Granite Hills Healthcare & Wellness Centre, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to investigate and analyze the root cause for recent weight loss for one of one resident (Resident 3) reviewed for nutrition. This failure had the potential for Resident 3 to experience additional weight loss. (Cross Reference F-641, F-685, F-842) Findings: Resident 3 was readmitted to the facility on [DATE], with diagnoses which included Parkinson's disease (a progressive brain disorder that causes nerve cells in the brain to deteriorate, leading to body movement problems), per the facility's admission Record. An observation was conducted of Resident 3 on 1/27/25 at 9:58 A.M., in his room. Resident 3 had a covered, untouched breakfast tray sitting on his bedside table. An observation and interview was conducted with Resident 3 on 1/27/25 at 12:52 P.M. in his room. Resident 3 was heard telling staff if did not want his lunch tray and to take it away. An unidentified staff returned Resident 3's lunch tray to the food cart. Resident 3 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 and record review, the facility failed to identify triggers related to PTSD ( post-traumatic stress disorder- difficulty recovering after experiencing or witnessing a traumatic event ) for two of two residents (Resident 27 and 35) reviewed for trauma-informed care. This failure had the potential to result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience) that could lead to severe psychosocial harm and affect the resident's quality of life. Findings: 1.) A record review of the facility's admission Record indicated Resident 27 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder, anxiety disorder, and schizoaffective disorder (a mental illness that affects thought, mood and behavior). An interview on 1/27/25 at 10:50 A.M., with Resident 27 was conducted . Resident 27 stated the staff here did not know how to handle his PTSD. Resident 27 stated, his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor behaviors and side effects of a psychotropic medication (a drug to control thoughts and behaviors) for one of five residents (Resident 11) reviewed for unnecessary psychotropic medications. This failure placed the resident at risk for receiving unnecessary medication and having unrecognized adverse reactions. Findings: According to the admission Record, Resident 11 was admitted on [DATE] with diagnoses which included Tourette's Disorder (a disorder that causes people to make sudden and repeated twitches, movements, or sounds) and dementia. According to the Minimum Data Set (MDS, an assessment tool) Resident 11 had a BIMS (a tool to assess cognition) of 8, which indicated cognitive impairment. On 1/27/25 at 8:46 A.M., an observation was conducted in Resident 11's room. Resident 11 was in bed and repeatedly stated, [NAME]! [NAME]! [NAME]! Resident 11 was observed with an open wound between the upper lip and nose. Resident 11 did not respond to…

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

Based on observation, interview, and record review, the facility failed to secure one of three treatment carts (East Station) and one of three medication carts (East Station), when reviewed for Pharmacy Services. This failure had the potential for residents, staff, and visitors to have access to unauthorized medications and wound supplies. Findings: An observation was conducted on 1/30/25 at 7:15 A.M., in East Station area near the nurse's station. A treatment cart was up against the wall between the nurse's station and the exit door to the secured unit (a specialized care unit which is locked and limits residents with memory loss or mental health issues from exiting the unit without supervision), and was unlocked. In the top drawer of the treatment cart were prescriptions creams and ointments. The second drawer contained scissors and wound dressing material. No staff were present in the area. An observation was conducted on 1/30/25 at 7:16 A.M., in the East Station area across from the treatment cart. A medication cart was pushed up against the exterior nurse's station 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, and record review, the facility failed to accurately document: 1. Food intake percentages (how much a resident consumes for each meal) for one of one resident (Resident 3), reviewed for nutrition; and 2. Care given to one of three residents (Resident 84) reviewed for Activities of Daily Living (ADL'S). As a result, resident records were inaccurate and did not give a clear picture of the resident's current status to other care providers. Cross Reference (F-692) Findings: 1. Resident 3 was readmitted to the facility on [DATE], with diagnoses which included Parkinson's disease (a progressive brain disorder that causes nerve cells in the brain to deteriorate, leading to body movement problems), per the facility's admission Record. An observation was conducted of Resident 3 on 1/27/24 at 9:58 A.M., in his room. Resident 3 had a covered, untouched breakfast tray sitting on his bedside table. An observation and interview was conducted with Resident 3 on 1/27/25 at 12:52 P.M. in his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its policy and procedure for fall prevention program for two of three sampled residents (Residents 2 and 3) who had incidents of repeated falls. This failure placed Residents 2 and 3 at risk for further falls and injuries. Findings: 1) According to the admission Record, Resident 2 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included history of falling, lack of coordination, and abnormalities of gait and mobility. A review of the facility's Incidents By Incident Type log indicated Resident 2 had unwitnessed falls on 11/1/24 and 12/3/24. On 12/27/24 at 9:55 A.M., Resident 2 was observed in bed. There was a small cut on the left side of Resident 2's forehead. Resident 2's call light was observed plugged into the wall and was missing the cord and button. On 12/27/24 at 10:04 A.M., a concurrent interview and observation was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she was the assigned…

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 resident rights were honored for 1 of 3 sample residents (1) when the Medical Record Department (MRD) could not provide evidence that Resident 1's representative received copies of the medical record requested in a timely manner. As a result, there was a delay in reviewing Resident 1's medical record. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, per the admission Record. On 10/2/24 at 2:20 P.M., an unannounced onsite visit at the facility was conducted for an complaint investigation related to a medical record request. On 10/2/24 at 3 P.M., an interview was conducted with the Medical Record Director (MRD). The MRD stated she did not have a log of the names of the residents or representatives who requested access to medical records. The MRD further stated their process was for the resident or representative to complete the request form. The MRD then asked the corporation via e-mail for…

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 follow appropriate discharge protocols for one of one resident (Resident 1). This failure had the potential for Resident 1 not being able to return to the facility which he considered his home and not being able to appeal the discharge. Finding: During a review of the admission Record, Resident 1 was admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (irreversible kidney failure). During a review of the Bed Hold Agreement dated September 10, 2024. The Bed Hold agreement indicated that the facility will hold Resident 1 ' s bed for up to seven (7) days if the resident is transferred to a general acute care hospital The document indicated that Resident 1 was being transferred to [name] Hospital. During a review of the facility census, it indicated Resident 1 had a bedhold for September 10, 11, 12, 13, 14, 15 and 16. Per the same facility census, on September 17, 18, 19 it indicated Resident 1 was no longer on the census 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 interviews and record review the facility failed to provide a medication as ordered by the physician to one (Resident 1) of three sampled residents. This failure had the potential to elevate Resident 1 ' s ammonia levels. Resident 1 ' s record was reviewed. Per Resident 1's admission Record, Resident 1 is a [AGE] year-old female admitted to the facility on [DATE]. Resident 1 ' s diagnosis included cirrhosis of the liver (scarring that prevents the liver from working properly) and hepatic encephalopathy (loss of brain function when the liver does not work properly). During a record review of Resident 1 ' s admission orders dated 8/30/24, Resident 1 was admitted with a physician's order for lactulose (a medication used to prevent and treat hepatic encephalopathy) 30 grams by mouth three times a day. During a record review of Resident 1 ' s Medication Administration Record (MAR) for August 2024, the Licensed Nurse (LN) had not initialed or signed (recorded administration) lactulose medication 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 observation, interview, and record review, the facility failed to ensure that cooks followed recipes when preparing meals. This deficient practice had the potential to impact the residents' nutritional status and not meet the residents' desires to be served food they felt was palatable and attractive. Findings: Between 6/24/24 and 6/25/24, nine alert, oriented residents were interviewed. Five complained of bad food ; bland food ; horrible, especially lunch ; not great, too small ; and losing weight due to bad food all day . On 6/24/24 at 1 P.M. an observation and interview were held with Diet Assistant (DA) 1. Raw chicken in bags were observed on top of ice-filled cooking sheets. DA 1 stated she was going to prepare the chicken for dinner. The chicken will go in the oven around 2:30 P.M., cook for 30-45 minutes and then go to the steam table. On 6/24/24 at 1:15 P.M. an interview was held with the Food Services Director (FSD). The FSD stated that putting the chicken in the oven as DA 1 planned, at 2:30, was too soon, and would affect the palatability, making the chicken…

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 develop and implement an individualized care plan for one of two residents (Resident 1) reviewed for elopement (leaving the facility without permission). This failure had the potential to put Resident 1 at risk for further elopements and injury. Findings: On 7/18/24, an unannounced visit was made to the facility following a facility reported incident of a resident's elopement from the secured unit. According to the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses that include paranoid schizophrenia (a mental disorder that affects a person's ability to think, feel and behave clearly) and bipolar disorder (a mental condition that causes extreme mood swings). On 7/18/24 at 10:26 A.M., an observation was conducted in the secured unit. Resident 1's bedroom was observed with a sliding glass door leading to the outside patio. On 7/18/24 at 10:50 A.M., a concurrent observation and interview 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 and record review, the facility failed to ensure the clinical record was complete and accurate for 1 of 2 sampled residents to meet the standard of practice, when Resident 1 had a blood draw performed (a procedure in which a needle is used to take blood from a vein, usually for laboratory testing). As a result, Resident 1's medical record could not accurately reflect the care provided. This lack of documentation poses a potential risk to Resident 1's health, as it hinders the ability to track and monitor the effectiveness of the care provided. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Failure (kidneys can no longer support the body's needs) and renal dialysis (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to), per the admission Record. On 3/28/24 at 3 P.M., Resident 1 stated he woke up and saw the phlebotomist (a trained professional who draws blood) draw…

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 was followed when Certified Nursing Assistant (CNA) 2 was inside the isolation room without appropriate Personal Protective Equipment (PPE-equipment worn to minimize exposure to infectious agents). As a result, there was a potential for cross-contamination (physical movement or transfer of harmful bacteria or viruses from one person, object or place to another). Findings: On 3/11/24 at 2:45 P.M., during the initial tour of the unit, signage indicating droplet precautions and PPE precautions was posted by the doors of rooms [ROOM NUMBERS]. Personal Protective Equipment: N-95 masks, gowns, and gloves were also hung on the door for staff use. On 3/11/24 at 3 P.M., room [ROOM NUMBER]'s door was observed opened, and CNA 2 was inside the isolation room without wearing proper PPE. CNA 2 was standing by the resident's bed near the handrail and talking to the resident. CNA 2 finished the conversation with the…

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

Based on observation, interview, and record review the facility failed to implement interventions to prevent a fall. This failure resulted in Resident 1 sustaining a fractured clavicle (a bone of the shoulder that joins the breastbone and the shoulder blade). Findings: A review of Resident 1 ' s face sheet indicated diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), abnormalities of gait and mobility (change in ability to walk), presence of left artificial hip joint (hip replacement), fracture of femur (a break in the long bone of the leg), fall on same level (a fall not more than the height of the person), lack of coordination (unsteadiness). A review of Resident 1's care plan dated 9/7/23 indicated an intervention of Adequate glare-free light and Be sure resident's call light is within reach and encourage the resident to use it. A review of Resident 1's care plan dated 12/14/23 indicated High backed reclining wheelchair. A review of Resident 1's care plan dated 12/25/23 indicated Room closer to 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 and record review, the facility failed to provide a proper discharge process for 1 of 2 sampled residents (1) when there was no documented evidence that the staff reviewed the personal property inventory and compared the medication list to the discharge medications. As a result, Resident 1's belongings and medications could not be accounted for. Findings: Resident 1 was admitted to the facility on [DATE] and discharged home on 7/12/23, per the facility's Face Sheet. A review of Resident 1's medical record was conducted. Per the Progress Notes, dated 7/12/23, Licensed Nurse (LN) 1 documented Resident 1 was discharged to an independent living with home health services. Resident 1 left the facility with all personal belongings and the remaining medications. Per the Resident Inventory Form, there were no signatures from Resident 1 and the staff under the sections Certification and Receipts to acknowledge all personal belongings were taken home by Resident 1. Per the Discharge Evaluation, there…

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 develop person-centered care plans for one resident (Resident 1) when care plans were not developed for the use of an indwelling urinary catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine) and the presence of a pressure ulcer (a bedsore). This failure could potentially affect the resident in the care areas that were not care planned. These included proper attention and assessment of infection for the use of an indwelling catheter and monitoring of interventions which addressed Resident 1 ' s pressure ulcer. Resident 1 was re-admitted to the facility on [DATE] with the diagnoses including Atherosclerotic Heart Disease (thickening or hardening of the arteries) according to the facility ' s admission Record. During a review of Resident 1 ' s physician orders dated 4/4/22, the physician orders indicated, Insert Foley Catheter and attach to urine bag. During a review of Resident 1 ' s skin evaluation…

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 five resident ' s (Resident 8) food dislike was honored. This failure had the potential to cause Resident 8 to experience an unplanned lose weight. Findings: A review of Resident 8 ' s undated admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. A review of Resident 8 ' s Minimum Data Sheet (MDS- an assessment tool), dated 4/4/22, indicated that Resident 2 had a BIM (Brief Interview of Mental Status – used to screen and identify the mental condition of a resident) score of 10, and per the scoring table, a score of 8-12 indicated moderate cognitive (mental) impairment. A meal observation and interview of licensed nurse (LN) 1 was on conducted on 5/19/22 at 12:54 P.M. LN 1 opened the meal cart and checked the residents ' meal trays. LN 1 checked Resident 8 ' s meal and tray-card and handed the meal tray to a certified nursing assistant (CNA) to deliver 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 to provide results of an abuse investigation within five days of the incident for one of one resident (Resident 1) reviewed for abuse. This failure had the potential to result in a delay in the facility ' s investigation of abuse allegation, and a delay in determining the occurrence of abuse. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of Dementia ((a condition characterized by loss of memory, language, problem solving and other thinking abilities) according to Resident 1 ' s admission record. During an interview on 7/31/23, at 9:10 A.M., with the Assistant Director of Nursing (ADON), the ADON stated Resident 1 was wheelchair bound and had a history of entering different rooms. The ADON stated on 7/17/23, Resident 1 had an altercation with the roommate (Resident 2). The ADON further stated staff heard the commotion from Resident 1 ' s room and separated Resident 1 from Resident 2. An interview was conducted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and dietetic services record reviews, the facility failed to ensure safe and effective dietetic service oversight for food and nutrition services in accordance with the regulation and facility policies when: 1. One of two sampled residents (Resident 71) had a severe weight loss of 12.79 % in six months and was not adequately or timely assessed by the RD, 2. Kitchen staff were not sufficiently trained for competency in food safety and sanitation tasks, and 3. Kitchen sanitation inspections were not performed on a regular basis in accordance with facility protocols and standards of practice. These failures in dietetic services oversight placed 94 residents at risk for compromised nutrition status. Cross reference 692, 802, 812, and 813 Findings: During the annual recertification survey from 6/14/21-6/17/21, multiple issues and concerns regarding dietetic services were unmet and identified including: Regular timely nutrition assessments and monitoring of a resident with significant…

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 ensure the food and nutrition services staff maintained current competency in dietetic task operations to safely carry out the kitchen functions in a sanitary manner according to facility policies and standards of practice when: 1. The A.M. [NAME] (CK 1) could not correctly demonstrate how to test the sanitizer concentration; 2. A Dietary Aide (DA 1) did not take the temperatures or properly store the milk served on lunch trayline; 3. The P.M. [NAME] (CK 2) did not know the correct process to cool down cooked foods. These failures had the potential to result in contamination of food, leading to widespread food borne illness for 94 residents who consume food from the kitchen. Cross Reference F 812 Findings 1. On 6/14/21 at 9:30 A.M., an interview was conducted with CK 1 and the DSS. CK 1 stated he typically checked the sanitizer in the red bucket every morning when he worked. CK 1 demonstrated how he tested the sanitizer strength in a red bucket solution. CK 1 took a test strip from a test strip…

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 ensure safe and sanitary conditions were met according to facility policy and standards of practice within the Food and Nutrition Services department when: 1. Walk-in freezer was overstocked with ice accumulation on the ceiling and cases of foods; 2. A kitchen drawer that stored loose plastic lids to rubber bowls and cups, was covered in black dirt, brown stains, and food crumbs; 3. A nurse's unit refrigerator with resident food had a temperature of 50 degrees F for two days and was dirty with brown and orange stains inside the door shelves and freezer space. These deficient practices had the potential to put residents at risk to foodborne illnesses. Cross reference 801, 802, and 813 Findings: 1. During the initial kitchen tour observation and concurrent interview with the DSS, on 6/14/21 at 8:30 AM, the walk-in freezer ceiling had several areas of ice build-up. The freezer had approximately 1-2 inches of ice accumulation build-up on the ceiling and on top of three cases of food. The DSS stated she was unaware…

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 consistently provide showers for 28 of 32 dependent residents (Residents 15, 19, 21, 27, 36, 37, 38, 40, 41, 48, 49, 50, 51, 52, 55, 56, 57, 58, 59, 60, 61, 63, 64, 65, 72, 75, 87, 93) reviewed for Activities of Daily Living (ADL, bathing, dressing and grooming) in the secured unit (requiring supervision). This failure had the potential for increased skin infections and a decrease in personal hygiene and socialization. Findings: 1. Resident 87 was re-admitted to the facility on [DATE] with diagnoses which included dementia (memory loss), per the facility Face Sheet. On 6/14/21 at 8:39 A.M., Resident 87 was observed sitting on the side of his bed wearing a blue Charger's football jersey, with colored stains going down the front of his jersey. On 6/14/21, Resident 87's clinical record was reviewed: The MDS (a clinical assessment), dated 5/10/21, listed a BIMS score (a cognitive assessment) of 4, (score 0-7 indicates severely impaired…

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 practices were followed appropriately, when: 1. Recommended COVID-19 (a contagious virus) personal protective equipment (PPE), which included the use of gowns, gloves, face shield, and N95 mask (higher level of face mask) were not worn by staff who entered the room of residents located in the yellow zone (unknown COVID-19 status for residents who were newly admitted or re-admitted to the facility), 2. Residents who smoked and were roomed in the yellow zone passed through the green zone (residents who have no exposure to COVID-19) to the smoking area; and, 3. An oxygen humidifier was resting on the floor of Resident 61's room. These failures had the potential for cross contamination of pathogens Findings: 1. On 6/14/21 at 9:35 A.M., an observation and interview was conducted with LN 1 in the yellow zone. LN 1 went into a residents room without putting on a gown and provided care to a resident. LN 1 stated…

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 develop individualized person-centered care plans for three of 19 resident's, (Resident 63, 93, 82) reviewed for care plans when: 1. Resident 63's urinary catheter (a flexible tube that drains urine from the bladder into an external bag) preferences were not documented, 2. Resident 93's dementia (memory loss) was not identified; and, 3. Resident 83's skin condition of psoriasis (a skin disorder), was not addressed. In addition, a physician's order related to tube feeding was not followed for one of four residents (Resident 29) reviewed for medication administration. These failures had the potential for individualized care to not be consistently applied and for Resident 29 to have an alteration in nutritional status. Findings: 1. Resident 63 was admitted to the facility on [DATE] with diagnoses which include hepatic failure (liver failure) per the facility's Face Sheet. On 6/14/21 at 10:16 A.M., an observation and interview 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, and record review, the facility failed to revise a person-centered care plan for four of 19 sampled residents (71, 345). These failures had the potential to negatively impact resident's quality of care. Findings: 1. Resident 71 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis (a disease that affects the brain, spinal cord and nerves), per the facility's Face Sheet. A record review was conducted: Resident 71's MDS, dated [DATE], indicated a weight loss of 5% or more between January and April of 2021. The weight log for Resident 71 had 12.79% weight loss in six months (December 2020 - May 2021). Resident 71's care plan, dated 10/14/20, indicated a risk for weight loss. There were no revisions or updates noted on the care plan to reflect actual weight loss. On 6/17/21 at 11:53 A.M., a concurrent interview and record review was conducted with the DON. The DON stated Resident 71's care plan should have been updated and it was important to revise…

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 comprehensive and effective systematic approach was implemented to monitor and maintain acceptable parameters of nutritional status for one of two sampled residents (Resident 71). Resident 71 experienced a 12.79 percent weight loss in six months that was not addressed by the facility according to facility policy and standards of practice. As a result, Resident 71 had a severe unplanned weight loss. Cross reference F801 Findings: Resident 71 was admitted to the facility on [DATE] with a diagnoses of multiple sclerosis (a chronic disease that affects normal immune system function), per the facility's Face Sheet. An observation and concurrent interview was conducted with Resident 71 on 6/14/21 at 10:45 A.M. Resident 71 was lying in bed awake and stated, I didn't eat the breakfast because I don't really like the food here .I like yogurt and the strawberry health shakes they give me but that's it. A review of Resident 71's medical…

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 physician's order was in place, prior to the administration of oxygen for one of two residents (Resident 61), reviewed for oxygen therapy. This failure had the potential for Resident 61 to develop oxygen toxicity (lung damage from too much oxygen being supplied). Findings: Resident 61 was re-admitted to the facility on [DATE], with diagnoses which included encephalopathy (a disease of the brain) per the facility's Face Sheet. On 6/14/21 9:54 A.M., an observation was conducted inside Resident 61's room. Resident 61 was sitting up in bed, with a nasal cannula (clean plastic tubing that delivers oxygen to the nose) in his nares (nose). The oxygen condenser (a medical device that delivers oxygen) was set at three liters of oxygen per minute (lpm). On 6/15/21 at 1:36 P.M., Resident 61 was observed in bed with his eyes closed, receiving oxygen at three lpm. On 6/15/21 a clinical record review was conducted for Resident 61: 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 provide pain medication to one of one residents reviewed for pain (Resident 146). As a result, Resident 146 had uncontrolled pain. Findings: Resident 146 was admitted to the facility on [DATE], with diagnoses which included pain, per the facility's Face Sheet. On 6/15/21 at 10:04 A.M., an interview was conducted with Resident 146. Resident 146 stated she had to wait a few times for pain medication in the morning. Resident 146 stated she was told by staff, they ran out of the medication during the night. Resident 146 stated she needed it first thing upon waking up in the morning, since she had not received any medication overnight. Resident 146 stated she woke up around 5 A.M., and her pain level became uncontrolled if she did not receive medication soon after waking. A record review was conducted. Per the physician's orders, dated 6/2/21, Resident 146 was prescribed a pain medication every six hours as needed. The CDR was reviewed, for 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 interview and record review, the facility failed to ensure a controlled substance medication (a controlled drug for pain with high abuse potential), was accounted for, for one of four residents reviewed for medication storage (Resident 29). This failure had the potential for the resident to receive more medication than ordered, and for staff diversion (theft). Findings: On 6/17/21 at 3 P.M., an observation of the east unit medication cart was conducted with LN 2. A random controlled medication card was removed for accuracy review. The medication card was labeled for Resident 29. The medication card label indicated Oxycodone/APAP (a pain medication) one tablet every six hours as needed for pain. Resident 29's CDR (a document to initial each dose of a controlled drug each time the medication was administered to the resident) and the MAR were reviewed for the timeframe of 6/1/21 through 6/15/21. The CDR had six doses that were signed out, but the MAR had not been documented on to indicate the medication was given. On 6/17/21 at 3:10 P.M., an interview was conducted with LN 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.

Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 15.63%. Out of a total of 32 opportunities, five medication errors were observed during the medication administration process for three of three randomly observed residents (84, 34). As a result, the facility could not ensure medications were correctly administered to all residents. Findings: 1. On 6/16/21 at 8:40 A.M., an observation of medication administration was conducted with LN 1. LN 1 prepared and administered medication to Resident 84, including Carafate (an antacid) and Reglan (a medication to prevent vomiting). The oral medications were administered together. Upon completion of the medication administration, Resident 84 requested her morning dose of insulin. LN 1 stated Resident 84 did not get any insulin in the morning. Resident 84 stated she usually got insulin with her breakfast. Upon request, a record review was conducted of Resident 84's MAR with LN 1. Insulin was ordered for morning…

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 safe and sanitary practices were implemented for residents' food brought in from the outside according to the facility policy. Failure to ensure safe storage and reheating procedures for residents' food from the outside has the potential to expose 94 residents to foodborne contamination in the facility. Findings: On 6/15/21 at 3:14 P.M., an observation and interview was conducted with LN 8 about resident food brought in from the outside. LN 8 stated resident food brought in from the outside should be labeled with the resident's name and date, then stored in the nurse's station refrigerator for 24 hours. The nurse's station refrigerator thermometer indicated 50 degrees F and had four cartons of Medplus (a high protein drink) and a bowl of applesauce dated 6/15/21. LN 8 stated the nurse's station refrigerator temperature at 50 degrees F was okay to store food safely. On 6/15/21 at 4:00 P.M., an interview was conducted with CNA 17 about resident food brought from the outside. CNA 17 stated resident food…

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

Based on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI), program failed to identify, implement, and evaluate systematic measures to ensure effective oversight, which were identified in the Federal recertification survey, dated 6/14/21 through 6/17/21, related to: 1. Weight loss and nutritional service (F-692) and; 2. Pharmacy services (F-755). As a result, the facility was noncompliant with deficiencies cited during the survey, which had the potential to affect the health and safety of the residents. Findings: On 06/17/21 at 4:22 P.M., an interview was conducted with the ADM, DON, and DSD regarding the facility's QA (Quality Assurance) committee. The ADM stated all department heads, attended the monthly QA meetings. The ADM stated their QAPI committee over the past year focused on staffing, COVID-19, bowel and bladder incontinence, pressure ulcers, and the reduction of behaviors both short term and long term. 1. The ADM stated the RD was in the building one day a week, and attended the monthly QA meetings. The ADM stated weights were…

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 provide timely personal care for three of 19 residents (16, 40 and 51), reviewed for dignity issues. This failure had the potential to cause psychosocial harm for the residents. Findings: 1. Resident 16 was readmitted to the facility on [DATE] with diagnoses to include end stage renal disease (ESRD-irreversible kidney failure) and dependence on renal dialysis (artificial process of removing waste products and extra fluid from the body), per the facility's Face Sheet. Per the record review of Resident 16's most recent MDS (an assessment tool) assessment, dated 5/3/19, the resident scored a 15 out of 15 on the BIMS (assessment of the ability to think and reason) which indicated the resident was cognitively intact (has ability, to think, reason and remember). Resident 16's MDS also indicated he required extensive assistance with bed mobility, transfers, toilet use and hygiene. Resident 16's care plan, titled Bowel and Bladder, indicated 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 develop a care plan which specifically addressed a language barrier for one of two residents reviewed for communication (28). This failure had the potential for Resident 28 's needs to not be met. Findings: According to the facility's Face Sheet, Resident 28 was admitted to the facility on [DATE] with a diagnosis of aphasia (a partial loss of the ability to speak). In Section A of Resident 28's MDS (a comprehensive assessment of a resident's functional capabilities), Resident 28's identified preferred language was language X, (not English). On 8/5/19 at 8:19 A.M., an observation of Resident 28 was conducted. Resident 28 was alone in her room. No communication board (board with symbols or pictures used to communicate with residents who do not speak English) was present at bedside or in Resident 28's drawer. On 8/5/19 at 8:20 A.M., an interview with LN 1 was conducted. LN 1 stated Resident 28 spoke and understood language Y (not English).…

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 communicate with one of two sampled residents (28) in her preferred language. This failure had the potential for Resident 28 to not have her needs met. Findings: Resident 28 was admitted to the facility on [DATE] with a diagnosis of history aphasia (a partial loss of the ability to speak) per the facility's face sheet. In Section A of Resident 28's MDS, (a comprehensive assessment of a resident's functional capabilities), Resident 28's identified preferred language is language X (not English). On 8/5/19 at 8:19 A.M., an observation of Resident 28 was conducted. Resident 28 was alone in her room. No communication board (board with symbols or pictures used to communicate with residents who do not speak English) was present at bedside or in Resident 28's drawer. On 8/5/19 at 8:20 A.M., an interview with LN 1 was conducted. LN 1 stated he could not really communicate with Resident 28. LN 1 stated Resident 28 speaks language Y. LN 1 stated he…

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, observation, and record review, the facility failed to identify the needs of one of two residents reviewed for pain management (52). This failure had the potential for Resident 52's pain to go unrecognized and untreated. Findings: Per the facility Face Sheet, Resident 52 was admitted to the facility on [DATE] with a history of Alzheimer's disease (a disease affecting memory and function). On 8/5/19 at 8:38 A.M., an observation of Resident 52 was conducted. Resident 52 was observed to be moved to the hallway via wheelchair by CNA 3. CNA 3 then left the area. Resident 52 called out, but no staff responded. On 8/5/19 at 9:10 A.M., an observation of CNA 3 and Resident 52 was conducted. Resident 52 was observed to be touching her right arm and saying, I have pain. CNA 3 stated, I will take you to the activity, but did not acknowledge the complaint of pain. On 8/5/19 at 9:15 A.M., an observation and interview was conducted with CNA 3. CNA 3 stated she would report Resident 52's pain to the LN. CNA…

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 nursing staff assessed the residents' dialysis (artificial process of removing waste products and extra fluid from the body) graft (access site) for the bruit (sound associated with blood flow through the shunt) or thrill (a sensation felt over the graft indicating blood flow) presence or absence for one of one resident's (16) reviewed for dialysis care. This failure could result in complications related to dialysis treatment and infection. Findings: Resident 16 was readmitted to the facility on [DATE] with diagnoses to include end stage renal disease (ESRD-irreversible kidney failure) and dependence on renal dialysis, per the facility's Face Sheet. On 8/5/19, a record review was conducted. Resident 16's MDS (an assessment tool), dated 5/3/19, indicated a BIMS (an assessment of the ability to think and reason) score of 15 out of 15, which indicated the resident was cognitively intact (has ability, to think, reason and remember). On 3/8/19, 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 and record review, the facility failed to provide sufficient staffing to provide care in a timely manner for four of 19 sampled residents (252,16, 40 and 51). These failures had the potential to result in resident's needs not being met in a timely manner, and to result in physical and/or psychosocial harm. Findings: 1. Resident 252 was admitted to the facility on [DATE], per the facility's Face Sheet. On 8/5/19, a record review was conducted. According to Resident 252's Resident admission Assessment, dated 7/21/19, the resident was aware of self, place and time. On 8/5/19 at 10:02 A.M., an interview was conducted with Resident 252. Resident 252 stated she would wait 30 to 60 minutes, especially on evening and night shift, for the call light to be answered. Resident 252 stated she considered that long of a wait unacceptable. 2. Resident 16 was readmitted to the facility on [DATE], per the facility's Face Sheet. On 8/5/19, a record review was conducted. Resident 16's BIMS (assessment 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 and record review, the facility failed to ensure concerns related to the lack of behavior monitoring for the use of an antipsychotic medication, was identified during the medication regimen review for one of five residents (29). This failure had the potential for Resident 29 to be placed on psychoactive medication unnecessarily. Findings: Per the facility's face sheet, Resident 29 was admitted on [DATE] with diagnoses to include generalized psychosis (a mental disorder characterized by a disconnection from reality). According to the History and Physical, dated 7/11/19, the resident had the capacity to understand and make decisions. A review of Resident 29's minimum data set assessment (assessment tool), dated 5/9/19, the resident had a BIMS (assessment of cognitive status) of 14 on a scale of 0-15 (13-15 score indicated intact cognitive response). A review of Resident 29's physician orders indicated the following: - Clozaril (an anti-psychotic medication) 350 mg at bedtime and to monitor for…

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 five residents (29) was free from unnecessary use of psychoactive medications when: 1. An inappropriate target behavior was monitored for the use of an antipsychotic medication. 2. Behavior monitoring for the use of an antipsychotic, anti-anxiety, and a mood stabilizer medications was not consistently performed and documented. 3. A hypnotic medication was ordered and administrated without clear indications for its use. These failures had a potential for Resident 29 to experience unnecessary side effects from the psychoactive medications. Findings: 1. Per the facility's face sheet, Resident 29 was admitted on [DATE] with diagnoses to include generalized psychosis (a mental disorder characterized by a disconnection from reality). According to the History and Physical, dated 7/11/19, the resident had the capacity to understand and make decisions. A review of Resident 29's minimum data set assessment (assessment tool), 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.

Based on observation, interview and record review, the facility failed to ensure the nutritional needs of the residents when portion sizes were not followed during the lunch meal on 8/7/19. This failure had the potential for residents to not receive adequate nutrition, further compromising their medical status. Findings: A record review of the menu spreadsheet provided by the facility for use on lunch, 8/7/19, titled Summer Menus, Week 1 Wednesday, showed Broccoli with garlic, 1/2 cup serving for all diets. On 8/7/19 at 11:56 A.M., a concurrent observation and interview was conducted in the kitchen. The trayline began serving lunch trays at 12:00 P.M. The broccoli with garlic had a serving utensil, or scoop, set in it for serving portions. The scoop was a #12, indicating 1/3 cup. Two trays were served the broccoli with garlic using the #12 scoop. Per CK 1, the menu spreadsheet listed a #12 scoop for the broccoli with garlic. The DSS then referred to the menu spreadsheet, and stated, It says #8 scoop. We used the wrong size. The scoop was replaced with the correct one. On 8/7/19 at…

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 deliver food at appetizing temperatures. As a result, residents were at risk of foodborne illness and unplanned weight loss. Findings: On 8/6/19 at 10:10 A.M., a confidential interview was conducted. Three of the five residents present stated the hot foods arrived cold. CR 3 stated, I've gotten all three meals too cold. On 8/7/19, starting at 12:00 P.M., during a lunch meal observation a test tray was requested on the last cart delivered (west nursing station). The temperatures at the start of the meal service were as follows: Tahitian Chicken: 180 degrees F (Fahrenheit, a measurement of heat) Classic Rice: 180 degrees F Broccoli with Garlic: 170 degrees F Chocolate Pudding: 35 degrees F Milk: 38 degrees F Water: 40 degrees F During the observation, the cart for the west nursing station was delivered at 12:59 P.M., and the test tray was removed after the last resident received their tray at 1:20 P.M. The test tray temperatures were checked in the presence of the Admin. The temperature of the food on the tray…

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 food in a sanitary manner. As a result, residents were at risk of foodborne illness. Findings: On 8/8/19 at 2 P.M., a concurrent observation and interview was conducted at the east nursing station. A refrigerator, designated for residents, was opened. Per the DSS, the refrigerator was only to be used for patient food. The refrigerator contained: Chobani yogurt, expiration date 7/10/19 Red Bull (a caffeinated beverage) Three plastic containers of fruit cocktail, dated 8/5/19 Two sandwiches, unlabeled and undated Styrofoam plate with cut fruit, plastic wrapped, unlabeled and undated 4 oz. milk in a plastic cup, unlabeled and undated One plastic container of applesauce, unlabeled and undated One used, dirty plastic spoon One covered plate of facility food, unlabeled and undated On 8/8/19 at 2:44 P.M., an interview was conducted with the DSS. Per the DSS, all foods should have been labeled and dated. The DSS stated the refrigerator had some foods which must have been brought from outside the facility, since…

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 keep accurate medical records for two of 19 sampled residents (50, 298). This failure had the potential for: 1. Resident 50 to have improper psychiatric treatment based on incorrect information included in her psychiatric evaluation. 2. Resident 298 to have incorrect treatment based on disorganized documentation in the medical record. Findings: 1. Per the facility Face Sheet, Resident 50 was admitted to the facility on [DATE]. On 8/5/19 at 10:25 A.M., Resident 50 was observed pacing the hallway and occasionally making hissing noises with her mouth. Resident 50 did not speak while pacing in the hallway. On 8/7/19 at 11:37 A.M., an interview was conducted with CNA 5. CNA 5 stated she has cared for Resident 50 for over a year. CNA 5 stated Resident 50 cannot talk. CNA 5 stated Resident 50 uses a hissing sound to communicate. On 8/8/19 at 8:13 A.M., an interview was conducted with CNA 4. CNA 4 stated she took care of Resident 50 often. CNA 4…

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