Diamond Ridge Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 52) was free from unnecessary medication, when Resident 52 was prescribed and given Risperidone (medication to treat symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions)) and did not have schizophrenia. This failure resulted in Resident 52 being administered an unnecessary medication and had the potential for increased morbidity (the condition of suffering from a disease or medical condition) and mortality (death). Findings: During a review of Resident 52's admission record, dated 8/13/24, indicated, Resident 52 had diagnoses of Unspecified Dementia (symptoms affecting thinking and social abilities interfering with daily functioning), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. During a review of Resident 52's Minimum Data Set (MDS - an assessment tool used to guide care), dated 4/25/24, 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.

Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices with census of 110, when: 1. Resident 5's inhalation medication with limited shelf life after opening was not dated for beyond used date in medication cart #2b, and 2. Resident 59's intravaginal (insertion through the vagina or birth canal) medication was stored together with the oral medications in medication cart #2a. These failures had the potential to contribute to unsafe use of medications and potential for medication error. Findings: 1. During a concurrent interview and observation on 8/13/24, at 11:10 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 5's opened and undated Symbicort (an inhalation drug used to treat breathing problems) was stored in medication cart #2b. The manufacturer label on the box indicated Discard within three months after removing from foil pouch. LVN 3 stated there was no open date written on the box nor on the inhaler. LVN 3 stated when an inhalation medication was opened, it should have been dated per the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical abuse when Certified Nursing Assistant 1 (CNA 1) raised her arm at Resident 1, as if she was to strike Resident 1. CNA 1 had previously exhibited aggressive verbal behavior towards Resident 4 and 5. This failure placed Resident 1 at risk for emotional and psychological distress. Findings: During a record review of Resident 1's admission record dated 4/17/24, indicated Resident 1 was admitted to the facility on [DATE] and had a diagnosis of Alzheimer's disease (A progressive disease that destroys memory and other important mental functions.). During a record review of Resident's 1's Minimum Data Set, (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) dated 3/1/24, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive…

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, for one of three sampled residents (Resident 1), the facility failed to notify and consult with the physician when Resident 1 was unable to sleep despite the use of sleep medication. This failure potentially contributed to increase in episodes of negative behavior and falls and had the potential to result in delayed modification of treatment regimen. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (abnormal blood sugar levels), non-traumatic chronic subdural hemorrhage (brain injury), dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), 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, for one of two sampled residents (Resident 2), the facility failed to ensure Resident 2 was administered olanzapine (treats psychosis, a mental illness), lexapro (anti-depressant, treats depression) and trazodone (anti-depressant) with adequate monitoring of adverse effects from the medications. This failure had the potential to result in delayed management of adverse effects and unnecessary use of medication. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, depression, paranoid schizophrenia and bipolar disorder, diabetes mellitus, and end stage kidney disease. During a review of Resident 2's Order Summary Report as of 9/6/23, the Order Summary Report indicated orders for Resident 2 to receive the following medications: lexapro 5 milligrams (mg) one tablet daily, olanzapine 5 mg one tablet in the morning and olanzapine 15 mg one tablet…

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, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1, who was at risk for aspiration, was provided honey thick liquids (thicker than nectar thick, less pourable from a cup or a bowl) as ordered by the physician when nectar thick consistency liquid (easily pourable than honey thick, like thicker cream soups) was served. This failure had the potential to result in aspiration (when food or liquid enters the airway and goes into the lungs). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility in August 2015 with diagnoses that included chronic pain syndrome, glaucoma (eye condition when pressure increases inside the eyes, damaging the optic nerve), hyperlipidemia (increased blood cholesterol levels), hypertension (high blood pressure) and hypothyroidism (underactive thyroid gland, thyroid does not produce enough thyroid hormones). During a review of…

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

Based on observation, interview and record review, the facility failed to maintain a safely operating toilet for two of 12 sampled residents (Resident 9 and 10). This failure resulted in toilet water leaking on the bathroom floor, attracting insects and had the potential to become a slip hazard resulting in injury or death. Findings: During an observation and interview, on 8/17/23, at 2:30 p.m., with Resident 9, a toilet was observed in Resident 9's bathroom. The bathroom was shared between Resident 9 and Resident 10. A blanket was folded and placed beneath the toilet. The blanket was wet and upon lifting the blanket, insects were found underneath. Photos of the insects were taken by surveyor. Resident 9 stated the toilet had not been fixed since the last time surveyor was in the facility in June 2023. During a record review of surveyor notes, dated 6/6/23, at 3:14 p.m., the notes indicated Resident 9's toilet was leaking, and a blanket was placed beneath the toilet. The notes indicated Resident 9 stated the toilet was leaking for over 2 years and a blanket was used to contain the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have a baseline care plan for four of five sampled residents when Residents 41, 254, 255, and 257 did not have baseline care plans within 48 hours of admission. This deficient practice had the potential to decrease the continuity of care and communication between care givers resulting in poor quality care and potential adverse outcomes. Findings: 1. During a review of the medical record for Resident 41, there were no baseline care plans. Resident 41 was admitted [DATE]. Resident 41 did not have a completed Minimum Data Set (MDS, an assessment tool for planning care). Resident 41 had diagnoses that included end stage kidney disease, diabetes (blood sugar disorder), left above the knee amputation, high blood pressure, and use of blood thinners. 2. During a review of the medical record for Resident 254, there were no baseline care plans. Resident 254 was admitted [DATE]. Resident 254 did not have a completed MDS. Resident 254 had diagnoses to include…

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, interviews, and record review, the facility failed to maintain sufficient staffing to provide care for five of five sampled residents, Resident 13, Resident 38, Resident 58, Resident 254, and Resident 255. This deficient practice resulted in Residents not getting call lights answered, not getting showers, not having assistance to use the bathroom which lowers the quality of care and the potential to cause an accident and psychosocial harm. Findings: 1. During an interview with Resident 254 on 4/11/22 at 11:30 a.m., Resident 254 stated on Sunday (4/10/22), he had to wait 30 minutes to go to the bathroom. During an interview with Resident 255 on 4/11/22 at 12:10 p.m., Resident 255 stated the facility is understaffed. Resident 255 stated on Friday (4/8/22), he called for assistance, and no one came. Resident 255 stated he got up to the bathroom by himself, which he knew he was not supposed to do, and had an accident (soiled self) on the way. During the Resident Council meeting on 4/12/22 at 10:15 a.m., Resident 58 stated call lights don't get answered in a timely…

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

Based on interview and record review , the facility failed to follow the policy and procedure for Medication Regimen Review to act upon the Consultant Pharmacist's (CP) report of medication irregularity for one (Resident 84) sampled resident when Resident 84 CP recommendation for use of quetiapine (Seroquel- antipsychotic medication) was not followed up in a timely fashion. {According to the manufacturer of Seroquel, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel not approved for use in psychotic conditions related to dementia. Although causes of death varied, most of the deaths appeared to be related to cardiovascular e.g. heart failure, sudden death}. [Reference: https://www.drugs.com/pro/seroquel.html] This deficient practice had the potential for residents to receive unnecessary drugs and adverse side effects. Findings: Review of the admission Minimal Data Set (MDS-an assessment screening tool used to guide care), dated 9/30/21, indicated Resident 84 had little interest or pleasure in doing things,…

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 serve palatable food when meatballs were served for lunch that lacked flavor. This deficient practice had the potential to decrease meal enjoyment and residents to decline to eat. Findings: During a residents council meeting on 4/12/22 at 10:16 a.m., residents complained about the taste of the food served. Review of the Cooks Spreadsheet dated 4/12/22 showed the spring menu was meatballs with gravy, penne (pasta) with garlic and herb, peas with margarine, and iceberg lettuce green salad. During a test tray on 4/12/22 at 1:26 p.m., accompanied by the Dietary Supervisor (DS), lunch served and sample tested consisted of a plate of pasta, meatball, gravy and vegetable. The meat balls when tasted had no flavor. DS stated the facility just changed the menu and thinks the meatballs were mixed with oat meal.

Based on observation, interviews and record review, the facility failed to follow proper sanitation and food storage practices when: a. Kitchen floor tiles had brownish black residual discoloration, b. Two dishwasher racks had brownish/black discoloration, c. Ten cans of applesauce had used-by-date that expired 9/30/21. These deficient practices had the potential for an unsanitary food environment or serving expired food resulting in foodborne illness. Findings: During the tour of the kitchen on 4/11/22 at 10:37 a.m., and accompanied by the Dietary Supervisor (DS), the following were observed: Kitchen floor tiles had brownish black residual discoloration and two dishwasher racks had brownish black discoloration. During an interview on 4/12/22 at 8:30 a.m., DS could not provide when the kitchen floor was last washed. DS stated the housekeeping department was responsible for cleaning and washing the kitchen floor. During an interview on 4/12/22 at 10:28 a.m., the Housekeeping Supervisor (HS) stated she was not aware that cleaning and washing the kitchen floor was part of her…

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 follow infection control practices during storage and handling of resident's respiratory equipment for four of four sampled residents. For Resident 255, Resident 256, and Resident 257, their oxygen cannula tubing was not dated for staff to know when the next tubing change should occur. For Resident 254, the Continuous Positive Airway Pressure (C-PAP, a machine to keep the airway open while sleeping) mask and tubing were undated and left exposed to the air on the night stand. This failure had the potential for the spread of infection and cross-contamination. Findings: 1. During an observation and concurrent interview on 4/11/22 at 12:00 p.m., Resident 254's C-PAP mask and tubing were lying out on the nightstand and not protected and stored in a bag. Resident 254 stated the C-PAP was brought from home and the mask has been on the night stand open to air since being admitted to the facility. During a review of the medical record for 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 interviews and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), was accurate for two ( Resident 82 and 90) sampled residents when Resident 82 and 90's preadmission screening for serious mental illness was not coded accurately. This deficient practice had the potential for residents to not received appropriate mental health care and services. Findings: 1. Review of Resident 82's Annual Minimum Data Set, (MDS - resident assessment tool used to guide care) dated 4/30/21, indicated section A preadmission screening and resident review (PASRR) was coded zero and indicated Resident 82 was not currently considered by the state level 11 PASRR process to have a serious mental illness. Resident 82's diagnoses included schizophrenia (a long term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior leading to faulty perception, withdrawal from reality into fantasy and delusion 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 develop a comprehensive, person-centered care plan with measurable objectives and goals for dialysis (artificial kidney machine to remove waste products and excess fluids) care for one (Resident 88) of one sampled resident. This deficient practice had the potential to negatively impact Resident 88's quality of life, and quality of care and services received. Findings: During a review of Resident 88's medical record, the Minimum Data Set, (MDS, an assessment tool), dated 3/23/22, indicated Resident 88 was admitted to the facility on [DATE]. During a review of Section C of the MDS, it indicated Resident 88 had a Brief Interview for Mental Status (BIMS) score of 14/15, meaning cognitively intact. Resident 88 had diagnoses that included atrial fibrillation (irregular heartbeat), heart failure, end stage renal (kidney)disease, diabetes, anxiety, depression, and was on dialysis. During a review of Resident 88's care plans showed there was no care plan 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.

Based on observation, interview, and record review, the facility failed to provide podiatry services (foot care including cutting of toenails) for one of two sampled residents (Resident 33). This failure had the potential to cause injury including ingrown toenails and scratches to feet and legs. Findings: A review of Resident 33's Face sheet (document with residents' general information) indicated Resident 33 had multiple diagnoses, including vascular dementia with behavioral disturbance (a form of dementia causing memory loss, problems with judgement/reasoning that can include issues with mood, sleep and agitation). A review of Resident 33's Minimum Data Set (MDS - comprehensive assessment of a residents' functional abilities) dated 2/1/22, indicated a Brief Interview of Mental Status (BIMS - test used to evaluate cognitive function) score of one out of 15, indicating severe impairment. During a concurrent observation and interview on 4/12/22, at 10:10 a.m., with Resident 33, Resident 33 was lying in bed with very long toenails on both feet. Resident 33 indicated she did not know…

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 obtain respiratory care orders or follow orders for three of four sampled residents when Resident 254 did not have an order for C-PAP (a machine that provides continuous positive airway pressure to keep airway open while sleeping). Resident 256 did not have the correct flow of oxygen being delivered, and Resident 257 did not have an order for oxygen. This failure had the potential to cause harm by delivering too much oxygen to Resident 256 with chronic obstructive pulmonary (lung) disease (COPD) or giving unnecessary supplemental oxygen or C-PAP to Resident 257. Findings: 1. During an observation and concurrent interview on 4/11/22 at 12:00 p.m., Resident 254's C-PAP mask and tubing were on the nightstand and not stored in a bag. Resident 254 stated the C-PAP was brought from home and the mask has been on the nightstand since he was admitted to the facility. During a review of the medical record for Resident 254, the record 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.

Based on observation, interview and record review, the skilled nursing facility did not effectively manage the pain for one of 20 residents (Resident 155). Resident 155 did not receive pain medication as ordered by the doctor. This failure resulted in unnecessary pain for Resident 155. Findings: Record review on 4/12/2022 of the document admission Record showed Resident 155 had diagnoses that included a fractured arm. Review of the document Order Summary Report dated 4/5/2022 showed Resident 155 was to receive, Aspercreme Lidocaine Cream 4% (Lidocaine HCl). Apply to skin topically one time a day for pain and remove per schedule. Review of the Medication Administration Record (MAR) showed Patient 155 was to receive the Aspercreme and the start date was 4/7/2022. Patient 155 complained of pain levels between 3 and 4 since her admission to the facility on 4/5/2020 (pain level scale 1 - 10, one is mild and 10 the worst pain). During medication pass on 4/12/2022 at 9:38 a.m., Licensed Vocational Nurse 3 (LVN 3) stated there was no Aspercreme in the medication cart and she was not sure…

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 consistently supply a medication prescribed by a physician for one (Resident 9) of five sampled residents. This failure resulted in Resident 9 experiencing nausea, dizziness and headaches. A review of Resident 9's Face sheet (document with residents' general information) indicated an initial admission date of 3/2/17 with multiple diagnoses including, chronic pain and neuropathy (a condition causing weakness, numbness, and pain from nerve damage). During an interview on 4/11/22 at 12:45 p.m., with Resident 9, Resident 9 stated recently, there were missed multiple doses of Nortriptyline (medication used to treat nerve pain and depression) because the facility ran out. Resident 9 stated with missed doses of the medication, resident felt nauseous, dizzy and got headaches. During an interview on 4/14/22, at 10:50 a.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated nurses are responsible for reordering resident medications before they run out. If a resident misses a dose of Nortriptyline, residents can have pain. During a…

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

Based on interviews and record review, the facility failed to ensure two sampled residents (Resident 60 and 84) were free from unnecessary drugs as follows: 1. Resident 60 was administered buspirone (antianxiety) without adequate monitoring of behavior manifestations and medication side effects. 2. Resident 84 was administered quetiapine (Seroquel- antipsychotics) without adequate monitoring of behavior manifestations and medication side effects. Definition: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. According to the manufacturer of Seroquel, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel not approved for use in psychotic conditions related to dementia. Although causes of death varied, most of the deaths appeared to be related to cardiovascular e.g. heart failure, sudden death}. [Reference: https://www.drugs.com/pro/seroquel.html]. These failures had the potential for residents to receive unnecessary medications and had the potential 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.

Based on interviews and record review, the facility failed to ensure the skills competency evaluations were completed for dietary staff. The dietary Aide (DA) and one [NAME] (CK) competency skills evaluations were not completed for providing the residents' food services. This deficient practice had the potential to result in unsafe food preparation practices. Findings: During an observation and concurrent interview on 4/12/22 at 8:57 a.m., DA could not demonstrate how to operate the three compartment sink. DA stated she was not trained on when and how to use the three compartment sink. The three compartment sink is the manual procedure for cleaning and sanitizing dishes when the dishwasher breaks down or fails to operate properly. During an observation of the tray line on 4/12/22 at 11:37 a.m., in the presence of the Dietary Supervisor (DS), CK had served food on a plate without first checking the food temperature. During an interview on 4/12/22 at 8:51 a.m., CK stated she was promoted from dietary aide to a cook when the previous cook resigned. CK stated she was not provided…

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 one (Resident 59) sampled resident's wheelchair in good working condition when Resident 59's wheelchair was squeaky and difficult to maneuver. This deficient practice resulted in Resident 59 having difficulty moving around the facility in his wheelchair. Findings: During an observation on 4/11/22 at 12:00 p.m., Resident 59's wheelchair had squeaky sounds when propelling self in the facility. During an interview on 4/11/22 at 12:00 p.m., Resident 59 stated his wheelchair was difficult to mobilize and makes squeaky sounds. Resident 59 stated he had reported the problem with his wheelchair to the staff. Review of the Annual Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 3/3/22, indicated Resident 59's Basic Interview of Mental Status (BIMS) score was 15 (meaning good long and short term memory, no cognitive impairment). During an interview on 4/11/22 at 12:43 p.m., the Maintenance Supervisor ( MS ) stated he was not notified of Resident 59's squeaky wheelchair. During an…

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

Based on observation, interview and record review, the facility failed to ensure the infection control program was implemented and to use the proper sanitary technique when: 1. Registered Nurse/Nursing Supervisor (NS 1) used gloves that was removed from her uniform pocket to clean an opened wound and applied a dressing. 2. One staff used their bare hands to cut a biscuit while serving breakfast. 3. Four of seven staffs' health records did not have proof of their vaccination against Measles, Mumps and Rubella (MMR-contagious viral infections) and Tdap (Tetanus, Diphtheria, Pertussis-whooping cough) which are communicable bacterial infections, with the exception of Tetanus. These failures had the potential for the transmission of infection. Findings: 1. The record review of the admission Record indicated Resident 79 had diagnoses that included quadriplegia (partial or total paralysis of all four limbs and torso of the body). The record review of the pressure ulcer (bedsore) care plan indicated Resident 79 had a Stage IV pressure ulcer (full skin and tissue loss) in the sacral area…

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 implement the Advance Directive (legal document with written instructions for the provision of health care) policy at the time of admission for two (Residents 55 and 209) of 30 sampled residents, or their legal representative about future healthcare choices, and name a person to make decisions when the resident is unable to do so. For Residents 55 and 209, this failure resulted in not verifying if there were existing advance directives for healthcare to guide choices for doctors and caregivers or contact the resident/representative if they wish assistance in formulating an advance directive. Findings: 1. The record review of Resident 55's, Physician Orders for Life Sustaining Treatment (POLST, a medical order form indicating the resident's intensity of treatment wishes in the event of a medical emergency) was prepared on 9/2/18. The form included three selections to indicate if Resident 55 did or did not have an Advance Directive or if the Advance Directive was not available. The check boxes for these selections were left…

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 fingernail care and nail hygiene for two (Resident 79 and 85) of 30 sampled residents as follows: 1. Resident 79 had hand contractures (the shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and long curved fingernails that were digging into the resident's right palm. 2. Resident 85 had long fingernails with brownish residue underneath the nails and chipped nail polish. These failures had the potential for nail bed injury, poor skin integrity, and harboring dirt and bacteria underneath the fingernails that could contribute to the spread of infection. Findings: 1. During an observation on 7/15/19 at 10:16 a.m., Resident 79 was noted with long, [NAME] fingernails that were digging into the palm of the resident's contracted right hand. During an interview on 7/15/19 at 10:16 a.m., Resident 79 stated he would like his long fingernails trimmed. A record review of 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, interviews, and record review, the facility failed to ensure one (Resident 79) of 30 sampled residents received restorative care services (assists patient to gain strength and mobility) according to the comprehensive care plan. For Resident 79, staff failed to apply a hand, palm roll for protection and intervention for contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). This failure had the potential to cause further decline of range of motion (ROM), joint mobility, and skin integrity. Findings: The record review of the admission record indicated the facility admitted Resident 79 on 4/30/17 with diagnoses that included quadriplegia (partial or total paralysis of all four limbs and torso of the body) and contractures. A record review of the Minimum Data Set (MDS- Resident Assessment tool used to guide care) dated 6/19/19 indicated Resident 79 had limited ROM and impairment to both upper and lower extremities, including the elbow, wrist, and hands. The record review of the Occupation…

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 provide assistance and arrange services to restore the hearing aids for one (Resident 7) of 30 sampled residents to maintain hearing ability . This failure resulted in no services to assist with repairing the faulty hearing aid and caused Resident 7 frustration due to impaired communication with staff and others. Findings: A record review of the admission Record indicated Resident 7 had diagnoses that included major depression (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 7/8/19, indicated Resident 7 had hearing loss that caused moderate difficulty with hearing. During an interview on 7/15/19 at 9:47 a.m., Resident 7 stated he was frustrated because his faulty hearing aids was not repaired. Resident 7 further stated he was informed by the Social Services Director (SSD) that he was not qualified for a replacement hearing aid. Resident 7 stated he could not hear when staff communicated with him 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, for one (Resident 66) of 30 sampled residents, the facility failed to elevate the head of bed (HOB) to 30-45 degrees to prevent potential complications while receiving enteral nutritional feeding (liquid formula via the gastrointestinal tract) through the percutaneous endoscopic gastrostomy (PEG) tube (a surgically placed tube into the patient's stomach). This failure had the potential for aspiration (fluids entering the windpipe) or aspiration pneumonia (lung infection). Findings: A review of the admission Record indicated Resident 66 was admitted on [DATE] with multiple diagnoses including, dementia (a decline in mental ability severe enough to interfere with daily life), dysphagia (difficulty swallowing) and receiving gastrostomy feeding. During an observation and concurrent interview on 1/9/17 at 8 a.m., Resident 66 was lying on his right side, flat in bed, and receiving enteral feeding at 70 milliliters (ml) via pump. The record review of the physician…

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 controlled medications were reconciled (count verification) to prevent potential diversion or tampering when one of five medication carts (Med Cart 1 A) had a blister-pack (pills stored in bubble seal and popped out through a paper or foil backing) of Hydrocodone (opioid pain medication) had a torn backing exposing the drug. In addition, one of five medication carts had no completed Controlled Drug-Count Record. These failures had the potential for unauthorized access, diversion, and abuse of controlled substances. Findings: 1. During the inspection of Med Cart 1 A on 7/16/19 at 10:45 a.m., number 15 of 30 Hydrocodone [5 milligrams (mg)/325 mg acetaminophen] controlled tablets in a blister-pack was torn exposing the drug. During an interview with the Licensed Vocational Nurse 2 (LVN 2) on 7/16/19 at 10:45 a.m., LVN 2 confirmed the blister-pack had a tear exposing the controlled drug. LVN 2 stated the drug did not have a secure closure, and this will be reported to the Director of Nurses (DON) 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.

Based on observation, interview, and record review, the facility failed to follow the policy for Medication Regimen Reviews (MRR) for one (Resident 46) of thirty sampled residents when the antidepressant medication was not reviewed monthly. This deficient practice had the potential to result in physical, mental or psychosocial harm for Resident 46. Findings: A record review of theadmission Record showed Resident 46 had multiple diagnoses including, dementia (a decline in mental ability severe enough to interfere with daily life) with behavioral disturbance and major depressive disorder. The record review of the physician's order dated 4/10/18, Paxil (antidepressant) 10 mg (milligram) by mouth, one time a day for resisting care. The quarterly Minimum Data Set (MDS-an assessment tool), dated 5/23/19 indicated Resident 46 did not have symptoms of depression. During an initial observation on 7/15/19 at 8:17 a.m., Resident 46 was receiving morning care from staff and cooperative. On 7/17/19 at 9:30 a.m., Resident 46 was calmly walking and going to attend an activity. During an interview…

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 an environment free from unnecessary drugs for three (Resident 46, 85, 93,) of 30 sampled residents as follows: 1. For Resident 46, an antidepressant (Paxil) was ordered without a medical indication for its use. 2. For Resident 85, an antipsychotic (Seroquel) medication was administered without supporting documentation for its continued use. 3. For Resident 93, a sedative medication was ordered with no monitoring of hours of sleep and adverse effects of the drug. These deficient practices had the potential for physical, mental or psychosocial harm. Findings: 1. A record review of the admission Record showed Resident 46 had multiple diagnoses including, dementia (a decline in mental ability severe enough to interfere with daily life) with behavioral disturbance and major depressive disorder. The record review of the physician's order dated 4/10/18, Paxil (antidepressant) 10 mg (milligram) by mouth, one time a day for resisting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled, stored, and secured in accordance with the facility's policy as follows: 1. An opened bottle of Procrit [used to treat anemia (low red blood cell count)] was expired, unlabeled, and had no opened date. 2. A half bottle of expired anticholinergic Glycopyrrolate (reduces excessive drooling) medication was stored with currently used medications in the top drawer of Medicine Cart 1 C. 3. One of two treatment carts was left unlocked and unattended. These practices had the potential for reduced potency of the medications due to improper storage, and placed residents at risk for accidental use or ingestion of topical medications when left unlocked. Findings: 1. During an inspection of the Medication Room (Med room [ROOM NUMBER]) on 7/15/19 at 10:53 a.m., an opened vial of Procrit 10,000 units/milliliters (ml) injection, stored in the refrigerator of Nursing Station 1, had expired on 6/30/19. The Procrit…

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 safe storage of laboratory test supplies when expired laboratory sample collection kits were stored with currently used laboratory test kits. This failure had the potential for inaccurate test results and affect the medical provision of care. Findings: During an inspection of Nursing Station 2-Medication Room on [DATE] at 10:53 a.m., four vials of Culture Swabs for Nasopharygeal Collection Kits for Viruses had expired 3/'19 and were stored on the shelf with currently used laboratory test kits. During an interview with the Nursing Supervisor 2 (NS2) on [DATE] at 10:53 a.m., NS 2 confirmed the culture swabs kits were currently used to collect samples from the residents. NS 2 stated the expired culture swabs will be discarded. The record review of the policy and procedure, Storage of Medications dated [DATE] indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations 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 observations, interviews, and record reviews, the facility failed to provide residents with a nourishing, well balanced diet that meets their daily nutritional intake and special dietary needs for two (Residents 16 and 162) of 30 sampled residents when: 1. Resident 16 did not receive his diet vanilla pudding and low sugar house shake. 2. Resident 162 did not receive his preferred scrambled eggs and biscuit. This failure resulted in residents not meeting their dietary needs and meals preferences. Findings: 1. A record review of the admission Record indicated Resident 16 had multiple diagnoses, which included diabetes mellitus (blood sugar disorder). During a lunch observation and concurrent interview with Resident 16 on 7/15/19 at 1:15 p.m., Resident 16 stated, I did not receive my vanilla pudding and house shake for two days. He further stated, Staff told me they were out of pudding and shakes. During an interview and record review of Resident 16's diet slip with Certified Nursing Assistant 1 (CNA 1) on 7/15/19 at 1:30 p.m., CNA 1 stated out means the kitchen was out of…

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

Based on observation, interview, and record review, the facility failed follow the policy and procedure to store, clean floors, and keep equipment under sanitary conditions when: - The Kitchen floor tiles had brown sediments and drainage pipe area had yellowish buildup. - The Ice machine had pink-white build up on the front panel cover plate, back plate, and around the condensing unit. - Emergency food supplies were missing eight cans of beef steak - The food processor, mixing bowl, and slicer had white & brown sediment. These failures had the potential to result in waterborne illnesses from the unsanitary ice machine, contamination from using unclean cooking equipment or not enough supplies to meet emergency preparedness. Findings: During the initial tour of the kitchen on 7/15/19 at 7:55 a.m., and accompanied by the [NAME] (CK), the following was observed: Hand washing sink with yellowish sediment and brownish stain, kitchen floor tiles and drainage pipe area with brownish stain and yellowish sediment buildup, the ice machine had pinkish-whitish buildup on the front panel, food…

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

Based on observations, interviews, and record reviews for three (Residents 160, 93, and 161) of 30 sampled residents, the facility failed to ensure the clinical records contained accurate health status information as required. 1. For Residents 160 and Resident 93, a care plan for the pacemaker (device to help control abnormal heart rhythms) did not contain the type of pacemaker, set rate and insertion date. This failure had the potential for not detecting a pacemaker malfunction. 2. For Resident 161, there was no complete labeling with date/time and initialed by the registered nurse (RN) for IV (intravenous, into the vein) antibiotic medication. This failure had the potential for medication errors. Findings: 1. A record review of the admission Record indicated Resident 160 had multiple diagnoses, which included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and had a cardiac (heart) pacemaker. During a record review of Resident 160's care plan, Cardiac-Pacemaker dated 7/16/19 reflected there was no information regarding the 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.