Ridgeway Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician's orders for one resident (Resident 1) of two sampled residents when licensed nurses did not communicate Resident 1's treatment orders written by a Wound Care Physician Assistant (PA - a licensed medical professional whose duties include ordering labs, medications, and treatments) for a wound on the left heel to the Attending Physician (a physician who is responsible for a patient's care in a hospital or skilled nursing facility) for approval and a signature. This failure decreased the facility's potential to ensure Resident 1's wound care treatments were ordered and carried out. Findings: A review of Resident 1's admission record indicated he was admitted on [DATE] with relevant diagnoses including: Type 2 Diabetes Mellitus (a disease that occurs when blood sugar is too high) with Diabetic Polyneuropathy (a complication of diabetes that affects nerves that branch out from the spinal cord to the arms, hands, legs, and feet),…

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 observations, interviews, and record reviews, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. Proper handwashing was not followed in the kitchen; 2. The proper cool down process of food and Temperature Control for Safety (TCS) process were not monitored; 3. The facility's thawing process for food was not followed; 4. The potential for cross contamination was not prevented; 5. Cleaning cloths were not placed in sanitizing solution between use; 6. Hair restraints were not utilized; 7. Food storage guidelines were not followed; 8. Food preparation equipment and utensils were not clean and kept in good working order; 9. Kitchen cleaning equipment was not stored properly; 10. Kitchen equipment and the environment were not clean; 11. Ice packs intended for resident personal use were stored with food in the resident nourishment refrigerator and a medication temperature log was used to monitor the temperature of the resident nourishment refrigerator; and, 12. The posted time for immersion of dishes in a sanitizing solution during 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 observation, interview, and record review the facility failed to ensure residents were treated with dignity and respect when: 1. A staff member was observed standing while assisting a resident with meals; and, 2. Three staff were observed speaking a language other than English by the dining room of the facility during lunch hour. These findings had the potential for residents to experience feelings of sadness, frustration, and helplessness for a census of 76 residents. Findings: 1. During an observation in the dining room of the facility on 9/23/24 at 12:25 p.m., the Unlicensed Staff M was observed assisting Resident 67 with her lunch meal while standing. The Resident 67 sat in her wheelchair, while the Unlicensed Staff M was observed looking down at Resident 67 while assisting with her meal. After a few minutes of this process, another unidentified staff brought Unlicensed Staff M a chair to sit on. During an interview on 9/23/24 at 12:56 p.m., Unlicensed Staff M confirmed she was standing while assisting Resident 67. The Unlicensed Staff M also stated staff could stand 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.

Based on interview and record review, the facility failed to promptly respond and ensure resolutions for concerns brought-up during resident council meetings for a sample of 13 residents. This failure had the potential to result in unresolved patient care concerns, and feelings of frustration and loss of control for the residents of the facility. Findings: During a resident council meeting attended by 13 residents on 9/25/24 at 10:35 a.m., Resident 2 stated the facility did not always respond or resolve issues discussed during the meetings. Resident 2 also stated when the facility did resolve an issue, it was not done promptly, as it was usually done the day before the next monthly resident council meeting. A review of the July 2024 resident council minutes indicated a meeting was conducted on 7/10/24, in which residents complained they could hear staff speaking in their native language in the halls and residents' rooms, and two residents were upset that staff were speaking in Spanish only. A review of a facility document attached to the July 2024 resident council minutes 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.

Based on observation, interview, and record review, the facility failed to post the location of the survey results in a easily noticeable manner. This failure decreased the facility's potential to honor the rights of 76 residents to examine the facility's survey results. Findings: During a concurrent interview and record review on 9/25/24 at 12:20 p.m., the Activities Director stated she did not discuss where to find the survey binder during regular resident council meetings. The Activities Director shared with the surveyor the location of the survey binder. The survey binder was observed on the shelf of a small table located in the entrance lobby, covered with dust, and unlabeled with any type of information. There were no postings around this area to indicate the survey binder was there. During a concurrent interview and record review with the Director of Nursing (DON) on 9/25/24 at 12:25 p.m., the DON confirmed the survey binder did not include the survey results of complaints or facility reported incidents investigated after January 2023. During an interview with the…

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

Based on observation, interview, and record review, the facility failed to provide a safe, functional, and comfortable environment for residents when: 1. Two of three shower rooms were being used as storage; and, 2. The facility's smoking area dirty and unkempt. These failures made the shower rooms and smoking area uncomfortable and not a homelike environment. Findings: 1. During the Resident Council meeting and interviews on 9/25/24, at 10:55 AM, Resident 232 and Resident 2 stated the water in the shower room by the Merlot Hall was scalding hot. The residents stated water in the shower room by the Chablis Hall was cold and the shower room was being used as a storage room. The shower room by the Burgundy Hall was the only shower often used. A review of the Resident Council meeting minutes, dated 5/15/24 at 2:15 PM, indicated residents discussed the shower room at the Chablis Hall was being used as storage instead of being used as extra shower room; the Merlot shower did not work well because the water temperature was difficult to adjust. During an observation of the shower rooms and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide its residents a safe and functional environment free of accident hazards when water temperatures measured above 120 degreed Fahrenheit (F) in two showers and seven resident rest room faucets. These failures increased the risk of scalds or burns from hot faucet water and showers for a census of 76 residents. Findings: During the Resident Council meeting and interviews on 9/25/24, at 10:55 AM, Resident 232 and Resident 2 stated the water is scalding hot at the shower room by the Merlot Hall. A review of the Resident Council meeting minutes, indicated the following resident concerns were discussed on the following dates: - 1/17/24 at 2:10 PM: Merlot Hall shower still too hot; - 5/15/24 at 2:15 PM: Shower in Chablis being used as storage instead of being used as extra shower room. Merlot shower did not work well, temperature was hard to get just right; - 6/19/24 at 2:06 PM: Maintenance Supervisor responded Chablis shower has a broken…

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

Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet residents needs for three of nine residents (Residents 39, 46 and 53) when: 1. Licensed Nurse A (LN A) did not identify Resident 39 prior to administering his morning medications on 9/24/24. 2. Resident 39's physician's order and Medication Administration Record (MAR) for a Lidocaine Patch (a topical medication for pain relief) did not follow the medication's package insert instructions for use. 3. The LN B administered a different resident's Metformin (a medication to treat diabetes/high blood sugar) to Resident 46. 4. The LN B administered Tylenol (a pain medication) to Resident 46 but did not document the medication administration on Resident 46's MAR. These failures decreased the facility's potential to safely administer medications and prevent harmful side effects to residents. Findings: 1. During a medication administration observation and concurrent interview with LN A on 9/24/24, at 8:30 a.m., the LN A stated Resident 39 had an order for Lidocaine Patch 5% 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 observation, interview and record review, the facility failed to: 1) Remove an unsampled discharged resident's medication from the medication cart and medications for four residents (Resident 25, Resident 69, Resident 27, and Resident 10) were not placed in their proper storage; and, 2) Maintain the temperature in the medication room between 68 degrees Fahrenheit (F) and 77 degrees F. These failures resulted in Resident 46 being administered Resident 27's medication and decreased the facility's potential to appropriately store medications. Findings: During an observation and inspection of the medication cart for the Burgundy Hall, and concurrent interview with Licensed Nurse B on 9/25/24 at 10:24 AM, the following were noted: - An Unsampled Resident's medication packet of Gabapentin (medication used to treat seizures or nerve pain) 300 mg (milligrams, a unit of weight) capsules was stored among Resident 69's medication. Licensed Nurse B confirmed the unsampled resident's medication was not removed from the cart after discharge from the facility over the weekend. - 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.

Based on observation, interview and record review, the facility failed to ensure the following: 1. The Certified Dietary Manager (CDM) ensured kitchen staff were competent in their job specific duties; and, 2. The Registered Dietitian (RD) did not have adequate oversight of the kitchen functions. These failures decreased the facility's potential to provide safe food handling and santiation for 76 residents who received preared food from the kitchen. Findings: A review of the facility document titled Diet Order Tally Report dated 9/23/24 showed 76 residents received food prepared in the kitchen. 1. During the CMS recertification survey from 9/23/24 to 9/27/24, [NAME] F did not adhere to the following required job duties: -Appropriate hand hygiene, -Monitoring the cool down process for TCS (time temperature control for safety food), food that need to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, -Adhering to the facility thawing guidelines, -Prevention of the potential for cross contamination while preparing food, -Proper storage of cleaning…

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 observations, interviews, and record review the facility failed to: 1. Follow the recipe for Pacific Rim Pork Roast and Carrots with Parsley and 2. Ensure the resident meals were flavorful, appetizing, and cooked meat was tender for 76 residents who were served food from the kitchen. This deficiency decreased the facility's potential to serve palatable food and could lead to unintended weight loss due to reduced oral intake. Findings: 1. A review of a facility document titled Diet Order Tally Report dated 9/25/24 indicated: 7 residents received a dysphagia mechanical diet, 12 residents received a mechanical soft diet, 5 residents received a puree diet, and 52 residents received a regular diet. In a concurrent observation and interview on 9/24/24 at 11:19 a.m. with the [NAME] F and the Registered Dietician (RD), the [NAME] F stated was going to prepare five servings of pureed Pacific Rim Pork Roast. The [NAME] F was observed to do the following: -Added two pieces of cooked pork roast (one weighed 5 ounces (oz, a measure of weight) and the second weighed 6 oz for a total 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 interview and review, the facility failed to ensure facility staff and resident visitors were educated on safe food handing practices and food brought to the facility from the outside for resident consumption had the option to be heated. These failures had the potential for unsafe food handling which could lead to food borne illness and resident preferences not honored regarding food temperature for 76 residents who resided in the facility. Findings: On 9/25/24 at 3:31 PM an interview was conducted with Licensed Nurse L (LN L). The LN L was asked to describe the process when visitors brought food from the outside for residents. The LN L confirmed outside food was never heated and if food was removed from the refrigerator, it must be discarded. When asked if she had been trained on safe food handling LN L stated the Director of Staff Development (DSD) was responsible for training. On 9/25/24 at 3:37 PM an interview was conducted with the Director of Nursing (DON). The DON confirmed food from outside could not be heated. When asked if facility staff and visitors were educated…

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

Based on observation, interview, and record review, the facility failed to maintain a sanitary storage area when one dumpster was overflowing with trash and its lid was unable to be closed, and the immediate area was strewn with trash and dirty resident equipment. This failure increased the potential to harbor and breed pathogens (organisms causing disease) and attract pests (insects and rodents). Findings: During a concurrent observation and interview with the Maintenance Supervisor (MS) on 9/23/24 at 10:37 AM, the following were observed in the outside trash storage area: - empty cardboard boxes on the ground, - two mop buckets stored on the ground with dirty mops inside the buckets, - a broom, a squeegee, and an electric floor cleaner stored on the ground, - an overturned milk crate with an uncoiled hose underneath it on the ground, - debris, litter, plastic bags, and a wash rag on the ground, - a paint roller in a plastic bag on the ground, - an empty chemical container on the ground, - two bedframes, three wheelchairs, three commodes, one mattress, and other unidentified…

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

Based on observation, interview and facility document and policy and procedure review, the facility failed to ensure essential equipment was maintained in proper working order when the ice machine was not clean and the manufacturer's guidelines were not followed. This failure had the potential for equipment to not function the way it was intended. Findings: On 9/23/24 at 11:04 AM, an observation of the facility ice machine located in the kitchen dry storeroom and concurrent interview was conducted with the Maintenance Supervisor (MS). The MS stated he cleaned the ice machine monthly and that the ice machine was last cleaned on 8/13/24. Upon inspection of the internal components of the ice machine, the ice harvester (area ice was produced) curtain, ice sensor and ice harvester had black residue that came off when wiped with a paper towel. The MS confirmed the findings. The MS was asked how he cleaned the ice machine. The MS stated he removed all internal components and cleaned them with a mixture of ice machine cleaner and water. The MS stated he filled up a bucket with half ice…

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

Based on observation and interview, the facility failed to ensure resident food preferences were honored for one resident (Resident 4) of 18 sampled residents when Resident 4 disliked pasta but was served pasta for lunch. This failure decreased the facility's potential to honor residents' preferences. Findings: On 9/23/24 at 12:34 P.M. a lunch meal observation was conducted with Resident 4. Resident 4's lunch meal tray was delivered by Unlicensed Staff J. Resident 4's lunch meal consisted of spaghetti with meat sauce, spinach, dinner roll and ice cream. Unlicensed Staff J confirmed Resident 4 did not like pasta. The Certified Dietary Manager (CDM) was notified and Resident 4's meal tray was removed. The CDM delivered another lunch meal tray with rice instead of pasta. On 9/26/24 at 9:23 A.M., an interview was conducted with the CDM. The CDM was asked who was responsible to ensure resident food preferences were followed. The CDM stated the diet aide was responsible to call out the diet order and check the accuracy of the meal tray according to the meal ticket. The CDM also stated…

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 records review, the facility failed to ensure one Unlicensed Staff (Unlicensed Staff B) wore an N95 respirator to care for COVID-19 positive residents. This failure can result to the spread of infection to other facility residents and staff and cause an outbreak of COVID-19 in the facility further endangering the lives of the already frail elderly residents of the facility. Findings: During an observation on 7/24/24, at 1:07 PM, this Surveyor knocked on the door of room [ROOM NUMBER] where Resident 6 and Resident 7 were roomed-in. Unlicensed Staff B opened the door and was observed wearing a gown, gloves, and a surgical mask pulled low on her face exposing her nose. During an interview on 7/24/24, at 2:33 PM, Licensed Staff C confirmed she also noted Unlicensed Staff B was wearing a surgical mask with her nose showing over the top of the mask. During an interview on 7/24/24, at 2:38 PM the Infection Preventionist (IP) confirmed Resident 6 and Resident 7 in room [ROOM NUMBER]…

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 observations, interviews and records review, the facility failed to ensure call lights (an alerting device for nurses or other nursing personnel to assist a patient when in need) was accessible to four of four sampled residents (Resident 1, 2, 3 & 4). This failure kept the residents' needs uncommunicated to the staff, potentially placing them at risk for neglect and harm. Findings: Resident 1 During a review of the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was readmitted to the facility on [DATE], with diagnoses including but not limited to: Flaccid (soft and limp) Hemiplegia (paralysis of one side of the body); Anxiety Disorder (intense, excessive, and persistent worry and fear about everyday situations) and Mild Cognitive Impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). During a review of the MDS (Minimum Data Set - an assessment tool completed by clinical…

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 observations, interviews and records review, the facility failed to revise and implement a Fall and Elopement Care Plan for four of five sampled residents (Resident 1, 3, 4 and 5). These failure had the potential for facility staff to provide inadequate care and supervision to ensure the health and safety needs of the Residents were met. (Reference F600 & F689) Findings: Resident 1 During an observation in Resident 1 ' s room on 1/18/24 at 11:36 a.m., Resident 1 was in bed with her head of bed elevated at approximately 45°, awake. Her white push button call light was hanging and wrapped on the right side bedrail. When Resident 1 was asked if she could reach her call light, she stated she did not know where her call light was. During a review of the Fall Care Plan for Resident 1 and concurrent interview with Licensed Staff H on 2/01/24 at 11:30 a.m., indicated, [Resident 1] is moderate risk for falls related to deconditioning (the decline in physical function of the body as a result of physical inactivity), and gait (walking)/ balance problems. One of the Care Plan…

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 observations, interviews and records review, the facility failed to update the Elopement (an unauthorized departure of a patient from an around-the-clock care setting) Risk Observation/ Assessment and failed to provide oversight supervision to ensure a safe environment to one of two sampled residents (Resident 5), when facility staff were aware of Resident 5 ' s attempt of leaving the facility unsupervised. These failures resulted to Resident 5 leaving the facility repeatedly without staff supervision, putting her at risk for serious physical harm or even death. Findings: During a review of the Face sheet indicated Resident 5 was readmitted to the facility on [DATE], with diagnoses including but not limited to: [NAME] encephalopathy (a degenerative (deterioration) brain disorder); Anxiety Disorder; and Bipolar Disorder (disorder associated with episodes of mood swings). During a review of the facility document titled, Nursing - Elopement Risk Observation/ Assessment, dated 9/06/23, indicated Resident 5…

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 interviews and records review, the facility failed to ensure its transfer or discharge policy was implemented for one of three sampled residents (Resident 1), when Resident 1 was discharged from the facility while being treated at the hospital and the Long-term Care Ombudsman (a person who investigates, reports on, and helps settle complaints) was not notified of the discharge. This failure prevented Resident 1 to exercise his right to appeal the facility's decision to be discharged and prevented the Ombudsman from advocating for Resident 1's best interest during the discharge process. Findings: During a review of the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE], with diagnoses including but not limited to Malignant Neoplasm (another term for a cancerous tumor [cancer cells form a lump or growth] of Rectum (end part of the large intestine that connects the colon to the anus); Colostomy Status (an operation that creates an opening…

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 interviews and records review, the facility failed to ensure notices of the bed hold policy were provided to two of three hospitalized residents (Resident 1 and Resident 2). This failure resulted in Resident 1 and Resident 2 not being informed they could return to the facility after hospitalization, and if they needed to submit payment to reserve a bed. Resident 1 During a review of the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE], with diagnosis including but not limited to Malignant Neoplasm (another term for a cancerous tumor [cancer cells form a lump or growth] of Rectum (end part of the large intestine that connects the colon to the anus); Colostomy Status (an operation that creates an opening for the colon, or large intestine, through the abdomen); and Artificial Opening of the Urinary Tract (also known as Urostomy [a surgical procedure to create a stoma (artificial opening) so urine can pass out of the body through 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 interviews and records review, the facility failed to allow one of two sampled residents (Resident 1) to return to the nursing facility, when Resident 1 was ready to be discharged from the hospital and wanted to return to the nursing facility. This failure had the potential to cause psychosocial (pertaining to the influence of social factors on an individual's mind or behavior) harm for Resident 1 from displacement (the act of forcing somebody/something away from their home or position). Findings: During a review of the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE], with diagnoses including but not limited to Malignant Neoplasm (another term for a cancerous tumor [cancer cells form a lump or growth] of Rectum (end part of the large intestine that connects the colon to the anus); Colostomy Status (an operation that creates an opening for the colon, or large intestine, through the abdomen); and Artificial Opening of the Urinary Tract…

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 interviews and record reviews, the facility failed to report to the State (the centralized, law-making, law-enforcing, politically [NAME] institution in society) and the Ombudsman (a person who investigates, reports on, and helps settle complaints) an allegation of abuse for one out of two sampled residents (Resident 2) when Resident 1 threatened to kill Resident 2. These failures could potentially put the facility residents ' safety at risk and could result to ongoing abuse. Findings: A review of Resident 1 ' s face sheet (demographics) indicated she was initially admitted to the facility on [DATE] Her diagnoses included Essential Hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), Type 2 Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) and Hyperlipidemia ((high cholesterol, is an excess of lipids or fats in your blood). Her Minimum Data Sheet Assessment (MDS, a federally mandated process…

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 records review, the facility failed to ensure effective kitchen oversight by the Registered Dietitian (RD) and designated Dietary Manager as evidenced by findings associated with meal production and meal distribution, food safety and sanitation, safe/functional environment, and staff orientation and training. This failure had the potential for putting 64 of 66 residents at nutritional risk or further compromising their nutritional status. Findings: During review of dietetic service operations during an annual recertification survey from 8/8/22 to 8/12/22, multiple deficient dietetic practices were noted. The RD and Dietary Manager did not: 1. ensure dietary staff followed the approved menu and physician diet orders to prepare food to conserve flavor and palatability and serve the correct amount of food when five (5) residents on small portion diets and an unidentified resident on double portion diet were served regular portion meals; and seven (7) residents on pureed diet were served salty pureed chicken. (Cross Reference F803 and F804); 2. ensure…

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

Based on observation, interview and record review, the facility failed to follow the approved menu and physician diet orders when one Confidential Resident and Resident 52 complained of meal portions, five (5) of 64 residents (Resident 50, Resident 34, Resident 28, Resident 41, and Resident 51) on small portion diet, and one (1) unidentified resident on double entree diet were served the same portion of food like all the other residents who were on regular portion diet. This failure could result in undesirable changes of nutritional status, impaired healing, or poor well-being of residents in the facility. Findings: During the resident council meeting on 8/9/22, at 10 AM, Confidentail Resident stated there was issue with portion control. She was supposed to receive 1/2 cup rice, but one time staff used an ice scream scoop and the rice she received was only 1/4 instead of 1/2 cup rice. During interview on 8/9/22, at 3:22 PM, Resident 52 stated food portions were different sizes, most often too small. Resident 52's diet order was regular minced and moist texture regular consistency…

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 prepare food to conserve flavor and palatability (tastiness) for 4 unsampled residents (Resident 14, Resident 52, and two confidential residents) and 7 of 64 resident (Resident 53, Resident 45, Resident 48, Resident 18, Resident 16, Resident 160, and Resident 43) who were on pureed diet, when pureed entrée was served salty to taste. This failure could lead to weight loss and decline in nutritional status of residents in the facility. Findings: During an interview on 08/08/22, at 12:21 PM, Resident 14 stated he does not like the food in the facility. During the resident council meeting on 8/9/22, at 10 AM, two confidential residents stated food was not good. During an interview on 8/9/11, at 3:22 PM, Resident 52 stated food was served cold, portions were different sizes, most often too small, and had a bland taste. During a concurrent observation and interview in the kitchen on 8/10/22, at 9:39 AM, Unlicensed Staff I was pureeing chicken patties in preparation for lunch. When asked how he prepared the pureed…

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 records review, the facility failed to ensure kitchen staff practiced safe food handling to prevent potential food contamination when an opened bag of all purpose flour was not transferred to a clean container with a lid after it was opened. These failure could potentially result to food contamination and outbreak of foodborne illness among residents of the facility. Findings: During an initial tour of the kitchen and concurrent interview on 8/8/22, at 10:04 AM, an all purpose flour was found in its opened original paper bag in the dry goods section. When asked about the flour, Unlicensed Staff I stated the flour was delivered over the weekend, opened the previous night and was not tranfered to a container with a lid. During a follow-up visit of the kitchen and concurrent interview on 8/10/22, at 10:18 AM, the all-purpose flour was observed in the same place in its original opened paper bag. When asked why it was not transferred in a clean container with a lid, Unlicensed Staff I stated he had informed and requested the other cook to store it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement measures to reduce the risk of disease and infection transmission when: 1. Licensed staff were unable to identify appropriate transmission based precautions in caring for two out of two sampled resident (Resident 53 and 46) who had ESBL (Extended Spectrum Beta-Lactamase, an enzyme found in strains of bacteria and is spread by direct contact with the infected persons' bodily fluids); and 2. Facility leadership A) Did not provide a clean and sanitary environment or implement infection prevention surveillance during an ongoing construction project within the building (dating back to approximately 11/2021) to ensure infection prevention standards were maintained, B) Did not verify construction workers, working inside the building, were fully vaccinated and tested for Covid prior to entering the facility, per facility policy; and C) Did not ensure the Infection Control Committee (IC; designated team that functions to prevent 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 follow up on the resident's reported missing personal items and ensure the residents aware of the Theft and Loss policy for three (Resident 37, 211 and 35) out of six sampled resident's personal belongings from theft/loss. These failures resulted in residents stating they felt frustration, grief and confusion regarding the facility's lack of care and respect to their personal items. Findings: 1. During a review of Resident 37's, admission Record, dated [DATE], indicated Resident 37 was admitted to the facility on [DATE] with a history of elevated blood pressure and major depressive disorder. During an interview on [DATE] at 4:17 p.m., with Resident 37, Resident 37 stated, there was a lot of stuff in this room (Resident 37's bedroom), but she did not know what was missing and what was not missing. Resident 37 stated she had been collecting coloring pages for the past six years and had collected a stack of loose coloring pages approximately six inches…

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 observations, interviews and record reviews, the facility failed to ensure that the required notice and communication posting with the State Survey Agency (SSA) can be read and understood by the residents without staff assistance for three confidential residents and three out three sampled residents (Residents 1, 14 and 56). This failure had resulted to residents not having an access to this contact Information should they need to file a complaint with the State Survey Agency and had the risk for residents to feel like their welfare and autonomy does not matter. Findings: During the Resident Council meeting on 8/9/12 at 10:00 a.m., Three confidential residents stated State Survey Agency information was not posted in the building and they had no way of reaching out to the state if they have a concern. Two of these three residents stated this was very frustrating. One of these three residents stated it would be great if the facility can post the State Survey Agency contact information in the building. During an observation on 8/9/22 at 11:20 a.m., the walk through inside the…

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

Based on observations, interviews and record reviews, the facility failed to ensure that the residents were aware on how to formally file a grievance for three out of 12 sampled residents (Residents 24, 35 and 211). This failure had the potential to result in residents unresolved grievance, leaving residents feeling angry and frustrated. Findings: During an interview on 8/8/12 at 10 a.m., Residents 24 and 35 stated the facility did not have a grievance process, or if they have, that they do not know how to file a formal grievance. Resident 24 stated there was usually no follow up on their grievance or complaints, so they do not know whether the grievance or complaint was looked into or if the grievance was resolved. During an interview on 8/10/22 at 10:42 a.m., Social Services Director (SSD) stated she was the grievance officer. SSD stated it was up to the residents if they would prefer to file a formal grievance or just report it to a manager. SSD stated there were no in services provided to staff regarding the grievance process. SSD stated she was the one who fills out the…

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

Based on observation, interview and record review, the facility: 1) Failed to protect one resident (Resident 41) from verbal abuse when she was subjected to sexual and inappropriate comments by 2 male residents (Resident 1 and Resident 2) and 2) Failed to protect one resident (Resident 21) from profane comments from Resident 1. These failures caused Resident 41 to feel uncomfortable and creepy, contributed to Resident 21 appearing upset, and caused potential for emotional distress and suffering, which in turn could cause decreased ability for Resident 41 and Resident 21 to attain or maintain their highest practicable psychosocial well-being. Findings 1) Review of Resident 1's medical record revealed he was a male resident with a BIMS (assessment tool) score of 8 (moderate cognitive impairment). Review of a nursing care plan (document that contains relevant patient information, goals of treatment, and specific nursing interventions needed to provide resident-specific care) for Resident 1 (revised on 5/3/2022) indicated, (Resident 1) has episodes of swearing at staff, calls staff…

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 timely report three allegations of abuse involving Residents 1, Resident 2, Resident 41, and Resident 21 to the State Survey Agency. These failures prevented the State Survey Agency from conducting independent abuse investigations on behalf of Resident 41 and Resident 21 and potentially negatively impacted the psychosocial well-being of all four residents. These failures also had the potential to result in re-occurrence abuse. Findings 1) Review of Resident 1's medical record revealed he was a male resident with a BIMS (assessment tool) score of 8 (moderate cognitive impairment). Review of a nursing care plan (document that contains relevant patient information, goals of treatment, and specific nursing interventions needed to provide resident-specific care) for Resident 1 (revised on 5/3/2022) indicated, (Resident 1) has episodes of swearing at staff, calls staff names, throws things, makes inappropriate comments to and about staff. An additional nursing care plan, created on 3/16/2022, indicated, (Resident 1)…

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 investigate three allegations of abuse involving Residents 1, Resident 2, Resident 41, and Resident 21. These failures prevented the facility from determining the root cause of the incidents and from assessing the victims for potential negative outcomes; these failures potentially prevented the facility from protecting the victims from further abuse and potentially negatively impacted the psychosocial well-being of all four involved residents. Findings 1) Review of Resident 1's medical record revealed he was a male resident with a BIMS (assessment tool) score of 8 (moderate cognitive impairment). Review of a nursing care plan (document that contains relevant patient information, goals of treatment, and specific nursing interventions needed to provide resident-specific care) for Resident 1 (revised on 5/3/2022) indicated, (Resident 1) has episodes of swearing at staff, calls staff names, throws things, makes inappropriate comments to and about staff. An additional nursing care plan, created on 3/16/2022,…

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 observations, interviews and record reviews, the facility 1) Failed to implement the interventions to reduce the fall risk and hazards for one out of one sampled resident (Resident 12), which had the potential to result in serious injuries, including fractures and broken bones; and 2) Failed to adequately supervise one resident (Resident 1), who had a history of aggression, when he pulled 2 televisions off the walls in his room and the incident was not documented. This caused potential harm to Resident 1 and Resident 49 (Resident 1's roommate) when the televisions were pulled from the wall and caused potential for inability to track Resident 1's behaviors when the incident was not documented in his, or Resident 49's, medical records. Findings: 1) Resident 12's face sheet (demographics) indicated he was [AGE] years old with a diagnosis of Osteoarthritis (OA- degenerative joint disease or wear and tear arthritis. The cartilage within a joint begins to break down and the underlying bone begins to change)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the respiratory care equipment was labeled with due dates for changing the tubing and humidifiers for 2 of 8 residents (Resident 161 and 162). This failure could lead to oxygen tubing and humidifiers not being changed. Residents were then placed at risk for infection if the tubing is contaminated or the humidifier water gets contaminated. Findings: Record review of Resident 161's admission record documented Resident 161 was admitted to the facility on [DATE] for orthopedic aftercare related to a closed fracture at the neck base of the left femur (fractured hip.) Other diagnosis included Asthma, Chronic Atrial Fibrillation (irregular heartbeat,) Hypertension (high blood pressure) and Major Depressive Disorder. Resident 161's physician orders dated 7/27/22 indicated she was to be on oxygen therapy per nasal prongs at 2 liters continuously. Resident 161's Nursing Care Plan documented resident has oxygen therapy for asthma and indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to maintain accurate medical records on two (Resident 1 and Resident 6) out of two sampled residents when: 1) Resident 1 had two outbursts of pulling television sets out of their wall mounted brackets and there was no documentation in the medical record regarding the event and 2) Resident 6 had nursing documentation indicating her toenails were short and clean when observed the toenails on both feet had been overgrown and full of dry flaky skin. These failures resulted in inaccurate medical records which either did not include important changes in condition or inaccurate nursing assessments which could potentially endanger each resident Findings: 1) Review of Resident 1's medical record revealed he was a male resident with a BIMS (assessment tool) score of 8 (moderate cognitive impairment). Review of a nursing care plan (document that contains relevant patient information, goals of treatment, and specific nursing interventions needed to provide resident-specific care) for Resident 1 (revised…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary services to maintain good grooming and personal hygiene for 1 of 8 residents on hall 2 (Resident 161) who did not get a shower or have hair washed for 10 days. This failure had the potential to lower a resident's self-esteem and leave resident at risk for infection. Findings: Record review of Resident 161's admission record documented Resident 161 was admitted to the facility on [DATE] for orthopedic aftercare related to a closed fracture at the neck base of the left femur (fractured hip.) Other diagnosis included Asthma, Chronic Atrial Fibrillation (irregular heartbeat,) Hypertension (high blood pressure) and Major Depressive Disorder. During an observation and resident interview on 8/8/22 at 10:30 a.m., Resident 161 was lying in bed wearing a hospital gown, and her hair was oily with stands of hair clumping together. Resident 161 was asked if staff was getting her up and/or to activities. Resident 161 stated I have 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 interview and record review, the facility failed to follow Physician orders to prevent and treat constipation for 1 of 8 Residents on hall 2 (Resident 18). This failure resulted in Resident 18 having a bout of constipation, which caused Resident 18 moderate pain and discomfort and put her at risk for tearing of the mucous membrane and forming hemorrhoids from being constipated. Findings: During a review of Resident 18's admission revealed that she was admitted to the facility on [DATE] as a Hospice patient with diagnosis of malignant neoplasm (cancer) of kidney, vascular dementia, adult failure to thrive, with a history of seizure disorder and a history of falling. During a review of Resident 18's Medication Administration Record (MAR,) the MAR indicated medication orders to prevent constipation. Resident 18 was on Senekot, a mild laxative, with 2 tablets to be given by mouth twice a day. Resident 18 was also ordered milk of magnesia (MOM), a stronger laxative to be given once every 24 hours for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary foot care treatment for one (Resident 6) of one sampled resident when the facility did not have a process for ensuring residents had appropriate foot care. This failure resulted in Resident 6 having significantly overgrown toenails. Findings: A review of Resident 6's admission Record, dated 9/17/21, indicated Resident 6 was admitted to the facility on [DATE] with a history of epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), mild asthma (a condition in which a persons' airways become inflamed, narrow and swell and produce extra mucous which makes it difficult to breathe) and muscle weakness. During a concurrent observation and interview on 8/8/22 at 9:16 a.m., with Unlicensed Staff L, Unlicensed Staff L stated when Resident 6 was given a bed bath, if a resident's toenails were long and needed to be trimmed, the nurse would be informed. Unlicensed Staff L was observed to pull…

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 observations, interviews and record reviews, the facility failed to ensure that one out of one sampled resident (Resident 49) who requires dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) received care consistent with professional standards of practice when there was no assessment of the Resident 49's left arm for bruit (a rumbling or swooshing sound of a dialysis fistula usually heard with a stethoscope) or thrill (a vibration felt on the overlying skin ) every four hours after dialysis treatments as stated on the facility's Nurses Dialysis Communication Record form. This failure could result to nurses missing the changes in the fistula bruit/thrill that could signal a serious issue with Resident 49's dialysis fistula such as stenosis, failure to dialyze, Aneurysm (a swollen area which develops as a result of the vessel becoming weakened) and Steal syndrome (result of the fistula depriving the area below it of blood). Findings:…

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

Based on observation, interview and record review, the facility failed to maintain a safe and sanitary environment in the kitchen as evidence by cracked and broken linoleum/tiles on the kitchen floor. This failure could cause trips and falls among the kitchen staff and cause dirt to build up on the floor attracting cockroaches and rodents. Findings: During a visit to the kitchen and subsequent interview on 8/10/22, at 10:22 AM, two spots of cracked and broken flooring at the front of one of the stove/oven were noted. RD K stated the break in the flooring was already discussed and a job order for repair was in the process. A copy of the job order was then requested of RD K. During a follow-up interview and review of records on 8/10/22, at 10:31 AM RD K provided a print-out of the work order dated 8/10/22 at 10:26 AM. RD K stated she proceeded with the job order request as it was not done as she expected. Review of the Food Code 2017 indicated: It is the standard of practice to ensure materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall 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 interview and record review, the facility failed to ensure a resident's wishes for code status were accurately documented for one (Resident (R) 227) of seven sampled residents whose clinical records were reviewed for advanced directives. The failure to allow a resident to formulate advanced directives that were clearly documented to facility staff had the potential to affect the seventy-six residents who resided in the facility. Findings include: According to the Face Sheet, R227 was admitted to the facility on [DATE]. The Medical Diagnoses section of the electronic health record (EHR) documented diagnoses that included chronic lymphocytic leukemia of B-cell type and chronic pain syndrome. The significant change of status Minimum Data Set (MDS), with an Assessment Reference Date of [DATE], indicated R227 had a Brief Interview for Mental Status score of 05, indicative of severe cognitive impairment. This MDS identified R227 had a California Physician Orders for Life-Sustaining Treatment (POLST) form 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.