Mainplace Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, facility document review, and facility P&P review, the facility failed to investigate an allegation of abuse for two of four nonsampled residents (Residents 54 and 154). * Resident 54 reported during the resident's council meeting on 2/11/26, about allegation of verbal abuse against CNA 4. * Resident 154 reported during resident's council meeting on 2/11/26 about allegation of verbal abuse against C.NA 4. This failure had the potential for Residents 54 and 154 to be vulnerable to further abuse and emotional distress.Findings: Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against revised 1/2021 showed It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse,…

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 plan was developed and implemented for two of 30 final sampled residents (Residents 1 and 7). * The facility failed to develop a care plan to address Resident 1's non-compliance with his prescribed fluid restriction. * The facility failed to implement a care plan intervention to provide an APP mattress for Resident 17, who was at risk for the development of pressure injuries. These failures placed the residents at risk of not being provided appropriate, consistent, and individualized care.Findings: 1. Medical record review for Resident 17 was initiated on 3/4/26. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's Care Plan Report showed a care plan focus titled Potential for Pressure Ulcer Development related to CVA, aging process, and decreased mobility initiated on 2/14/26. The care plan interventions included an APP mattress for skin integrity maintenance, 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 the necessary care and services were provided to prevent the risk and development of pressure injuries for two of two final sampled residents (Residents 17 and 147) reviewed for pressure injuries. * Resident 17 was at risk for the development of pressure injuries. The facility failed to ensure Resident 17's physician's order dated 2/28/26, for an APP mattress for skin maintenance/prevention was implemented. * The facility failed to reposition Resident 147 at least every shift which potentially led to the development of his pressure injury after admission on 8/2025. These failures placed the residents at risk for the development or worsening of pressure injuries.Findings: Review of the facility's P&P titled Skin Management System revised 12/2019 showed any resident who entered the facility without pressure ulcers would have appropriate preventative measures taken to ensure that the resident does not…

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 appropriate care and services for the use of the enteral feedings for one of one final sampled resident (Resident 147) reviewed for enteral feedings. * The facility failed to ensure the enteral water flush for Resident 147 was accurately programmed per the physician's order. In addition, the facility failed to change Resident 147's water bag and enteral feeding tubing after 24 hours of use. These failures posed the risk for developing dehydration complications and potential infections for Resident 147.Findings: Review of the facility's P&P titled Enteral Feeding Administration dated 3/2022 showed to administer the enteral feeding at a constant controlled infusion rate per the physician's orders. Review of the Cardinal Health user manual for the Kangaroo Omni Enteral Feeding Pump dated 2024 showed the Kangaroo OMNI Feeding Set included a water flush bag, feeding bag, and a feeding set connector. 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, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for four of four final sampled residents (Residents 10, 45, 102 and 163) reviewed for respiratory services. * The facility failed to discard Resident 10's nasal cannula tubing dated 1/22/26. In addition, the facility failed to ensure the set-up bag for the nasal cannula for Resident 10 was dated. * The facility failed to ensure a physician's order was obtained when oxygen was administered to Resident 45. * Resident 102's nebulizer mask and tubing was not dated and changed once a week. * The facility failed to ensure the nebulizer mask was dated and labeled, and stored in a set-up bag for Resident 163. These failures had the potential for these residents not to receive appropriate respiratory care, and for increased risks of infection.Findings: Review of the facility's P&P titled Oxygen, Use of, revised 5/2021 showed the following: - The oxygen cannula or mask…

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 appropriate pain management for one of one final sampled resident (Resident 4) reviewed for pain management. * The facility failed to ensure the nonpharmacological interventions were provided to Resident 4 prior to the administration of hydrocodone hydrocholoride (HCl) (pain medication). This failure had the potential to put the resident at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication. Findings: Review of the facility's P&P titled Management of Pain revised 4/2016 showed the facility will assist each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by interviewing or observing the resident to determine if pain is present, evaluating pain with the resident to develop a plan of care that considers their needs, and implementing a plan using non-pharmacological and/or pharmacological interventions to manage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the pharmacy consultant's recommendations were acted upon for one of 30 final sampled residents (Resident 1) reviewed for drug regimen review. * The facility failed to follow-up the pharmacy consultant's recommendation to add a warning to the medication sheet regarding the handling of finasteride (medication used to treat benign prostatic hyperplasia or enlarged prostate) for Resident 1. This failure had the potential to put the licensed nurses at risk for adverse consequences related to the medication. Findings: Medical record review for Resident 1 was initiated on 3/4/26. Resident 1 was readmitted on [DATE]. Review of the Consultant Pharmacist's Medication Regimen Review for Resident 1 dated 2/19/26, showed women who are pregnant or may get pregnant must not handle/administer broken or crush Proscar (finasteride) tablets, the active ingredient could harm the unborn baby. Please advise the nurses to wear gloves when handling 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 interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 156) observed for the medication administration was free from significant medication errors. * The facility failed to ensure Resident 156 received Dorzolamide Ophthalmic Solution 2% (used to reduce high pressure inside the eye) as ordered when Resident 156 did not receive at least three doses of dorzolamide eye solution. This failure had the potential to have a negative impact on the resident resulting in poor eye pressure control and long-term vision loss.Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed medications are administered in accordance with prescriber's orders. On 3/4/26 at 0924 hours, a medication administration observation for Resident 156 was conducted with LVN 3. LVN 3 prepared and administered several medications to Resident 156 including four pills and cyclosporine 0.05% ophthalmic emulsion (used to increase tear…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure proper medication storage for two of six medication/treatment carts inspected (Medication Cart A and Treatment Cart B). * The facility failed to ensure an outdated insulin, unlabeled insulin, and opened undated insulin pens were removed from Medication Cart A. * The facility failed to ensure a partially used sterile wound dressing was removed from Treatment Cart B. These failures had the potential for unsafe medication administration/wound treatment and to negatively impact the residents' well-being.Findings: 1. Review of the facility's P&P titled Insulin Injection dated 2/2015 showed do not use if opened over 28 days. Review of the facility's P&P titled Medication Ordering and Receiving: Medication Labels dated 2/2015 stated if a label does not fit directly onto the product, the label may be affixed to an outside container or carton, but the resident's name at least, must be maintained directly on the actual product container. Review of the facility's P&P titled…

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 ensure food brought to the facility from outside sources for the resident consumption was properly labeled, dated, and stored one of 30 final sampled residents (Resident 108). * Resident 108's food was unlabeled, undated, and not properly stored. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consume food brought from outside sources.Findings: Review of the facility's P&P titled Bringing in food and/or beverages for residents (undated) showed food and/or beverages brought in should be labeled to monitor for food safety. The item should include: resident's name, room number, and date. Further review of the P&P showed perishable foods/beverages are encouraged for immediate consumption. If food is to be consumed at a later date, the food and/or beverage can be given to the nurse and stored in the resident's designated refrigerator. Unused food will be discarded after…

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 garbage was properly stored in one of four garbage dumpsters of the facility. * One garbage dumpster was observed with the lid partially propped open by garbage bags and boxes. This failure had the potential to attract pest/rodents that carried diseases.Findings: Review of the facility's P&P titled Miscellaneous Areas, Garbage and Trash dated 2023 showed the garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. According to the 2022 FDA Food Code, the outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. On 3/4/26 at 0739 hours, an observation was conducted of the facility's one of four outside garbage dumpsters. One garbage dumpster was observed with the lid partially propped open by the garbage bags and boxes, preventing the lid from fully closing. On 3/4/26 at 0902 hours, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was developed to reflect the individual care needs for one of six sampled residents (Resident 1). * There was no care plan developed for Resident 1's refusals to shower or bathe. This failure had the potential for the resident to not be provided with appropriate, consistent, and individualized care.Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised 12/2023 showed the following:- it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment;- the resident has the right to refuse or discontinue treatment. In the event that a resident refusescertain services posing a risk 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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of six sampled residents (Resident 1). * The facility failed to ensure a change in condition assessment and monitoring was completed for Resident 1's rash on the bilateral hands. This failure posed the risk of the resident to not receive appropriate care.Findings: Review of the facility's P&P titled Significant Change of Condition Response revised 1/2022 showed the following:- if, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware;- the Nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using…

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 one of four sampled residents (Resident 1) was free from the significant medication errors. * The facility failed to administer Resident 1's Cortef (generic name: hydrocortisone, a corticosteroid) as ordered by Resident 1's neurosurgeon. This failure posed the risk for Resident 1 to have an increased pain, swelling, fatigue, weakness, and nausea. Findings: Review of the facility's P&P titled Administration of Medications dated 10/2021 showed the medications shall be administered as prescribed by the resident's physician. Medical record review for Resident 1 was initiated on 4/3/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 3/12/25, showed Resident 1 did not have the capacity to understand and make medical decisions. Resident 1 had a diagnosis of a pituitary adenoma and was readmitted to the facility following a pituitary tumor removal. Review of Resident 1's…

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

Based on interview and medical record review, the facility failed to ensure one of three sampled residents (Resident 2) maintained their rights to manage the financial affairs. * The facility failed to ensure Resident 2 was involved in the decision-making process for his financial affairs and failed to inform Resident 2 that his personal funds (social security money) was directly deposited into the RFMS account. These failures resulted in Resident 2 losing control of his social security benefit money to the facility and further risk for Resident 2's finances to be lost, misused, and not easily accessible. Findings: Review of the facility's P&P titled Accounts Receivable Policy and Procedure revised March 2024 showed in part, the RTF policy and procedure established guidelines to manage and monitor resident's funds in a uniform process that allows residents the appropriate access to their funds while ensuring protection of resident funds in accordance with state and federal regulatory requirements The resident has the right to determine how their trust money is spent. The facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the medical record was complete and accurately documented for one of three sampled residents (Resident 3). * Resident 3's MAR failed to show the lung sounds were documented. * There were no documented interventions after Resident 3's blood pressure reading of 91/49 mmHg. * There was no documentation of Resident 3's meal percentages. * There was no documentation Resident 3 was monitored for signs and symptoms of a urinary tract infection. * There was no documentation Resident 3 was being monitored for side effects of Bumex (diuretic). These failures had the potential for the resident's care needs to not be met as their medical information was not complete and accurate. Findings: Closed medical record review for Resident 3 was initiated on 12/9/24. Resident 3 was admitted to the facility on [DATE], and discharged on 11/7/24. Review of Resident 3's MDS SectionC dated 10/14/24, showed Resident 3 had a BIMS score of 10, indicating had…

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 five of five final sampled residents (Residents 27, 55, 98, 101, and 440) reviewed for respiratory care were provided with the appropriate respiratory care when: * The facility failed to ensure Resident 440's physician's order for the use of CPAP machine was clarified to the physician. In addition, the facility failed to provide proper maintenance for the CPAP machine use at bedside. * The facility failed to follow the physician's order for the administration of continuous oxygen and failed to ensure the nasal cannula was stored in a sanitary manner for Resident 55. * The facility failed to clarify the physician's order for the oxygen administration when the order for the use of oxygen did not specify the amount of oxygen to be administered for Resident 55. * The facility failed to ensure Resident 98's nebulizer mask was stored in a sanitary manner. * The facility failed to ensure Resident 101's nasal…

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 residents were free from the unnecessary psychotropic medications for four of five final sampled residents (Residents 45, 75, 85, and 101) reviewed for the unnecessary medications. * The facility failed to ensure the PRN order for the antipsychotic (medications used to treat symptoms of psychosis) medication was limited to 14 days for Resident 45. * The facility failed to ensure the non-pharmacological interventions were implemented prior to the administration of psychotropic medications for Resident 85. * The facility failed to ensure the nonpharmacological interventions were implemented prior to the administration of psychotropic medications for Resident 101. * The facility failed to ensure Resident 75 had informed consent and GDR for melatonin, was monitored for side effects for melatonin and mirtazapine, and had non-pharmacological interventions implemented prior to the administration of psychotropic…

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 food was served at a temperature to ensure palatability for one of 30 final sampled residents (Resident 60) and two nonsampled residents (Residents 62 and 131). This deficient practice had the potential to impact the residents' nutritional status and not meet the residents' desires to be served food they felt was palatable and attractive. Findings: Review of the facility's P&P titled Meal Service dated 2023 showed meals that meet the nutrtitional needs of the residents will be served in an accurate and efficient manner, and served at the appropriate temperatures. The temperature of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot. Further review of the facility's P&P showed the recommended food temperatures at delivery to the residents are as follows: - Cold entree and fruit or cold dessert at less than or equal to 50 degrees F. - Salads, milk/cold beverage at less than or equal to 45 degrees 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 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 proper labeling and dating of food in the refrigerator. * The facility failed to ensure the kitchen utensils had smooth cleanable surfaces and were in good repair. * The facility failed to ensure the kitchen utensils were stored and kept in sanitary conditions and free of food particle or residue. * The facility failed to ensure the blender and metal pans were air-dried prior to storing. These failures had the potential for cross contamination and cause foodborne illnesses in a medically vulnerable population who consumes food prepared in the facility's kitchen. Findings: Review of the facility's Diet Type Report dated 10/21/24, showed 140 of 149 residents consumed the foods prepared in the facility's kitchen. 1. Review of the facility's P&P titled Labeling and Dating of Foods dated 2022 showed all food items in the storeroom, refrigerator, and freezer need to be…

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, facility document review, and facility P&P review, the facility failed to inform the physician of the residents prescribed antibiotics with signs and symptoms not meeting McGeer's Criteria (criteria used by long-term care facilities to determine a true infection) for five of 30 final sampled residents (Residents 60, 75, 101, 110, and 840) and 24 nonsampled residents (Residents 16, 21, 24, 48, 50, 63, 96, 100, 117, 120, 123, 740, 741, 742, 743, 745, 746, 747, 748, 749, 750, 751, and 752). This failure had the potential risk for continued use of unnecessary antibiotics, potentially resulting in adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria. Findings: According to the Centers for Disease Control and Prevention (CDC), antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics over a year. Studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 30 final sampled residents (Residents 11 and 98) were assessed to determine if it was safe for them to self-administer their medications prior to self-administering their medications. * Resident 98 had a tube of Preparation H (topical medication used for hemorrhoids) and a tube of mometasone furoate (topical corticosteroid medication used for certain skin conditions) at the bedside. Resident 98 did not have a physician's order for self-administration of medications at the bedside. * A bottle of Lumify eye drops (medication to temorarily relieve eye redness and itching) and a bottle of Systane eye drops (medication to temporarily relieve dry, irritated eyes) were kept at Resident 11's bedside table. Resident 11 had self-administered the Lumify and Systane eye drops without being assessed for self-administration of medications. In addition, there were no physician's order for the eye drops…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed the conduct the status post change of condition assessments for one of three closed records reviewed (Resident 138). * Resident 138 had a change of condition involving an episode of vomiting, abdominal discomfort, and refusing to eat. The facility failed to follow up with the physician regarding the change of condition in a timely manner, failed to monitor Resident 138's vital signs, and failed to conduct and assessment related to the resident's change in condition. These failures had the potential for Resident 138's changes in medical condition not being identified, potentially delaying necessary care and treatment. Findings: Review of the facility's P&P titled Significant Change in Condition, Response revised 12/2023 showed it is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial…

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 necessary care and services were provided to prevent the development and worsening of pressure injuries and promote the healing of existing pressure injuries for one of three final sampled residents (Resident 840) reviewed for pressure injuries. * The facility failed to provide Resident 840 with the LAL mattress as ordered by the physician. Additionally, the facility failed to ensure Resident 840's pressure injuries were assessed weekly in accordance with the facility's policy and the resident's plan of care. These failures had to potential for Resident 840 to not receive the appropriate care and services to promote healing or prevent the development and worsening of pressure injuries. Findings: Review of the facility's P&P titled Skin and Wound Monitoring and Management Care Guidelines revised 2/2023 showed it is the policy of this facility that a resident having pressure ulcers receives the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four final sampled residents (Resident 91) reviewed for falls was free from accident hazards. * The facility failed to place the floor mats on both sides of Resident 91's bed as ordered by the physician and resident's care plan for Resident 91. This failure had the potential for serious injury to the resident. Findings: Review of the facility's P&P titled Fall Management System revised 6/2018 showed it is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls to minimize complications if a fall occurs. On 10/21/24 at 1157 hours, and 10/21/24 at 1605 hours, Resident 91 was observed lying in bed and no floor mats were in place. Medical record review for Resident 91 was initiated on 10/21/24. Resident 91 was admitted to the facility on [DATE]. Review of Resident 91's Change in Condition Evaluations dated 2/27, 4/26, and 8/15/24, 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 interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain management for two of two final sampled residents (Residents 85 and 98) reviewed for pain management. * The facility failed to administer pain medication according to the physician's order for Resident 98. * The facility failed to ensure Resident 85 was consistently provided non-pharmacological interventions for pain prior to the administration of narcotic pain medication. These failures put Residents 85 and 98 at risk for ineffective pain management. Findings: Review of the facility's P&P titled Recognition and Management of Pain revised 7/2017 showed it is the policy of the facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility P&P showed the facility assists each resident with pain management to maintain or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the Pharmacy Consultant failed to recognize the irregularity for one of five sampled residents (Resident 75) reviewed for unnecessary medications when Resident 75 who was a diabetic and on Insulin (an injectable medication used to lower blood sugar) did not have any HbA1C level checked for 10 months. This failure placed Resident 75 at an increased risk for developing preventable dangerous effects from uncontrolled high blood sugar. Findings: Review of the facility's P&P titled Medication Regimen Review (MRR) revised on 8/2017 showed the Pharmacist reviews each resident's medication regimen at least once a month in order to identify irregularities, MRR included identification of irregularities and use of unnecessary drugs. Medical record review for Resident 75 was initiated on 10/23/24. Resident 75 was admitted to the facility on [DATE]. Reviewed of Resident 75's H&P examination dated 1/23/2024, showed the physician's…

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

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 medications were not stored at the bedside for one nonsampled resident (Resident 107). In addition, the facility failed to ensure the proper disposal of treatment supplies for one of five medication/treatment carts (Treatment Cart 1)inspected for medication storage and labeling. *The facility failed to ensure one tube of CalaZinc (ointment used to treat and prevent skin irritation and diaper rash, and to protect minor cuts, burns, and dry, cracked skin), one spray bottle of Sea-Clens (saline-based solution for cleansing acute and chronic wounds), and one tube of Critic-Aid (ointment that helps prevent and treat most skin irritation due to incontinence) were not stored in 107's bedside drawer. * The facility failed to ensure the expired culture swabs were removed Treatment Cart 1. These failures had the potential to result in unsafe medication administration and posed the risk for inaccurate test…

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 maintain the safe infection control practices to help prevent the development and transmission of diseases and infection. * The licensed nurse (LVN 1) failed to use the appropriate sanitizing wipes when disinfecting the blood pressure machine. This failure had the potential for cross contamination (spread of germs and bacteria) and infection. Findings: Review of the facility's P&P titled Cleaning and Disinfecting Non-Critical Resident-Care Items revised 2/2022 showed reusable items are cleaned and disinfected between residents. Medical record review for Resident 35 was initiated on 10/21/24. Resident 35 was admitted on [DATE]. On 10/21/24 at 0828 hours, during a medication administration observation for Resident 35, LVN 1 was observed cleaning a wrist blood pressure monitoring device with Velcro cuff with Micro Kill One Germicidal Alcohol wipes prior to obtaining Resident 35's blood pressure. LVN 1 stated she used the wrist blood…

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 pneumococcal vaccine was administered to one of five residents (Resident 31) reviewed for immunizations. This had the potential to put Resident 31 at risk of contracting pneumococcal disease. Findings: Review of the facility's P&P titled Immunizations - Resident revised 7/2023 showed it is the policy of the facility to offer and administer influenza, pneumococcal, and COVID-19 immunization to eligible residents after providing education on the risks and potential side effects of the vaccine(s) and obtaining consent. The policy further showed the purpose of the policy is to minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza, pneumococcal disease, or COVID-19 by assuring that each resident is informed about the benefits and risks of immunization; and has the opportunity to receive the influenza, pneumococcal, or COVID-19 vaccine(s), unless medically…

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 one of three sampled residents (Resident 1) was informed in advance of their proposed treatments or treatment options to choose the preferrable option for the change in services. * The facility failed to ensure Resident 1 was informed and given the right to choose his treatment services when the facility changed his outpatient psychiatry services to inhouse psychiatry services. This failure had the potential to prevent the resident from participating in his treatment decisions. Findings: Review of the facility's P&P titled Resident Rights (undated) showed the resident has the right to be informed in advance by the physician or other practitioner or processional of the risks and benefits of proposed care of treatments and treatment alternative options to choose the alternative or options the resident prefers. Medical record review for Resident 1 was initiated on 5/1/24. Resident 1 was admitted to the facility 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 interview, medical record review, and facility P&P review, the facility failed to provide the laboratory services for one of three sampled residents (Resident 1). * The facility failed to carry out the physician's order for laboratory testing for Resident 1. * The facility failed to ensure the abnormal laboratory test results for Resident 1 were reported to the physicianin a timely manner. Thesefailures had the potential to adversely affect the resident's physical health and well-being. Findings: Medical record review for Resident 1 was initiated on 5/1/24. Resident 1 was admitted to the facility on [DATE]. a. Review of the facility's P&P titled Physician's Orders, Telephone Orders, and Recapitulation Process (undated) showed all orders must be specific and complete with all necessary details to carry out the prescribed order without any question. Review of Resident 1's Physician Orders dated 1/31/24, showed a physician's order to complete the CBC, CMP, and HbA1C tests in the AM. However, further 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 implement their P&P regarding the AMA discharge for one of two sampled residents (Resident 1). * The facility failed to provide the appropriate instructions including to contact the physician immediately when Resident 1 was AMA discharged as per the facility's P&P. In addition, the physician was not informed of the resident wanting to leave AMA until after the resident had left the facility. These failures had the potential to place Resident 1 at risk for medical complications post-discharge. Findings: Review of the facility's P&P titled Discharge Against Medical Advice revised 5/2007 showed to ensure the safe departure from the facility when it is without medical approval, give any appropriate instructions to the resident, and instruct to contact the physician immediately; and document instructions given on the record. Closed medical review for Resident 1 was initiated on 3/26/24. Resident 1 was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, closed medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was provided quality care when LVN 3 failed to administer Resident 1's Lasix (diuretic) as ordered and did not inform the physician. This failure had the potential to cause harm and delayed medical treatment for Resident 1. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed medications are administered in accordance with the prescriber's orders. Medical record review for Resident 1 was initiated on 1/10/24. Resident 1 was admitted to the facility on [DATE], and discharged on 12/20/23. Review of Resident 1's Order Summary Report for December 2023 showed an order dated 11/24/23, to administer Lasix 20 mg one tablet by mouth one time a day for bilateral lower extremities edema (swelling). Review of Resident 1's MAR for December 2023 showed Resident 1 was not administered Lasix 20 mg on 12/18/23. Review of Resident 1's…

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

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 necessary care and services were provided to prevent the development of new pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of existing pressure injuries for two of two sampled residents (Residents 2 and 3). * The facility failed to ensure Resident 2's wound treatments were administered as per the physician's orders. * The facility failed to provide a LAL mattress as per Resident 3's care plan. These failures posed the risk for worsening of the existing pressure injuries or development of new pressure injuries for these residents. Findings: Review of the facility's P&P titled Skin and Wound Monitoring, revised 1/2022 showed it is the facility's policy that a resident having pressure injury(s) receives necessary treatment and services to promote healing,…

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 maintain the infection control practices in accordance with the facility's P&P to help prevent the transmission of diseases and infections. * The facility failed to ensure CNA 1 wore proper PPE when entering Resident 5's room which was on transmission-based precautions. This failure posed the risk for transmission of communicable diseases to other residents in the facility. Findings: Review of the CDC document titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19, an infectious disease caused by the SARS-CoV-2 virus) Pandemic updated 5/8/23, showed healthcare personnel who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e. googles or a face shield 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 observation, interview, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to conduct the infection surveillance for the months of November and December 2021. This posed the risk of the facility not accurately investigating and preventing new infections from developing and an outbreak going unrecognized within the facility. * The facility failed to ensure COVID 19 screening which included screening for symptoms of COVID-19 of the visitors and resident's families were completed before allowing to enter the facility. This posed the risk for COVID 19 transmission in the facility. Findings: 1. According to the facility's P&P titled Surveillance of Infections and Reporting revised on 9/2017, the facility will maintain an ongoing system of surveillance designed to identify possible communicable diseases or infections to ensure that measures are taken 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 and interview, the facility failed to provide a safe and homelike environment for one of 28 sampled residents (Resident 127). * The sliding door in Resident 127's room was derailed and broken, which prevented it from closing. This deficient practice had the potential to negatively impact the quality of life and increased risk for physical discomfort for Resident 127. Findings: On 3/23/22 at 1053 hours, a concurrent observation of Room A and interview was conducted with Resident 127. The sliding screen door which provided Resident 127 access to the patio was observed to be partially open. The sliding screen door had a broken handle and with the bottom portion derailed, which did not allow the screen to fully open or close. Resident 127 stated he notified the housekeeping staff about the broken sliding screen door a few weeks ago. Resident 127 stated he felt the facility did not care enough to fix the sliding screen door and it made his room feel less homelike. On 3/23/22 at 1430 hours, the sliding screen door in Room A still remained partially open, the lower…

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 maintain an environment free from accident hazards and failed to implement the interventions to reduce the risks of accidents and injury for two of 28 final sampled residents (Residents 65 and 70). * Resident 70's smoking paraphernalia were observed at bedside. This failure had the potential to increase the risk of injury to Resident 70 and the risk of fire to the environment and other residents. * Resident 65 was assessed as high risk for fall and the intervention was to use a tab alarm (a pull-string that attaches magnetically to the alarm with garment clip to the resident) on the wheelchair. The facility failed to ensure Resident 65's wheelchair tab alarm was in good working order. This failure had the potential to result in the injury due to falls. Findings: 1. Review of the facility's Smoking Policy revised 2021 showed in part, .3. A designated tackle box for tobacco products and smoking devices will be…

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 oxygen tubing (device used to deliver supplemental oxygen) was dated and changed once a week as per the facility's P&P for one of 28 final sampled residents (Resident 20). This deficient practice had the potential to result in contamination of the resident's oxygen equipment and placed Resident 20 at risk for infection. Findings: Review of the facility's P&P titled Use of Oxygen dated 5/2001 showed the oxygen tubing or masks will be changed at least every seven days. Review of Resident 20's medical record was initiated on 3/21/22. Resident 20 was admitted to the facility on [DATE]. Review of the physician's orders dated 11/10/21, showed an order to administer oxygen at 2-3 liters per minute via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) continuously. Review of the MDS dated [DATE], showed Resident 20 was cognitively impaired 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, facility document review, and facility P&P review, the facility failed to ensure the food was served at a temperature to ensure palatability for one of 28 final sampled residents (Resident 45) and three nonsampled residents (Residents 8, 69, and 103). This deficient practice had the potential to impact the residents' nutritional status and not meet the residents' desires to be served food they felt was palatable and attractive. Findings Review of the facility's P&P titled Meal Service dated 2018 showed the recommended food temperatures at delivery to the residents are as follows: - Cold entree and fruit or cold dessert at less than or equal to 50 degrees F - Salads, milk/cold beverage at less than or equal to 45 degrees F, - hot entree, waffles, french toast, starch, vegetable at more than or equal to 120 degrees F, - hot beverage, soup or hot cereal at more than or equal to 140 degrees F. On 3/22/22 at 0930 hours, during the Resident Council meeting, Residents 8, 69, and 103 expressed concerns about the temperatures of the food served during meals…

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 as evidenced by: * Multiple undated and expired foods in the kitchen. * Refrigerators A and B's temperatures were out of range. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Condition of Residents completed by the facility dated 3/21/22, showed 133 of 138 residents in the facility received foods prepared in the kitchen. 1. According to the facility's P&P titled Labeling and Dating of Foods, all food items in the storeroom, refrigerator and freezer need to be labeled and dated based on established procedure for either food safety or product rotation (First in-First out). For food that are prepared by the facility, held greater than 24 hours cold shall be clearly marked to indicate the date by which the food shall be consumed or discarded-use by. a. On 3/21/22 at 0730 hours, an initial tour 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.

Based on observation, interview, and facility P&P review, the facility failed to ensure the safe and sanitary handling of food brought from home for one of 28 final sampled residents (Resident 15). * Multiple resealable plastic bags filled with food found in Resident 15's room were unlabeled and undated. This failure had the potential for food borne illnesses. Findings: Review of the facility's P&P titled Resident or Personal Food Storage (undated) showed the food brought from outside sources for storage in the facility or resident room will be monitored by designated the facility staff for food safety. On 3/22/22 at 0738 hours, multiple resealable plastic bags filled with food were observed at Resident 15's bedside. The resealable plastic bags were unlabeled, undated, and contained the following food items: - one bag of white colored snacks, - one bag of yellow colored chips, - one bag of gummies, - one bag of caramel, - one bag of chocolates, and - three bags of cheese popcorn. On 3/22/22 at 0915 hours, an interview was conducted with CNA 2. CNA 2 was asked about the personal 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.