Grossmont Hospital D/P SNF

Based on observation, interview and record review, the facility failed to ensure food safety and practices were maintained in the kitchen according to standards of practice and policy when food items were not labeled and dated. These failures had the potential to expose the residents to contaminated food and unsanitary practices and place them at risk of developing foodborne illness. Findings: During a kitchen observation conducted on 6/17/25, with the certified dietary manager (CDM), the following items were observed. 1. In the fresh produce walk-in refrigerator at 8:40 A.M., a box of strawberries and a box of potatoes were observed without a label of date received. The CDM stated that the box of strawberries and box of potatoes should have been labeled but were not. The CDM stated it was important to ensure stored items had labels, date and time for the safety of residents from food borne illness. 2. In the dairy walk-in refrigerator at 8:46 A.M., a container of margarine was observed unlabeled and was stored together with the string cheese. The CDM stated the margarine should 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer a bedhold (the practice of reserving a resident's bed when they are hospitalized ) for one of three sampled residents (Resident 17). This failure had the potential for Resident 17 to not receive continuity of care. According to the admission Record, Resident 17 was admitted to the facility on [DATE] with diagnoses which included severe asthma (a condition in which the airways become narrow, making it difficult to breathe), and immune deficiency disorder (a disorder which affects the body's ability to fight infections). The admission Record indicated Resident 17 was transferred to acute care (short-term care for severe injuries, illnesses or other urgent medical conditions) on 3/22/25. During a joint record review with Licensed Nurse (LN) 5 on 6/19/25 at 11 A.M., LN 5 stated there was no documentation in Resident 17's medical record that a bedhold was offered to Resident 17. LN 5 stated a bedhold was supposed to be offered to all residents before…

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 on specimen collection for one of two sampled residents (Resident 69) when Resident 69 was instructed to provide a sputum specimen. As a result, staff did not follow-up on what to do with the specimen. This failure resulted in the resident feeling bothered and not cared for when the sputum specimen was left at his bedside and not picked up by staff who instructed him to provide the sputum specimen. Findings: Resident 69 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (condition where lungs cannot provide adequate oxygen), pneumonia (lung infection) and hemoptysis (coughing out blood), per the clinical record. Resident 69's minimum data assessment (MDS - nursing assessment tool) dated, 6/18/25 indicated that Resident 69 was cognitively intact. During a concurrent observation and interview with Resident 69 on 6/18/25 at 8:40 A.M., a specimen cup with reddish liquid inside 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 provide appropriate care and services for one of two sampled residents (Resident 72) when Resident 72 had a delay in straight urinary catheterization (SUC -tube to drain the bladder). This failure had the potential to result in discomfort and/or health complications for Resident 72. Findings: Resident 72 was admitted to the facility on [DATE] with diagnoses including cystitis (inflammation of the bladder) and generalized weakness, per the clinical record. During an interview with Resident 72 on 6/17/25 at 8:45 AM, Resident 72 stated that she was retaining urine in her bladder and the staff sometimes delayed providing SUC. Resident 72's physician order dated 6/13/25, indicated .bladder scan of intermittent catheter . [Resident 72] .if unable to void (empty; the act of urinating) in 6 hours for post void residual (PVR - urine retained in the bladder after urinating) . During a concurrent interview and record review with licensed nurse (LN) 2 on 6/19/25…

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 infection control procedures when visitors were not educated regarding the need to wear Personal Protective Equipment (PPE-gown, gloves, masks) or hand hygiene. This failure had the potential for the spread of infection to other residents in the facility. Findings: According to the Face Sheet, Resident 73 was admitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection and microcytic anemia (a condition where red blood cells are smaller than normal). On 6/18/25 at 9:09 A.M., an observation of Resident 73's room was conducted. A green sign was posted outside the room, which indicated Resident 73 was on Contact Precautions, and All visitors please report to the nursing station .To Enter Clean Hands .Put on and tie gown .Cover cuffs with gloves .To Exit, Remove Gloves, Remove gown in room, Clean Hands . On 6/18/25 at 9:18 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored and served in accordance with professional standards for food safety when: 1. Spoiled food was stored amongst non-spoiled food inside the walk-in refrigerators; Food was stored without being covered in the refrigeration units; Food was not consistently labeled and dated; The cool-down process (a time sensitive procedure to chill cooked food to a safe temperature range) was not initiated for two trays of cooked chicken. 2. Three dietary aids (DA 1, DA 2, and DA 3) with long facial hair were not wearing beard guards in the kitchen and during food service; One DA (DA 1) used contaminated gloves to touch ready-to-eat food. These failures had the potential for residents consume contaminated and/or hazardous food which put them at risk for foodborne illnesses. Findings: 1. On 5/21/24 at 8:20 A.M., an observation of the facility's kitchen was conducted with regulatory affairs (RA) 1. A reach-in refrigeration unit contained three small-sized salads that were uncovered and were not labeled 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 interview and record review, the facility failed to implement an Antibiotic Stewardship Program to monitor antibiotic use. This failure had the potential to increase the risk of adverse events from unnecessary or inappropriate antibiotic use. Findings: A review of Resident 121's untitled facesheet indicated the resident was admitted on [DATE]. On 5/21/24 at 2:41 P.M., an interview was conducted with the infection prevention nurse (IPN) 1. During the interview, IPN 1 was informed of what the survey team would need to review and discuss with her regarding the facility's infection control practices, including antibiotic stewardship, monitoring, and the status of all residents' antibiotic use. On 5/24/24 at 10:42 A.M., a joint interview and record review was conducted with IPN 1. IPN 1 was asked how she tracked and monitored antibiotic use in the facility. IPN 1 logged into her email account and retrieved an untitled document with random words and names on it. IPN 1 stated the untitled document was her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure 1 of 8 residents (74) was reassessed after pain medications were administered. As a result, the resident's pain may not have been relieved. Findings: Resident 74 was admitted to the facility on [DATE], with diagnosis that included gout and cancer. During initial survey screening on 5/22/24 at 9:02 A.M., Resident 74 requested a pain pill. On 5/22/24 at 9:13 A.M., a concurrent interview and review of Resident 74 physician orders was conducted with LN 10. Resident 74 had an order for Tylenol 650 mg (milligram) every 4 hours prn (as needed) for mild 1-4 pain, hydrocodone/acetaminophen 7.5/325 mg every 4 hours prn for moderate pain 5-6, and hydromorphone 2 mg every 6 hours prn for severe pain 7-10. On 5/18/24, Resident 74 received pain medications on the following times: At 1:58 A.M., pain medication was given for 6 out of 10 pain level. There was no documented evidence pain was reassessed. At 10:31 A.M., pain medication was given but there was no…

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 two of five residents (5, 124) were appropriately offered the pneumococcal vaccine and had the education regarding benefits and potential side effects of pneumococcal vaccine explained to them and documented in the medical record. In addition, the facility's infection prevention nurse (IPN) 1 did not have a process to readily identify the residents' vaccination status. As a result of this deficient practice, the facility missed opportunities to ensure pneumococcal vaccines had been offered to all residents which put residents at potential risk of contracting pneumonia. Findings: A review of Resident 5's untitled Facesheet indicated the resident was admitted to the facility on [DATE]. A review of Resident 124's untitled Facesheet indicated the resident was admitted to the facility on [DATE]. On 5/21/24 at 2:41 P.M. an interview was conducted with IPN 1. During the interview, IPN 1 was informed of what the survey team would need to review 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 interview and record review, the facility failed to ensure two of five residents (122, 11) were offered/re-offered the COVID-19 vaccination and had documentation that education regarding the vaccine had been provided. In addition, the facility's infection prevention nurse (IPN) 1 did not have a process to readily identify the residents' vaccination status. As a result of this deficient practice, the facility did not provide all residents the opportunity to accept or change their decision to accept a COVID-19 vaccine which put residents at potential risk of contracting COVID-19. Findings: A review of Resident 11's untitled facesheet indicated the resident was admitted to the facility on [DATE]. A review of Resident 122's untitled facesheet indicated the resident was admitted to the facility on [DATE]. On 5/21/24 at 2:41 P.M., an interview was conducted with IPN 1. IPN 1 stated the facility was currently experiencing a COVID-19 outbreak, with the first positive case on 5/15/24. During the interview, IPN 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the kitchen staff consistently documented accurate final rinse temperature of the dishwashing machine. As a result, there was a potential the final rinse temperatures were not in the required range. Findings: On 5/16/23 at 8:32 A.M., a concurrent interview and record review of the document titled, Dishwashing/Warewashing Machine Temperature Log was conducted with the Manager of Nutrition Services (MNS) and Kitchen Supervisor (KS) 1. The log indicated the following temperature requirements: Wash 150F, Rinse 160F and Final Rinse 180F. The final rinse temperatures were not consistently documented accurately from 5/1/23. The MNS stated the kitchen staff were not looking at the correct gauge, which was the blue gauge for the final rinse temperature. The MNS stated the staff were instructed by the Executive, Nutrition Services ([NAME]) to check the green gauge for the final rinse temperature. KS 1 stated the staff was instructed 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.

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 for oxygen therapy was in place before administration for one of three sampled residents (Resident 113) with respiratory issues. As a result, there was a potential Resident 113 did not receive the correct amount of oxygen. Findings: Resident 113 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (a type of lung disease which causes breathing-related problems) exacerbation. On 5/16/23 at 9:49 A.M., an observation of Resident 113 was conducted. Resident 113 was receiving two liters per minute (LPM) of oxygen through a nasal cannula. On 5/17/23 at 8:26 A.M., an observation of Resident 113 was conducted. Resident 113 was receiving two to three LPM of oxygen through a nasal cannula. On 5/17/23 at 8:29 A.M., an observation, interview and record review with Respiratory Therapist (RT) 1 were conducted. RT 1 stated there was a physician's order to administer oxygen…

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 consistently monitor specific target behaviors and adverse side effects for the use psychotropic medications for two of three residents (3, 8) selected for unnecessary medication review. As a result, the residents were at increased risk for receiving unnecessary medication. 1. Resident 3 was admitted to the facility on [DATE] with diagnoses that included left humerus (arm) fracture, per the resident's demographic sheet. On 5/17/23, Resident 3's clinical record reviewed. A physician's progress note, dated 4/28/23, indicated Resident 3 also had diagnoses that included bipolar disorder and adjustment disorder. According to the physician's orders, on 2/1/23 Resident 3 was prescribed quetiapine (antipsychotic) 150 mg at bedtime for bipolar disorder. The order directed staff to monitor the resident for episodes of agitation every shift, and to monitor side effects of quetiapine every shift. Resident 3 was also prescribed sertraline (antidepressant) 200 mg…

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 kitchen staff were knowledgeable of the proper chemical sanitation range values. As a result, there was a potential for spread of food-borne illness. Findings: On 5/17/23 at 10:50 A.M., a review of the 3 Compartment Sink and Sanitizer Log was conducted. The required sanitizer range value was indicated to be 272-700 parts per million (PPM). On 5/17/23 at 10:56 A.M., a joint observation and interview of Food and Nutrition Services Staff (FAN) 1 was conducted with the Executive, Nutrition and Services ([NAME]). FAN 1 was unable to state the required chemical sanitation values for the three-compartment sink. On 5/17/23 at 11:11 A.M., a joint observation and interview of Kitchen Supervisor (KS) 1 was conducted with the [NAME]. KS 1 was unable to state the required sanitation values for the three-compartment sink. On 5/17/23 an interview with the Manager of Nutrition Services (MNS) was conducted. The MNS stated the kitchen staff did…

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.