Valley Skilled Nursing Center

Based on observation, interview, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBPs) were provided for 2 (Resident #111 and Resident #24) of 7 residents reviewed for transmission based precautions and failed to ensure staff followed infection control practices observed during medication administration for 1 (Resident #46) of 6 residents during medication administration and 1 (Resident #111) of 1 resident during wound care. Findings included: 1. A facility policy titled, Enhanced Barrier Precautions, dated 08/2022, revealed Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-frug resistant organisms (MDROs) to residents. The policy revealed, 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. The policy revealed, 3. Exampled of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f.…

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 facility document and policy review, the facility failed to protect Resident #44's right to be free from physical abuse perpetrated by another resident (Resident #259). This deficient practice affected 1 (Resident #44) of 2 sampled residents reviewed for abuse. Findings included: A facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 04/2021, revealed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. An admission Record revealed the facility admitted Resident #44 on 10/01/2024. According to the admission Record, the resident had a medical history that included diagnoses of depression, major depressive disorder with severe psychotic symptoms, and legal blindness. An admission Minimum Data Set (MDS), with an Assessment Reference Date…

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, record review, and facility policy review, the facility failed to ensure Level I Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of a diagnosed serious mental illness for 1 (Resident #35) of 1 sampled resident reviewed for PASARR requirements. Specifically, the facility failed to ensure Resident #35's initial PASARR reflected that the resident had a diagnosis of depression. Findings included: A facility policy titled, Pre-admission Screening and Resident Review, revised 12/2016, indicated, The objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. An admission Record indicated admitted Resident #35 on 11/30/2024. According to the admission Record, the resident had a medical history that included a diagnosis of depression (onset date 11/30/2024). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/05/2024, revealed Resident #35 had a Brief Interview for Mental…

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, record review, and facility document and policy review, the facility failed to ensure staff assisted a dependent resident with activities of daily living (ADLs) for 1 (Resident #7) of 5 sampled residents reviewed for ADLs. Specifically, the facility failed to provide nail care for Resident #7. Findings included: A facility policy titled, Activities of Daily Living (ADLs), Supporting, revised 03/2018, indicated, Residents will [sic] provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. An admission Record revealed the facility originally admitted Resident #7 on 02/02/2022 and most recently admitted the resident on 10/01/2024. According to the admission Record, the resident had a medical history that included diagnoses of quadriplegia (loss of function in all four limbs), hemiplegia (a…

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

Based on interview, record review, and facility policy review, the facility failed to provide indwelling urinary catheter care per the facility's policy and accepted infection control standards and failed to maintain an indwelling urinary catheter bag below the level of the bladder for 1 (Resident #111) of 3 residents reviewed with an indwelling urinary catheter. Findings included: A facility policy titled, Catheter Care, Urinary, revised 08/2022, revealed the section titled Maintaining Unobstructed Urine Flow, included, 3. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. The policy revealed the section titled Steps in the Procedure Routine Perineal Hygiene, included, c. Change the position of the washcloth (or wipe) with each cleansing stroke. d. With a clean washcloth (or wipe), rinse using the above technique. Further review revealed, 15. Use a clean washcloth with warm water and soap (or bathing wipe) to cleanse and rinse the catheter from insertion site to approximately four inches outward. An admission…

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 and policy review, the facility failed to provide food that accommodated resident allergies and preferences for 2 (Resident #257 and Resident #41) of 3 residents sampled for food. Findings included: A facility policy titled, Food Allergies, dated 2023, revealed, Policy: Residents with food allergies will be identified upon admission. The policy also indicated, Procedure: 1. Allergies will be noted in the medical record. 2. All allergies will be communicated in writing directly to the FNS [Food and Nutrition Services] Director by Nursing. 3. Appropriate food substitutions will be offered for foods the resident cannot eat. 4. Refer to [Vendor Name] Diet Manual for food allergy information. 5. Allergies will be noted on the tray card, the resident diet profile, and posted in the kitchen and nursing station, if necessary. A facility policy titled, Food Preferences, dated 2023, revealed, Policy: Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food…

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 follow their policies and procedures (P&P) titled, Psychotropic Medication Use,regarding the safe and appropriate prescribing and administering of psychotropic (used to treat psychosis- conditions that affect the mind, where there has been some loss of contact with reality) medication for one of five sampled residents (Resident 1) when Divalproex sodium (medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and mental disorders and to prevent migraine headaches) was prescribed and administered prior to determining the appropriate indication for use. This failure increased Resident 1 ' s risk of serious side effects that included but were not limited to nausea, vomiting, headaches, liver complications, tardive dyskinesia (condition causing uncontrolled movements various body parts like the arms and legs or of the tongue in a chewing motion) and changes to mood, behaviors and thought processes. Findings:…

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 meet professional standards of quality for two of three sampled residents (Resident 1 and Resident 2), when: 1. Resident 1 had an unwitnessed fall on 7/24/24 and facility staff did not complete a change of condition (COC) assessment (used to describe situation, background, assessment of resident and physician recommendations). 2. Resident 2 had a change in urine patterns on 7/28/24, blood in urine on 7/30/24 and the facility did not complete a COC for both instances for Resident 2. These failures resulted in incomplete documentation for Resident 1 and Resident 2 putting Resident 1 at risk for falls and Resident 2 at risk for delay in care when there was no documentation of change in condition to inform other facility staff of changes in resident care. Findings: 1. During a record review of Resident 1 ' s Post Fall Evaluation (PFE), dated 7/25/24, the PFE indicated, Resident 1 had an unwitnessed fall on 7/24/24 resulting in fracture to the olecranon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan per facility ' s policy and procedure titled Care Planning-Interdisciplinary Team for one of three sampled residents (Resident 1), when Resident 1 sustained a fracture (broken bone) of left arm on 7/24/24 and there was no care plan created for Resident 1 ' s care of the fractured right arm. This failure had the potential for harm when the facility staff did not create a care plan with interventions to monitor Resident 1 ' s fractured right arm with bandage that could have led to skin breakdown, pain, and acute compartment syndrome (bandage or cast placed on injured arm or leg too tightly) causing swelling, numbness, weakness, difficulty moving the affected body part. Findings: During an observation on 8/13/24 at 11:22 a.m. of Resident 1 in Resident 1 ' s room. Resident 1 was observed walking around facility with four wheeled walker. Resident 1 was observed to have an arm brace…

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 Licensed Vocational Nurses (LVN) followed professional standards of practice for one of three sampled residents (Resident 2), when on 9/30/23 at 6:30 a.m., Resident 2's blood glucose (sugar) level was of 55 mg/dl [milligrams per deciliter [a unit of measurement]) and LVN did not communicate the result to Resident 2's physician and did not recheck Resident 2's blood glucose within 15 minutes as per the facility's Hypoglycemia (low blood glucose) policy. This failure increased the potential for Resident 2 to experience complications such as confusion, coma (a state of deep unconsciousness that lasts for a prolonged or indefinite period), headache and restlessness. Findings: During a review of Resident 2 ' s Face Sheet (FS- a document containing resident profile information), dated 10/17/23, the FS indicated, Resident 2 was admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus (body cannot properly use insulin…

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 establish and maintain an effective infection control and prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable (contagious) diseases and infections when staff did not disinfect equipment with an agent that would kill Clostridium difficile (C. diff -bacterial infection that causes life threatening diarrhea) bacteria. These failures had the potential to increase the risk of transmission of C. diff infection to all residents and staff of the facility. Findings: During an observation on 10/17/23 at 10:05 a.m. in the north hallway, Resident 1's room had a plastic compartment drawer. A germicidal [brand name} agent wipes was on top of the drawer. During a review of Resident 1's Order Summary Report, dated 10/10/22, the order summary report indicated, .The resident must remain in his/her room. This requires that all services be brought to the resident .for isolation precaution C-diff for 13 days . During a concurrent…

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 safe and sanitary food preparation and storage practices in the kitchen when: 1. There was no air gap for Prep sink and dishwasher machine. 2. Torn gaskets found on both Reach-in refrigerator's doors. 3. Dust found on these areas: a) Hanger for pot, pans and utensils. b) Under Food Prep stainless steel table. c) Wall in storeroom d) Four storage shelves in storeroom e) Storeroom's doorway. f) Ventilator fans in Reach-in refrigerator. g) Walk in refrigerator insulation black pipe. h) Under stainless steel table for beverage area. i) Stainless shelves for spices. 4. Storeroom's floor found food particles; walk in refrigerator's floor had rough surface and chipped paint; floor under oven had black grime and floor in dish washing area had black grime. 5. Five serving bowls did not had smooth surface. 6. One broken tile found under hand washing sink. 7. Two food storage shelves in walk in refrigerator had brown/black, white fuzzy…

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 timely revise and implement a person centered comprehensive care plan for one of 12 sampled residents (Resident 1) when Resident 1's psychotropic medication (any drug that affects behavior, mood, thoughts, or perception) care plan was not individualized for each specific medication. This failure placed Resident 1 at risk for complications due to care needs not being planned by licensed nurses and the interdisciplinary team to determine if interventions needed to be added, changed or completed. Findings: During a review of Resident 1's admission Record (AR-a document with personal identifiable and medical information), dated 7/27/23, the AR indicated, Resident 1 was admitted on [DATE] with diagnoses which included fracture (partial or complete break in the bone) of right lower leg, fracture of left foot, surgical aftercare, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the services provided met professional standards of practice for two of six sampled residents (Residents 3, and Resident 94) when: 1. Licensed Vocational Nurse (LVN) 1 did not take a blood pressure (the force of your blood pushing against the walls of your arteries. Each time your heart beats, it pumps blood into the arteries. Your blood pressure is highest when your heart beats, pumping the blood. This is called systolic pressure) reading for Resident 94 with blood pressure (BP) medication administration on 7/26/23 at 9 a.m. before administering Lisinopril (medication used to treat high blood pressure). This failure had the potential to result in an unwanted decrease in Resident 94's BP which could lead to lethargy, loss of consciousness and/or death. 2. Registered Nurse (RN) 2 placed physician orders for Risperidone (a drug used to treat certain mental disorders) for indications of Bipolar Disorder (a serious mental illness 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 prepare food in a form to meet individual needs for 12 of 12 sampled residents (Resident 3, 8, 10, 11, 12, 15, 16, 28, 30, 37, 38, and 241) when: 1. Residents 3, 8, 10, 11, 15, 16, 28, 30, 37, 38, and 241 did not receive Mechanical Soft diet (is a diet that contain food that is chopped into small pieces for residents who have limited chewing and swallowing ability) as indicated on physician's orders and received a regular texture dessert for lunch on 7/26/2023. 2. Resident 12 had physician order for Pureed diet (a diet with food texture of smooth like pudding or mashed potatoes that requires no chewing) but received scalloped potatoes which contained chunks of potatoes for lunch on 7/26/2023. These failures placed Residents 3, 8, 10, 11, 12, 15, 16, 28, 30, 37, 38, and 241 on choking hazard. Findings: During a concurrent observation and interview on 7/26/23 at 11:48 a.m. with Diet Aide (DA) 1, no chopped peaches were observed at the tray…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility did not give written notification residents and/or rps about transfer to acute hospital. Resident #3 Hospitalization 07/26/23 10:43 AM recently hospitalized , not sure why. RES admitted for COPD exacerbation, hematuria, and encephalopathy. 07/27/23 10:22 AM [NAME], RN (RR) COPD exacerbation, hematuria and encephalopathy; res was on oxygen-94% NC (I)she was no 2L but not documented. RES is her own RP so nobody was notified just the NP. OMB notification of transfer was not seen in the chart. 07/27/23 10:32 AM [NAME]-only sends the OMB notification when the res discharges from ; for hospitalizations she sends them a list at the end of the month; for the discharges she gives a copy to res/rp and send it to OMB. 07/27/23 11:41 AM [NAME], DON; when a res is transferred there is a form when res gets d/c or transfer filled out and provided to RP/RES. She doesn't know if there was a physical paper when a res is transferred, its usually a verbal notification to res/rp. a 07/27/23 02:53 PM [NAME], DON;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services for one of 25 residents (Resident 93), when the facility did not obtain medications for Resident 93 after admission to the facility on 7/25/23, and Resident 93 did not receive medications per physician's orders. This resulted in Resident 93 not receiving his medications on 7/25/223 to treat his medical conditions, and place Resident 93 at harm. Findings: During a review of Resident 93's admission Record (AR-a document with personal, identifiable and medical information), dated 7/28/23, the AR indicated, .admission Date 7/25/23 .Primary Diagnosis .Schizophrenia, Unspecified (condition that involves delusions (false beliefs), hallucinations (seeing or hearing things that don't exist), unusual physical behavior, and disorganized thinking and speech) .Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure drugs were labeled in accordance with currently accepted professional standards of practice for five of six sampled residents (Resident 191, Resident 3, Resident 6, Resident 1, and Resident 34) when: 1. Resident 191 had one eye drops bottle stored in the medication cart in Hallway 3 without a resident identifier. 2. Inhalers (a device used to give medications in the form of a spray that is breathed in through the mouth) for Resident 3, Resident 6, Resident 18, and Resident 34 were stored in the medication cart in Hallway 3 without residents' identifiers. These failures had the potential for the medications to be given to the wrong residents which could cause adverse reactions (harmful, unintended result caused by a medication) and/or cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) which could cause an infection (when germs enter a person's body and multiply,…

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 dispose garbage under sanitary conditions for one of two dumpsters when trash was found on the ground around the dumpster. This failure had the potential to attract rodents, insects, and flies and could spread infection which placed the residents at risk for foodborne illness. Findings: During a concurrent observation and interview on 7/25/2023, at 4:05 p.m., with the Minimum Data Set Coordinator (MDSC) in the facility trash dumpster area near the parking spaces, there was trash, white plastic bag, plastic food bag, napkin/tissues, torn pieces of Styrofoam, and various pieces of paper, found on ground between the dumpster and a chain-link fence. MDSC confirmed there was trash on the ground between the dumpster and a chain-link fence. The MDSC stated, the dumpster should not have any trash around it because it would attract pests. During a review of the facility's policy and procedure (P&P) title, Sanitization, revised November 2022, the P&P indicated, .waste is properly contained in dumpsters/compactors 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.

Based on observation, interview, and record review, the facility failed to ensure nursing staffing information was posted daily at the beginning of each shift for two out of four days (4/13/22 and 4/15/22). This failure resulted in facility staffing information not readily accessible to residents and visitors. Findings: During a concurrent observation and interview on 4/13/22, at 2:30 p.m., with the Assistant Director of Nursing (ADON), near the front entrance of the facility, the posted nursing staffing information was for 4/12/22 [previous day]. ADON stated he had forgotten to post the nursing staffing information for today [4/13/22]. ADON stated he was responsible for posting the nursing staffing information from Monday to Friday. ADON stated he does not print and post the weekend nursing staffing information. ADON stated he was not aware that he must post the nursing staffing information every day, including weekends. ADON stated without the posted nursing information, residents, staff and visitors would not know if the facility was meeting the required daily nursing hours 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 safe and sanitary food preparation and storage practices in the kitchen when: 1. The three compartment sinks (three sinks used for washing dishes, one for washing, one for rinsing and one for sanitizing dishes) and a food preparation sink did not have an air gap. 2. The handwashing sink in dish room did not have soap and one Dietary Aide (DA) failed to properly wash hands after handling soiled items; 3. There were multiple areas in the kitchen, kitchen equipment and food storage areas that were not clean. 4. Dietary staff was storing food ingredients in trash bags; and 5. Dietary staff were storing personal items in food storage areas. The facility's failures to ensure safe and sanitary conditions may result in the likelihood of cross contamination and exposure of microorganisms that harbor foodborne pathogens of residents' food resulting in food-borne illness to a population of Fifty three of 57 residents who received food from the kitchen and are medically compromised. Findings: 1. During 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 dispose of garbage and refuse properly when trash was found outside on the floor surrounding the dumpster. And the lids of the dumpsters did not close properly. This failure had the potential to attract pests and rodents. Findings: During an observation on 4/12/22, at 1:52 PM, outside facility, there were 2 dumpsters. One of the dumpsters was recycle dumpster. The recycle dumpster lids were not closed. Trash was surrounding another dumpster floor and one of the lid was not closed. During an interview on 4/12/22, at 3:05 PM, with Food and Nutrition Director (FND), in front of dumpsters, FND stated it is inappropriate to have trash surrounding dumpster. My expectation is to have someone to clean, sanitize the area. Keep the odor away to avoid attract pests. During a review of the facility's policy titled Garbage, and Trash, Revised January 2021, indicated, Garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed The trash collection area is…

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

Based on observation, interview, and record review, the facility failed to maintain an effective infection control and prevention program when: 1. There was no documented evidence that the screening questionnaires regarding signs and symptoms (S/S) of Coronavirus (COVID-19, a serious respiratory illness caused by a virus which is the cause of a current worldwide pandemic transmission) and vaccination status of each visitor/staff had been reviewed by a facility representative from 4/1/2022 until 4/14/2022 [14 days]. This failure placed all residents, visitors and staff who entered the facilitity from 4/1/2022 until 4/14/2022 at risk for COVID-19 . 2. Hospice Nurse (HN, a nurse providing care for individual with terminal illness) did not disinfect the blood pressure cuff and sphygmomanometer (medical instrument for checking blood pressure) after use for one of four sampled residents (Resident 24). This failure placed Resident 24 at risk for cross contamination. Findings: During a concurrent interview, and record review on 04/14/22, at 09:59 AM, with the Certified Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable environment when the window sills were separating from the window's wooden frame exposing nails, splinters and letting in outside air for two of 34 resident rooms (room [ROOM NUMBER]B and room [ROOM NUMBER]B). This failure placed Resident 20 and Resident 30 at risk for splinters and nail injuries and placed Resident 20 and 30 at risk for increased hot and cold temperatures. Findings: During a review of Resident 30's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/13/22, the AR indicated, Resident 30 was a [AGE] year old female who was admitted from an acute care hospital on 5/15/21 to the facility, whose diagnoses included Congestive Heart Failure (CHF, weakness in the heart where fluid accumulates in the lungs) and Generalized Muscle Weakness. During a review of Resident 30's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and/or implement a comprehensive person-centered care plan for five of 15 sampled residents (Residents 158, 24, 25, 26, and 8) when: 1. Resident 158's use of dentures were not care planned. This failure resulted in Resident 158 not enjoying her food due to being on a puree diet and having her needs not met. 2. The hospice status (the type of care provided at the end of life and centered on promoting comfort and pain-free existence) for Resident 24 and Resident 26 was not care planned. These failures had the potential for the hospice needs for Resident 24 and 26 to go unmet. 3. Resident 25 care plan for site dressing change for tube feeding was not followed. This failure had the potential for infection at the insertion site of Resident 25's Gastrostomy (G-tube- an opening into the stomach from the abdominal wall, made surgically for the introduction of food) site. 4. Resident 8 did not have a care plan developed and implemented for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services provided meet professional standard of practice for one of four sampled residents (Resident 42) when facility staff did not follow the physician's order to administer continuous oxygen via nasal cannula (a device used to deliver supplemental oxygen). This failure had the potential to cause Resident 42 to experience shortness of breath, headache, weakness, and trouble sleeping. Findings: During a review of Resident 42's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/13/22, the AR indicated, Resident 42 was admitted from an acute care hospital on [DATE] to the facility, whose diagnoses included Intracranial Hemorrhage (brain bleed, bleeding between the brain tissue and skull), Dysphagia (difficulty in swallowing), and Chronic Obstructive Pulmonary Disease (COPD, group of lung diseases that block airflow and make 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.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than five percent when 15 medication errors were observed during 27 medication administration opportunities, which resulted in an error rate of 55.56 percent. These failures resulted in Resident 8 and Resident 30 not being informed of the medications being administered and had the potential for unsafe medication administration and untherapeutic medication effects for Resident 8 and Resident 30. Findings: During a concurrent observation and interview on 4/14/22, at 10:38 a.m., with Licensed Vocational Nurse (LVN 4), LVN 4 was observed preparing Resident 8's medications. LVN 4 was outside Resident 8's room. LVN 4 stated she was giving Resident 8 the following medications: amiodarone (irregular rhythm medication), amlodipine (blood pressure medication), Aspirin (pain, fever, and inflammation reducer), Carvedilol (treats high blood pressure and heart failure), Eliquis (blood thinner), Ferrous sulfate (treats low iron levels), Finasteride (treats benign prostatic hyperplasia),…

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

Based on observation, interview and record review, the facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services when: 1. Food and Nutrition Director (FND) did not follow manufacture temperature guideline for testing the Quaternary (Quat) ammonia sanitizer. 2. [NAME] 2 was unable to properly calibrated the thermometer. 3. [NAME] 1 did not follow the recipe for making Cabbage and carrots. Failure to ensure staff competency may result in resident exposure to bacterial growth associated with foodborne, incorrect and/or holding temperatures and practices that affect meal palatability to a population of Fifty three of 57 residents who received food from the kitchen and are medically compromised. Findings: 1. During a concurrent observation and interview on 4/12/22, at 9:59 AM, the Food and Nutrition Director (FND) was preparing Quat sanitizer. It was noted as the FND filled the bucket, there was moisture resembling steam on the surface of the solution in the bucket. The FND checked the temperature of the solution 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 meal delivery observation, resident and staff interview, and record review, the facility failed to follow its policy on Meal Service to provide appetizing food at appropriate temperatures according to residents' preferences for four of fifty-three sampled residents (Resident 24, Resident 50, and Resident 53 and Resident 158). This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutrition status. Finding: During an interview on 4/13/22, at 11:15 AM, Resident 158 stated, . sometimes the food is cold . During the confidential resident council meeting, on 4/13/22, at 2:00 PM, three of five residents (Resident 24, Resident 50, and Resident 53) stated they received cold foods. During an observation on 4/14/22, at 4:58 PM, with the Food and Nutrition Director (FND), meal cart containing a test tray left the kitchen. On 4/14/22, at 5:13 PM, the last resident meal was served. On 4/14/22, at 5:14 PM, in the small dining room, in the presence of the Administrator (ADM), and FND, an evaluation for temperature and palatability, of 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, the facility failed to ensure complete and accurate documentation of medical records in accordance with accepted professional standards of practices for one of 15 sampled residents (Resident 58) when: 1. Licensed Vocational Nurse (LVN) 5 did not conduct a complete assessment and accurately document Resident 58's medical condition. 2. Certified Nurse Assistant (CNA) 2 did not complete and accurately document Resident 58's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's body functions). These failures resulted in inaccurate documentation and resulted in delayed treatment for Resident 58. Findings: 1. During a review of Resident 58's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/13/22, the AR indicated, Resident 58 was admitted from an acute care hospital on 1/16/22 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide care consistent with professional standards of practice for one of 15 residents (Resident 25) when: 1. Resident 25's gastrostomy tube (G-tube, is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) feeding was not changed in accordance with the physician orders. 2. Resident 25's G- tube dressing was not changed daily in accordance with the physician orders. These failures had the potential for Resident 25 to receive inadequate nutrition via the G-tube feedings and had the potential for Resident 25 to develop gastrointestinal issues and infection. Findings: 1. During a review of Resident 25's admission RECORD (AR- document that provides residents name, date of birth , admission date, insurance information, contact information, diagnosis's and more), dated 4/14/22 was reviewed. The AR indicated, Resident 25 was admitted on [DATE], with a diagnosis 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, and record review the facility failed to provide respiratory care services in accordance with their policy and procedure titled, Oxygen Administration, when the oxygen tubing was not changed as ordered for one of 15 sampled residents (Resident 35). This deficient practice had the potential for Resident 35 to develop a respiratory infection. Findings: During a review of Resident 35's admission RECORD (AR- document that provides residents name, date of birth , admission date, insurance information, contact information, diagnosis's and more), dated 4/14/22, the AR indicated Resident 35 was admitted on [DATE] with diagnoses including Hemiplegia (severe or complete loss of strength on one side of the body) and hemiparesis (mild loss of strength in leg, arm or face) following Cerebral Infarction (damage or death to brain tissue due to lack of oxygen), Disorders of Diaphragm (major muscle of respiration located below the lungs), Anxiety disorder (feelings of worry, anxiety, or fear 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.

Based on interview, and record review, the facility failed to conduct adequate monitoring for one of 15 sampled residents (Resident 54) when bupropion (a medication used to treat depression) was not appropriately monitored for negative effects. This failure had the potential to cause serious negative effects to Resident 54, including but not limited to changes in mood, thoughts of suicide, fast heartbeat, muscle pain, seizures, constipation, weight gain or weight loss. Findings: During a review of Resident 54's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/15/22, the AR indicated, Resident 54 was admitted from an acute care hospital on 4/23/21 to the facility, whose diagnoses included Paraplegia (immobility of the legs and lower body), Major Depressive Disorder (a persistent feeling of sadness and loss of interest) and Muscle Weakness. During a review of Resident 54's Order Summary Report (OSR), dated 4/15/22, the OSR indicated, buPROpion Hcl [Hydrochloride] . Tablet 100 MG…

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

Based on interview and record review, the facility failed to ensure the Food and Nutrition Director (FND) effectively monitored the dietetic service operations in accordance with the Dietary Service Manager job description. This failure had the potential to result in ineffective and inadequate directing of the day-to-day foodservice operations to ensure the nutritional needs fifty three of 57 residents were met in a safe and sanitary manner. Findings: During the initial kitchen tour on 4/12/22, beginning at 8:43 A.M., observations and concurrent interviews were conducted with the FND regarding overall kitchen sanitation and cleanliness. There were multiple areas and equipment in the kitchen that were not clean including but not limited to dust and black/brown debris on the fan above dish room, the light fixtures above 3 compartment sinks and above tray line and the air conditioner in the dry food storage. Additionally, staff were using a black trash bag as a food liner to store flour and dietary staff were storing personal items in dry food storage room. During an observation, on…

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

Based on observation, interview, and record review, the facility failed to ensure resident's food preferences were honored for one of 57 sampled residents (Resident 158) when beef was placed on Resident 158's lunch plate, despite beef being listed as a dislike. This failure had the potential to result in decreased food intake, and could result in unplanned weight loss, further compromising Resident 158's nutritional and medical status. Findings: During a concurrent observation and interview on 04/13/22, at 12:31 PM, with Resident 158, in the dining room, Resident 158 meal tray ticket indicated dislike beef. Resident 158 received Corned Beef with her lunch. In a concurrent interviewed, Resident 158 stated I do not like beef. During an interview on 04/13/22, at 12:32 PM, with Certified Nursing Assistant (CNA) 1 and Food and Nutrition Director (FND), in the dining room, CNA 1 checked menu posted on the dining room wall and stated, today lunch is Corned Beef, and the brown color pureed meat is Corned Beef. Verification of meal tray ticket with the CNA 1, confirmed dislikes in meal…

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 follow the physician's prescribed diet order, regular diet, regular texture, for one of 57 sampled residents (Resident 33) during lunch on 4/13/22 which result in Resident 33 receiving the wrong prescribed lunch meal. This failure had the potential to result in decreased food intake, and could result in unplanned weight loss, further compromising the nutritional and medical status of Resident 33. Findings: During an observation, of the noon meal plating, on 4/13/22, at 12:02 PM, [NAME] 1 served mechanical soft Corned Beef for Resident 33. Resident 33's lunch meal tray ticket indicated, Diet: 2 gram Sodium, Consistency: Mechanical soft. During a review of the Resident's 33 Order Summary Report, dated 4/14/22, Physician's Diet order indicated, Regular diet, Regular texture . During an interview on 04/14/22, at 11:40 AM, with Resident 33, at Resident 33's room, Resident 33 stated, I do not like provided foods. I do not know what kind of diet they give it to me. I want a regular diet and regular texture. During…

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.