Brookside Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from unnecessary drugs when: 1. The adverse reactions for antibiotic medication were not monitored for one of 21 sampled residents (Resident 46). 2. Indication for an antibiotic medication was not clear and clarified with the doctor for one of 21 sampled residents (Resident 46). These failures had the potential to put the resident at risk of receiving unnecessary medications that could result in serious harm. Findings: 1. A review of Resident 46's Order Summary Report (a document with list of active physician's orders) for October 2024, indicated a medication order of Amoxicillin-Pot Clavulanate (a generic name of antibiotic medication) Tablet 500-125 MG (milligram - unit of measurement) Give 1 tablet by mouth every 12 hours for bacterial infection for 7 days, with a start date of October 20, 2024. During an interview with the Infection Preventionist (IP), on October 23, 2024, at 12:59 p.m., the IP stated that each 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 provide services in compliance with state requirements when Physician 1 did not complete a history and physical exam (H&P- a formal assessment of a resident done by a physician that includes a medical history, physical exam, and a summary of any tests) within the timeframe specified in the facility's policy for one of three sampled residents (Resident 341). This failure had the potential to prevent Resident 341 from receiving appropriate and timely care and services. Findings: A review of Resident 341's admission Record, dated October 25, 2024, indicated Resident 341 was admitted to the facility on [DATE] under the services of Physician 1, with diagnoses that included multiple fractures (a break or crack in a bone) of ribs on the left side, with interstitial pulmonary disease(a large group of diseases that cause scarring of the lungs), and depression (a mental health condition that causes a persistent low mood and loss of interest in activities), among…

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 policy for one of three sampled residents (Resident 1), wound measurements on admission. This failure placed a clinically compromised Residents (Resident 1) health and safety at risk. When the left trochanter wound was not measured four days from admission. Findings: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: fracture of upper and lower end of right fibula (broken long bone in leg), difficulty walking, diabetes type II (body does not produce enough insulin), hypertension (high blood pressure). During a concurrent interview and record review of Resident 1 ' s Medical Record with the Director of Nursing (DON) reviewed and verified the following: 1. Initial Assessment Record March 09, 2024: Open area from popped blister on left hip, skin is intact otherwise over bony prominences. (no wound measurements) 2. Skin…

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 policy and procedure to ensure call lights were answered in timely manner to provide care and services for three of three sampled residents (Resident 1,2, 3). This failure had the potential to place a clinically compromised Residents (Resident 1,2, 3) health and safety at risk. When resident's needs were not met in a timely manner. Findings: During review of Residents 1's (R1) admission Record (general demographics), the document indicated R1 was admitted to the facility on [DATE], with diagnoses to include hemiplegia and hemiparesis (weakness/paralysis on one side of body), intracerebral hemorrhage ( a ruptured vessel causes bleeding inside the brain), generalized muscle weakness ( decrease in muscle strength ), and aphasia (is a language disorder that makes it hard for you to read, write and say what you mean to say ), hypertension ( high blood pressure ), and hyperlipidemia ( abnormally high levels of lipids, or fats , in the blood).…

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

Based on observation, interview, and record review, the facility failed to ensure insulin (drug used to lower blood sugar) was used in accordance with facility ' s manufacturer ' s recommendations and direction for storage, use, and disposal for two of 14 residents receiving insulin (Residents 4, and 5). 1. Resident 4 insulin was actively in use and available past the manufacturer ' s beyond-use date (BUD- last date a product can be safely used after it has been altered for resident use). 2. Resident 5 insulin was actively in use and available without an open date. These failures had the potential for Residents 4, and 5 to receive insulin with reduced potency which could cause inadequate blood sugar control. These may result in the physician increasing insulin doses based on the blood sugar results placing the residents at risk for harm. Findings: 1. An inspection of a medication cart (the Middle Cart), and interview were conducted with a Licensed Vocational Nurse 2 (LVN 2) on December 19, 2023, at 1:55 PM. An opened 100 units/ milliliter (ml- unit of measurement) multiple-dose vial…

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 adequate supervision was provided to prevent avoidable accidents for one of three sampled residents (Resident1). When Resident 1 fell out of wheelchair while sitting in front lobby. This failure contributed to Resident 1 sustaining an open injury to forehead and being set out to hospital for further evaluation. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: NON-ST elevation myocardial infarction (partial blockage of coronary arteries, reducing blood flow to heart), muscle weakness, difficulty in walking, diabetes type II (body does not produce enough insulin, hypertension (high blood pressure). During concurrent interview and record review of Resident 1's Medical Record with the Director of Nursing (DON) and Minimum Data Set (MDS) nurse, reviewed and verified the following: 1. Progress Note dated…

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 closed record review, the facility failed to ensure a care plan was followed according to the facility's policies and procedures (P&P) for one of three sampled Residents (Resident 1) when: 1. There were no documentation of neuro checks and floor mats. 2. There were missing documentation for monitoring intake and recording of every meal. These failures had the potential to adversely affect the health and safety of one resident, Resident 1, by placing Resident 1 at risk of increased malnutrition (not enough nutrients in the body) and further potential injuries from another fall. Findings: 1.During a review of Resident 1's clinical record, the admission Record (contains demographic and medical information), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of Parkinson's disease (unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), cognitive communication deficits (difficulty with thinking and how someone…

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 and sanitary food preparation and storage practices in the kitchen when: 1. There were fifteen water pitchers and eight plastic containers stored wet. The blender was stored with water at the bottom of it. 2. There were crumbs and black grime on the floor under the freezer, sticky residues under the crate in the dry storage room, and crumbs and trash under the stove. These failures had the potential to attract pests, contaminate residents' food and/or cause foodborne illnesses, to a population of 83 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview with the Dietary Services Supervisor (DSS), on April 19, 2022, at 8:49 AM, in the main kitchen, there were fifteen water pitchers and eight plastic containers that were stored wet on a shelf and was available for use. The DSS stated they should be air dried. During a concurrent observation and interview with the DSS, on April 19, 2022, at 9:20 AM, in the main kitchen, the blender was stored with…

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 their recyclable dumpster was covered and closed completely. This failure had the potential to attract pests and rodents in the facility with medically compromised population of 84 residents. Findings: A concurrent observation and interview were conducted with the Maintenance Supervisor (MS) on April 20, 2022, at 9:43 AM, in the garbage storage area. The recyclable dumpster was filled with used boxes. It was not closed or covered. The MS stated it should have been closed. During an interview with the Registered Dietitian (RD), on April 20, 2022, at 2:16 PM, the RD acknowledged the recyclable dumpster should not be left uncovered. During a review of the FDA Federal Food Code 2017, 5-501.113, it indicated, Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered .(B) with tight-fitting lids or door if kept outside the food establishment. and proper storage and disposal of garbage and refuse are necessary the minimize the development of odors, prevent such waste…

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 provide sufficient licensed nursing staff to ensure residents received nursing care and treatment as ordered by the physician and specified in their care plans (an individualized plan for the medical care of a resident) when: 1. A registered nurse (RN) was not available to administer antibiotics (medications that destroy or slow down the growth of bacteria) intravenously (IV- administered into the veins) to five residents (Residents 45, 65, 230, 231, 235) on April 15, 2022, during the 3:00 PM to 11:00 PM shift (PM shift). This resulted in Residents 45, 65, 230, 231, and 235 to not receive their physician prescribed antibiotics which had the potential for worsening or prolonged infection. 2. Licensed nursing staff were not available to perform wound treatment for four residents (Residents 5, 35, 74, and 281) on April 16, 2022. This also resulted in Residents 5, 35, 74, and 281 to not receive physician prescribed wound treatment which had the potential…

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 implement pharmaceutical services procedures to meet the needs of residents when: 1. The on-coming licensed nurses and off going licensed nurses failed to verify and document the controlled medications (medications that are controlled by the government because it may be abused or cause addiction) were counted and verified as being accurate each shift. This failure had the potential for controlled drugs to be diverted to people they were not prescribed for, and to result in unnecessary pain or anxiety for the residents for which they were prescribed. 2. A pain medication was administered by a licensed nurse without following the physician's order for one of seven residents (Resident 237) reviewed for medication administration when Resident 237 received Acetaminophen (pain medication) 1,000 milligrams (mg- unit of measurement) on April 20, 2022. (Resident 237 had an order of Acetaminophen 650 mg. The dose recieved by Resident 237 was 350 mg…

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 their daily menu for lunch on April 19, 2022, when: 1. [NAME] 1 did not use the proper scoop size for the puree (food that is blended until it is a thick, smooth, lump-free consistency) chicken for seven of 83 residents. (Cook 1 used a number 10 scoop. The menu indicated to use a number 8 scoop.) 2. [NAME] 1 did not use the proper scoop size for the vegetarian (a diet that does not include any meat, poultry, or seafood) diet entrée for four of 83 residents. (Cook 1 used a number 6 scoop. The menu indicated to use a number 5 scoop.) These failures had the potential compromise the nutritional status of four residents receiving a vegetarian diet and six residents receiving puree diets of 83 residents. Findings: 1. During a tray line observation (food preparation method in which food trays travel around the production line) , on April 19, 2022, at 11:39 AM, while serving food on a plate , [NAME] 1 used a number 10 scoop (3.25 ounces [oz- unit of measurement]) for the pureed chicken for seven residents on 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their infection prevention and control program when: 1. Licensed Vocational Nurse (LVN 1) did not clean or disinfect a glucometer (a device used to check blood sugar) in-between use on two residents (Resident 235 and Resident 51). 2. Registered Nurse 2 (RN 2) did not disinfect the rubber stopper (a rubber top on medication vials) of two Vancomycin (an antibiotic) vials during medication administration preparation for Resident 235. 3. Resident 31's CPAP (Continuous Positive Airway Pressure - machine to treat sleep apnea disorders) mask was left exposed and touching Resident 51's nightstand. These failures had the potential the spread and transmission infections (establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms) in a highly vulnerable population of 84 residents, placing their health and safety at risk. Findings: 1. During a review of Resident 235's clinical record, the 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 interview, and record review, the facility failed to ensure one of five residents (Residents 230) reviewed for advance directives (written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitated) was assisted to formulate her advance directive. This failure had the potential to result in a delay of treatment for the Residents 230 as related to advance directives, or for life sustaining measures to be rendered against what she wanted. Findings: During a review of Resident 230's clinical record, the admission Record (contains demographic and medical information) indicated Resident 230 was admitted to the facility on [DATE], with diagnoses which included arterial embolism (clot that causes interruption of blood flow), left lower limb cellulitis (skin infection of left lower leg), and peripheral vascular disease (slow and progressive circulation disorder). A review of 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 follow-up with the physician after a resident's change in condition for one of two residents (Resident 51) reviewed for dialysis (a process of removing waste products and excess fluids from blood). This failure had the potential to result in a delay of management of Resident 51's medical care. Findings: During a concurrent observation and interview, on April 19, 2022, at 3:35 PM, in Resident 51's room, Resident 51 was sitting on a wheelchair, watching television. Resident 51 stated he reported having a mass on his left thigh but had not received updates from the physician. During a review of Resident 51's clinical record, the admission Record (contains demographic and medical information) indicated Resident 51 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (a condition in which kidneys cease functioning), kidney transplant failure, immunodeficiency due to drugs (impaired immune system function due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure four of four residents (Residents 5, 35, 74, and 281) reviewed for pressure ulcers (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) were provided wound care treatment as prescribed by their physician on April 16, 2022. This failure had the potential to place Residents 5, 35, 74, and 281 at risk for delayed wound healing and increased risk for infection (establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms). Findings: A review of the facility document titled, [name of facility] Nursing Department Staff Sign in Sheet [a form used by staff to sign in for their shift], dated April 16, 2022, indicated a blank next to the title TX [treatment - a nurse whose primary responsibility is to perform wound treatments on residents] for the AM shift (7:00 AM - 3:00 PM). There was no treatment nurse who signed in for the shift. During an interview with a Licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report a fall with sustained major injuries to California Department of Public Health (CDPH) for one of six residents (Resident 70) reviewed for falls. This failure had the potential to delay investigations of the incident, delay the identification of contributing factors, and delay the implementation of interventions to prevent further injury to Resident 70. Findings: During a review of Resident 70's clinical record, the admission Record (contains clinical and demographic data) indicated Resident 70 was initially admitted to the facility on [DATE], with diagnoses which included presence of implantable automatic cardiac defibrillator (a device implanted inside the body, able to perform defibrillation), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and age-related osteoporosis (condition in which bones become weak and brittle). During a concurrent observation and interview, on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a dialysis (a process of removing waste products and excess fluids from blood) access site was assessed in accordance with the physician's orders and facility policy for one of two residents (Resident 51) reviewed for dialysis. This failure had the potential to increase the risk of infection, bleeding or blood clots at Resident 51's dialysis access site. Findings: During a concurrent observation and interview, with Resident 51, on April 19, 2022, at 3:40 PM, Resident 51's room, Resident 51 was sitting on a wheelchair, watching television. Resident 51 stated he goes to dialysis every Monday, Wednesday and Friday. During a review of Resident 51's clinical record, the admission Record (clinical record with demographic information), indicated Resident 51 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (a condition in which kidneys cease functioning), and dependence on dialysis. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were appropriately stored and labeled when: 1. Two unlabeled, opened insulin (a drug used to lower blood sugar) pens were found stored in the medication storage refrigerator after they were obtained by a Licensed Vocational Nurse (LVN 1) from the insulin emergency kit (insulin E-kit - a container where spare insulin is stored for emergent or urgent use). This failure had the potential to result in single resident use insulin pens to be used on multiple residents, 2. One of three nursing station medication carts had a loose single tablet of medication found at the bottom of a drawer. This failure had the potential for loose medication tablets to be unaccounted for and not stored in their original containers which may lead to medication diversion (unintended use of a medication by an unauthorized individual). Findings: 1. An inspection of the [NAME] Station medication storage refrigerator was conducted with a Registered…

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 have a process in place where residents and staff were made aware of the process of filing a grievance within the facility for seven of eight sampled residents (Residents 78, 83, 96, 88, 342, 37and 45). This failure had the potential for residents' concerns not being addressed which could affect their well-being and sense of security in the facility. Findings: During an interview at the Resident Council Group meeting with Residents 78, 83, 96, 88, 342, 45 and 37, on July 15, 2019, at 3:07 PM, they all stated they were not aware of how to file a grievance and they stated they were not aware of their right to file a grievance. During an interview with Resident 96, on July 15, 2019, at 3:07 PM, she stated she had made a complaint to a staff member but was never given a grievance form and no one had followed up with her. During an observation on July 18, 2019, at 1:27 PM, in the front hallway near the entrance, there is a plaque giving information on filing a grievance, however, due to the small print 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.

F812 Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Bowls were found stacked and stored wet. 2. Shelves under the steam table used to store clean utensils and bowls of prepared ready to eat cereal, were dusty to touch and had drip stains from the steam table above. Wires under the steam table, hanging over the clean dishware were covered in a dust like material. 3. Ice machine bin (where the clean ice was stored) had a build-up of yellowish substance, that was removable with a white paper towel. These failures had the potential to lead to harmful bacteria and cross contamination that could lead to foodborne illness for a medically compromised population of 86 residents who received food from the kitchen. FINDINGS: 1. During an observation on July 15, 2019, at 7:27 AM, ten small bowls and four small plates were stacked and stored wet without air circulation. According to the FDA Food Code 2017, Items must be allowed to drain and air-dry before being stacked and stored.…

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 initiate a care plan for refusal of care for one of three sampled residents (Resident 1), when Resident 1 refused several showers and ADL's (Activities of daily living such as bathing, eating and toileting) . This failure had the potential to result in a lack of continuity of care and awareness of Resident 1's individual needs. Findings: During an interview with a Licensed Vocational Nurse (LVN1), on July 18, 2019, at 11:31 AM, she stated that Resident 1, would refuse his ADL's a lot. We would try to get him to the shower but he would refuse. During an interview with a Certified Nursing Assistant (CNA1), on July 18, 2019, at 1:37 PM, she stated, He [Resident 1] had a thing about washing. He would refuse ADL care like dressing, baths and showers. She stated they would beg him and ask him, but he would still refuse. During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on July 18, 2019, at 1:42 PM, she stated that he would have episodes where he wouldn't want to take a shower. She…

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.