Palm Terrace Healthcare & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to ensure accurate administration and reconciliation of medications. * The facility failed to ensure LVN 5 flushed Resident 10's GT with 50 ml of water before and after medication administration as per the physician's order. In addition, the facility failed to ensure LVN 5 flushed Resident 10's GT in between medications. * The facility failed to ensure the oxycodone (opioid pain medication to treat moderate to severe pain) removed from the bubble pack was recorded and accounted for in the Narcotic and Hypnotic Record for Resident 109. * The facility failed to ensure the correct medication was administered to Resident 52. * The facility failed to ensure the voltaren topical gel (topical medication use to relieve pain) was available for Resident 12. * The facility failed to ensure the lidoderm patch (topical hydrogel patch use to relieve…

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 medical record review, the facility failed to ensure two of 22 final sampled residents (Residents 4 and 27) were free from the unnecessary medications. * The facility failed to ensure Residents 4 and 27 were monitored for the signs and symptoms of bleeding related to the use of apixaban medication (anticoagulant medication, use to treat or prevent blood clots). These failures had the potential for the residents to receive unnecessary medications and delay in detecting significant side effects.Findings: According to DailyMed Drug Label Information for apixaban updated 6/15/21, the section for Warnings and Precautions included Bleeding. The apixaban tablets increases the risk of bleeding and can cause serious, potentially fatal, bleeding. 1. Medical record review for Resident 4 was initiated on 1/29/26. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's MDS assessment dated [DATE], showed Resident 4 had moderate cognitive impairment. Review 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 medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 20% * The facility failed to ensure LVN 5 administered the correct dosage of the apixaban (anticoagulant), docusate sodium (stool softener) and sennoside (laxative) medications via GT to Resident 10. The medication cups were observed with significant residue after the medications were administered. * The facility failed to ensure Resident 12 received the voltaren topical gel (topical medication use to relieve pain). * The facility failed to ensure LVN 9 administered the correct dosage of the diclofenac sodium topical medication (medication used to relieve joint pain) for Resident 45. These failures posed the risk for the residents to have potential side effects or complications related to the medications.1. On 1/29/26 at 1610 hours, a medication administration observation for Resident 10 was conducted with LVN 5. LVN 5 prepared the following…

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, medical record review and facility P&P review, the facility failed to ensure proper storage of medications in one of four medications cart inspected (Medication Cart A). * The facility failed to ensure the ondansetron (antiemetic medication) for Resident 63 who was discharged from the facility was removed from Medication Cart A. This failure had the potential for the medication to be accidentally administered and/or diverted. * The facility failed to ensure the amiodarone (antiarrhythmic medication) and ondansetron medications in the bubble packs for Resident 96 were secured/sealed and free from tears or damage. This failure posed the risk of affecting the potency of the medications, and potential for medications to be diverted. * The facility failed to ensure an opened glargine (long-acting insulin) pen for Resident 108 was dated. This failure posed the risk of affecting the potency of the insulin medication.Findings: Review of the facility's P&P titled Medication Storage and Labeling (undated) showed discontinued drug containers shall be marked 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed for two of 22 final sampled residents (Residents 14 and 85) * The lunch meal ticket for Resident 14 was not followed when he was served with only one carton of milk. * The facility failed to follow the weekly food menu on 1/29/26 at noon and ensure food preferences and flavor of a boost glucose control were provided to Resident 85. These failures had the potential for the residents not to receive adequate nutrition. Findings: 1. On 1/29/26 at 1013 hours, an interview was conducted with Resident 14. Resident 14 stated he had a concern about not getting the correct amount of milk every meal. Resident 14 stated he was supposed to get two eight ounces of milk every meal, but he was seldom getting the milk that he should. Resident 14 stated he was frustrated, and he had been in the facility for a long time, and they still cannot work it out. On 1/29/26 at 1234 hours, Resident 14…

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, facility document review and facility P&P review, the facility failed to ensure food prepared for the residents was cooked to preserve nutritive value. * The vegetables were cooked more than one hour prior to meal service and held in the steam table with a temperature set on high. This failure had the potential to affect the nutritive content of the food and the amount of food residents consume, potentially resulting in a decrease in residents' food intake leading to poor nutrition and health outcomes.Findings: Review of the professional reference titled https://www.healthline.com/nutrition/cooking-nutrient-content dated 11/7/19, showed in part, the following nutrients are often reduced during cooking: water-soluble vitamins: vitamin C and the B vitamins - thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), folic acid (B9), and cobalamin (B12), fat-soluble vitamins: vitamins A, D, E, and K, and minerals: primarily potassium, magnesium, sodium, and calcium. [NAME] peas contained vitamin C, which is water-soluble 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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of one final sampled resident (Resident 13) reviewed for hospice services. * The facility failed to ensure the hospice skilled nurse visit notes were available and included in Resident 13's medical records. This failure posed the risk of delay in communication between the hospice provider and facility which may affect resident care.Findings: Review of the facility's P&P titled End of Life Care; Hospice revised date 11/2007 showed it is the policy of the facility to provide end of life care for dying residents that emphasizes prevention and relief of symptoms as well as compassionate attention to the resident's dignity and preferences. Through continuing interdisciplinary assessment, individualized plans will be developed and implemented to address the residents' physical, intellectual, emotional, social, spiritual, and practical needs. Hospice…

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 facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure LVN 5 wore a gown when administering medications via GT for Resident 10 who was on EBP. * The facility failed to ensure Resident 24's call light was disinfected prior to use, when it was on the floor. These failures had the potential for cross-contamination and spread of infectious organisms in the facility.Findings: 1. Review of the CMS QSO-24-08-NH dated 3/20/24, for Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of MDROs, showed MDRO transmission is common in long-term care facilities such as nursing homes, contributing to substantial resident morbidity and mortality and increased healthcare costs. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs.…

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

Based on observation, interview, and facility document review, the facility failed to ensure one of one glucometer was maintained in a safe operating condition. * The facility failed to ensure the glucometer calibration was performed correctly. In addition, the facility failed to ensure the glucose strip bottle had an open date and the lot number of the glucose strips was documented in the quality control record. Furthermore, the facility failed to ensure the glucose strips and control solutions had an expiration date of 90 days after opening, as per the manufacturer's information. This failure had the potential for residents requiring glucose checks to have inaccurate readings.Findings: Review of the blood glucose meter manufacturer's information sheet titled Quality Assurance/ Quality Control Reference Manual revised 12/2017 showed the following:- under the Performing a Control Solution Test section, the first two of six steps were: Step 1: Insert test strip into the blood glucose meter, and Step 2: Press the Back or Forward button one time to enter the control solution mode. 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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to two of three sampled residents (Residents 1 and 2). * The facility failed to ensure Resident 1's medication was administered timely as ordered by the physician. * The facility failed to ensure Resident 2's medication was administered as ordered by the physician and accurately documented in the MAR. These failures had the potential for the residents to not receive the medications and posed the risk to negatively affect the residents' well-being.Findings: Review of the facility's P&P titled Medication Administration dated 1/2019 showed the following:- Medications are administered in accordance with the written orders of the attending physician;- Medications are to be administered at the time they are prepared;- Medications are administered within 60 minutes of schedule time; and- The individual who administers the medication dose records…

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, medical record review, and facility P&P review, the facility failed to ensure two of two final sampled residents (Resident 38 and 587) observed for medication administration were free from the medication errors. * The facility failed to ensure Resident 38's IV medication was dated and documented time of administration. * The facility failed to ensure Resident 587's PIV was dated and labeled. These failures posed the risk for the residents to develop complications related to the IV therapy. Findings: Review of the facility's P&P titled Nursing Clinical undated showed to label the IV container with the resident's name, medication, dose initials of nurse, time, date, document additives on resident record and dispose of needles and syringes properly. 1. During the initial tour of the facility on 1/29/25 at 1029 hours, Resident 38 was observed in bed awake, receiving an IV antibiotic medication Vancomycin one gram. However, Resident 38's IV medication bag label was undated, no time it…

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 2. Medical record review for Resident 28 was initiated on 1/29/24. Resident 28 was readmitted to the facility on [DATE]. Review of Resident 28's Order Summary Report showed a physician's order dated 3/26/24, for continuous oxygen at a rate 2 lpm via nasal cannula. On 1/29/25 at 0851 hours, Resident 28 was observed lying in bed with the supplemental oxygen being administered at a rate of 2 lpm via nasal cannula. On 1/29/25 at 1020 hours, an interview was conducted with LVN 1. LVN 1 stated the oxygen tubing should be changed weekly and as needed. LVN 1 stated the date when it was changed should be written on the tubing. On 1/29/25 at 1219 hours, an interview was conducted with the Central Supply. The Central Supply stated the oxygen tubing was changed every Friday. The Central Supply stated Resident 28's nasal cannula tubing was dated 1/13/25, when she changed out the tubing that morning. 3. Medical record review for Resident 438 was initiated on 1/29/24. Resident 438 was admitted to the facility on [DATE]. Review…

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, medical record review, and facility P&P review, the facility failed to ensure one of four residents (nonsampled resident, Resident 736) observed for medication administration was free from the significant medication errors. This failure had the potential to negatively impact the resident's health outcomes. Findings: Review of the facility's P&P titled Medication Administration revised 8/2021 showed it is the policy of this facility that medications shall be administered as prescribed by the attending physician. Medications must be administered in accordance with written orders of the attending physician. On 1/31/25 at 0845 hours 0836 hours, a medication administration observation for Resident 736 was conducted with LVN 3. LVN 3 prepared the following medications for Resident 736: - hydralazine (medication to treat high blood pressure) 25 mg one tablet. The medication bubble pack showed the directions to hold the medication if the SBP less than 110 mmHg or pulse rate less than 60…

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, facility document review, and facility P&P review, the facility failed to ensure eight of eight residents who received pureed food from the kitchen received the proper diets when the facility's puree recipes and menu were not followed as evidenced by: * The facility failed to ensure the puree recipe for potatoes and menu for pureed wheat rolls were followed. This failure had the potential to negatively impact the residents' well-being. Findings: Review of the facility's census on 1/29/25, showed 95 of 98 residents received food from the kitchen. The facility's document titled Diet Type Report dated January 2025 showed the kitchen provided puree diets to eight residents in the facility. Review of the facility's P&P titled Regular Pureed Diet/IDDSI Level #4 dated 2024 showed the pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the prepared food items included on this diet should be smooth and free of lumps, hold their shape, while not being too firm or sticky, and should…

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, facility P&P review, and facility document review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure the food preparation utensils and equipment were in good, sanitary, and cleanable working conditions. * The facility failed to ensure the food items were dated and labeled. * The facility failed to ensure the kitchen staff wore hair restraint. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the facility's census on 1/29/25, showed 95 of 98 residents received food from the kitchen. 1. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-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 medical record review the facility failed to ensure one of nine sampled residents (Resident 2) was free from the significant medication errors. * The facility failed to ensure the licensed nurse properly checked and identified the resident prior to administering the medication. This failure had the potential to negatively affect Resident 2's health outcomes. Findings: Review of the facility's P&P titled Medication Administration dated 1/2019 showed the residents are identified before the medication is administered using at least two identifiers. Methods of identification may include checking identification band, checking photograph attached to medical record and if necessary, verify resident identification with other care center personnel. Review of Resident 2's medical record was initiated on 9/30/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 9/7/24, showed Resident 2 had capacity to make decisions. Review of Resident 2's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary pharmacy services were provided to two of two sampled residents (Residents 1 and 2) when the medications were not provided within their prescribed time. This failure had the potential for negative health outcomes for Residents 1 and 2. Findings: Review of the facility's P&P titled Medication Administration - General Guidelines dated 1/2019 showed medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the care center. Review of the facility's document titled Medication Administration Times, (undated), showed the medications are scheduled to be administered as follows: - daily, administer at 0800 hours; - twice a day, administer at 0800 and 1600 hours; - three times 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, and interview, the facility failed to ensure resident's meals were served at the desired temperatures. This failure had the potential for the undesirable food temperatures to result in decreased oral meal intake and undesirable weight loss for the residents. Findings: a. Medical record review for Resident 3 was initiated on 9/3/24. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 8/30/24, showed Resident 3 had the capacity to make decisions. On 8/29/24 at 1505 hours, an interview was conducted with Resident 3. Resident 3 stated the hot food items on the meal tray were not hot enough. Resident 3 stated he would like to at least eat the warm food. b. Medical record review for Resident 4 was initiated on 9/3/24. Resident was admitted to the facility on [DATE]. Review of Resident 4's MDS assessment dated [DATE], showed Resident 4 was able to make to make self-understood and understand others. Resident 4's BIMS summary score showed 15 (cognitively…

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 medical record review, the facility failed to ensure the responsible party and physician for one of 26 sampled residents (Resident 5) were notified when Resident 5 refused to receive the COVID-19 vaccine. This failure resulted in Resident 5's physician and responsible party not being aware of change in the care of Resident 5, which had the potential to negatively affect the resident's well-being. Findings. Medical record review for Resident 5 was initiated on 11/27/23. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's History and Physical examination dated 10/15/23, showed Resident 5 did not have the capacity to understand and make medical decisions. Review of Residents 5's MDS dated [DATE], showed mild cognitive impairment. Review of Resident 5's vaccination record showed on 9/19/22, a family member (Family Member 1) gave verbal consent for Resident 5 to receive the vaccination. Review of Resident 5's Medication Administration Record for October 2022 showed 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 interview, medical record review, and facility P&P review, the facility failed to ensure two of 26 sampled residents (Residents 2 and 4) were monitored every shift for at least 72 hours following the fall incidents. This failure had the potential to not provide the necessary care and services timely for the residents. Findings: Review of the facility's P&P titled Change of Condition Reporting revised 2/2023 showed the licensed nurse responsible for the resident will continue assessment and documentation every shift for at least seventy-two (72) hours or until condition has stable. Review of the facility's P&P titled Fall Management System (undated) showed when a resident sustains a fall, a physical assessment will be completed by a licensed nurse with the results documented in the medical record. Follow-up documentation will be completed for a minimum of 72 hours following the incident. 1. Medical record review for Resident 2 was initiated on 11/20/23. Resident 2 was originally 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, interviews, facility P&P review, and facility document review, the facility failed to ensure the safe and sanitary food preparation and storage practices in the kitchen as evidenced by: * Fruit flies were observed in the kitchen . * Multiple areas in the kitchen, kitchen equipment, and food storage areas were not cleaned. * The sanitizer red bucket was stored above the clean sheet pans. * Three opened food items (corn kernel, diced carrot, and hot dog) were found in the reach-in freezer. * The dietary staff stored the personal items (drinks) in the kitchen. * Several resident beverages brought in by families were not labeled. These failures had the potential to cause food borne illnesses for the medically vulnerable residents who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 5/17/22, showed 90 of 91 residents in the facility received food prepared in the kitchen. 1. Review of the Food and Drug Administration Federal Food Code 2017 showed, Insects and other pests…

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

Based on observation, interview, and facility P&P review, the facility failed to maintain an environment free of pests. * Fruit flies were observed on multiple days in the food storage and food production areas. This failure had the potential to cause cross contamination of food and food production surfaces as well as the spread of infections in the facility. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 5/17/22, showed 90 of 91 residents in the facility received food prepared in the kitchen. Review of the Food and Drug Administration Federal Food Code 2017 showed Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. Review of the facility's P&P titled Pest Control dated 7/27/21, showed an expectation the facility maintain an ongoing pest control program to provide an environment free of pests and pest control and that problems will be reported promptly. During the initial…

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, medical record review, and facility P&P review, the facility failed to obtain and maintain a copy of advance directives in the medical records for two of 19 final sampled residents (Residents 21 and 66) and one nonsampled resident (Resident 30). This failure had the potential for the residents' decisions regarding health care and treatment options not being honored. Findings: 1. Medical record review for Resident 21 was initiated on 5/17/22. Resident 21 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 21's POLST dated 3/11/22, showed the section for advance directive was not completed. Review of the History and Physical examination dated 3/12/22, showed Resident 21 had the capacity to understand and make decisions. Review of Resident 21's IDT Care Plan Review dated 3/20/22, showed Resident 21 confirmed his advance directive had been formulated. However, Resident 21's medical record failed to show a copy of Resident 21's advance directive. On 5/17/22 at 1305…

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 medical record review, the facility failed to provide an ongoing activity program to meet the needs and interests of two of 19 final sampled residents (Residents 2 and 77). * The facility failed to provide Resident 77 with an individualized activity program which met her identified preference of listening to music. * The facility failed to provide Resident 2 with an individualized activity program which met her identified preference of watching television. These failures had the potential to negatively impact the residents' well-being. Findings: 1. On 5/17/22 at 0840 hours, Resident 77 was observed in the hallway self-propelling her wheelchair. On 5/17/22 at 1020 hours, Resident 77 was observed sitting in her wheelchair inside her room. The television was observed to be turned off. There was no in-room sensory stimulation observed. On 5/17/22 at 1121 hours, Resident 77 was observed in the hallway self-propelling her wheelchair. On 5/17/22 at 1242 hours, an observation 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for four of 19 final sampled residents (Residents 10, 21, 66, and 77). * The facility failed to ensure a comprehensive and effective systematic approach was implemented to monitor and maintain acceptable parameters of nutritional status for Resident 10 as evidenced by: - The facility failed to ensure Resident 10 with several unplanned weight loss was monitored effectively as per the facility's P&P and standard of care. - The facility failed to ensure Resident 10's weight goal range was established with the involvement of the resident and/or resident's legal representative, and in accordance with standards of practice. - The facility failed to monitor the effectiveness of Resident 10's nutrition interventions as per the facility's P&P and standard of care. As a result, the facility's system was not effective at ensuring the RD had evaluated unplanned severe weight loss.…

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 medical record review, the facility failed to provided the necessary care and services for one of 19 final sampled residents (Resident 77) who was on dialysis. * The facility failed to ensure Resident 77's medication was administered as ordered by the physician on the days she was out for dialysis. This failure posed the risk to negatively impact the resident's medical condition. Findings: Medical record review for Resident 77 was initiated on 5/17/22. Resident 77 was admitted to the facility on [DATE], with diagnoses including end stage renal disease requiring hemodialysis. Review of the Order Summary Report showed a physician's order dated 3/11/22, for Resident 77 to receive dialysis every Monday, Wednesday, and Friday at a dialysis center. Resident 77's transportation pick up time was scheduled at 1130 hours. Another physician's order dated 12/11/21, showed an order for isosorbide mononitrate extended release (blood pressure medication) 60 mg one-half tablet by mouth every 12 hours.…

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 ensure the competency of the licensed nurses in the calibration of medical equipment. * RN 1, and LVNs 1 and 2 were unable to demonstrate competency in the calibration of glucometer (a device to measure BS levels). This failure had the potential to put residents at risk for care not provided in a safe and competent manner. Findings: 1. On 5/19/22 at 1104 hours, a medication cart observation and interview was conducted with LVN 1. LVN 1 was asked to demonstrate the calibration of a glucometer. LVN 1 stated the glucometers were calibrated on the night shift and she had not calibrated a glucometer in a while. When prompted to calibrate the glucometer, LVN 1 stated she did not know how to calibrate the glucometer. On 5/19/22 at 1428 hours, a concurrent interview was conducted with the DON. The DON was informed of the observation. The DON stated the staff were trained on the glucometer calibration upon hire and every year. The DON stated the night shift nurses were assigned to do routine glucometer calibration; however, all…

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 medical record review, the facility failed to ensure safe storage of medications. * The facility failed to ensure Resident 77's medications were not left unattended in the resident's room. This failure had the potential to result in unsafe administration of medications. * Expired medications were observed in one of seven medication carts (Treatment Cart 2). This failure had the potential for the residents to be administered the expired medications. Findings: 1. On 5/17/22 at 1249 hours, a medication cup containing several pills and a clear plastic cup containing white powdered medication were observed on top of the overbed table in Resident 77's room. Resident 77 was observed sitting in her wheelchair next to the overbed table. Resident 77's family member was in the room. Resident 77's roommate was observed self propelling her wheelchair inside the room. There was no licensed staff inside the room. A concurrent interview was conducted with Resident 77's family member. Resident 77's family member stated the medications were left by the licensed…

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, facility P&P review, and facility document review, the facility failed to ensure the menu was followed for two nonsampled residents (Residents 24 and 41). * The facility failed to provide diet gelatin for Residents 41 and 24, both of whom had the physician's orders for CCHO (controlled carbohydrate/diabetic) diets. This failure had the potential for the 22 residents receiving a CCHO diets at risk for nutritionally related health complications. Findings: Review of the CMS 672 Resident Census and Conditions of Residents, a document completed by the facility dated 5/17/22, showed 22 of 91 residents in the facility had the physicians' orders for a CCHO diet. Review of the facility's P&P titled Menus Planning dated 7/27/21, showed the food served should adhere to the written menu. Review of the planned lunch menu dated 5/18/22, showed for CCHO diet, dessert: diet version. Review of the facility's P&P titled Tray Card System dated 7/27/21, showed each meal tray at breakfast, lunch, and dinner will have a tray card which designates the resident's name 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 facility P&P review, the facility failed to follow to provide the appetizing food at appropriate temperatures for three of 19 final sampled residents (Residents 8, 31, and 51) and one nonsampled residents (Resident 23). This failure placed the residents at potential risk for decrease nutritional intake which may affect the resident's overall nutrition status. Finding: Review of the facility's P&P titled Meal Service dated 7/27/21, showed in part, . 7. Temperature of the food when the resident receive it is based on palatability. The goal is to serve cold food cold and hot food hot . Recommended Temperature at Delivery to resident .Hot entrée equal or greater 120 degrees Fahrenheit, Starch equal or greater 120 degrees Fahrenheit, Vegetable equal or greater 120 degrees Fahrenheit . On 5/17/22 at 0919 hours, an interview was conducted with Resident 8. Resident 8 claimed his food was always cold. On 5/17/22 at 1007 hours, an interview was conducted with Resident 31. Resident 31 stated food had a bad texture. On 5/18/22 at 1030 hours, during 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, medical record review and facility P&P review, the facility failed to ensure the medical records were accurate for two of 19 final sampled residents (Residents 10 and 77). * Resident 10 was not provided one on one assistance during meals as ordered by the physician. However, the Medication Administration Record for May 2022 showed one to one feeding assistance was provided. * The facility failed to accurately document Resident 77's fluid intake. These failures posed the risk of the residents not receiving appropriate intervention as the medical record information was not accurate. Findings: Review of the facility's P&P titled Charting and Documentation revised 5/2007 showed the resident's clinical record is the concise account of treatment, care, response to care, signs, symptoms, and progress of the resident condition. 1. On 5/17/2022 at 1321 hours, and on 5/18/2022 at 0830 hours during a dining observation, CNA 3 was observed passing a tray to Resident 10. CNA 3 was observed…

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.