Grossmont Post Acute Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their own policy when Resident 1 was transferred from bed to wheelchair without the use of a gait belt (assistance safety device). This failure resulted in Resident 1 ' s injury of chipped fracture to his right tibia (shin bone). Findings. A review of the Facility ' s undated admission Record indicated, Resident 1 was admitted on [DATE] with diagnoses that included Repeated Falls, Cognitive Communication Deficit and Retention of Urine Unspecified. An interview on 4/23/24 at 10:55 A.M., with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated she was supposed to be watching lights and provide assistance to residents when needed. CNA 1 stated if a resident wants to be left alone, CNA 1 will leave them alone but would be watching from a distance. A phone interview on 4/29/24 at 4:13 P.M., with CNA 2 was conducted. CNA 2 stated, she worked with Resident 1 that night of 3/15/24. CNA 2 stated at around 5:45 A.M., she asked Resident 1 if…

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

Based on observations, interviews, and record reviews the facility failed to ensure effective dietetic systems related to food and nutrition services were executed according to facility policy and standards of practice when: 1. A resident's (Resident 6), nutrition care plan was not carried out, and experienced unintentional weight loss. 2. Kitchen staff were not trained in day-to-day food safety and sanitation practices. 3. Residents' meals were not served at palatable temperatures according to policy. 4. Expired foods, dirty dishes, and dirty equipment were found in the kitchen. 5. Kitchen equipment was not maintained for proper operation. These deficient practices led to a resident to experience unintentional weight loss, and exposed 81 residents to unsafe and unsanitary food practices, which may have further compromised their nutrition status. Cross reference F656, F692, F802, F804, F812, and F908 Findings: According to the Federal FDA Food Code section 2-103.11, titled Person in Charge (PIC), .The PERSON IN CHARGE shall ensure that .(H) EMPLOYEES are using proper methods to…

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

Based on observation, interview and record review, the facility failed to ensure kitchen staff received the competencies and training needed to perform their job duties when: 1. A [NAME] could describe the cool down process for cooked foods, and 2. A Diet Aide could not describe the correct temperatures of the three-compartment sink for manual dish washing These failures placed residents at risk of cross contamination and acquiring food-borne illnesses. Findings: 1. During an interview on 7/24/23 at 9:40 A.M. with [NAME] (CK 1) and the Director of Dietary (DD), CK 1 stated there was no cool down process for foods, but only for meats. CK 1 stated if they cooled meats to serve later, they would cool it for a couple of hours, label it, date it then place it in the refrigerator. CK 1 further stated it had been a while since he received training on the cool down process. The DD acknowledged CK 1 did not correctly verbalize the cool down process for cooked foods. According to the 2022 Federal FDA Food Code, section 3-501.14 titled Cooling, .Time/temperature control for safety foods are…

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 safety and sanitation practices were met in the kitchen according to standard of practice when: 1. A tray with fourteen small glasses of milk and four glasses of juice each dated 7/14/23, were on the shelf for use in the walk-in refrigerator. 2. The kitchen's clean dish storage area had dirty serving utensils and food items stored on them. 3. The ceiling vent was full of grayish-black dust. 4. The facility did not use a cool down process for ambient temperature prepared foods. 5. An ice cream freezer door gasket had dark brown and black stains and was not clean. These failures exposed residents' to contaminated food and unsanitary practices, which had the potential to place them at risk of developing a foodborne illness. Findings: 1. During an initial kitchen tour on 7/24/23 at 8:50 A.M. conducted with the facility's Director of Dietary (DD) and Lead [NAME] (LCK), inside the walk-in refrigerator there was a tray with twelve small 4 ounce glasses of milk covered with plastic wrap on top and other…

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 Minimum Data Set (MDS, an assessment tool) was accurately coded for one of 18 residents (Resident 59) reviewed for accurate MDS. This failure had the potential for Resident 59 to receive inappropriate care due to inaccurate diagnosis. Findings: A review of Resident 59's admission Record indicated Resident 59 was admitted to the facility on [DATE] with diagnoses to include Benign Prostatic Hypertrophy (BPH, also called enlarged prostate). During a reconciliation of Resident 59' medication administration record and Resident 59's physician order on 7/26/23 at 9:53 A.M., Resident 59 was diagnosed with BPH. Resident 59's hospital records prior to admission to the facility did not indicate diagnosis of BPH. During a concurrent interview and record review on 7/26/23 at 10:50 A.M., with the minimum data set nurse (MDSN), the MDSN reviewed Resident 59's MDS dated [DATE] section I-1400. The MDSN stated Resident 59 was coded incorrectly with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure the nutrition care plan was implemented for one of 18 residents reviewed for care plans. (Resident 6) This failure resulted in Resident 6 not receiving foods listed in the care plan, which may have led to the resident's continued gradual weight loss. Cross reference F692, F800 Findings: Resident 6 was admitted to the facility on [DATE] with a diagnosis of Dysphagia, Oropharyngeal Phase (swallowing problem occurring in the mouth and/or throat) according to the admission Record. A review of Resident 6's Minimum Data Set (MDS-tool that measures health status), dated 6/10/23 indicated a Brief Interview of Mental Status (BIMS) score of 15, cognitively intact. During a dining room observation on 7/24/23 at 1:00 P.M., Resident 6 was having lunch. Resident 6 was observed eating the soup and stated he did not want the rest of the meal. Resident 6 requested a strawberry yogurt from staff. An interview was conducted on 7/25/23, at 10:31…

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 adequate nutrition was provided for one of two sampled residents with severe weight loss in less than one month. (Resident 6) This failure had the potential to result in Resident 6's further unintentional and unplanned weight loss. Cross reference F656, F800 Findings: During a review of professional reference titled, Practice Paper of the American Dietetic Association, dated 2010, indicated , . In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost . that may trigger sarcopenia [a condition characterized by loss of skeletal muscle mass and function] and functional decline [a loss of independence in self-care capabilities and deterioration in mobility and in activities of daily living]. (Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities, October 2010 Journal 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and Record Review, the facility failed to accurately record medications given for one of one resident reviewed for IV medication administration. This failure had the potential for harm, leading to missed or additional medication being given. Findings: The admission Summary for Resident 217 indicated that the Resident was admitted on [DATE], with health problems that included: urinary tract infection (UTI). The Physician admitting orders included: Zosyn (an antibiotic) 3.375 grams , via IV (given through a soft flexible tube inserted in a vein), four times a day for nephrolithiasis (kidney stones) with UTI until 7/29/23. The physician order included administration times of 1 A.M., 7 A.M., 1 P.M. and 7 P.M. On 7/26/23, at 11:19 A.M. a concurrent record review and interview was held with the Director of Staff Development (DSD), the Director of Nursing (DON) and the Infection Preventionist Nurse (IP). The e-MAR (the electronic health record for Medication Administration Record) was reviewed, 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 implement their Infection Prevention Program, when: 1. A Certified Nursing Assistant (CNA 3) did not disinfect the vital signs machine between each resident use. 2. The Business Office Manager (BOM) did not perform hand hygiene when delivering meal trays to the residents. This failure had the potential to spread infections between residents. Findings: 1. On 7/25/23 at 2:58 P.M.,an observation was conducted with CNA 3. CNA 3 went to residents' room and took the vital signs of the two residents. CNA 3 then exited the first room and went to another resident's room without sanitizing the vital sign machine. On 7/25/23 at 3:01 P.M., an interview was conducted with CNA 3. CNA 3 stated she had nine residents and had already took their vital signs. CNA 3 stated the process was the vital sign machine should be sanitized between each resident use. CNA 3 stated she did not wipe the vital sign machine after taking each resident's vital signs. CNA 3 stated she should have sanitized after each use to prevent infection 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 observations, interviews, and document reviews, the facility failed to ensure essential kitchen equipment and vents were maintained and operational according to standards of practice and facility policy. This deficient practice had the potential to negatively affect the temperature of hot and cold foods and expose clean dishes to contaminants from a dirty ceiling vent, which could have led to foodborne illness in 81 residents. During the initial kitchen tour on 7/24/23 at 10:16 A.M. with the Registered Dietitian (RD) and the Dietary of Dietary (DD), a cord connected to the tray line steam table was observed hanging out of the socket. The RD and the DD stated the cord should not be exposed because it may cause damage and it was a safety risk. There was a large air vent with black and gray dirt and lint contaminants observed blowing air directly above a clean dish drying rack. The RD and DD further acknowledged the dirty vent above the clean dish rack and stated it should be clean. During a kitchen observation and interview with the DD on 7/24/23 at 11:45 P.M., there was an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to treat with dignity, one of two residents (162) reviewed for resident rights. This failure had the potential to affect Resident 162's physical, mental, emotional and psychosocial well-being. Findings: Resident 162 was admitted to the facility on [DATE], with a diagnoses of cellulitis (bacterial infection of the skin) on her lower legs and difficulty walking per the facility's admission Record. On 7/8/19, a record review was conducted for Resident 162. Resident 162's BIMS (a cognitive assessment) was 15, indicating she was cognitively intact. On 7/8/19 at 9 A.M., an interview with Resident 162 was conducted. Resident 162 stated that she did not want CNA 4 to take care of her. Resident 162 stated CNA 4 did not help her when something was poking her in the back, making her uncomfortable. Resident 162 stated CNA 4 did not move her from the wheelchair to the bed, when she requested it. Resident 162 stated two days later she informed an unknown…

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 the facility's procedures for investigating potential abuse for one of one resident (162) reviewed. This failure had the potential for resident abuse to not be reported and investigated. Findings: Resident 162 was admitted to the facility on [DATE], with a diagnoses of cellulitis (bacterial infection of the skin) on her lower legs and difficulty walking per the facility's admission Record. On 7/8/19, a record review was conducted for Resident 162. Resident 162's BIMS (a cognitive assessment) was 15, indicating she was cognitively intact. On 7/8/19 at 9 A.M., an interview with Resident 162 was conducted. Resident 162 stated that she did not want CNA 4 to take care of her. Resident 162 stated CNA 4 did not help her when something was poking her in the back, making her uncomfortable. Resident 162 stated CNA 4 did not move her from the wheelchair to the bed, when she requested it. Resident 162 stated two days later, she informed an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care plan interventions were developed and implemented for two of 18 residents (364, 362) reviewed for care plans when: 1. A care plan for hearing aids was not developed for Resident 364. 2. A care plan related to swallow precautions was not implemented for Resident 362. Findings: 1. Resident 364 was admitted to the facility on [DATE] with diagnoses which included unspecified hearing loss, bilateral (reduced hearing in both ears) per the facility's admission Record. An observation was conducted on 7/8/19 at 4:43 P.M. Resident 364 was sitting in a wheelchair outside of her room. Resident 364 was not wearing hearing aids. A concurrent observation and interview was conducted on 7/9/19 at 2:39 P.M. with Resident 364. Resident 364 was sitting in a wheelchair in her room. A visitor was seated on the opposite side of the overbed table in front of Resident 364. Resident 364 stated she could not hear very well. Resident 364 was not wearing…

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 update a resident's care plan to reflect their current condition for one of three residents (56) reviewed for the Bowel and Bladder Program. This failure had the potential to result in Resident 56 receiving inappropriate care for toileting. Findings: Resident 56 was admitted to the facility on [DATE] with a diagnosis of back pain related to a compression fracture (the collapsing of bone tissue in a back bone) per the facility's admission Record. On 7/8/19 a review of Resident 56's MDS (an assessment tool), dated 6/23/19, was conducted. Her BIMS (a cognitive assessment tool) score was 15, indicating Resident 56 was mentally alert and aware. On 7/8/19 at 3:51 P.M., an interview with Resident 56 was conducted. Resident 56 stated she was always continent (able to control bowel and bladder) and never has an accident. She stated she did require assistance to walk to the restroom. On 7/9/19 at 1:27 P.M., an interview with CNA 1 was conducted.…

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 professional standards of quality were met when neurological examinations (an assessment for level of consciousness, pupil reaction, vital signs, sensory and motor responses for early indication of a head injury) were not conducted for one of five residents (48) reviewed for falls. As a result, there was the potential for Resident 48 to have an undetected, untreated head injury. Findings: Resident 48 was admitted to the facility on [DATE], with diagnoses which included difficulty walking, per the facility's admission Record. On 7/8/19, Resident 48's medical record was reviewed. Per the facility's progress notes, dated 7/3/19 at 3:52 P.M., titled Change of Condition, .Patient was lying in the middle of the room on the floor, in front of his wheelchair.M.D. made aware. Orders received to initiate neurological (neurological) checks x (for) 72 hours and monitor vital signs. The clinical record did not include evidence that a 72-hour neurological…

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 scheduled and requested showers for one of one resident (162) reviewed for ADL. This failure had the potential to affect Resident 162's self-image and confidence. Findings: Resident 162 was admitted to the facility on [DATE] with diagnoses of cellulitis (bacterial infection of the skin) on her lower legs and difficulty walking per the facility's admission Record. On 7/8/19 Resident 162's clinical record was reviewed. Resident 162's BIMS (a cognitive assessment), dated 7/5/19, score was 15, indicating Resident 162 was mentally alert and aware. On 7/8/19 at 4:41 P.M., an interview with Resident 162 was conducted. Resident 162 stated she had received only one shower since she was admitted 11 days ago. Resident 162 stated she was told she was only scheduled for showers on Saturdays, and could not have a shower unless she was scheduled. On 7/10/19 at 3:40 P.M., a joint interview and record review was conducted with the DSD. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a physician's order related to the use of an arm sling was followed for one of four residents (362) reviewed for rehabilitation. This failure had the potential to affect Resident 362's comfort and physical well-being. Findings: Resident 362 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (slight paralysis or weakness on one side of the body) following cerebral infarction (also known as a stroke - damage to tissues in the brain due to loss of oxygen to the area), per the facility's admission Record. A clinical record review of Resident 362 was conducted. The physician's order dated 7/3/19 indicated, Left arm sling when OOB (out of bed) and not on for rehab (rehabilitation therapy) . An observation was conducted on 7/8/19 at 9:10 A.M. Resident 362 was sitting in a wheelchair outside of her room. Resident 362 was not wearing an arm sling. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess two of five residents (7, 362), reviewed for falls. These failures had the potential to place Residents 7 and 362 at a higher risk for falls and/or injuries. Findings: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses of respiratory failure with hypoxia (inability to get enough oxygen) and weakness per the facility's admission Record. A review of Resident 7's MDS (assessment tool) dated 4/10/19 was conducted. Resident 7's BIMS (a cognitive assessment) score was 3, indicating Resident 7 had difficulty being alert and aware. On 7/8/19 at 8:27 A.M., an interview was conducted with Resident 7. Resident 7 stated he could not remember if he had a fall in the facility. On 7/9/19 at 8:40 A.M., a review of Resident 7's medical record was conducted. Resident 7's fall risk evaluation, dated 4/3/19, indicated a score of 13, identifying the resident at a high risk for falls, based on the facility's fall risk…

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 incontinence (loss of bowel and/or bladder control) interventions for one of three residents (163) reviewed for the facility's Bowel and Bladder Incontinence Program. This failure had the potential to result in Resident 163 not improving his bowel and bladder continence (control of bowel and/or bladder). Findings: Resident 163 was admitted to the facility on [DATE] with diagnoses of difficulty walking and Type 2 Diabetes (condition which effects the body's ability to control blood sugar) per the facility's admission Record. On 7/8/19 a review of Resident 163's MDS (assessment tool) dated 7/2/19 was conducted. Resident 163's BIMS (a cognitive assessment) score was 10, which indicated he was moderately alert and aware. On 7/8/2019 at 10:30 A.M., an interview was conducted with Resident 163. Resident 163 stated sometimes it took a long time to receive care when he needed toileting or needed a soiled brief changed. He stated that…

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 O2 was administered per physician's order for one of one residents (52), reviewed for oxygen therapy. This failure had the potential to affect the health and well-being of Resident 52. Findings: Resident 52 was admitted to the facility on [DATE] with diagnoses which included systolic congestive heart failure (weakness of the heart that leads to a buildup of fluid in the lungs) per the facility's admission Record. An observation was conducted on 7/11/19 at 9:12 A.M. Resident 52 was sitting in a wheelchair in his room. Resident 52 wore a nasal cannula (NC; device used to deliver supplemental oxygen or increased air flow to an individual in need of respiratory help). The O2 was set and delivered at four (4) L/min (liter per minute - flow rate). A concurrent observation and interview was conducted on 7/11/19 at 10:15 A.M. with LN 11. Resident 52 wore a NC. The O2 was set and delivered at 4 L/min. LN 11 stated Resident 52 was supposed…

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 pain was appropriately managed and assessed for two of six residents (39) (63), reviewed for pain management. These failures had the potential to affect the physical and psychosocial well-being of Residents 39 and 63. Findings: 1. Resident 39 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (stroke - damage to tissues in the brain due to loss of oxygen to the area) per the facility's admission Record. On 7/8/19 a record of MDS (an assessment tool) dated 6/13/19 was conducted. Resident 39's BIMS (a cognitive assessment) score of 13, indicated Resident 39 was mentally alert and aware. On 7/8/19 at 9:40 A.M., an interview was conducted with Resident 39. Resident 39 stated she had pain in her right leg on some nights, caused by muscle spasms. Resident 39 stated, sometimes her pain was 8 out of 10 on the pain scale (0 being no pain, 10 indicated extreme pain). Resident 39 stated she was given Tylenol 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.

Based on observation, interview, and record review, the facility failed to remove expired milk that was stored for resident consumption. This failure had the potential to affect the quality of foods containing milk, prepared for residents who consumed food from the kitchen. Findings: A concurrent interview and inspection of the facility's kitchen walk-in refrigerator was conducted on 7/8/19 at 7:58 A.M. with the DSS. Four one-gallon containers of milk were stored on the refrigerator shelf. One container was opened with approximately one quarter of milk remaining in the container. Each gallon container had a best by date of 7/6/19. The DSS stated the facility had just received the milk on 7/8/19, and did not know why the best by dates were 7/6/19. The DSS acknowledged that the milk was outdated and should not have been in the refrigerator. An interview was conducted on 7/11/19 at 3:50 P.M. with the DON. The DON acknowledged that the four one-gallon containers of milk with best by dates of 7/6/19 were expired, and should not have been accepted upon delivery or stored in 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 infection control practices were followed when: 1. An RNA did not perform hand hygiene before and after resident contact during meal service for four of 11 residents. 2. A CNA did not perform hand hygiene after removing dirty gloves. 3. A CNA served a resident's meal tray in an unsanitary manner. These failures had the potential to spread infection among residents, staff, and visitors. Findings: 1. On 7/8/19 at 12:39 P.M., a meal service observation was conducted in the resident dining room. RNA 23 was observed touching the shoulder and clothing of a female resident, seated at table one while applying a food drape. RNA 23 then went to another female resident at the same table and began unwrapping a straw, placing it in her juice and removing food covers from the second resident's food tray. On 7/8/19 at 12:42 P.M., RNA 23 was observed getting a tray and bringing it to a male resident seated at table two, without washing or…

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.