 PM, Resident 56 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.

Based on interview, and record review, the facility failed to ensure glucometer (device used to measure sugar levels in blood) calibration monitoring were complete for three of three nursing units (Unit 1, 2 and 3). These failures had the potential to get inaccurate blood glucose results for 20 residents receiving insulin. Findings: During a concurrent observation and interview on April 6, 2022, at 5:49 AM, with the License Vocational Nurse (LVN 1), medication cart for Unit 1's Quality Control Record [name of the glucometer] (QCR), dated April 2022, was reviewed. The QCR includes Operators Initials, Meter Cleaned and Disinfected, Meter Strip Lot #, Test Exp. Date, Test Strip Normal Lot #, Expiration Date, Normal Control Range, Normal Control Result, Normal High Lot #, Exp. Date, High control Range, High control Result, High Corrective Action. The QCR indicated the following: a. On April 2, 2022, all columns were left blank. b. On April 3, 2022, all columns were left blank. c. On April 4, 2022, all columns were left blank. The LVN 1 stated that the QCR had some missing documentation…

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 did not ensure to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for three of three medication carts (Carts 1, 2 and 3). These failures placed the facility at potential for diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff. Findings: During a concurrent observation and interview on April 6, 2022, at 5:47 AM, with the License Vocational Nurse (LVN 1), medication cart 1's Floor Narcotic Release (FNR - a form used by facility to verify counting of controlled drugs at the change of shift by oncoming and off going licensed nurses), dated April 2022, was reviewed. The FNR indicated the following: a. On April 1, 2022, missing signatures from incoming nurses (IN) and outgoing nurses (OUT) at 7:00 A (7-3 IN), 3:00 P (7-3 OUT), 11:00 P (11-7 IN). b. On April 2, 2022, missing signatures from incoming…

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 did not accommodate one of 78 residents (Resident 387) preferences on a vegetarian diet (a diet that does not include any meat, poultry, or seafood) by not having a vegetarian menu available. This failure had the potential for Resident 387 to have a compromised nutritional status due to not eating a varied (a number of different types) and nutritionally balanced (the correct number of calories and nutrients) vegetarian diet due to the facility not having a vegetarian menu planned a week in advance. Findings: During an observation on April 4th, 2022, at 12:10 PM, the cook served Resident 387, scalloped potatoes, garlic spinach, and a roll. The Diet Aide grabbed the plate and put a cover on it and put it on the cart for delivery. The registered dietitian stopped the staff and said that this resident needed a protein. She told them to add a serving of cottage cheese. During a concurrent interview and record review on April 5, 2022, at 10:55 AM, with…

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.