Greenfield Care Center of Fillmore, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to meet professional standards when : 1. Resident 719 supplemental oxygen was administered without a physician order. 2. Acetylcysteine (an oral inhalation used to help with breathing) was not administered as ordered by the physician for one of four sampled residents (Resident 27). 3. A respiratory therapist (RT1) failed to follow the facility's policy and procedure on medication administration ( nebulizer /aerosol medication) and documentation for one of four sampled residents (Resident 27). 4. Resident 4's insulin (a medication to lower blood sugar levels) was not administered per physician's ordered insulin sliding scale parameters. 5. Resident 4's insulin medication was not administered in a timely manner. These failures can result to residents medications ordered at a specified dose for a designated reason with specific timing and maximum dosing parameters when needed to be missed. Findings: Review of [NAME] and [NAME], 7th Edition,…

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 inspection of the facility's Medication storage room on Unit 3, interview with the facility's IP, and review of the facility's policy and procedures the facility failed to: 1. follow their policy and procedure for sharps waste, 2. ensure that Emergency Drug supplies (E-Kits), had not been opened for more than 72 hours as outlined in the facility's policy and procedure, 3. ensure that no expired medications were available for use, 4. ensure that medications were administered in accordance with the hospital's policies and procedures and 5. ensure that medications are immediately documented in the Medication Administration record (MAR) after the administration of medications to a resident. Findings include: 1) Inspection of the facility's Blue and white (non-controlled) waste containers (which were open, and not closed or sealed), the surveyor found three syringes full of drugs with needles still attached to the syringes. One syringe contained the dilutant for Glucagon (1 ml) and the other two syringes…

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 Medication Pass observation, review of the resident's Medication Administration Record (MAR) and Physician's orders, Two out of two medication nurses observed for a total of 45 medication pass opportunities. Out of these 45 medication pass opportunities, there were a total of 8 medication errors which were observed. These 8 medication errors resulted in an overall medication error rate of 17.7% for the facility. Findings include: This LVN 3 administered medications to sample Resident 29 on 3/6/2025 at 9:00 am, which included Divalproex DR 250 mg tablet. The medication nurse proceeded to crush all of this resident's medications including this resident's Divalproex which had the designation of DR on the label of the bubble pack. Review of the manufacturer's package insert for this medication read: .The tablets should be swallowed whole and can be taken with or without food, Divalproex sodium delayed-release tablets are intended for oral administration. Divalproex sodium delayed-release tablets should be swallowed whole and should not be crushed or chewed, based on the drug…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the exhaust hoses of the portable air conditioning units (PACU) were properly installed as directed (not duct taped to the window frames) and filters were routinely cleaned according to manufacturer's guidelines (MFU) in 12 of 12 PACU's found inside Rooms 15, 20,21,22,23,24,25,26,27,28,30, and 32. This failure had the risk for entrapment in the event of a fire secondary to the windows becoming inoperable due to exhaust hoses duct taped to the window frames, with the potential for poor air quality as filters were not cleaned as directed. Findings: During an observation on 3/04/25 at 10:40 a.m. the slider kits (plastic frame where exhaust hoses are attached) of the PACUs, inside Rooms 15, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, and 32 were noted to be short in length, horizontally installed, and card boards were used to fill in the gaps in the windows. The sliders were then duct taped to the window frames, preventing the windows to be…

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

Based on observation, interview and record revie and facility policy and procedure, the facility failed to ensure Interdisciplinary Team (IDT- a group of healthcare professionals from various disciplines who collaborate to provide comprehensive, patient-centered care) assessed resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for 1 of 20 sampled residents (Resident 51). This failure can result with resident not taking the medication correctly. Findings: During a concurrent observation and interview on 3/6/25 at 2:45 p.m., in Resident 51's room, two vials of DuoNeb (a medication in a small plastic container that contains as a liquid that you breathe into the lungs with a nebulizer (special breathing machine) breathing treatments were observed in Resident 51's drawer. When resident was asked about the medication, Resident 51stated he administers the medication himself. During a concurrent observation and interview on 3/6/25 at 3:02 p.m. in Resident 51's room, Licensed Nurse (LN 1) confirmed the two DuoNeb…

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 have the most current survey results accessible to the public, in the facility survey results binder. This facility failure denied the opportunity for residents, family members, and legal representatives of residents, to be aware of the most recent survey results. Findings: During a concurrent observation and interview, on 3/6/25 at with the Director of Nursing (DON) inside the facility's main entrance, the facility's survey results binder was reviewed. The most current survey results in the binder were from 5/22/24. The survey results binder lacked the survey results from 8/8/24 through 2/19/25. The DON acknowledged the survey results binder was not current and verbalized the survey results binder would need to be updated. During a review of the facility's policy and procedure tilted Survey Results, Examination of dated 4/7, indicated in part A copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, etc., along with state approved plans of correction of…

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

Based on observation, interview and record review, the facility failed to accurately assess 2 of 20 sampled residents (Resident 35 and 39) using the Minimum Data Set (MDS - a standardized tool used to assess and plan care of residents in a nursing home) when: 1. Resident 35 - had an inaccurate language assessment. 2. Resident 39 - had an inaccurate functional status assessment. These failures resulted in the facility reporting inaccurate data to Centers for Medicare & Medicaid Services (CMS) that does not reflect Resident 35 and 39 statuses in MDS assessment. Findings: 1. During a review of Resident 35's admission Record (AR), dated 3/6/25, the AR indicated, Resident 35's primary language is Spanish. During a review of Resident 35's most recent MDS Annual Assessment, Assessment Reference Date (ARD - the end of observation period), dated 12/21/24, section A for language indicated, Resident 35's preferred language is Spanish. Further review of the language assessment, section A1110B was coded 0 (meaning an interpreter was not needed to communicate with a doctor or health care staff).…

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 review of the facility's medication refrigerator logs, review of the facility's policy and procedures, and interview with the facility's I P Nurse the facility failed to ensure that the refrigerator temperatures had been documented and remained within the temperature requirements as outlined by the facility's policy and procedure. Findings include: Inspection of the facility's Medication refrigerator temperature logs for station 3 on 3/4/2025 at 4:10 pm revealed that on 12/4/2024 the refrigerator temperature had been recorded as 35-degree Fahrenheit (which was below the facility's policy range). Review of the facility's policy and procedure entitled: Policy and Procedure on medication refrigerator temperature, date 1/2025, read: Per regulations, the Medication refrigerator temperature range should be between 36 degrees Fahrenheit and 46 degrees. Further review of the facility's refrigerator logs revealed that on 2/19/2025, that no temperature had been documented on the facility's refrigerator temperature logs, so the facility was unable to indicate what the actual…

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 policies and procedures for labelling and dating foods. This failure has the potential for Foodborne illnesses (infections or intoxications caused by consuming contaminated food or beverages). Findings: During an observation on 03/05/25 at 9:00 AM, the following were observed: 6 large bins each containing rice, pinto beans, long grain rice, brown rice and split peas with different dates but does not indicate received date/opened date and or expiry date; 1 bin labelled pasta with dated 9/18/24 not indicating expiry date or open date and contains 2 packs of pasta with 2 different dates; 1 box containing mixed vegetables, baby lima beans, green beans but the labeled delivery dates on the side of the box is not specific for the packaged produce. During an interview on 03/05/25 at 07:30 AM with the Kitchen Manager (KM) and Dietician (DT), both staff acknowledge the labelling is not specific and should indicate the expiry date and or opened date. During a review of Policies and Procedures (P&P) titled…

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 infection control practices when: 1. Respiratory care equipment was not stored properly after use by Residents (4 and 27) 2. Oxygen plastic tubing and nasal cannula were not labelled according to the facility's policy for one of four residents (Resident 27). 3. Personal protective equipment (PPE) was not available prior to entering resident rooms on contact precautions in rooms [ROOM NUMBERS]. These facility failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable Healthcare Associated Infections (HAI) for residents with compromised condition. Findings: 1. During review of Resident 4's, admission Record (AD), the AD indicated diagnoses including gastrostomy (an opening into the stomach from the abdominal wall used to insert a tube to provide a route for tube feeding), dysphagia (difficulty swallowing) following a cerebral…

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 record review and interview, the facility failed to document its response and resolution on the recurring complaints of call lights not being answered in a timely manner raised by residents at its Resident Council Meetings for two consecutive months. This failure put the residents at risk of receiving poor and unmonitored care, with the possibility of the issues continuing. Findings: During a review of the resident council minutes for 12/2024 and 01/2025, recurring complaints were identified. On 12/2024, the resident council attendees expressed concerns about a long wait time for call lights to be answered, taking an hour to answer call lights, and lights being turned off; the resident reported that this occurred during the night shift. On 1/2025, the complaints were call lights not being answered in a timely manner; one patient stated that when the call lights were turned on, the staff that came in the room attended to a resident who does not use the call light; another resident stated that she had to hold her bladder longer, and that staff did not help much. During 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 record review and interview, the facility failed to ensure that a total dependent resident (Resident 1) received necessary treatment and services, to promote healing, and prevent new pressure ulcers (deep tissue injury) from developing. This facility failure resulted in Resident 1 acquiring a new stage 3 pressure ulcer (full thickness tissue loss) to the right buttock. Findings: Review of Resident 1's medical record indicated, resident was admitted to the facility on [DATE] with diagnoses that included history of respiratory failure (a condition that makes it difficult to breathe on your own), Tracheostomy (opening in the windpipe to help with breathing), Quadriplegia (paralysis (loss of the ability to move and sometimes feel of all four limbs), Epilepsy (is a chronic brain disorder that causes repeated seizures, which are episodes of abnormal electrical activity in the brain), Diabetes (high sugar in the blood). Review of Resident 1 ' s admission Minimum Data Set (MDS (a standardized assessment tool…

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 comprehensive person-centered care plans (CP) with regard to the Restorative Nursing Assistant (RNA- provides support and assistance to patients in their recovery and maintenance of physical function) program for fourteen sampled residents (Resident 1, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16). These failures increased the potential for Residents 1, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16 to not receive treatment and care according to their needs. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted on [DATE] with diagnoses including, Acute Chronic Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in the tissues in your body), Amyotrophic Lateral Sclerosis (ALS; a disease that weakens muscles and impacts physical function), Chronic Obstructive Pulmonary Disease (COPD; a group of lung diseases that block airflow 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 ensure adequate supervision and assistance was provided for one of three sampled residents (Resident 1) to prevent avoidable accident and injury. This failure resulted in, Resident 1 fell on the floor and sustained a right distal (further from the trunk of the body) femur (thighbone) fracture (partial or complete break in the bone). Findings: During a concurrent observation and interview, on 4/4/2024 at 9:45 a.m., in Resident 1's room, Resident 1 was observed on a bed wearing a soft helmet (head protection) with blankets up to her chest. No bed tab alarm was observed. Resident 1 was awake and asked about her recent fall stated, My knee hurts, right side .I don't remember. I think I was going to get up or something, but I don't know. Certified Nursing Assistant (CNA 1) entered Resident 1's room and verbalized, Resident 1 didn't have a bed alarm. During an interview on 4/4/2024 at 9:53 a.m., in Resident 1's room with a Licensed Nurse (LN 2), when asked if Resident 1 had a bed tab alarm LN 2 stated, Not that I…

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 professional standards of care for one of two sampled residents (Resident 1) when: 1. A graft site discharge order was not followed up with the admitting physician. 2. Removal of the sutures from a post tracheostomy (surgical procedure that help with breathing through an opening on the neck) site was not obtained per facility policies and procedures. 3. Skin assessment was not accurately done upon admission ([NAME]-coccyx (tail bone)redness, right side open area on the neck). These failures had the potential and risk for Resident 1 to develop further skin breakdown, and infections from unmonitored skin areas with issues. Findings: According to Fundamentals of Nursing, Mosby ' s sixth edition by [NAME] and [NAME]; Chapter 34, page 847, A registered nurse checks all transcribed orders against the original order for accuracy and thoroughness. If an order seems incorrect or inappropriate, the nurse consults the prescriber. Review of [NAME]…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) had an accurate documentation of Resident 1 ' s tracheostomy (a procedure that help with breathing through an opening on the neck) site skin condition. This failure had the potential for Resident 1 ' s skin condition to be unmanaged and posed a risk for the delay in treatment. Findings: During a review of the facility's policy and procedure (P&P) titled, Surgical Wound Care, dated 7/12, the Surgical Wound Care indicated, It is the policy of this facility to care for all types of wounds and prevent possible complications .4. Assess the surgical wound site for signs of infection like skin irritation, swelling, redness and drainage . During a review of admission Nursing Assessment (ANA), dated 2/13/24, the ANA indicated, Resident 1 was admitted with tracheostomy with redness on the surrounding area of the tracheostomy stoma (opening). During a review of the document titled, Skilled Charting, dated 2/13, 2/14, 2/18, 2/18, 2/20, 2/21, 2/22, 2/23, 2/24, 2/25, 2/26, and 2/27, 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 develop and implement a comprensive person-centered care plan (document that provides the resident's condition, diagnosis and the nursing team's goals) for one of three residents (Resident 1), when Resident 1 had a new onset of right leg redness and swelling and required medical treatment. This failure had the potential for Resident 1's care needs to go unmet. Findings: During a review of Resident 1's medical record titled face sheet (a document that gives a resident's information at a quick glance) indicated, Resident 1 was with admitted to the facility on [DATE] with diagnoses of end stage Huntington ' s disease (a progressive breakdown of nerve cells in the brain) severe depression, dementia, and muscle wasting. During a record review of Resident 1 ' s Nursing Progress Notes (NPN- accurate descriptions of nursing assessments and changes in patient conditions)) dated 4/3/24, the NPN indicated, upon assessment redness and swelling was noted on right…

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 repair a loose, broken handrail in the hallway of station three (3) where three sampled residents (Residents 10, 21, 10) and 16 unsampled residents, resides. This failure placed the residents at risk for injuries and accidents. Findings: During a concurrent observation and interview on 11/13/23 at 12:00 PM with a licensed nurse (LN1), in the hallway of station 3, the corner piece of an assistive handrail was loose and broken with a sharp edge. LN1 stated, the broken handrail was loose and sharp and should be replaced. During an interview on 11/13/23 at 12:04 PM with the maintenance supervisor (MS), MS stated the handrail on station 3 is loose and sharp and should be replaced. During an interview on 11/13/23 at 15:15 PM with the administrator (Admin), Admin stated the handrail on station 3 is loose and sharp and should be replaced. During a review of the facility's Policy and Procedure (P/P) titled, Handrails/Grab Bars, undated, indicated in part . 1. The Maintenance Supervisor or his/her designee will check…

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, record review, the facility failed to follow professional standards of nursing practice for 2 of 16 sampled residents (Resident 52 and 63) when: 1. Licensed Nurse (LN3) flushed the gastrostomy tube (G-tube - a tube inserted through the abdomen that delivers nutrition directly to the stomach) of Resident 52, with 10 milliliters (ml) of water in between medication administration with no physician orders or standard of practice reference. This failure can result to the clogging of the GT or less water intake of the resident which can be both detrimental to the resident's overall condition . 2. Resident 63's head-of-the-bed was not elevated ( at 30 degrees high instead of 45 ) enough, while the resident's feeding formula was infusing via G-tube. This failure can result to the formula going directly to the resident's lungs instead to the stomach causing aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed). Findings: 1.…

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 medications were locked, and inaccessible to unauthorized staff, residents, and visitors when medications were left on top of a treatment cart (large capacity, flexible organization and simple maneuverability for easy transport and storage of medical or treatment supplies) unattended. This failure had the potential for visitors, residents, and unauthorized staff to access prescription medication assigned to residents. Findings: During an observation at station 2 hallway on 11/15/23 at 9:17 a.m., medications meant for residents was seen left on the treatment cart by a Pharmacy delivery personnel, unattended and easily accessible to anyone. During an interview with Licensed Nurse (LN 3) on 11/15/23 at 9:25 a.m. LN 3 stated It wasn't supposed to be left on the treatment cart unattended and further stated that she had told the pharmacy delivery personnel to wait for a Supervisor. During a concurrent observation and interview with Director of Nursing (DON) on 11/15/23 at 9:25 a.m. DON picked up 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 ensure a cook had the skill set to calibrate a food thermometer ( gadget to measure food themperature) to verify appropriate and acceptable food temperatures. This failure had the potential to place residents at risk for developing foodborne illness (food contaminated with bacteria, viruses, parasites, or toxins). Findings: During a concurrent observation and interview on 11/14/23, at 09:22 a.m., with [NAME] (C), in the presence of the facility's Dietary Services Supervisor (DSS), in the kitchen, C was observed calibrating a digital thermometer she used to check food temperatures. C obtained a cup with a small amount of ice and inserted the thermometer into the cup of ice. C stated the thermometer read 44 degrees F (Fahrenheit). DSS spoke to C in Spanish to ask C if 44 degrees F meant that the thermometer was calibrated, and C stated, yes. DSS stated, C should have known to look for 32 degrees F to demonstrate the thermometer was calibrated, and how to manually calibrate the digital thermometer from 44 degrees…

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 the menu and/or resident's individualized meal tray card as planned when: 1. The portion size for one pureed item did not match the menu for one of 16 sampled residents (Resident 14). 2. The small portion size directions listed on Resident 44's meal tray card was not honored during lunch trayline ( A system of food preparation in which trays move along an assembly line) in the kitchen. 3. A diet order that included chopped was not followed during lunch trayline in the kitchen for one of 16 sampled residents (Resident 4). This facility failure had the potential to not meet the resident's nutritional needs per the planned menu as approved by the facility's Registered Dietitian. In addition, failure of kitchen staff recognizing the chopped portion of a diet order and lack of knowledge base to follow the therapeutic menu spreadsheet for size of chopped placed resident's with a chopped diet order at an increased risk of choking. Findings: 1. During a concurrent observation and interview on 11/14/23, at 11:55…

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 fans inside the walk-in refrigerator were maintained in a sanitary manner. This failure had the potential to cause cross contamination and place residents at risk for developing a foodborne illness (Illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: During a concurrent observation and interview on 11/13/23, at 8:57 a.m., with Dietary Services Supervisor (DSS), inside the walk-in refrigerator located in the kitchen, two fans were observed circulating and appeared with brown fuzzy extensive build up of debris along the circular rims of both fans. DSS stated, there were dust bunnies and the fans were not clean. During an interview on 11/13/23, at 10:14 am., with DSS, DSS stated, maintenance was responsible for cleaning the fans inside the refrigerator and should be done once a month. DSS was asked if the fans were on a cleaning schedule, and DSS stated, she did not know. During a concurrent observation and interview on 11/13/23, at 10:38 am., with Maintenance…

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 assess one of two sampled residents (Resident 1) for the safe handling and use of an electronic cigarette (a cigarette-shaped device containing a nicotine-based liquid that is vaporized and inhaled, used to simulate the experience of smoking tobacco). This facility failure had the potential for Resident 1 to experience negative outcomes. Findings: During an interview on 10/18/23 at 12:16 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 confirmed prior to 9/11/23, CNA 1 had seen Resident 1 with an electronic cigarette in Resident 1's possession. During an interview on 10/17/23, at 3 p.m., with Licensed Nurse (LN 1), LN 1 verbalized a couple of weeks prior to 9/11/23, LN 1 saw Resident 1 in the possession of an electronic cigarette and verbally reminded Resident 1 that he wasn't allowed to smoke. During an interview on 10/18/23 starting at 11:34 a.m. with the Administrator (Admin 1), Admin 1 was asked if Resident 1 had been assessed for the ability to safely use an electronic cigarette prior to 9/11/23. Admin 1…

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.