Newport Nursing And Rehabilitation Center

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the ice machine utilized for the residents and staff was maintained in a sanitary condition. * The facility failed to ensure the microwave utilized to warm up the food was in sanitary condition and free of food residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting board was kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the countertop mounted can opener was in sanitary condition and free of residue. * The facility failed to ensure the heavy-duty blender used for puree preparation and the stainless-steel bucket were…

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 maintain the infection control practices to prevent the development and transmission of diseases and infections. * The facility failed to show documentation of the Legionella facility risk assessment and testing protocols for Legionella and other opportunistic waterborne pathogen. * CNA 1 failed to remove the gown and gloves and perform hand hygiene after touching Resident 498 and before touching Resident A's environment. * The facility failed to ensure a N95 respirator was stored in a sanitary manner, at the entrance to a resident COVID-19 isolation room. * CNA 6 placed Resident 298's shower bin (which contained a clean towel and bathrobe belt) on top of a soiled linen cart during Resident 298's shower. * The residents' clean linen cart was observed with several bath robe belts lying on top of the clean linen cart. These failures had the potential to result in the transmission of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure LVN 1 informed the physician of a change in condition for one of three sampled residents (Resident 598) reviewed for falls. This failure had the potential for Resident 598 to have a delay in care and treatment. Findings: Review of the facility's P&P titled Neurological Assessment (Routine) revised 10/2023 showed a routine neurological assessment is conducted to evaluate the resident for small changes over time that may be indicative of neurological injury. Routine neurological exams include assessing the mental status and level of consciousness, pupillary response, motor strength, sensation, and gait. Under the section Pupillary Response, showed to test both the pupils to ensure they are equally round and reactive to light and accommodation. Under the section Reporting, showed to notify the physician of any change in a resident's neurological status and report other information in accordance with facility policy 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 medical record review, the facility failed to ensure the comprehensive care plans were implemented for one of thirteen final sampled residents (Resident 298) and one nonsampled resident (Resident 301). * The facility failed to implement the bilateral floor mats in accordance with the Risk for Falls care plan for Resident 298. * The facility failed to administer Resident 301's Lidocaine 4% external patch for pain management in accordance with Resident 301's At Risk for Pain care plan. These failures placed the residents at risk of not being provided appropriate, consistent, and individualized care. Findings: 1. Medical record review for Resident 298 was initiated on 12/2/24. Resident 298 was admitted to the facility on [DATE]. Review of Resident 298's care plan titled At Risk for Falls initiated 11/30/24, showed Resident 298 was at risk for falls related to generalized weakness, and a history of CVA and TIA. The care plan approaches included the placement of floor pads (mats)…

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 ensure the necessary care and services were provided to prevent the development of a new pressure ulcers and promote the healing of the existing pressure ulcers for two of two final sampled residents (Residents 598 and 599) reviewed for pressure ulcers. * The facility failed to ensure the LAL mattress setting was consistent with Resident 599's weight and failed to ensure the wound treatment was administered as per the physician's order for Resident 599. * The facility failed to ensure the LAL mattress setting was consistent with Resident 598's weight. These failures had the potential for Residents 598 and 599 to not benefit from the therapy provided by the LAL mattress, and potential for delayed wound healing or worsening of existing pressure ulcers for Resident 599. Findings: Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown- Clinical Protocol revised 3/2014 showed…

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 three final sampled residents (Residents 298 and 600) reviewed for accident hazards remained free from the accident hazards. * The facility failed to ensure CNAs 2 and 3 used a gait belt as per the fall risk evaluation and care plan when transferring Resident 600 to the commode. * The facility failed to implement the bilateral floor mats for safety and fall prevention in accordance with the physician's order for Resident 298. These failures have the potential to place Residents 298 and 600 at risk for serious injury. Findings: Review of the facility's P&P titled Falls and Fall Risk, Managing revised 3/2018 showed based on the previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. According to the MDS, a fall is defined as…

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 to maintain the IV access for one of 13 final sampled residents (Resident 398). * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented in the medical record for Resident 398. This failure had the potential to delay the identification of catheter related complications for the resident. Findings: Review of the facility's P&P titled Central Venous Catheter Care and Dressing Changes dated 2001 showed the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion. For PICCs, measure…

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 safe respiratory care for one of three final sampled residents (Resident 12) reviewed for respiratory care. * The facility failed to ensure Resident 12's CPAP machine was cleaned as per the manufacturer's user cleaning guidelines. This failure had the potential to adversely affect the health and well-being Resident 12 and posed the risk for equipment contamination and respiratory complications. Findings: Review of the facility's P&P titled CPAP/BiPAP Support revised 3/2015 showed the specific cleaning instruction guidelines are obtained from the manufacturer of the PAP device. For the machine cleaning, to wipe the machine with warm, soapy water and rinse at least once a weeks and as needed. For the humidifier (if used), to use clean, distilled water, to clean the humidifier weekly and air dry, to disinfect, place vinegar-water solution (1:3) in the clean humidifier, soak for 30 minutes and rinsed…

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 appropriate pain management for two of two final sampled residents (Residents 12 and 599) reviewed for pain management. * The facility failed to administer pain medication according to the physician's order for Resident 12 and failed to ensure non-pharmacological interventions for pain (NPI) were provided/documented prior to the administration of pain medications. * The facility failed to ensure Resident 599 was consistently provided non-pharmacological interventions for pain prior to the administration of narcotic pain medication. These failures put Residents 12 and 599 at risk for ineffective pain management. Findings: Review of the facility's P&P titled Administering Medications revised 9/2019 showed the medications are administered in accordance with the prescriber orders, including any required time frame. Review of the facility's P&P titled Pain Assessment and Management revised 10/2022 showed…

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. On 12/4/23 at 1007 hours, a concurrent observation and interview was conducted with LVN 4. LVN 4 was observed administering medications to the facility residents. LVN 4 stated she had seven residents (which included Residents 42, 302, and 305) remaining who had yet to receive their morning medications, which were scheduled to be administered at 0900 hours . LVN 4 stated in accordance with the facility's P&P, resident medications were to be administered within one hour of their prescribed time. LVN 4 stated she was unable to administer the morning medications scheduled for 0900 hours, to Residents 42, 302, and 305, due to having to provide nursing care to a resident (Resident 43) who had an episode of vomiting. a. Review of Resident 42's Order Summary Report dated 12/2024, showed the following medications were ordered to be administered on 12/4/24 at 0900 hours: - Lidoderm Patch 5% (analgesic), apply to right knee topically once a day for pain management, - Cardizem extended release (antihypertensive) 120 mg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 16.13%. * LVN 2 failed to administer three medications as ordered by the physician for Resident 602. * Resident 301 had a physician's order for Calcitriol 0.25 micrograms two capsules orally one time a day for supplement, however, LVN 4 administered two capsules of Calcitriol 0.5 micrograms orally (twice the ordered dose). * Resident 301 had a physician's order for Lidocaine 4% external patch to apply to the right hip and right foot topically for pain management, apply two patches one time a day at the same time, however, LVN 4 applied one lidocaine 4% external patch to Resident 301's hip. These failures had the potential to negatively affect the residents' health. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in accordance with the prescriber…

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 store the drugs, biologicals, and medical supplies in a safe manner as evidenced by the following: * The facility failed to ensure the opened medical supplies in Medication Carts B and C were properly disposed. * The facility failed to ensure the discontinued medications were properly disposed. These failures had the potential for the drug diversion and to result in an unsafe handling and storage of the residents' medications. Findings: 1a. Review of the facility's P&P titled Discarding and Destroying Medications dated 2001 showed for unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA recommends destruction and disposal of the substance with other solid waste following the steps below: a. Take the medication out of the original containers. b. Mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter,…

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 the menus were followed. * The soup was served to the residents without following recipe and nutritional analysis. * The wrong scoop size was used to serve green beans for the residents on the soft-and-bite size diet. * The regular bread was used instead of garlic bread during the pureed bread preparation for the residents on the soft-and-bite size diet. * The pureed bread was not served to Resident 11 during lunch as per the menu. These failures had the potential for residents not receiving adequate nutrition, and appropriate servings. Findings: Review of the Form CMS-672 titled Resident Census and Conditions of Residents completed by the facility dated 4/4/23, showed 54 of 54 residents residing in the facility received food prepared in the kitchen. Review of the facility's P&P titled Menu dated 11/17 showed the residents receive food in the amount, type, consistency, and frequency to maintain normal body weight and acceptable nutritional values. Menus meet basic…

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 ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the ice machine was clean. * The facility failed to ensure the food items in the freezer were properly labeled. * The facility failed to ensure the cooking utensils were in good repair. * The facility failed to ensure the cutting boards were in sanitary condition. These failures had the potential to expose the residents who consumed food prepared in the kitchen to foodborne illnesses. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 4/4/23, showed 54 of 54 residents in the facility received food prepared in 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 and utensils shall be clean to sight and touch. On 4/5/23 at 0815 hours, an observation of the ice machine and concurrent interview was conducted with the Maintenance Director. 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 determine if it was safe for two of 17 final sampled residents (Residents 27 and 497) to self-administer the medications. * Resident 497 was observed with a bottle of Carboxymethylcellulose Ophthalmic Solution 0.5% (a medication used to relieve dry and irritated eyes) at the bedside table. Resident 497 did not have a physician's order to keep the medication at his bedside. Resident 497 did not have an assessment, or a care plan problem addressing the self-administration of medication. * Resident 27 was observed with ACT dry mouth lozenges (formulated with xylitol to help soothe dry mouth and moisturize mouth tissue) at the bedside. Resident 27 did not have an assessment, physician's order, or a care plan problem addressing the self-administration of medication. In addition, there was no physician's order to administer the lozenges. These failures had the potential for Residents 27 and 497 to administer 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 medical record review, the facility failed to ensure the quality of care was provided to two of 17 final sampled residents (Residents 41 and 296) as evidenced by: * No information related to Resident 296's pacemaker was documented. The apical pulse for Resident 296's pacemaker was not monitored and recorded. * Resident 41's anti-embolism stockings were not consistently placed on the resident. These failures had the potential for the residents to not receive quality of care. Findings: 1. On 4/4/23, medical record review for Resident 296 was initiated. Resident 296 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 296's H&P examination dated 3/30/31, showed Resident 296 was admitted to the facility with diagnoses including high blood pressure, coronary artery disease, and permanent atrial fibrillation. Review of Resident 296's March 2023 Order Summary Report showed an order dated 3/27/23, for Resident 296's left upper chest pacemaker. 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 interview, medical record review, and facility P&P review, the facility failed to ensure the necessary treatment and services were provided to help improve or correct performance or prevent further deformity for one of 17 final sampled residents (Resident 10). * Resident 10 was observed wearing cervical collar (commonly used by those who have had a surgical intervention of the cervical spine, to immobilize the neck) while in bed. The facility failed to ensure Resident 10 followed the physician's order to apply TLSO (thoracic lumbar sacral orthosis, brace used to limit motion in the thoracic, lumbar and sacral regions of the spine) brace when the resident was out of bed. In addition, the facility failed to monitor Resident 10's application of the cervical collar while in bed. This failure had the potential for Resident 10 to develop complications from the orthotic device application. Findings: On 4/5/23 at 0933 hours, and 4/7/23 at 0808 hours, Resident 10 was observed in bed wearing a cervical collar.…

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 pharmacy services for one of 17 final sampled residents (Resident 37). * The facility failed to ensure Resident 37's oxycodone hydrochloride (a narcotic pain medication) Drug Control Receipt/Record/Disposition Form did not match Resident 37's MAR. This failure posed the risk for diversion of controlled medications. Findings: Review of the facility's P&P titled Controlled Substances revised April 2019, under the section for Administration, showed the nurse administering the medication is responsible for recording the time of administration. On 4/5/23 at 1110 hours, review of Resident 37's Drug Control Receipt/Record/Disposition Form and MAR was conducted with the IP. Review of Resident 37's oxycodone Drug Control Receipt/Record/Disposition Form showed Resident 37 was administered oxycodone 5 mg two tablets on 3/19/23 at 2044 hours. Medical record review for Resident 37 was initiated 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.

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 five unnecessary medication sampled residents (Resident 41) was free from unnecessary psychotropic medication (any drug that affects brain activity). * The facility failed to monitor the side effects for Resident 41's use of Trazadone (anti-depressant medication). This had the potential for inaccurate side effect monitoring for Resident 41's physician not having the necessary information if Resident 41 had side effects from medication. Findings: Review of the facility's P&P titled Psychotropic Medication Use revised July 2022 showed the residents, families, and/or the representative are involved in the medication process. Psychotropic medication management includes indication for use, dose, duration, adequate monitoring for efficacy and adverse consequences, and preventing, identifying and responding to adverse consequences. Medical record review for Resident 41 was initiated on 4/7/23. 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, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 15.38%. Two licensed nurses (LVNs 4 and 5) who were observed during the medication administration were found to have made errors. * LVN 4 failed to administer the correct dose of Clearlax oral powder (medication to treat occasional constipation) to Resident 294. * LVN 5 failed to administer Resident 24's medications as ordered by the physician. In addition, LVN 5 failed to administer Resident 344's medications with food or meals as ordered by the physician. These failures had the potential to negatively affect the residents' health. Findings: According to the facility's P&P titled Administering Medications dated June 2016 showed it is the facility's policy that medications shall be administered in a safe and timely manner, and as prescribed. Further review of the policy showed that medications must be administered in…

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, record review, and the facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * The facility failed to store Resident 24's difluprednate emulsion (an eye drop medication to treat eye swelling and pain) 0.05% in a locked compartment at bedside. This failure had the potential for the residents, staff, and visitors to have an easy access to the medication. * Multiple outdated Indicaid Covid-19 (a respiratory disease caused by SARS-CoV-2) Rapid Antigen Test buffer solution bottles were observed in Medication Cart A. This had the potential for use of expired medications or biologicals. * Multiple outdated intravenous (into or within a vein) insertion needles were observed in Medication Cart B. This had the potential for use of expired medical supplies. * Medication Cart C had Resident 24's bottle of rhopressa (eyedrops medication) was stored at room temperature. This had the potential for administration of deteriorated medication. 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, observation, and facility document review, the facility failed to ensure the food served to one of 17 final sampled residents (Resident 296) was attractive to the resident. This failure had the potential for the resident not enjoying his meals. Findings: Medical record review for Resident 296 was initiated on 4/4/23. Resident 296 was readmitted to the facility on [DATE]. Review of Resident 296's H&P examination dated 3/30/31, showed Resident 296 had the capacity to understand and make decisions. Review of Resident 296's April 2023 Order Summary Report showed an order dated 4/1/23, for Resident 296's diet as soft and bite size texture, solid bread okay. On 4/4/23 at 0825 hours, Resident 296 was served pureed bread. Resident 296 stated he did not know what to do with the pureed bread. On 4/4/23 at 1302 hours, Resident 296 was served minced main entrée and pureed bread. Per the facility's menu, the main entrée was supposed to be chicken salad. Resident 296 stated the salad served was too dry 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the dietary texture guidelines were followed for the residents on the soft-and-bit-sized diet. * The facility failed to ensure the chopped pot roast and chopped green beans were served to the residents on the soft-and-bite sized diet. This failure had the potential for the residents not liking the food based on the dietary modification and could affect the residents' quality of life. Findings: Review of the facility's P&P titled Therapeutic Diets revised 10/2017 showed the therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and treatments. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: altered consistency diet. Review of the facility's document titled Soft 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, medical record, facility P&P, and facility document review, the facility failed to follow the residents' preferences when the facility ran out of a food items to be served for breakfast. The facility failed to served fruit cups for one of 17 final sampled residents (Resident 344) and two nonsampled residents (Residents 345 and 346). This failure posed the risk of the residents' nutritional needs not being met and the residents' preferences not being honored. Findings: Review of the facility's P&P titled Menus dated 11/17 showed resident preferences and needs are incorporated into the development of the individual food plan. 1. On 4/4/23 at 0853 hours, during the initial tour of the facility, Resident 344 was observed with her breakfast tray. Resident 344's meal ticket card showed fruit cup, oatmeal. Fruit cup was not observed in Resident 344's breakfast tray. Resident 344 stated she wanted her fruit cup. When asked if the dietary staff offered something else other than a fruit…

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 establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections. * The facility failed to ensure the licensed nurse performed hand hygiene between changing of gloves during the medication administration observation. * The facility failed to ensure CNA 3 used the proper PPE in an enhanced standard/barrier precaution room when assisting Resident 295. * The facility failed to ensure CNA 5 performed hand hygiene when assisting the residents with meals. * The facility failed to ensure the staff performed proper hand hygiene when providing care. These failures posed the risk for transmission of disease-causing microorganisms and infections to the residents. Findings: 1. Review of the facility's P&P titled Glove Use with effective date 8/2017, under the general information section, showed the employees shall perform hand hygiene…

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 freezer compartment inside the residents' refrigerator was free of ice buildup. This had the potential for the refrigerators not being maintained in safe operating condition. Findings: On 4/4/23 at 0753 hours, an inspection of the residents' refrigerator was conducted with the DSS. The surrounding of the freezer compartment of the residents' refrigerator was observed with a build-up of ice. The DSS verified the above findings. The DSS stated the dietary staff was responsible to check the temperature of the refrigerator and make sure the food items inside the refrigerator were not expired. The DSS stated the maintenance department was responsible to check the build-up of ice inside the resident's refrigerator. On 4/6/23 at 0735 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated the dietary staff was responsible to check the resident's refrigerator daily and to inform the maintenance department if the refrigerator needed to be fixed such as if there was a build-up of ice.

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 regular inspection of all the bed frames, mattresses, and side rails were performed as part of the regular maintenance program to identify areas of possible entrapment. This had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death. Findings: Review of the facility's P&P titled Bed Safety revised March 2017 showed the facility strives to reduce hazards such as resident entrapment associated with side rails, mattresses and/ or bedrails. In an effort to reduce injuries associated with bedside rails, the DON Services/Environmental Supervisor/ designee and the community IDT shall: - Inspect all bed frames, bedside rails and mattresses according to the regular preventive safety schedule to identify potential areas of possible entrapment; - Ensure that no gap between the mattress, bedframe or side rails exceeds FDA regulations; and - Ensure that replacement…

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.