River Valley Healthcare & Wellness Centre, LP

Based on observation, record review, interview, and review of the Centers for Medicare & Medicaid (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure staff accurately coded a Minimum Data Set (MDS) for 4 (Residents #8, #25, #44, and #52) of 22 sampled residents. Findings included: The Centers for Medicare & Medicaid Resident Assessment Instrument 3.0 User's Manual version 1.19.1 dated 10/2024 indicated, 1.3 Completion of the RAI included Over time, the various uses of the MDS have expanded. While its primary purpose as an assessment instrument is to identify resident care problems that are addressed in an individualized care plan, data collected from MDS assessments are also used for the Skilled Nursing Facility Prospective Payment System (SNF PPS) Medicare reimbursement system, many State Medicaid reimbursement systems, and monitoring the quality of care provided to nursing home residents. The manual indicated, The RAI process has multiple regulatory requirements that require (1) the assessment accurately reflects the resident's status. 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 interview, record review, and facility policy review, the facility failed to accurately complete a Level I Pre-admission Screening and Resident Review (PASRR) for 2 (Resident #6 and Resident #18) of 6 residents reviewed for PASRR. Findings included: A facility policy titled, P-NP04 admission Screening Resident Review (PASRR), revised on 04/24/2024, indicated, 5. The Facility MDS [Minimum Data Set] Coordinator will be responsible for accessing and ensure updates to the PASRR are completed per MDS guidelines. 1. An admission Record revealed the facility admitted Resident #6 on 07/21/2023. According to the admission Record, the resident had a medical history that included diagnoses of unspecified bipolar disorder (onset date 07/31/2023), mild recurrent major depressive disorder (onset date 07/31/2023), and generalized anxiety disorder (onset date 07/31/2023). An annual MDS, with an Assessment Reference Date (ARD) of 08/07/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. 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, record review, and facility policy review, the facility failed to have a person-centered comprehensive care plan for 2 (Resident #44 and Resident #52) of 22 sampled residents. Specifically, the facility failed to include the use of a non-invasive mechanical ventilator for Resident #44 and Level II Preadmission Screening and Resident Review (PASRR) results for Resident #52 on the comprehensive care plan. Findings included: A facility policy titled, Care Planning, revised 03/01/2014, indicated, It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. 1. An admission Record indicated the facility admitted Resident #44 on 12/12/2019. According to the admission Record, the resident had a medical history that included diagnoses of obstructive sleep apnea and dependence on supplemental oxygen. 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, record review, and facility policy review, the facility failed to ensure non-invasive mechanical ventilation equipment was cleaned and stored properly for 1 (Resident #44) of 3 residents reviewed for respiratory care. Findings included: A facility policy titled, BiPAP [bilevel positive airway pressure] and CPAP [continuous positive airway pressure], dated 09/10/2020, specified, Continuous Positive Airway Pressure (CPAP) is delivered in a single constant pressure during inhalation and exhalation. BiPAP is the Bilevel Positive Airway Pressure or Non-Invasive Positive Pressure Ventilation (NPPV) that delivers two pressures, lesser pressure delivered on exhalation and a second greater pressure on inhalation. The policy also indicated, VIII. Cleaning included A. Keep the outside of the machine free from dust and debris. Clean using a cloth and disinfectant weekly and as needed. B. Replace the hose weekly and as needed. C. Disassemble the CPAP/BiPAP mask by removing the head hear (straps) and cushion from face D. Replace head gear (straps) weekly or as…

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

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure medications were received from the pharmacy in a timely manner for 1 (Resident #58) of 6 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Medication Ordering and Receiving From Pharmacy, dated 02/2008, indicated, Medications and related products are received from the dispensing pharmacy on a timely basis. An admission Record indicated the facility admitted Resident #58 on 08/17/2022. According to the admission Record, the resident had a medical history that included a diagnosis of bipolar disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/27/2024, revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #58's care plan included a focus area initiated 05/31/2023 that indicated the resident used psychotropic medications related to bipolar disorder. Interventions directed staff to administer…

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

Based on interview, record review, and facility policy review, the facility failed to notify the physician of pharmacy consultant recommendations for 1 (Resident #56) of 6 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Consultant Pharmacist Reports IIIAI: Medication Regimen Review, revised 01/2018, indicated, All findings and recommendations are reported to the director of nursing and the attending physician the medical director and the administrator. The policy also indicated, G. Recommendations are acted upon and documented by the facility staff and/or the prescriber. An admission Record indicated the facility admitted Resident #56 on 07/11/2022. According to the admission Record, the resident had a medical history that included a diagnosis of major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/21/2024, revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update care plans (a plan that outlined resident goals, care needed, and support the facility staff would provide) for two out of three sampled residents (Residents 2 and 7) when Licensed Nurses (LN) did not update the care plan after Residents 2 and 7 had a fall. This had the potential for an increase in falls and injuries. Findings: A review of the facility ' s policy and procedure (P&P) titled, Fall Prevention and Management Program, revised, 8/1/14, indicated, after a resident fell, the care plan would be initiated or updated. A review of the facility ' s P&P titled, Comprehensive Person-Centered Care Planning, revised 11/1/18, indicated, Additional changes or updates to the resident ' s comprehensive care plan will be made based on the assessed needs of the resident. A review of the undated admission Record, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnoses of dementia (memory loss), epilepsy (brain disorder that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure proper infection control procedures were followed when two staff members were observed not wearing proper personal protective equipment (PPE-equipment worn to create a barrier between infectious material and a person including, gloves, gown, N95 (specialized mask), and eye shields) in COVID-19 (a highly contagious respiratory disease caused by the coronavirus) positive resident rooms. This failure had the potential to spread infection among residents, visitors, and staff. Findings: During an observation in Station 1 ' s hallway on 9/23/24 at 9:10 AM, eight rooms (23, 24, 29, 31, 33, 34, 35, and 36) were observed having isolation signs outside their doors. The signs posted read Isolation room with instructions indicating that prior to entering the room, one must clean hands (hand hygiene), don (put on) gown, N95 (mask), eye protection (eye shield) and gloves. During a concurrent observation and interview, on 9/23/24 at 9:31 AM, Licensed Vocational…

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 their abuse policy and procedure (P&P) for an abuse allegation that involved two out of four sampled residents (Residents 1 and 2) when the facility did not provide the State Survey Agency (SA) with results of the facility ' s investigation of the alleged abuse within five (5) working days. The lack of facility oversight placed residents at risk for further potential abuse. Findings: A review of the facility ' s P&P titled, Reporting Abuse, revised 1/8/14, indicated, The Administrator, or his designee, shall provide the appropriate agencies or individuals with a written report of the findings of the investigation withing five (5) working days of the incident A review of Resident 1 ' s undated admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of high blood pressure and anxiety. Resident 1 was not her own responsible party (RP, person that made decisions). A review of Resident 2 ' s undated admission…

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 identify specific risk factors (root cause, the reason why), reevaluate interventions (written instructions that described care provided), monitor interventions for effectiveness, and follow their policies and procedures (P&P) for one out of three sampled residents (Resident 1) that were identified as an elopement (leave without supervision) risk. This failure resulted in Resident 1 ' s second elopement on 9/7/24 and placed Resident 1 at an increased risk for continued elopement and injury. Findings: A review of the facility ' s P&P titled, Wandering and Elopement, revised 7/1/17, indicated, the Interdisciplinary Team (IDT, a group of medical professionals that discussed resident concerns and required care needs) would review, re-evaluate, and develop a care plan (a plan that included interventions and care the resident required) that included individual risk factors for residents that were identified as elopement risks. The P&P…

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

Based on interview, record review, and policy review the facility failed to report the results of the facility investigation with corrective actions related to abuse, per state law and the facility policy, to the State Survey Agency within five (5) working days of the incident, when one of two sampled resident ' s abuse incidents (Resident 1 and 2) was not reported to the California Department of Public Health (CDPH) within 5 working days of the alleged abuse incidents occurring and presumptively being investigated with result determination and corrective action taken. This failure to report that an abuse incident was investigated resulting in a determination with corrective action taken by the facility had the potential to subject residents to continued abuse situations with no oversight. Findings: The facility reported to CDPH on 8/2/24 that Residents 1 and 2 were involved in an altercation where Resident 1 slapped Resident 2 on the arm on 8/1/24. During a review of the facility ' s policy and procedure titled, Reporting Abuse, dated 1/18/14, indicated, The Administrator, or his…

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 one of two sampled residents (Resident 1) mail was delivered unopened and within 24 hours, per facility policy. This failure resulted in violating Resident 1's right to forms of communication with privacy and the potential for mental anguish. Findings: During a review of the facility ' s policy titled, Resident Rights-Mail revised 1/1/12, the policy indicated, Mail is delivered to the resident unopened. Mail is delivered to the resident within twenty-four (24) hours of delivery to premises or to the Facility ' s post office box (including Saturday deliveries). A review of Resident 1's admission Record (undated), indicated she was admitted on [DATE] with diagnoses that included, bone infection of the left leg, anxiety, cancer, and homelessness. A review of Resident 1's admission Minimum Data Set (MDS, a standardized assessment of an adult's functional, medical, psychosocial, and cognitive status), dated 7/10/24, indicated Resident 1's Brief…

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 effectively assess and obtain a wound care treatment order for a surgical wound for two weeks after admission, for one of three sampled residents (Resident 1), when Resident 1 was admitted with a surgical wound that Resident 1 refused to have assessed by staff, and the facility waited two weeks for the Orthopedic (Ortho, medical branch concerned with conditions involving the musculoskeletal system), follow-up appointment to obtain an order for Resident 1's wound care and treatment. This failure had the potential to result in increased health and healing deterioration including worsening of the wound, heightened infection issues, including sepsis, loss of limb, and death, and aggravated mental and psychosocial decline. Findings: During a review of the facility's policy and procedure titled, admission and Orientation of Residents , dated October 2017, the admission and Orientation of Residents indicated, Upon admission, the resident's Attending 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that one of four sampled residents (Resident 1) got an activities schedule and a newletter (a written document about facility news and upcoming activities), for the months of June and July 2024. These failures caused Resident 1 to not know when activities were scheduled, what activities were being offered, or what the current news of the facility was, which violated his right to be informed and make decisions regarding his activities. Findings: Review of Resident 1's Face Sheet (a document in a patient's medical chart or electronic health record that summarizes important information about the patient), indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included Epilepsy (seizure disorder which is caused by excessive and abnormal nerve cell activity in the brain), muscle weakness, difficulty walking, and depression. During an interview and observation on 7/2/24 at 2:30 PM, in Resident 1's room, Resident 1 pointed…

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 one or four sampled residents (Resident 2's) dignity was honored and that Resident 2 was respected when Certified Nursing Assistant (CNA) X did not stop when Resident 2 asked CNA X to stop trying to move her without the help of another person. This failure resulted in Resident 2 feeling afraid because the lack of respect shown by CNA X triggered Resident 2's Post Traumatic Stress Disorder (PTSD - anxiety and flashbacks triggered by a traumatic event). Findings: Review of Resident 2's Face Sheet (a document in a patient's medical chart or electronic health record that summarizes important information about the patient), indicated that Resident 2 was admitted to the facility on [DATE] with diagnoses that included depression, morbid obesity (body weight more than 80-100 pounds above their ideal body weight, Epilepsy (seizure disorder which is caused by excessive and abnormal nerve cell activity in the brain), PTSD, developmental delay (when a child…

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 Certified Nursing Assistant (CNA) X had knowledge about how much assistance was needed for one of four sampled residents (Resident 2), when CNA X provided cleaning for incontinence (inability to control the flow of urine from the bladder or the escape of feces from the rectum), without the help of a second person to roll Resident 2 in bed. This failure resulted in Resident 2 experiencing unnecessary discomfort during incontinent care. Findings: Review of Resident 2's Face Sheet (a document in a patient's medical chart or electronic health record that summarizes important information about the patient), indicated that Resident 2 was admitted to the facility on [DATE] with diagnoses that included depression, morbid obesity (body weight more than 80-100 pounds above their ideal body weight), Epilepsy (seizure disorder which is caused by excessive and abnormal nerve cell activity in the brain), Post Traumatic Stress Disorder (PTSD - anxiety 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 their dialysis policy and procedure (P&P) for four out of four sampled residents (Residents 1, 3, 4, and 5) when: 1. Resident 1 was not provided lunch before leaving the facility for a dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stopped working) appointment, was not provided a meal to take to dialysis, and was not provided a meal upon return to the facility after her dialysis appointment. 2. Pre (before), during, and post (after) dialysis assessments (the assessment included information regarding the residents before, during, and after dialysis, such as, vital signs, lung sounds, skin condition, dialysis access site, weight, and if a meal was sent) were not completed consistently for Residents 1, 3, 4, and 5). These failures had the potential for decline in health to go unnoticed and negatively impact resident health status. Findings: 1. A review of the facility's P&P titled, Dialysis…

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 the resident ' s rights of being treated in a dignified manner for one of three sampled residents (Resident 2), when Certified Nursing Assistant (CNA) 1, rolled Resident 2 from side to side during changing her brief, and Resident 2 thought she smacked her on the hip which made her feel violated and indignant. This failure had the potential to cause harm both physically and emotionally leading to a decline in health status due to possible withdrawal and desolation from care providers and the care being provided. Findings: Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses that included, a stroke, diabetes, and high blood pressure. The Minimum Data Set (MDS, tool for resident assessment and care screening), dated 9/29/2023, indicated that Resident 2 ' s Brief Interview for Mental Status (BIMs), revealed Resident 2 was assessed at 15/15, no cognitive deficits. 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 interview and record review, the facility failed to maintain a safe infection control program when unlicensed staff performed COVID-19 (COVID, a respiratory illness that caused many elderly people to be hospitalized ) testing on residents of the facility and COVID testing in-service (education and training provided to staff) documentation was not available. This failure had the potential to result in harm to residents and for COVID specimen samples to be collected incorrectly which could cause a false negative or false positive test result. Findings: During a review of Frequently Asked Questions (FAQ), revised 6/28/23, (a document created by the California Department of Public Health (CDPH) Center for Health Care Quality) utilized by skilled nursing facilities, the FAQ clarified information and instructions that were discussed during Infection Prevention Calls regarding COVID. The FAQ indicated, Certified Nurse Assistant (CNA, unlicensed assistive personnel) could observe someone who performed a self-swab COVID test and were not permitted to perform a COVID swab test…

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

Based on interview, and record review, the facility did not have sufficient Certified Nursing Assistant staffing to provide timely care of residents, answering of call lights and prevention of incontinence. This failure has the potential to cause mental distress, anguish and adverse clinical outcomes. Findings: During private interviews on 12/07/21 at 10:01 am, three residents reported that they have to wait up to a half hour for CNA's to answer call lights. They reported that the slow responses have been more frequent lately and on the night shift. The residents have reported that they have had some accidents because of having to wait. All residents interviewed, were and oriented. During a concurrent record review, and interview, on 12/7/21 at 3:30 pm, with the Director of Nursing (DON). She reviewed staffing sheets for Station 2, dated 10/29/21, and 10/30/21. The DON stated, There are between 55-60 Residents on Station Two, and we should have one licensed nurse and three CNAs on the night shift. The night shift staffing sheets on 10/29/21, 10/30/21, and 12/04/21, had two or fewer…

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 food safety and resident nutrition care processes were adequately in place when: 1. There was no facility Registered Dietitian (RD) from mid-September 2021 through 12/3/2021. 2. Regular monthly food safety and sanitation inspections were not consistently performed by the RD to monitor food safety, sanitation and resident nutrition care processes, and identified deficiencies in the Dietary Department, that would then be addressed or resolved timely. 3. There was not an effective or consistent system in place to ensure timely communication between nursing services, and dietary services related to resident nutrition care. These failures have the potential to result in foodborne illness, negatively impact resolution of resident food preference and quality concerns, decrease timely and effective nutrition care, and negatively impact the health of residents living in the facility. Findings: 1. The facility did not have a Registered Dietitian from mid-September 2021 to 12/3/2021. The facility's document 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 provide food that was flavorful and prepared by methods that conserved nutritive value. This failure has the potential to negatively impact resident's nutrition intake, health, and quality of life. Findings: On 12/6/21 at 10:20 am, surveyors stated that during initial interviews, that multiple residents had complained about mushy vegetables, and one complained of no salt being available. During an interview, in the dining room with Resident 48 on 12/6/21 at 1:35 pm, he stated he is not a picky eater, but they don't put enough seasoning in the food. During a confidential interview, on 12/6/21 at 1:45 pm, a resident stated that the breakfast toast was stale. It's served without jelly, and seems a lot like it is not toasted. I am not getting any jam at all. During an interview, with Resident 47 on 12/7/21 at 9:40 am, she complained I don't like their food. It has no flavor. It's terrible. It has no flavor, no taste. The pasta has no salt. Salt and pepper packets are provided on meal trays, but the food is still…

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 create and implement a menu system that met resident food preferences into the facility menu cycle. This failure has the potential to result in resident dissatisfaction with the meal service, decrease meal intakes, and increase the risk for weight loss, malnutrition, and overall health decline. Findings: During an interview, in the dining room with Resident 48 on 12/6/21 at 1:35 pm, he stated he is not a picky eater, but they don't put enough seasoning in the food. A review of Resident 48's meal tray ticket, printed 12/8/21, indicated that he was on a Fortified diet (provides extra calories) with regular consistency. Dislikes listed were rolls and bread. There were no Likes, listed. During a confidential interview, a resident stated if you wanted a food substitute you had to let the kitchen know two-hours in advance. Like fish and chips, I may not know (it's being served), and then it is too soon for getting the substitute. The posted menu is now what I get. My room is too far away for my (alternative) menu's…

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

Based on observation, interview, and record review, the facility failed to ensure that food was stored, prepared and distributed in accordance with professional food safety standards when: 1. Staff failed to wash hands, change gloves between tasks, and use gloves as personal protective equipment, increasing the potential for cross contamination to occur. 2. Staff did not consistently wear aprons, potentially resulting in cross-contamination between staff clothing, food, and equipment during food preparation meal service, and dish washing processes. 3. The kitchen was not sanitary. 4. Fixed equipment (equipment that cannot be cleaned in the dish washer or in the three-compartment sink) was not washed and rinsed prior to sanitizing, and air dry. 5. Food was not stored, labeled, dated or discarded appropriately. 6. Produce was not washed according to professional standards of practice. These practices have the potential to result in foodborne illness for residents consuming food from the facility food services which could lead to negative clinical outcomes. Findings: 1. Staff failed to…

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

Based on interview, and record review, the facility's Quality Assessment and Assurance and Performance Improvement (QAPI) committee failed to identify, develop, and implement a plan of action to correct deficiencies related to residents receiving adequate nutrition to prevent significant weight loss, and facility acquired pressure ulcers. As a result of this failure deficiencies were present regarding severe weight loss for two residents, and facility acquired pressure ulcers for two residents. (Refer to F 686 and 692) Findings: During an interview, on 12/09/21 at 2:57 pm, the Administrator (Admin) reported that he started in his current position around 45-days ago. The Admin reported that the Quality committee meets monthly now, but before he arrived, the committee had been meeting quarterly, which he did not think was sufficient. When he first started as Administrator, they had a QAPI meeting to help staff focus on issues. The issues identified included weight loss, pressure ulcers, falls, staffing, and gradual dose reductions for psychotropic medications (drugs used to control…

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 its policies regarding pneumococcal immunizations (vaccines to prevent pneumonia) were followed when three of five randomly sampled residents (Residents 26, 28, and 49) had not received both pneumococcal immunizations. This failure had the potential to result in these residents, and other residents residing in the facility becoming ill with pneumonia. Findings: The facility's policy titled, Pneumococcal Disease Prevention, dated 2/18/21, was reviewed, and indicated that the facility will offer pneumococcal immunizations to each Resident, according to Centers for Disease Control and Prevention (CDC) recommendations, unless it is medically contraindicated, or the Resident has already been immunized. Pneumococcal vaccination is recommended for the following residents: Adults 65-years old and older, residents of nursing homes or long term care facilities. The policy indicated that two pneumococcal vaccines are currently approved for adult use in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop an initial baseline care plan within 48-hours of admission, for one of four newly admitted residents (Resident 112). Resident 112 was admitted with known skin issues, and the baseline care plan did not include this problem. This failure had the potential to result in the worsening of the skin problems, which could lead to negative clinical outcomes. Findings: The facility's policy titled, Comprehensive Person-Centered Care Planning, dated 11/2018, was reviewed, and indicated that the baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission. It should address resident specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. Resident 112's medical record was reviewed. Resident 112 was admitted on [DATE], with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The facility's policy titled, Fall Management Program, revised 3/13/21, was reviewed, and indicated that following every resident fall, the licensed nurse will perform a post-fall evaluation and update, initiate or revise the resident's care plan as necessary. For an unwitnessed fall, or a witnessed fall with suspected or known head injury, the licensed nurse will complete neurological checks for 72-hours following the fall incident. Resident 63's medical record was reviewed. Resident 63 was admitted to the facility on [DATE], with diagnoses that included; a pubic rami fracture (fracture of the ring of bones near the tailbone), a right femur (upper leg bone) fracture, diabetes (high blood sugar), dementia, anxiety, and high blood pressure. Resident 63's record indicated that on 9/17/21, Resident 63 had an unwitnessed fall. A fall care plan was not developed until 9/24/21, seven days after the fall. The care plan problem had not included the root cause of the fall therefore, no new interventions were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for two of 22 residents (Residents 36 and 42), the facility failed to provide activities as indicated in their comprehensive care plans. This failure had the potential to result in a decline in their mental and psychosocial well-being, which could lead to negative clinical outcomes. Findings: The facility's policy titled, Activities Program, dated 11/1/13, was reviewed and indicated that its purpose was, to encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain their highest attainable social, physical, and emotional functioning. The policy indicated that after completion of the initial Activity Assessment and the MDS, an individualized Care Plan will be developed and implemented for each resident. The resident's activity plan will be reviewed, and up-dated at least quarterly and with any change of condition. As needed,…

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 implement their fall management policy for one of five sampled residents (Resident 63) when they failed to initiate appropriate assessments and monitoring following multiple falls. This had the potential for post fall injuries and changes in condition to go unrecognized, and therefore untreated which could lead to negative clinical outcomes. Findings: The facility's policy titled, Fall Management Program, revised 3/13/21, was reviewed and indicated that following every resident fall, the licensed nurse will perform a post-fall evaluation and update, initiate or revise the resident's care plan as necessary. For an unwitnessed fall or a witnessed fall with suspected or known head injury, the licensed nurse will complete neurological checks (which includes monitoring for injuries associated with head trauma) for 72-hours following the fall incident. The neurological checks are ordered at the following frequency listed equaling a total of 72-hours. 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 observation, and interview, the facility failed to make sure that there was a secure, and safe method for disposal of medications and narcotics (strong pain medications). This failure had the potential to lead to drug diversion (the illegal distribution, or abuse of prescription drugs, or their use for purposes not intended by the prescriber) and possible exposure of the residents to potentially hazardous substances. Findings: The facility policy titled, Controlled Substance Disposal, revised 1/1/18, was reviewed, and indicated that medications included in the Drug Enforcement Administration (DEA) classification as controlled substances were subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. The Director of Nursing (DON), in collaboration with the consultant pharmacist, are responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. When a dose of a controlled medication was removed from the container 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 did not ensure a safe, functional and sanitary environment when: 1. The floors, walls, ceiling, cabinets and shelving in the Food and Nutrition Services kitchen were not maintained clean and in good repair. 2. The walk-in refrigerator fans and light were not maintained sanitary and it good repair. These failures have the potential to negatively impact the food safety and sanitation of food service areas and can be a safety issue for staff. Findings: During an observation, and concurrent record review, and interview, with the Dietary Services Supervisor (DSS) on 12/6/21 at 9:30 am, in the Ice Room, metal shelving storing dietary services supplies were rusty. The ceiling in the ice room had broken tiles, a water stain, and an opening larger than the two tubes running through the ceiling to the top of the ice machine. The ceiling vent was rusty, and built up with grime. Paint on the walls and door frame was chipped and uncleanable. The exterior of the ice machine was covered with a white substance resembling mineral…

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.