Country Crest Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received wound preventative measures as ordered to prevent skin breakdown, promote circulation, and provide pressure relief. This failure resulted in Resident 1 sustaining a stage 2 pressure ulcer (partial-thickness skin loss, where the epidermis (outer layer) and part of the dermis (second layer) are damaged caused by prolonged pressure) to their coccyx (tailbone), which had the potential to lead to complications including pain, discomfort, and infection. Findings: During a record review of the facility policy titled Skin Integrity Management Protocol dated 1/2019, it was indicated that staff were to relieve the underlying cause, addressing pressure, shear, other physical friction, and maceration/moisture factors. The facility policy indicated to keep local areas clean, dry, and free of body wastes such as urine, feces, perspiration, and wound drainage. The policy indicated to inspect skin frequently…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Medical Director (MD) for one of three sampled residents (Resident 1), when there was a need to alter Resident 1's healthcare decision maker as Resident 1 was still listed as the decision maker. Resident 1 had a St. Louis University Mental Status (SLUMS) examination (a cognitive screening test designed to detect the early signs of mild cognitive impairment and dementia) done on 7/22/24, and had a score of 3 out of 30, indicating that Resident 1 was cognitively impaired. This failure resulted in the facility continuing indicating that Resident 1 Has the capacity to make and understand decisions , and only notified Resident 1 when there was an alleged abuse allegation. Findings: During a review of the facility's policy titled, Change in a Resident's Condition or Status , revised 5/2027, indicated: 1. Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident'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 interview and record review, the facility failed to report an abuse allegation for one of three sampled residents (Resident 1) when Resident 1 informed Certified Nursing Assistant (CNA) A that a male staff was Really rough when getting her [Resident 1] in & out of bed, grabbed her really hard, and wanted to hurt her on 10/24/24. This failure had the potential to result in psychosocial and emotional harm for Resident 1 and had the potential to place all the residents at risk for undetected/unreported elder neglect or abuse. Findings: During a review of the facility's policy titled, Abuse Prevention Program , revised 12/1/22, indicated this policy is to, Promote and environment free from any form of resident abuse, neglect, misappropriation of resident property, exploitation and /or mistreatment. The policy also indicated that: 1. The facility shall thoroughly investigate allegation of abuse by identifying and interviewing all involved, including the alleged victim, alleged perpetrator, witness (es) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure social services met the needs for two of three residents (Resident 1, 2) when: 1. The Social Service Director did not investigate and reported to the authorities after Resident 1 informed the Certified Nursing Assistant (CNA) B of an allegation of abuse on 10/24/24. This failure had the potential to result in psychosocial and emotional harm for Resident 1 and had the potential to place all the residents at risk for undetected/unreported elder neglect or abuse. 2. The Social Service Director failed to ensure the Behavior Management Committee address the appropriateness of the use of the psychotropic medication when Resident 2 was prescribed with PRN Lorazepam (brand name: Ativan - used to relive anxiety) for extended time period without the rationale. This failure could contribute to unsafe use of psychotropic medications that could have placed residents at risk for adverse consequences. Findings: A review of a facility policy titled, Social…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure safe use of psychotropic medications (medication that alters mood, behavior, and cognition) for one of three sampled residents (Resident 2) when Resident 2 was prescribed with Lorazepam (brand name: Ativan - used to relive anxiety) for extended time period without the rationale. This failure could contribute to unsafe use of psychotropic medications that could have placed residents at risk for adverse consequences. Findings: During a review of the State Operations Manual (SOM -contains guidance on certification and survey activities, a federal document from the Centers for Medicare & Medicaid Services), revised 8/8/24, indicated, 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. 2. As needed (PRN) for psychotropic drugs are limited to 14 days. 3. Order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order.…

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 policy review, the facility failed to ensure sanitary preparation and service of meals. Specifically, the facility failed to practice proper hand hygiene and glove use during food preparation, and the facility failed to hold foods at safe temperatures during meal service. This had the potential to affect all residents who received meals from the facility's kitchen. Findings included: 1. During an observation on 09/24/2024 at 11:23 AM, the temperature of pizza's being served to residents was at 136 degrees Fahrenheit (F). The temperature of the pizza's was measured again at 12:17 PM, and was at 122 degrees F. It was also observed that there were three stacked pizza pans underneath the pizza, separating it from the heat source. There were four pizza slices that remained, and they were served to two unidentified residents. During an interview on 09/25/2024 at 1:47 PM, the Food Services Director (FSD) stated that the facility staff should have discarded the four slices of pizza that were served and instead served the pizza that remained 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.

Based on observation, interview, facility policy review, and review of the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure 1 of 1 dumpster was closed to prevent the potential for vermin and pest attraction. This had the potential to affect all 56 residents that resided in the facility. Findings included: The U.S. FDA 2022 Food Code, dated 01/18/2023, revealed Chapter 5. Water, Plumbing, and Waste, section 5-5 Refuse, Recyclables, and Returnables, included, 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE and recyclables such as an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and, if the unit is not installed flush with the base…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure oxygen was administered appropriately for 3 (Residents #204, #17, and #11) of 4 residents reviewed for respiratory care. Specifically, the facility failed to ensure Resident #204 and Resident #17 received oxygen at their prescribed flow rates and failed to ensure the humidifier bottle on Resident #11's oxygen concentrator was functioning properly. Findings included: A facility policy titled, Oxygen Administration (Mask, Cannula, Catheter), revised 12/2016, revealed, The purpose of the oxygen therapy is to provide sufficient oxygen to the blood stream and tissues. The policy also indicated, It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. The facility policy procedures revealed, 9. Attach the oxygen delivery device to the oxygen unit. 10. Turn the unit on to the desired flow rate and assess equipment for proper functioning. A. Airflow should be felt through the oxygen…

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

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure an effective infection prevention and control program was followed and maintained for 1 (Resident #38) of 1 resident reviewed for urinary catheters and 3 (Residents #37, #17, and #204) of 4 residents reviewed for respiratory care. Specifically, Resident #38's urinary catheter bag was observed on the ground or floor, and respiratory equipment was inappropriately stored to prevent infections for Residents #37, #17, and #204. Findings included: 1. A facility policy titled, Urinary Catheter Care, revised 03/2021, under the section, Infection Control, revealed b. Be sure the catheter tubing and drainage bag are kept off the floor. An admission Record revealed the facility originally admitted Resident #38 on 01/19/2023 and readmitted the resident on 07/11/2024. According to the admission Record, the resident had a medical history that included a diagnosis of obstructive and reflux uropathy. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date…

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

Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure oxygen use was accurately coded on the Minimum Data Set (MDS) assessment for 2 (Resident #17 and Resident #11) of 4 residents reviewed for respiratory services. Findings included: The Centers for Medicare and Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, Version 1.19.1, dated 10/2024, Section O: Special Treatments, Procedures, and Programs revealed, Coding Instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days. The user's manual further revealed, O0110C1, Oxygen therapy Code continuous or intermittent oxygen administered via mask, cannula, etc. [et cetera, and other similar things] delivered to a resident to relieve hypoxia in this item. The user's manual…

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

Based on interview, record review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, the facility failed to ensure a Level I PASRR accurately reflected the presence of a serious diagnosed mental disorder and the use of prescribed psychotropic medication for 1 (Resident #30) of 4 residents reviewed for PASRR requirements. Findings included: The California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, dated 01/12/2023, revealed, Section III-Serious Mental Illness Questions 10-12 This section helps determine if the individual may have a serious mental illness and benefit from specialized services. Question 10. Diagnosed Mental Illness *Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? *If yes, there will be a text box question [to] provide the type of mental…

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

Based on interview, record review, and facility policy review, the facility failed to develop and a comprehensive person-centered care plan for 1 (Resident #34) of 4 sampled residents who had cardiac pacemakers. Specifically, the facility failed to develop a care plan for the care and treatment of Resident #34's cardiac pacemaker. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, indicated, 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and k. Reflect treatment goals, timetables and objectives in measurable outcomes. An admission Record revealed the facility most recently admitted Resident #34 on 07/06/2024. According to the admission Record, the resident had a medical history that included diagnoses of presence of cardiac pacemaker, atrial fibrillation, and presence of prosthetic heart valve. Resident #34's Pacemaker…

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

Based on interview, record review, and facility policy review, the facility failed to ensure pharmacy recommendations were addressed for 1 (Resident #40) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Medication Monitoring-Medication Regimen Review and Reporting, dated 01/2024, revealed, 8. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days or per facility specific protocols. An admission Record revealed the facility originally admitted Resident #40 on 04/06/2023 and readmitted the resident on 12/29/2023. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia, bipolar disorder, and major depressive disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/2024, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS revealed 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 interview, record review, and facility policy review, the facility failed to ensure PRN (pro re nata, as needed) psychotropic medication use was limited to 14 days for 1 (Resident #7) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Psychotropic Medication Use, revised 02/2024, specified, Procedure The facility should comply with the State Operations Manual, and all other Applicable Law relating to the use of psychoactive medications, including gradual dose reductions. The policy further indicated, 3. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms. Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for psychotropic drugs are limited to 14 days. a. For psychotropic PRN medications, excluding…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%). The facility had 2 errors out of 36 total opportunities, resulting in a medication error rate of 5.55 %, affecting 2 (Resident #6 and Resident #34) of 5 residents observed during medication administration. Findings included: A facility policy titled, Medication Administration (General), dated 08/18/2022, indicated, 9. The licensed nursing or medical personnel administering the medication shall check the label at least THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 10. The following information must be checked/verified for each resident prior to administering medications: a. Allergies to medications b. Vital signs, if necessary. An admission Record indicated the facility most recently admitted Resident #6 on 07/10/2024. According to the admission Record, the resident had a medical history that included diagnoses…

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

Based on interview, record review, and facility policy review, the facility failed to maintain a complete medical record for 1 (Resident #4) of 4 residents reviewed who had a cardiac pacemaker. Specifically, the facility failed to ensure Resident #4's medical record contained information regarding the model and/or serial number and the implant date for the resident's cardiac pacemaker. Findings included: A facility policy titled, Pacemaker, Care of a Resident with a, revised 12/2015, indicated, The purpose of this procedure is to provide information about and guidance for the care of a resident with a pacemaker. The policy revealed for monitoring the resident's pacemaker, 5. Make sure the resident has a medical identification card that indicates he or she has a pacemaker. The medical record must contain this information as well. The policy also indicated, 1. For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address and telephone number of the cardiologist; b. Type of pacemaker; c. Type…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report injury of unknown origin for one resident (Resident 1) out of three sampled residents reviewed for abuse within 2 hours, to the California Department of Public Health (CDPH). This failure had the potential to delay investigation and interventions to prevent abuse to other residents in the facility. Findings: The facility ' s policy revised1/10/24, titled Abuse Reporting and Investigation, indicated to promptly report all allegations of abuse as required by law and regulations to appropriate agencies within the required time frames. All allegations of abuse, neglect, exploitation, or injury of unknown cause/origin shall be reported to the Abuse Prevention Coordinator (APC) immediately. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property shall be reported by APC/Designee to local CDPH, Long Term Care Ombudsman and Local Law…

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

Based on interview, record review and observation, this regulation was not met when two vinegar bottles, one molasses bottle, and a 20 gallon jug of unlabled cooking oil, and five bags of bread and rolls were observed not to have expiration, open dates, or use-by dates. This resulted in the potential for foodborne illness and lack of palatability of the affected food, for all residents. Findings: Review of the the facility's record titled Policy and Procedure, Food Service Management, Nutricopia, Inc, dated 2018, indicated as follows: Store, prepare, distribute and serve food in accordance with professional standards for food service safety; and, All open food items will have an open date and use-by date per manufacturer's guidelines. Additionally, the policy indicated that the shelf life of opened vinegar and syrups is 12 months. The policy indicated that refrigerated biscuits, rolls, pastries . were recommended to be used by expiration date on label. In an observation and concurrent interview in the kitchen with Prep [NAME] B (PCB) on 10/24/23 at 1:00 PM, two open one-gallon…

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 dietetic services observations, dietary staff interview and departmental document review, the Registered Dietitian (RD) and/or the Dietary Services Supervisor (DSS) failed to ensure: 1) Vegetarian menus were in place and followed. 2) Timely and effective communication and monitoring system was in place between the facility kitchen and the contract kitchen regarding resident diet orders and food allergies. These failures had the potential to result in nutritionally inadequate meals, and the potential to promote decline in medical and nutritional status as well as quality of life for residents who received food from the facility food services. Findings: 1) During concurrent observations, interviews and record reviews between 01/10/22 at 9:15 AM and 1/13/22 at 4 PM showed: a vegetarian menu was not used or followed. Menus were not followed for mechanical soft diets; Portions were not served according to the menu; and menus for therapeutic diets were not followed (Cross Reference F803). 1A) A menu was not followed for Vegetarian Diets. During an observation of the lunch meal…

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

Based on resident interviews, meal delivery observations and departmental document review the facility failed to ensure meals were presented at a temperature that met the individual preferences of two Residents (Residents 36 and 246). Failure to ensure meals are prepared and delivered in a manner that meets residents needs may result in decreased food intake, resulting in weight loss further compromising medical status. Findings: During an interview on 1/10/2022 at 9:30 AM, Resident 246 stated Breakfast is always cold. During an interview on 01/10/22 at 12:05 PM, Resident 36 stated Food is sometimes cold, they need some plate warmers or something . Eggs and toast are not hot. I think I'm the last of the line. The toast is ice cold. On 01/12/22 beginning at 8:05 AM, a test tray was conducted on Unit B. The cart contained 11 resident trays in addition to the test trays. It was noted Unit B was designated as a COVID-19 yellow zone. The COVID-19 yellow zone is intended for residents who are awaiting COVID-19 test results or may have been exposed to someone who has tested positive.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure food were stored, prepared, distributed and maintained in safe and sanitary condition in their contracted kitchen when: 1. a. The facility kitchen staff were not following the departmental dress code. b. Internal bin of the ice machine had an area with pink, clear slimy appearing material. c. The kitchen areas and equipment were not clean. 2. a. Refrigerated food were not labeled, dated, monitored and raw foods were not separated from ready-to-eat foods. b. Potentially hazardous foods (PHF) were not at safe temperatures below 41°F. These failures had the potential for the spread of infection and foodborne illness to occur to residents. Findings: 1. a. On 1/10/2022 at 9:15 AM, during the initial tour of the facility contract kitchen and concurrent interviews with Dietary Aide (DA) L and DA M, the following were observed: * DA L and DA M wore no apron. * DA M did not wear a hair net or hat. DA M's forehead was sweating and he wiped…

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) A review of Resident 7's record indicated she was admitted to the facility on [DATE] with diagnoses that included dementia and muscle weakness. MDS, dated [DATE], indicated Resident 7 had severe cognitive impairment (unable to think and reason), total dependence for activities of daily living (ADLs), and required two person assistance for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed), transfers (how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), and toilet use. Resident 7's range of motion was impaired on both sides of her upper and lower extremities, and used a wheelchair for mobility. A review of Resident 7's Nurses Progress Note, dated 10/22/2021 at 6:21 AM by Licensed Nurse (LN) F, indicated Resident 7 had a witnessed fall. Certified Nursing Assistant (CNA) D informed LN F that on her last round at 5:20 AM, Resident 7 had fallen out of bed onto the floor while being changed by CNA D.…

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

Based on observation, interview and record review, the facility failed to ensure contracted kitchen staff were able to verbalize or demonstrate their competence to carry out the responsibilities of the food and nutrition services when: 1) Staff did not properly complete the food cooling process to ensure food safety. 2) Staff signed off on cleaning schedules, indicating 100% of daily cleaning assignments were completed when equipment was not clean. 3) Staff did not follow standardized recipes. These failures had the potential to result in foodborne illness, decreased nutritional status, and medical decline for residents consuming food prepared in the contract kitchen. Findings: During observations and concurrent interviews with the contract kitchens' Food and Nutrition Services Director (FNSD) and staff between 1/10/2022 at 9:45 AM and 1/12/2022 at 4 PM staff knowledge and professional standards of practice were not consistently in place. Temperatures were not monitored or documented for food stored in the sandwich station. Expired food was not discarded. Food was not properly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure menus were in place and followed when: 1. A vegetarian menu was not used or followed, and the nutritional adequacy of vegetarian meals served to two residents (Residents 14, 42) since admission was unknown. 2. Menus were not followed for 10 of 10 residents (Residents 3, 17, 18, 28, 30, 34, 245, 251, 254, 397) on mechanical soft diets. 3. Portions were not served according to the menu for six of 43 residents (Residents 4, 10, 12, 19, 38 and 397). 4. Menus for therapeutic diets were not followed for three residents (Residents 22, 24 and 28). These failures created the potential for residents to receive food that did not comply with the physician ordered diet, did not meet resident nutritional needs, and had the potential to compromise residents' medical status, nutritional status, and quality of life. Findings: 1. During an interview with Dietary Aide (DA) L on 1/10/22 at 11:30 AM, she stated they currently had 2 Vegetarian residents…

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 dietetic services observations, dietary staff interview and departmental document review the facility failed to ensure pureed foods for seven residents (Residents 7, 8, 32, 40, 252, 244 and 396) were prepared in accordance with standards of practice and departmental policies. Failure to ensure meal preparations were in accordance departmental procedures may result in decreased meal intake compromising the nutritional status of residents. Findings: The International Dysphagia Diet Standardization Initiative describes a pureed diet as one where all food should be pureed to a homogenous, cohesive, smooth texture. Foods should be pudding-like and hold its shape on a spoon. Contains no lumps. Not sticky. Pureed foods can be piped or molded and will not spread out if spilled. The prongs of a fork make a clear pattern when drawn across the surface of the puree. During meal plating observation on 1/11/22 beginning at 11:20 AM, it was noted the pureed broccoli resembled a thickened creamed soup. It was noted when it was plated it did not hold shape, rather spread out on the plate.…

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

Based on interview and record review, the Administrator (ADMIN) failed to provide and administer oversight and use its resources effectively when: 1. Infection control program for soiled resident laundry was not implemented, staff training, to ensure their policy and procedures followed Center of Disease Control (CDC) infection control standards. This failure resulted in resident clothing not being clean and sanitary and had the potential to spread disease and infection throughout the facility. Refer to F 880 and F 867 2. Dietary services did not follow national standards and guidelines for kitchen cleanliness, food temperatures,storage and nutritional needs. Refer to F 803, F804, F 805 and F 812. This commulative failures resulted in a potential for spread of disease and infection and dietary needs of residents' not to be met. Findings: A review of the facility's Administrator Job Description, dated 2017, indicated the ADMIN was responsible to Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified…

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

Based on observation, interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify and implement plans of action to correct deficiencies when: 1. Laundry services for residents did not meet standards for sanitation and infection control. This failure resulted in resident clothing not being cleaned and sanitary and had potential for the spread of diseases and infection throughout the facility. Refer to F880. 2. Dietary services did not meet the nutritional and palatability needs of residents. These failures created the potential for residents to receive food that did not comply with the physician ordered diet, did not meet resident nutritional needs, and had the potential to compromise residents' medical status, nutritional status, and quality of life. Refer to F803, F804, and F805. 3. Dietary services did not follow national standards and guidelines for kitchen cleanliness, food temperatures, and storage. These failures had the potential for the spread of infection, and foodborne illness to occur in residents. Refer 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 interview and record review, the facility failed to ensure Center of Disease Control (CDC) infection control standards for residents' soiled laundry were implemented. This failure resulted in residents' clothing not being cleaned and sanitary and had the potential to spread disease and infection throughout the facility. Findings: A review of a facility policy titled, Infection Control Manual - Laundry Department dated 5/7/2019, indicated, It is the policy of this facility to practice safe and sanitary laundry procedures, and the purpose of the policy is to decrease the risk of disease transmission . and ensure an effective infection control program. Administrative staff act jointly with the infection control committee to create policies and procedures to laundering resident's personal clothing. Monitor linen handling in resident care and laundry areas to ensure proper procedures are followed. Act jointly with infection control committee in making periodic facility inspection to ensure infection control standards consistently maintained. Soiled linen will be removed from 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.

4) During an observation on nursing unit C, on 01/10/2022 at 11:10 AM, it was noted the shower room sink had a small clump of gray hair that had not been cleaned out. In a concurrent observation and interview with Certified Nursing Assistant (CNA) J, on 01/10/2022 at 11:16 AM, CNA J stated staff rinsed out used wash cloths in sink but they didn't wash resident's hair in the sink. CNA J confirmed there was a clump of gray hair in sink drain in the shower room on nursing unit C. 5) Review of a facility policy titled, Medication Administration, revised 02/2013, indicated that, The nurse or authorized staff member on duty ensures equipment and supplies relating to medication storage and use are clean and orderly. On 01/12/2022 at 08:16 AM, it was observed that the Medication Storage room on nursing unit C had a moderate amount of dirt and dust on the floor, and empty shipping boxes with corrugated cardboard stored under the medication supplies. In an interview with Housekeeping (HK) G, on 01/12/2022 at 11:09 AM, HK G stated housekeeping was not given the assignment of cleaning the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) D was competent to provide safety measures during resident care, when Resident 7 rolled off the bed. This failure resulted in Resident 7 sustaining injuries that required a trip to emergency department services for evaluation and treatment. Findings: A review of Resident 7's record indicated she was admitted to the facility on [DATE] with diagnoses that included dementia and muscle weakness. The Minimum Data Set (resident assessment), dated 10/10/2021, indicated Resident 7 had severe cognitive impairment 9unable to think or reason), total dependence for activities of daily living (ADLs), and required two person assistance for bed mobility, transfers and toilet care. Resident 7's range of motion was impaired on both sides of her upper and lower extremities, and used a wheelchair for mobility. A review of Resident 7's Interdisciplinary Team (IDT, a team of health care professionals who assess,…

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.