Crystal Ridge Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 26 sampled residents (Resident 86) was evaluated and treated by a podiatrist (foot doctor) when Resident 86's toenails were thick, discolored and long. This failure resulted in Resident 86 having pain when walking and had the risk potential to cut the skin. Findings: A review of the facility's document titled admission Record indicated Resident 86 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During an interview on 5/21/25, at 11:25 a.m., Responsible Party 1 (RP 1) stated she was concerned about her father's long toenails. She stated she noted the toenails were long and had fungus in March. RP 1 further stated she was going to cut them myself but realized his toenails were too thick to do it safely. During an observation and concurrent interview in Resident 86's room with Resident 86 and Certified Nurse Assistant 2 (CNA 2)…

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

Based on interview and record review, the facility failed to ensure physician visits were provided timely for one of 26 sampled residents (Resident 14) when Resident 14 was not seen by the attending physician every 30 days during the first 90 days of admission. This failure had the potential to delay detection of declining health and the provision of care. Findings: A review of the facility's document titled admission Record, indicated Resident 14 was admitted to the facility late 2024 with diagnoses of Diastolic Heart Failure (the heart cannot pump enough blood to meet the body's needs causing multiple symptoms), Sleep Apnea (a disorder characterized by repeated pauses in breathing during sleep) and Peripheral Vascular Disease (a condition where circulating blood has difficulty in reaching the body's tissues due to narrowing of blood vessels). A review of Resident 14's Minimum Data Set (MDS-a federally mandated assessment tool), dated 5/5/25 indicated a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure its medication error rate was less than five percent (5%) for three of 26 sampled residents, Resident 32, Resident 74, and Resident 194, when: 1. Licensed Nurse 3 (LN 3) did not follow the physician's order in administering Resident 32's prescribed medication; and 2. LN 1 did not perform a pre-flush (flushing the tube with water before administering medication, to ensure the tube remains clear and patent) to Resident 74's Gastrostomy Tube (GT, tube inserted into the stomach to deliver nutrition, and medications. GT has 2 ports called feeding port and balloon port which is not used for feeding or medications. These ports are covered with red caps); and 3. LN 5 did not follow the physician's order in administering Resident 194's prescribed medication. These failures resulted in the facility's medication error rate of 12%, and had the potential for harm, worsening of existing conditions or develop new illnesses for Resident 32,…

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 one of 26 sampled residents (Resident 14) received timely dental treatment when prior dental visits indicated that follow up dental services was necessary. This failure had the potential to place Resident 14 at risk for further oral decline and overall health. Findings: A review of the facility's document titled admission Record, indicated Resident 14 was admitted to the facility on 10/2024 with diagnoses of Diastolic Heart Failure (the heart cannot pump enough blood to meet the body's needs causing multiple symptoms), Sleep Apnea (a disorder characterized by repeated pauses in breathing during sleep) and Peripheral Vascular Disease (a condition where circulating blood has difficulty in reaching the body's tissues due to narrowing of blood vessels). A review of the facility's document from a traveling hygienist, dated 12/3/24, indicated Resident 14 had, .heavy calculus and heavy inflammation. [Resident 14] will need additional cleaning visits to fully improve the health of his tissue. This document also…

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

Based on observation, interview and record review, the facility failed to provide adaptive eating equipment (specialized tools and devices designed to assist individuals with disabilities or physical limitations in eating and drinking independently. These aids help make mealtimes easier, more enjoyable, and promote independence) to one out of 26 sampled residents, Resident 10, when Resident 10 did not have a plate guard (a device that clips onto a plate to prevent food from accidentally sliding off) and a two handled cup with a lid during his meals. This failure had the potential to cause dehydration, malnutrition and increased dependency on staff for feeding for Resident 10. Findings: A review of Resident 10's admission Record, indicated, Resident 10 was admitted to the facility on 2/2023 with diagnoses that included Dysphagia, Oropharyngeal Phase (swallowing disorder) and generalized muscle weakness. A review of Resident 10's Minimum Data Set (MDS, an assessment tool used to guide care) Cognitive Patterns, dated 5/5/25, indicated Resident 10 had short-term and long-term memory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow guidelines for infection control practices and provide safe, and sanitary environment for two of 26 sampled residents, Resident 74 and Resident 40 when: 1. Resident 74's Gastrostomy Tube's (GT, tube inserted into the stomach to deliver nutrition, and medications. GT has 2 ports called feeding port and a balloon port which is not used for feeding or medications. These ports are covered with red caps) red cap fell on the floor, and Licensed Nurse 1 (LN 1) picked up the red cap and connected it back to one of the GT's ports; and 2. Certified Nursing Assistant (CNA 5) touched the inside of Resident 40's nosey cup (NC, designed with a nose cutout to encourage correct head position) with her bare hands. These failures had the potential to result in infections for vulnerable residents. Findings: 1. During a concurrent observation and interview with LN 1 on 5/21/25 at 1:45 p.m., LN 1 took out medications for Resident 74 from her medication…

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

Based on observation, interview and record review, the facility failed to ensure call lights were placed within easy reach of residents for one of 26 sampled residents (Resident 34). This failure had the risk potential for the residents to be unable to call for staff assistance with their daily care needs. Findings: Review of an admission Record indicated Resident 34 was admitted to the facility March 2025 with several diagnoses including hemiplegia (total paralysis of the arm, leg and trunk on the same side of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (decreased blood flow and oxygen to the brain) affecting left side. Review of Resident 34's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/2/2025, indicated Resident 34 required substantial/maximal assistance (Helper does more than half the effort) with activities of daily living (ADLs-routine tasks/activities such as bathing, personal hygiene and dressing) and was dependent for toileting. During a concurrent observation and interview on 5/20/25 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 promote safety measures for one of 26 sampled residents (Resident 82) when Resident 82's order for the use of a wanderguard (a device that activates sensors on doors to alarm, alerting staff to intervene when wandering residents attempt to elope) was not followed. This failure increased Resident 82's risk for elopement. Findings: A review of an admission record indicated Resident 82 was admitted in September 2024 with diagnoses including dementia (a progressive state of decline in mental abilities) with behavioral disturbance. During an observation on 5/20/25 at 8:40 a.m. Resident 82 was noted pacing up and down the hallway. Resident 82 was observed being redirected by staff to keep him from wandering to other resident's rooms. A review of Resident 82's Order Summary Report (OSR) dated 4/15/25 and 5/16/25 indicated an order for Resident 82 to wear a wanderguard bracelet to the right ankle for safety related to wandering/exit seeking behavior. The order directed nursing staff to check placement 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 The facility failed to follow their medication administration policy and procedure (P&P) for one out of three sampled residents (Resident 1) when Licensed Nurse (LN) A documented that LN A had administered medication to Resident 1 when another nurse administered the medication on LN A ' s behalf. This failure resulted in inaccurate documentation and could cause confusion. Findings: A review of the facility ' s P&P titled, Administering Medication, revised 12/1/22, indicated, medication would be administered in a safe manner. The P&P indicated, The individual administering the medication must note the administration on the eMAR [electronic medical record] after giving medication. The P&P indicated, the eMAR would include The signature and title of the person administering the drug. A review of the undated admission Record indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses of type 2 diabetes (body had hard time controlling blood sugar levels) with diabetic neuropathy (nerve damage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medication was stored safely for one out of three sampled residents (Resident 1) when Resident 1 stored medication in an unlocked drawer of the bedside table. This failure had the potential for unauthorized persons to have access to medication that was not prescribed to them. Findings: A review of the facility ' s policy and procedure (P&P) titled, Storage of Medications, revised 4/1/19, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The P&P indicated drugs would be stored in locked compartments. A review of the undated admission Record indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses diastolic congestive heart failure (the heart's main pumping chamber becomes stiff and unable to fill properly) personal history of other venous thrombosis (blood clot that usually occurred in the leg or arm) and embolism (blood clot in the lung). A review of the annual…

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 a sanitary environment for one out of three sampled residents (Resident 1) when the floor was sticky through out the room. This had the potential to spread infection. Findings: A review of the facility ' s policy and procedure titled, Infection Prevention and Control, revised 11/1/23, indicated, the facility had established an infection prevention program that helped prevent the spread of infection and residents would be provided a safe and sanitary environment. A review of the undated admission Record indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses of diastolic (congestive) heart failure (when the heart did not adequately pump blood) and had a history of falling. A review of the annual (yearly) Minimum Data Set (MDS, an assessment tool), dated 9/26/24, Section C, indicated, Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment that tested a resident ' s ability to recall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were administered per physician ' s orders when three of four sampled residents (Resident 2, 3, and 4) did not receive their morning medications in a timely manner as per professional standards. These failures resulted in the delay of prescribed medications being administered and the potential for negative outcomes that could affect residents ' health and well-being. Findings: A review of the facility ' s policy titled Physician Orders dated 8/2024, indicated The staff shall carry out physician/nurse practitioner ' s orders as prescribed. A review of the facility ' s policy titled Administering Medications revised 3/22/18, indicated Medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. A review of Resident 2 ' s admission Record (undated), indicated that Resident 2 was admitted to the facility…

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

Based on observation, interview, and record review, the facility failed to provide an incentive spirometer (IS, a handheld device that helps patients improve lung function by teaching them to breathe in slowly and deeply) to meet the needs for one of four sampled residents (Resident 2). This failure had the potential to adversely affect the health and well-being of Resident 2. Findings: A review of the facility ' s policy titled Respiratory Care-Clinical Protocol revised 11/22, indicated The staff and physician/nurse practitioner will monitor the progress of individuals with respiratory conditions, including ongoing evaluation of condition changes. The physician/nurse practitioner will monitor the individual for beneficial and adverse effects of medications used to treat respiratory conditions. A review of the facility ' s policy titled Physician Orders revised 8/2024, indicated Prescribed medication and treatment orders will be carried out in accordance with the physician/nurse practitioner order. A review of Resident 2 ' s admission Record (undated), indicated that Resident 2 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 ensure medications were stored and labeled in accordance with currently accepted professional standards when: 1. A discontinued medication was not removed and discarded from an active medication drawer in Medication Cart B2 (MC B2, a movable piece of equipment used to store, transport, and dispense medicines). 2. MC B2 was not locked and left unattended. 3. Physician ' s instructions on the Medication Administration Record (MAR) for Pradaxa (a medication used to prevent blood from clotting) and the pharmacy label instructions for Pradaxa did not match. These failures had the potential for medication errors and drug misuse. Findings: A review of the facility ' s policy titled Medication Labeling revised 2/2023, indicated Medications are labeled in accordance with applicable federal and state requirements and currently accepted Pharmacy practices. 8. If medication containers have missing, incomplete, improper, or incorrect labels, contact…

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 one of two residents (Resident 1) was provided with a nourishing meal to meet his daily nutritional need when Resident 1 did not receive a meal for. This deficient practice resulted in Resident 1 being hungry throughout the night. Findings: A review of the policy titled Food and Nutrition Services revised October 2017, indicated Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration and the preferences of each resident. A review of Resident 1 ' s admission Record (undated), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including epilepsy (seizure disorder), heart failure, depression, and bipolar disorder (personality disorder). A review of Resident 1 ' s Annual Minimum Data Set (a complete clinical assessment) dated 9/12/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, evaluates a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one out of three sampled residents (Resident 1), received medication and blood sugar monitoring (checking the level of sugar in the blood for diabetics) at the correct time as ordered by the physician when: 1. Famotidine (medication to decrease stomach acid) was not administered to Resident 1 at 6:00 am for 6 out of 15 days in December 2023 (12/1, 12/7, 12/8, 12/9, 12/13, 12/14.) This failure caused Resident 1 to experience burning in his stomach and made it hard for Resident 1 to eat his meals. 2. Blood sugar monitoring was ordered by the physician 4 times a day for Resident 1 and the facility was monitoring Resident 1 ' s blood sugar 3 times a day. This failure had the potential for Resident 1 to have untreated high or low blood sugar levels. Findings: 1. During a review of Resident 1 ' s record titled, admission Record, dated 9/9/2022 indicated Resident 1 was admitted to the facility on [DATE] and had a diagnosis of Crohn ' s…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. The preparation sink next to the stove (Cook prep sink) did not have an air gap (an air gap refers to a fixture that provides back-flow prevention. When installed and maintained properly, the air gap works to prevent drain water from backing up into the sink and possibly contaminating the area used for washing food. An air gap is a way to make certain wastewater and contaminants never re-enter the clean water supply), which had the potential for backflow from the drain to contaminate the sink. This had the potential to cause foodborne illness, (stomach illness acquired from ingesting contaminated food). 2. The ice machine was not kept in sanitary condition with brownish discoloration when checking with a white paper tower. This had the potential to cause foodborne illness. 3. The rusting silver shelves were not smooth and easily cleanable and had stored clean water pitchers and cleaned storage containers which had 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 and interview, the facility failed to make it known to five out of six sampled residents how a grievance was formally filed. This had the potential to prevent residents making their grievances known, particularly those who wished to do so anonymously. Findings: A review of a facility policy titled Filing Grievances/Complaints, revised 1/2021, indicated, A copy of our grievance/complaint procedures is posted on the resident bulletin board. During a Resident Council interview, on 10/6/22, at 10:24 AM, to the question, Do you know how to file a grievance? five out of six Council attendees indicated they knew they could have lodged a complaint to staff verbally but were unaware they could have filed a written grievance. During an observation, on 10/6/22, at 11:56 AM, with the Administrator (ADMIN), there was no process on the main resident bulletin board about filing a written grievance. The Patients' Rights: Skilled Nursing Facilities posting, which contained a passage regarding the right to file grievances, was high on the top row, above standard height, in print…

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 supervision adequate to meet the increasing needs of one resident out of a sample of eight (Resident 42), when they failed to proactively intervene to prevent him from wandering into other residents' rooms and touching them/their belongings, and from witnessing his aggression toward staff. This failure resulted in residents feeling unsafe and had the potential to result in injuries and other negative outcomes for Resident 42 and other residents. Findings: A review of a facility policy, titled, Safety and Supervision of Residents, revised 7/2021, indicated, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. A review was made of an admission Record for Resident 42 who was admitted to the facility on [DATE]. Resident 42's diagnoses included cerebral infarction (the brain's…

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

Based on observation, interview, and record review, the facility failed to ensure training to staff who provided residents with supervision during cigarette, smoking breaks when two out of three staff members were not able to state where to find fire safety equipment (fire extinguisher, fire blanket) at the designated resident smoking area. This failure had the potential to cause physical and psychosocial harm to residents in the event of a fire. Findings: During a concurrent observation and interview, on 10/6/22, at 7:03 PM, located at the resident smoking area, Certified Nurse Assistance (CNA) C had supervised two residents during a scheduled resident smoking break. CNA C was asked where the fire safety equipment was located and had been observed looking around the area. CNA C pointed to the corner of the building and stated there was the fire extinguisher. CNA C was not able to state where the fire blanket was located, what a fire blanket was, or what the fire blanket was used for. CNA C stated no training had been provided by the facility prior to supervising resident smoking…

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 dietary staff had appropriate competencies to carry out the functions of food and nutrition services when two Dietary Aides (DA A and DA B) were unable to follow Quat container test strip paper's length of time instruction to check the concentration of the quaternary sanitizer (Quat, a solution used to sanitize kitchen work surfaces). This failure had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) to all residents, in a medically compromised population of 83 out of 85 residents who received foods from the kitchen. Findings: During a concurrent observation and interview on 10/4/22 at 10:29 AM, with the Dietary Aide A (DA) checked the Quat sanitizer red bucket located in the diet aide prep sink area. DA A dipped Quat test strip into the Quat red bucket for five seconds, it showed as yellowish color. DA A compared Quat test strip with Quat test strip paper container and stated the Quat sanitizer was not in the correct concentration. 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.

Based on observation, interview, and record review, the facility failed to protect residents from loss of personal property when more than 30 pieces of unlabeled resident clothing items had been observed hanging in a covered clothing rack and staff were unaware of facility expectations with regards to who was responsible for the inventory and labeling of residents' personal clothing. This failure resulted in the loss of resident personal property. Findings: During an interview on 10/6/22, at 7:48 AM, Janitor (JAN) stated Certified Nurse Assistants (CNA) should have inventoried resident personal clothing, placed the clothing in a bag, and labeled the bag with the resident's name and room number. JAN stated responsibility for labeling resident personal clothing fell upon JAN, and staff would often deliver resident personal clothing to the laundry area without any resident identifiers (name or room number). During a concurrent observation and interview on 10/6/22, at 8:04 AM, Housekeeping Manager (HM) stated the Social Services Department performed initial inventory of resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide effective pain management for one out of two residents (Resident 228) when staff failed to notify the facility's General Internal Medicine ([NAME]) of Resident 228's consistent use of as needed (PRN) pain medication. This failure caused a delay in effective pain management and psychosocial harm. Findings: A review of the facility's record indicated Resident 228 had been admitted to the facility on [DATE] with the diagnoses of chronic pain due to trauma, cervicalgia (neck pain), low back pain, pressure ulcer of sacral region (lower back), stage two (open wound that can be tender or painful), pressure ulcer of left hip, stage three (wound extends past the top layer of skin), and pressure ulcer of left buttock, stage four (wound may extend to muscle, tendon or bone). Resident 228 was her own responsible party and could make her own medical decisions. During a concurrent observation and interview, on 10/5/22, at 10:55 AM, resident 228…

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 provide a Registered Nurse (RN) for eight consecutive hours a day, seven days a week. This failure had the potential for RN assessment skills and supervision not to be provided daily to residents and staff. Findings: The facility policy, titled, Staffing, revised 10/1/17, was reviewed. The policy indicated that the facility provided sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. The facility Job Description, titled, RN - SNF (Skilled Nursing Facility) or Sub-acute, revised 3/1/14, was reviewed. It indicated that the primary function of the RN was to ensure that effective and efficient nursing care was provided as prescribed by the physician and as required by the facility's policies and procedures. Also listed among the job functions was the ability to demonstrate and supervise direct nursing care to improve standards of nursing. A United States Department of Health and Human Services…

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 (1 of 3) of the garbage dumpster lids were closed properly. This failure to ensure the garbage was contained properly had the potential to attract pests and rodents. Findings: During an observation on 10/4/22 at 9:33 AM, located outside of the facility at the kitchen exit, the middle dumpster lid was not closed. During an observation on 10/4/22 at 5:05 PM, located outside of the facility at the kitchen exit, the middle dumpster lid was not closed. During an interview on 10/5/22 at 8:53 AM, with the Certified Dietary Manager (CDM) stated I always have to go outside to close the dumpster lids. CDM claimed the potential issue that dumpster lids were not closed was birds and animals could get into the dumpsters to get trash. CDM confirmed leaving the dumpster lids opened had the potential to create a high level of contamination issues. During an interview on 10/5/22 at 3:10 PM, with the CDM confirmed Yes, I know there is a problem with the dumpster lids and keeping them closed. During an observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately complete Minimum Data Set (MDS- an assessment tool for a residents cognitive and physical abilities) Assessments for two of 12 sampled residents (Residents 12 and 41) when: 1. Resident 12's hearing function was not coded accurately on the MDS assessment. 2. Resident 41's use of the urinary catheter (a tube placed in the body to drain and collect urine from the bladder) was not coded accurately on the MDS assessment. These failures placed Resident 12 and 41 at risk of not receiving an individualized plan of care based on the residents' specific needs. Findings: During an observation on 3/5/19, at 8:20 a.m., in Resident 12's room, she capped her hand on her right ear and stated, Can't hear. Resident 12 stated she was unable to hear from her right ear. During a concurrent interview and clinical record review for Resident 12, with the assistant director for social services (DSS), on 3/07/19, at 1:50 p.m., the DSS reviewed the MDS…

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

Based on observation, interview, and record review, the facility failed to maintain professional standards for food service safety, sanitary conditions, and the prevention of foodborne illness when: 1. RN 1 handled and distributed resident meal trays prior to performing hand hygiene and after touching her hair. 2. [NAME] 1's apron strings touched the floor and were tied by [NAME] 1 after being donned and prior to plating food. 3. Wet brushes used to spread butter were placed in a drawer without being thoroughly dried. This failure had the potential for unsanitary conditions that could lead to contamination and foodborne illness. Findings: 1. During an observation of Registered Nurse (RN) 1 in the Main Dining Room on 3/5/19, at 12:45 p.m., RN 1 entered the dining room without washing her hands. RN 1 walked toward the food tray cart and opened the doors to check the meal trays. RN 1 picked up the plate lids and grabbed the plate with her unwashed hands. RN 1 verified the meals served on the trays, she picked up a served glass of beverage from the cart and began to run her left hand…

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 staff interview and administrative document review, the facility failed to have a policy and procedure regarding the handling and storage of foods brought to residents by family and visitors from outside the facility to ensure safe and sanitary storage, handling and consumption. This failure has the potential to limit the resident rights to have food brought in by the family and visitors and stored by the facility for later consumption. Findings: During an interview with Certified Nursing Assistant (CNA 9), on 3/7/19, at 2:46 p.m., she stated there was no way to heat up food for families who requested food brought in from outside the facility to be reheated. CNA 9 stated just last week someone asked her to reheat a food plate brought from outside for a resident of the facility. CNA 9 stated she was not able to reheat the food plate and fulfill the request because she was not allowed to enter the kitchen with food brought in from outside the facility.s During an interview with CNA 10, on 3/7/19, at 2:50 p.m., she stated items such as fruit or ice cream brought in 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 provide a complete and accurate record when the POLST (Physician Orders for Life-Sustaining Treatment) form (describes patient wishes on end-of-life care), was unsigned by a physician for one of five residents (Resident 67). This failure had the potential for Resident 67's wishes not to be honored in the event of an emergency. Findings: During a concurrent interview and record review with the Medical Records Director (MDR), on 3/6/19, at 9:18 a.m., she reviewed the clinical record and stated there was a POLST form without a physician's signature. The POLST was attached to the top of the chart with a rubber band and dated 2/1/19. The MDR stated she had no idea why the POLST wasn't signed by the physician. During an interview with Licensed Vocational Nurse (LVN 2), on 3/7/19, at 2:36 p.m., she reviewed Resident 67's POLST form and stated it required a physician signature in order for it to be valid. LVN 2 stated the POLST had not been signed by 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 maintain an infection prevention control program for 4 of 42 sampled residents (Resident 64, Resident 480, Resident 66 and Resident 41) when: 1. Resident 64, Resident 480 and Resident 66's oxygen cannula's (device with tubing to deliver oxygen) were left uncovered and exposed. 2. Certified nursing assistant (CNA 1) and the license vocational/treatment nurse (LVN/Tx Nurse) performed resident care on Resident 41 with soiled gloves and without performing hand hygiene. These failures placed the residents' health and safety at risk for cross contamination and spread of infection. Findings: 1. During an observation on 3/5/19 at 8:45 a.m., in Resided 64 's room, an oxygen cannula laid uncovered on the wheel chair seat. During a concurrent observation and interview with Resident 480, on 3/5/19, at 9:15 a.m., in Resident 480's room, an uncovered oxygen cannula was coiled around the humidifier attached to the oxygen source and to Resident 480's wheelchair. Resident 480 stated, I use the oxygen when I need it, that's why…

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 promote a dignified dining experience for one of five sampled residents (Resident 67) when Certified Nursing Assistant (CNA) 2 wore gloves while feeding Resident 67. This failure had the potential to diminish Resident 67's self-worth. Findings: During an observation in the main dining room, on 3/5/19, at 12:56 p.m., CNA 2 sat at the table next to Resident 67 feeding the resident while wearing gloves. During an interview with CNA 2 in the main dining room, on 3/5/19, at 1:10 p.m., CNA 2 stated she usually wore gloves to feed residents. CNA 2 stated she wore gloves while feeding residents in case she had to touch other residents' meal trays. CNA 2 stated her practice of wearing gloves while feeding residents and handling other resident meal trays with the same gloves was to make sure she did not violate infection control practices. CNA 2 stated she could have used hand sanitizer to disinfect her hands instead of wearing gloves while feeding Resident 67. CNA 2 stated wearing gloves while feeding Resident 67…

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 a Person-Centered baseline care plan within 48 hours of a resident's admission to meet the resident's immediate needs for one of 12 sampled residents (Resident 41) when baseline care plans were not developed on the use of Indwelling Urinary Catheter (a sterile tube inserted into the bladder to drain urine), and Fall risk. These failures placed Resident 41's health at risk when resident's needs were not care planned to meet her immediate needs. Findings: 1. During an observation on 3/5/19 at 8:35 a.m. in Resident 41's room, the resident was on her bed in a semi-sitting position eating breakfast. Resident 41 had a urinary catheter connected to a urine bag covered with a cloth attached to the lower right side of the resident's bed. During a review of the clinical record for Resident 41, titled, Face Sheet (document with resident's demographic information and medical diagnosis) included, . Neuromuscular dysfunction of bladder [a problem in which a…

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

Based on interview and record review, the facility failed to develop and implement an activity person-centered comprehensive care plan for one of two sampled residents (Resident 19) to meet Resident 19's activity preferences and goals identified in the resident's comprehensive assessment. This failure had the potential to result in not meeting Resident 19's activity preferences. Findings: Resident 19's Minimum Data Set (MDS- assessment of resident's cogniitve and physical abilities) Comprehensive Assessment, dated 9/19/18, Section F400 Interview for Activity Preferences, indicated, While at the facility, it was very important to have books, newspapers, and magazines to read, . to listen to the music you like . to do favorite activities . During a concurrent interview and record review of Resident 19's care plan on Activities on 3/6/19, at 4 p.m., with the activity director (AD), the AD reviewed the Activities care plan and stated the care plan did not include hobby interest and preferences that were identified in the resident's comprehensive assessment on activity. The AD 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.

Based on interview and record review, the facility failed to develop a comprehensive care plan within seven days from the completion of the comprehensive assessment for one of two sampled residents (Resident 40) when the comprehensive care plan for Resident 40's indwelling urinary catheter (tubing inserted into the bladder) was not completed in a timely manner. This failure placed the resident's health and safety needs at risk of being unmet. Findings: During a concurrent observation and interview with Resident 41, on 3/5/19, at 8:35 a.m., in Resident 41's room, the resident was on her bed in a semi-sitting position eating breakfast. There was a urine drainage bag covered with a cloth attached to the lower right side of the resident's bed. Resident 41 stated she had an indwelling urinary catheter. During a review of the clinical record for Resident 41, titled, Face Sheet (document with resident's demographic information and medical diagnosis) included, . Neuromuscular dysfunction of bladder [a problem in which a person lacks bladder control.] During a review of Resident 41's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a resident centered activities program for one of two sampled residents (Resident 19) when she was not offered activities of choice and preference to promote pleasure, creativity and self fulfillment. This failure resulted in Resident 19's preferences in activities to go unmet. Findings: During a review of the computerized printed activity calendar on 3/5/19, at 9 a.m., activities for for 3/5/19 included the following: At 7:45 a.m. Music [in facility activity room [ROOM NUMBER]], at 9:15 a.m., Local News-The Union Newspaper, at 10:30 a.m. History of Mardi Gras [in activity room [ROOM NUMBER]], at 11:15 a.m., Sit and stretch with [activity staff], at 2 p.m., Crafts-Beading [in activity room [ROOM NUMBER]] at 3 p.m. Mardi Gras Social, at 6:45 p.m., Movie [in activity room [ROOM NUMBER]]. During an interview with Resident 19 on 3/5/19, at 2:36 p.m., she stated she had not attended activities at the facility because she was not…

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