Avondale Villa Post-Acute

Based on observation and record review, the facility failed to provide food items according to the menu when nine of 30 sampled residents receiving a regular diet order (Residents 4, 6, 13, 15, 16,17, 29, 186, and 188) were not served with one teaspoon (tsp) of margarine at lunch. This failure had the potential for residents to receive and/or consume inadequate caloric intake. See also tag F 808. Findings: During a review of the facility document, Diet Type Report, dated 2/28/24, the document indicated Residents 4, 6, 13, 15, 16,17, 29, 186, and 188 were on a regular textured diet that allowed margarine consumption. During a lunch tray line observation, on 2/26/24 at 12:11 p.m., there was no margarine served on any resident lunch tray, including the lunch trays of Residents 4, 6, 13, 15, 16,17, 29, 186, and 188. During a review of the facility document, Winter Menus, dated 2/26/24, the Menu indicated one tsp of margarine should be included on the lunch tray for all regular textured diets, excluding the low/fat, low cholesterol diet. During a review of the facility's P&P titled, Diet…

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 residents were served palatable food when food was served at a low temperature, tasted bland, and had poor texture. These failures had the potential for 30 of 30 residents to consume a decreased amount of nutrients leading to weight loss and/or nutrient related medical complications. Findings: During an interview on 2/26/24 at 10:28 a.m., Resident 1 stated the meals served at the facility were often cold and not palatable. Resident 1 stated the same menu was served repeatedly. Review of the Minimum Data Set (MDS), a Resident Assessment and care guide tool, dated 1/25/24, indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's Basic Interview of Mental status (BIMS) score was 13 (meaning cognitively intact). Resident 1's diagnoses included hypothyroidism (a condition in which the thyroid gland that regulates metabolism doesn't produce enough thyroid hormone). Review of the resident council meetings' minute,s dated…

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 store, prepare, distribute, and serve foods in a sanitary manner that prevents foodborne illness for the facility when: 1. Cool down method was not performed for a leftover meat sauce and Pozole soup in the refrigerator. 2. Frozen food items were incorrectly thawed and refrozen. 3. A box of cherry tomatoes in the refrigerator was covered with white fuzzy material and dark spots. 4. A bag of cooked chicken was stored together in the same compartment with frozen raw meat and poultry. 5. Multiple unlabeled and undated food items were found in the freezer. 6. Staff did not handle drinkware in a manner to protect the drinkware from contamination. 7. The ice machine evaporator plate had black build-up residue, the evaporator cover had white mineral build-up, and the cleaning and sanitizing procedures was not followed according to the manufacturer's instruction. These failures had the potential for residents to be exposed to food borne illness. Findings: 1. During an observation on 2/26/24 at 10:12 a.m., 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 adequate supervision was provided to prevent falls and implement appropriate interventions for one (Resident 16) of 12 sampled residents when, Resident 16 had repeated unwitnessed falls. The facility did not implement Resident 16's need for supervision with stand-by assistance during transfers. These failures caused Resident 16 to sustain repeated falls and had the potential to result in injuries. Findings: Review of the Interdisciplinary Team (IDT, consists of staff members from different departments) progress notes, dated 2/26/24, indicated Resident 16 had an unwitnessed fall in the dining/activity room. Resident 16 called out for help and was seen sitting on the dining room floor in front of a wheelchair and facing a regular chair that he was previously sitting in. Review of the Significant Change in Status-Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 9/8/23, indicated Resident 16 was admitted…

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 record review, the facility failed to ensure pureed food was the appropriate consistency for six out of 30 residents. This failure had the potential for residents on pureed diet to aspirate (draw food into the lungs) and/or negatively impact the resident's dining experience resulting in poor food intake and compromising their nutritional status. Findings: During the tray line observation, on 2/26/24 at 11:30 a.m., the pureed chili had the texture of a thickened cream soup and pureed cornbread was a thin pudding texture. Both foods did not hold their shape and spread out when placed on the resident lunch plate. During a follow up tray line observation, on 2/27/24 at 11:23 a.m., the pureed beef roast and zesty spinach were plated. Each were runny and spread out on the plate. During a review of the Diet Type Report, dated 2/28/24, the document indicated, six residents were on pureed diet order. During a review of the undated Regular Pureed Diet document from the facility's Registered Dietician (RDs) for Healthcare diet manual, the document indicated, The…

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

Based on observation, interview, and record review, the facility failed to: 1. Offer a substitute of equal nutritive value when milk on the planned menu was routinely not provided when milk was on the planned menu for all diets. 2. Effectively maintain a system to ensure the resident's food preferences were accurately recorded on their individual tray cards. These failures had the potential for 30 of 30 residents who received food from the kitchen to not receive the nutrients intended by the planned menu and not receive foods according to resident preferences. Findings: 1. During a review of the winter menus, dated 2/26/24 and 2/27/24, the menu indicated, milk was the beverage to be served to residents on all diets. During the tray line observation, on 2/26/24 at 12:11 p.m., meal trays were prepared, placed on a food delivery cart, and were transported to residents for lunch. One 4 oz cup of water and one 4 oz cup of cranberry juice were on 29 lunch trays. One meal tray had one 4 oz cup of water and one 4 oz cup of yellow sugar-free beverage. Over 20 trays did not include milk.…

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

Based on observation, interview, and record review, the facility failed to provide the physician- prescribed therapeutic diet (a diet order as part of treatment for a disease or clinical condition to decrease or increase specific nutrients in the diet) when: 1. Six of six sampled residents (Residents 4, 6, 13, 15, 16,17) on a Fortified diet (a diet with added protein, fat, and/or carbohydrate to increase calories) did not receive supplemental food items as ordered. 2. Three of three sampled residents (Residents 5, 28, 21) on a Consistent Carbohydrate diet (CCHO - a diet that promotes stable blood sugar levels) received a regular diet instead of the CCHO diet. 3. One of one sampled resident (Resident 16) with a diet order for extra protein did not receive extra meat as ordered. These failures had the potential to result in weight loss and/or unstable blood sugar for the residents who did not receive their therapeutic diets as ordered. See also tag F 803. Findings: 1. During a review of the facility document, Diet Type Report, dated 2/28/24, the document indicated Residents 4, 6, 13,…

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 accurate documentation of medication administration for three (Residents 5, 13, and 16) of five sampled residents when two nursing staff (Director of Nursing and Licensed Vocational Nurse 3) failed to document multiple medications' administration on four separate days (2/2/24, 2/11/24, 2/14/24, 2/17/24) These failures had the potential to result in unnecessary duplication of medication administration, and prevented accurate analysis of effectiveness of medication due to lack of clarity as to whether or not the medication was administered. Findings: During a review of the facility admission Record, undated, the admission Record indicated Resident 5 was admitted to the facility in 2022. During a review of Resident 5's Medication Administration Record (MAR) dated February 2024, the MAR indicated no entries for administration of the following scheduled medications: 2/11/24 at 9 a.m.: amiodarone (to treat high blood pressure), amlodipine (to treat…

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

Based on observation, interview, and record review the facility failed to ensure one out of the one facility dishwashing machine was able to maintain water temperatures during the wash and rinse cycles within the manufacturer's recommended water temperature range of 120 degrees Fahrenheit (ºF) and 140 ºF. This failure had the potential for dishware used by residents to not be sanitized sufficiently to prevent food borne illness. Findings: During a continuous observation on 2/27/24 at 10:13 a.m., in the kitchen, Dietary Aide (DA) 2 placed dishes in the dishwashing machine and began the dishwashing cycle. During the wash cycle, the dishwashing machine water temperature gauge reached a maximum of 106 degrees Fahrenheit (ºF), the water temperature gauge remained at a temperature of 106 ºF during the rinse cycle. During an interview on 2/27/24 on 10:15 a.m. with DA 2, DA 2 stated she had checked and recorded the dishwashing machine water temperature earlier in the Dish Machine Temperature Log. During a concurrent interview and record review on 2/27/24 at 10:20 a.m. with DA 2, the Dish…

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 complete a baseline care plan within 48 hours of admission and provide three (Resident 187,185, and 188) of 12 sampled residents and their representatives with a summary of the baseline care plan. This failure did not ensure the residents or their representative were informed of the plan for the provision of care. Findings: Review of the admission Record indicated Resident 187 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) and was discharged home on 2/26/24. During a review of Resident 187's clinical records and concurrent interview on 2/29/24 at 11:57 a.m., with the Director of Nursing (DON), DON stated the baseline care plan was not developed for Resident 187 within 48 hours of admission. DON further stated Resident 187 had been discharged home without a baseline care plan. Review of the admission Record…

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, for one (Resident 6) of two sampled resident, the facility failed to implement its Care Plans, Comprehensive Person-Centered policy and procedure when there was no care plan developed to address Resident 6's risk of aspiration with appropriate interventions This failure had the potential to result in Resident 6 develop aspiration, pneumonia and respiratory infection and for residents' not receiving appropriate care and treatment. Findings: Review of Resident 6's admission record, dated 9/1/21, indicated Resident 6 was admitted to the facility with multiple diagnoses included dysphagia orophapharryngeal phase (difficulty in swallowing). Review of Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 12/22/23, indicated Resident 6's Basic Interview of Mental status (BIMS) score was 05 (meaning poor cognition). Resident 6 had swallowing disorder related to holding food in mouth/cheeks or residual food in mouth after meals. Resident 6 diagnoses included dysphagia and Non-Alzheimer's Dementia (a group of diseases…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to assess one sampled resident (Resident 16) when the resident experienced a severe weight loss. This failure had the potential to result in continuous, unplanned weight loss for one of 13 sampled residents. Findings: Review of the document titled, Weight Change Protocol dated 2023, showed Early identification of a weight problem and possible cause(s) can minimize complications. Assessment of residents experiencing weight changes should be completed in a timely manner . Residents will be weighed monthly and weekly for those newly admitted and those deemed to be at high risk for weight changes . Variances are calculated from monthly and weekly weights that are obtained by facility staff. Residents who experience significant changes in weight or insidious (continuous weight loss that does not necessarily meet the significant/severe weight loss guidelines) weight loss will be assessed by the Facility RD [Registered Dietitian]. The following criteria define…

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 two (Resident 2, 16 ) of five sampled residents were free from unnecessary drug when psychotropic medications were administered without adequate clinical indication and monitoring for its use when; 1. Resident 2 was administered Ziprasidone HCL (hydrochloride), an antipsychotic medication at bedtime for dementia and depression manifested by hitting, striking out during care and mobility. Resident 2 was administered Ziprasidone without adequate monitoring of target behaviors. 2. Resident 16 was administered Zyprexa, an antipsychotic medication for altered sensorium (inability to think clearly or concentrate), throwing objects, hitting/punching staff. Resident 16 was administered Trazadone, an antidepressant for sleep without adequate monitor of hours of sleep. Resident 16 was administered PRN (as needed) Lorazepam (Ativan), an antianxiety medication without the implementation of non-pharmacological interventions first before offering…

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 consider alternative recommendations for the use of the provale cup assistive device (helps prevent choking by delivering a measured amount of liquid. Cups vary with different delivery amounts) while allowing the patient to eat and drink independently, for one (Resident 6) of 12 sampled residents. Resident 5 was identified at risk for aspiration (food or liquids enters the windpipe). This failure resulted in staff not using an assistive device with meals or consulting with the Speech Therapist for recommendations when Resident 5 refused using the provale cup. This had the potential to result in aspiration and the development of pneumonia. Findings: During an observation on 2/26/24 at 12:56 a.m., Resident 6 was seated at the dining table in the dining area and fed by the Restorative Nursing Assistant (RNA 1). Resident 6 coughed repeatedly when fed corn bread and salad. When Resident 6 coughed, RNA 1 gave Resident 6 water to drink from 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 and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 was provided supervision when staff were unaware of Resident 1's whereabouts for two eight-hour shifts (16 hours). This failure had the potential to result avoidable accidents while Resident 1 was not in the facility unsupervised. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included, abnormal posture, difficulty walking, anemia (when your blood produces a lower-than-normal amount of healthy red blood cells), depression (persistent feeling of sadness and loss of interest and can interfere with your daily life), anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), end stage kidney disease (kidneys are no longer able to work at a level needed for day-to-day life) and was dependent on hemodialysis…

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

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to maintain medical records on Resident 1 that were accurately documented and complete when; - Licensed Vocational Nurse (LVN) 1 did not document Resident 1's whereabouts for the entire afternoon/evening shift. - LVN 1 signed off Medication Administration Record (MAR) indicating medications were administered to Resident 1 while Resident 1 was actually not in the facility. These failures resulted in inaccurate medical records and falsification of medication administration. Findings: During a concurrent interview and review of clinical records with Director of Nursing (DON) on 11/8/23 at 11:20 a.m., Resident 1's progress notes were reviewed. DON stated Resident 1 went to dialysis clinic on 10/25/23 for treatment and did not return to the facility. DON stated Licensed Vocational Nurse (LVN) 1, during the afternoon shift, did not document the incident and did not notify the incoming night shift that Resident 1 was not in the building. On the following day after being unable 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, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 received care and services with reasonable accommodation when the bathroom did not have a grab bar on the left side to assist Resident 1's toileting needs. This failure had the potential to result in decreased independence to perform activities of daily living (ADLs). Findings: During a review of Resident 1's admission Record dated 8/8/23, the admission Record indicated Resident 1 was admitted to the facility in June 2022 with diagnoses that included aphasia (loss of ability to understand or express speech, due to brain damage), hemiplegia (paralysis of one side of the body), muscle weakness, osteoarthritis (type of arthritis when cartilage/ flexible tissue at the end of the bones wear down) and the need for assistance with personal care. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/27/23, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment…

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, for one of two sampled residents (Resident 1), the facility failed to ensure assessment accurately reflects Resident 1's status when the Minimum Data Set (MDS, an assessment tool used to direct resident care) coded a diagnosis of diabetes mellitus without supporting documentation. This failure had the potential to result in uncoordinated care. Findings: During a review of Resident 1's admission Record, dated 8/8/23, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included aphasia (loss of ability to understand or express speech, due to brain damage), hemiplegia (paralysis of one side of the body), muscle weakness, osteoarthritis, and diabetes mellitus (inappropriately elevated blood sugar levels). During a telephone interview with Family Member (FM) 1 on 8/7/23 at 7:09 p.m., FM 1 stated facility staff had been saying Resident 1 was diabetic and was filling out forms for Resident 1 incorrectly despite Resident 1 not having…

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, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 received treatment in accordance with professional standards and Resident 1's choices when: 1. A long-standing skin rash was not treated in a timely manner. 2. Neurovascular Specialist's (one who has expertise in treating a variety of conditions and vascular malformations of the brain, spine, and peripheral nerves) recommendation for a 30-day heart function monitor was not followed up. This failure resulted in delayed management of care. Findings: 1. During a review of Resident 1's admission Record, dated 8/8/23, the admission Record indicated Resident 1 was admitted to the facility in June 2022 with diagnoses that included aphasia (loss of ability to understand or express speech, due to brain damage), hemiplegia (paralysis of one side of the body), muscle weakness, osteoarthritis (type of arthritis when cartilage/ flexible tissue at the end of the bones wear down) and the need for assistance with personal care. During a review of Resident 1's…

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

Based on interview and record review the facility failed to ensure the recommendations from the January 2022 medication regimen review (MRR, a review of all medications prescribed to each resident to check for provision of pharmaceutical services not consistent with accepted professional standards) for five (Resident 5, 6, 7, 11, 12) of 13 sampled residents were reviewed by the attending physician. This failure had the potential to result in the administration of unnecessary medications for the five residents during January 2022. Findings: A review of Resident 5's admission Record, undated, indicated he was admitted in 2021 with a diagnosis of depressive disorder (a mood disorder resulting in sadness and loss of interest in life). A review of Resident 6's admission Record, undated, indicated he was admitted in 2021 with a diagnosis of end stage renal disease. (ESRD, the stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplant to maintain life.) A review of Resident 7's admission Record, undated, indicated she…

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 infection control policies and procedures were followed when: 1. Two scheduled nursing staff (Licensed Vocational Nurse 1, Certified Nursing Assistant 1), had no documented completion of pre-entry screening for symptoms of COVID-19 (COVID-19, a respiratory infection which can result in breathing difficulty and other complications, including death. Symptoms include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea). Licensed Vocational Nurse 1 had no documented screening for 3/15/22, 3/16/22, 3/17/22, or 3/20/22. Certified Nursing Assistant 1 had no documented screening for 3/17/22. 2. Certified Nursing Assistant 3 (CNA 3) failed to perform hand hygiene after doffing gloves, and properly dispose of the soiled gloves, for one of 14 sampled residents (Resident 14). 3. For two of 14 sampled residents (Resident 10, Resident 14), nursing staff moved 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.

Based on observation, interview, and record review, the facility failed to: 1. Have a prescribed medication available for one (Resident 14) of eight residents. 2. Ensure one pill crusher and one pill cutter were cleaned after use. The failure to administer two consecutive doses of Resident 14's medication for reduction of fluid inside the eye had the potential to result in increased fluid pressure inside the eye causing nerve damage and impaired vision. The failure to remove medication residue from the pill crusher and cutter after use had the potential for administration of unordered medications or incompatible medications due to the mixing of different medications used in the pill crusher and pill cutter. Findings: 1. A review of Resident 14's admission Record indicated Resident 14 was admitted to the facility in 2017 with a diagnosis of diabetes (the body's inadequate production of the hormone insulin results in high blood sugar levels causing excessive urination and damage to body organs), eye disease related to diabetes, and glaucoma (a condition of increased eye pressure from…

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

Based on observation, interview, and record review, the facility failed to ensure one of two kitchen staff wore a head covering while working in the kitchen. This failure had the potential to result in food contamination from hair shed by staff and cause food to be less palatable and/or spread food borne illness. Findings: During an observation and concurrent interview on 3/24/22, at 10:36 a.m., in the kitchen, [NAME] 1(CK 1) was in the kitchen with no head covering. CK 1 stated he forgot to put on a hairnet when he entered the kitchen. CK 1 stated residents could get sick from hair shed onto their food. During an interview on 3/24/22, at 10:43 a.m., with the Dietary Manager (DM), DM stated, all staff were required to wear a hairnet upon entry into the kitchen. During a telephone interview on 3/24/22, at 12:14 p.m., with Registered Dietician (RD), RD stated all staff must wear a hairnet when inside kitchen so hair does not get on food. RD stated hair in resident food was both a potential source of foodborne illness, and was very unsanitary, unappetizing, and unappealing. A review 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.