Vineyard Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement an effective discharge planning process for one of four sample residents (Resident 60) when Representative (RP) 2 was not involved and notified of Resident 60 ' s discharge from the facility on 12/22/24. This failure resulted in Resident 60 being discharged without RP 2 ' s knowledge or consent and placed Resident 2 ' s safety at risk. Findings: During a review of Resident 60's admission Record (AR), dated 2/24/25, the AR indicated, Resident 60 was admitted to the facility on [DATE] with diagnoses which included stable burst fracture (an injury in which the vertebra, the primary bone of the spine, breaks in multiple directions) of the lumbar (the lower part of the back) vertebra, fracture with routine healing, and unspecified dementia (the loss of the ability to think, remember, and reason to levels that affect daily life and activities). During a review of Resident 60's Progress Note dated 12/20/24, the Progress Note indicated, .past medical…

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 residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of three sampled residents (Resident 21) when Resident 21 had an order of prn (as needed) oxygen and received oxygen continuously due to episodes of increasing shortness of breath and Licensed Nurses (LNs) did not notify his Attending Physician (AP) of the change of condition. This failure placed Resident 21's respiratory needs to go unmet and increased his risk to experience frequent episodes of shortness of breath. Findings: During an observation and interview on 2/18/25, at 11:12 a.m. in Resident 21's room, Resident 21 was using oxygen via nasal cannula (N/C- a medical device that provides supplemental oxygen therapy to people who have lower oxygen levels). Resident 21 stated he was using the oxygen continuously and was short of breath without it. During an interview on 2/20/25 at…

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 effective pain management was provided consistent with professional standards of practice and comprehensive person-centered care plan for one of 10 sampled residents (Resident 3) when Licensed Nurses did not address Resident 3's frequent complaints of pain to her right knee. This failure resulted in Resident 3's frequent complaints of pain going unrelieved and limited her ability to participate in physical therapy on multiple occasions meant to support her physical well-being. Findings: During a concurrent observation and interview on 2/18/25 at 10:13 a.m. with Resident 3 in Resident 3's room, Resident 3 was observed laying in bed watching the television (TV) wearing a gown over her shirt and wearing oxygen tubing via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). Resident 3 stated she had been at the facility for two to three years because she could not walk. Resident 3 stated she had been having knee pain for four days. Observed 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 provide food prepared in a form designated to meet individual needs for one of 10 sampled residents (Resident 311) on a mechanical soft (chopped, ground and pureed food designed for people who have trouble chewing and swallowing) diet was served with a regular diet. This failure placed residents with difficulty chewing or swallowing and, on a physician prescribed mechanical soft diet at risk of choking. Findings: During an observation on 2/18/25 at 11:50 a.m. with Resident 311 in the dining room, Resident 311 was served a plate with chunks of cooked meat in an orange gravy, yellow tinted rice with flecks of green leaves, a whole flour tortilla and a side dish of fresh tomato cut into small pieces. Resident 311 was alert, sitting in a wheelchair with a cloth drape to protect her clothing. Resident 311 had eaten less than 10% of her food. The lunch meal ticket, dated 2/18/25, indicated, Resident 311 was on a mechanical soft diet. 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 observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for one of eight sampled residents when: 1. Registered Nurse (RN) 1 did not change her gloves after cleansing a wound, and before applying medication and a clean dressing to Resident 41 during a dressing change. RN 1 did not perform hand hygiene after removing her gown and exiting Resident 41's room after performing the dressing change on Resident 41 who was on Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities). 2. Licensed Vocational Nurse (LVN) 1 did not perform hand hygiene before entering and exiting resident's rooms and in-between residents during the administration of medications to residents in one of three facility wings (wing C [a designated area where residents reside]). These failures placed residents at risk 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 develop and implement a comprehensive person-centered care plans (CP- a detailed approach to care customized to an individual resident's needs) for one of three sampled residents (Resident 1) when Resident 1 was bedbound for eight months and did not have an activity care plan. This failure resulted to Resident 1 spending her waking hours picking on her skin and resulted to excoriations to her various body parts, including her abdomen, left hip and right hip. Findings: During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 11/26/24, the AR indicated, Resident 1 was re-admitted from the home on 4/2/24 to the facility, with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), Congestive Heart Failure (CHF - weakness in the heart where fluid accumulates in the lungs), Major depressive…

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 maintain a functioning communication system (call light system-an alerting device used by residents to request assistance) when seven (14 A, 14 B, 14 C, 13 A, 18 B, 19 B and 20 A) of 56 resident call lights were not functioning properly. This failure had the potential for resident needs to go unmet and placed resident's health and safety at risk. Findings: During a concurrent observation and interview on 12/4/24 at 12:21 p.m. with Resident 2, a bell was heard ringing from the wing B hallway. Resident 2 stated she heard the bell ringing frequently. During an interview on 12/4/24 at 12:27 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated the bell sound was from the resident in room [ROOM NUMBER] A (Resident 5). CNA 2 stated the call light in 14 A had not functioned for a couple of months, so the resident used a handbell. During a concurrent observation and interview on 12/4/24 at 12:33 p.m. with CNA 2, in room [ROOM NUMBER] 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, interview, and record review, the facility failed to ensure food was palatable and served at an acceptable temperature to the residents in accordance with the facility policy and procedure. This failure had the potential to affect meal and food intake which could impair the nutrition status for 45 of 45 residents who are served food from the kitchen. Findings: During the initial survey resident screening process on 12/12/23 at 9:53 a.m., multiple interviews with residents were conducted, and the residents had complaints of lack of food variety, food temperature and palatability concerns. During a test tray evaluation of the lunch meal for the Regular Diet and Pureed Diet on 12/13/23 at 12:37 p.m., an observation and interview was conducted with the FSD and the Registered Dietitian (RD). The Regular tator tots were 116 degrees fahrenheit (F-measure of temperature) and the Pureed tator tots were 118 degrees F. Both the Regular and Pureed diet tator tots were lukewarm to bland without any flavor to taste. The Pureed carrots were 116 degrees F with a gritty taste…

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 develop and implement a comprehensive person-centered care plans (CP- a detailed approach to care customized to an individual resident's needs) for two of 12 sampled residents (Resident 17 and Resident 47) when: 1. Resident 17's activity care plan did not have individualized interventions. 2. Resident 47 did not have an activity [NAME] plan. These failures had the potential to prevent the residents from receiving appropriate, and individualized care and services consistent with their needs. Findings: 1. During a review of Resident 17's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 12/14/23, the AR indicated, Resident 17 was admitted from the acute care hospital on 5/3/23 to the facility, with diagnoses that included End Stage Renal Disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis…

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 complete an annual performance review of licensed nurses (LN) for two of nine sampled licensed nurses (Registered Nurse [RN] 1 and Infection Preventionist [IP]) when RN 1 and IP did not have annual performance evaluations and skills competencies review from 2022 to 2023. This failure had the potential to result in RN 1 and IP to not develop or maintain competencies to provide residents with needed and appropriate care and services. Findings: During an interview on 12/13/23 at 1:14 p.m., with Licensed Vocational Nurse/Infection Preventionist (IP), the IP stated she can't recall if she had her annual performance evaluation for the past 12 months. The IP stated, I am not sure. Maybe last year with the previous Director of Nursing (DON). The IP stated her role required her to be updated with new infection control regulations and best practices. The IP stated she occasionally performs medication pass and treatments. The IP stated without the annual performance evaluation, she does not have any idea if she was meeting 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 and record review, the facility failed to complete a performance review of a nurse aide for three of 12 sampled Certified Nursing Assistants (CNA 1, CNA 2 and CNA 3) when CNA 1, CNA 2 and CNA 3 did not have annual performance evaluations and skills competencies review within the last 12 months. This failure had the potential to result in CNA 1, CNA 2 and CNA 3 to not develop or maintain competencies to provide residents with needed and appropriate care and services. Findings: During an interview on 12/13/23 at 1:00 p.m., with CNA 1, CNA 1 stated he could not recall if he had his annual performance evaluation for the past 12 months. CNA 1 stated the Director of Staff Development (DSD) usually schedules his annual evaluation and discuss his work performance and areas for improvement. CNA 1 stated without the annual performance evaluation he does not have any idea if he is meeting the standards of care in skilled nursing facility (SNF). During a concurrent interview and record review on 12/14/23 at 8:59 a.m., with the DSD, the Employee Performance Evaluations for the…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen for food preparation tools and food storage methods, according to standards of practice and facility policy when: 1. Two cutting boards were found visibly worn with multiple tears and discolorations. 2. A case of molded onions was found on a shelf underneath the Cook's prep counter. 3. A case of Corn tortillas and a bag of Parsley did not have use by dates. These failures had the potential to expose residents to contaminants that could cause foodborne illness. The facility census was 45. Findings: During the initial kitchen tour on 12/12/23 at 9:33 a.m., observations of unsanitary and unsafe food practices and interviews with the Food and Nutrition Services Director (FSD), Registered Dietitian (RD), and [NAME] (CK) 1 were conducted. 1. A green cutting board and a red cutting board were found visibly worn with several tears, rips, discolorations, and indentations in them. CK 1 stated she used the cutting boards to chop vegetables and the red…

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 pharmaceutical services on acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for one of 12 sampled residents (Resident 31) when the contracted pharmacy for the facility did not deliver Resident 31's prescribed Clonazepam (a medication used to treat severe anxiety, panic disorders, and seizures) between 12/8/23 and 12/12/23. This failure resulted in Resident 31 to experience increased anxiety and restlessness which caused disturbance to other facility residents. Findings: During a review of Resident 31's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 12/14/23, the AR indicated, Resident 31 was admitted from the acute care hospital on 4/25/21 to the facility, with diagnoses that included Alzheimer's Disease (loss of memory and ability to carry simple tasks), Anxiety Disorder (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 ensure residents were free from unnecessary medications in their treatment plan for one of 12 sampled residents (Resident 18) when Resident 18 had no appropriate indication and monitoring for the use of Atorvastatin (a medication used to lower cholesterol levels in the blood). This failure placed Resident 18 to be at risk of being administered Atorvastatin unnecessarily which could potentially lead to constipation, muscle pain and liver damage. Findings: During a review of Resident 18's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 12/14/23, the AR indicated, Resident 18 was admitted from the acute care hospital on [DATE] to the facility, with diagnoses that included Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Hypertension (high blood pressure),…

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 the menu was followed for the grilled cheese offered as an alternate menu item. This failure had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the resident's nutritional status. The facility census was 45. Findings: During a review of the facility's Alternate Menu, the alternate menu indicated the menu items were .Lunch/Dinner Alternates: Cheese Quesadilla, Turkey sandwich with lettuce leaf and tomato slice, Grilled cheese sandwich . During an interview in the kitchen on 12/13/23 at 10:05 AM with the [NAME] (CK) 2, CK 2 was observed making two grilled cheese sandwiches on the grill station. CK 2 stated she used two slices of processed American cheese and two slices of white bread to make the grilled cheese sandwiches. CK 2 stated she did not use shredded cheese or weigh the American cheese slices, as mentioned in the grilled cheese recipe. CK 2 further stated at least three grilled cheese sandwiches are made daily at lunch 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.

Based on observation, interview and record review, the facility failed to follow CDC guidance and facility policy and procedure for the prevention of infections when the Director of Nursing (DON) did not provide evidence of vaccination and did not wear a surgical mask in accordance with written standards. This failure resulted in the increased risk of the spread of infectious diseases. Findings: During an observation on 12/12/23 at 9:45 a.m., the DON was observed in resident care areas, conversing, and assisting residents and interacting with other staff members without a surgical mask or other facial covering over her nose or mouth. During an observation on 12/13/23 at 9 a.m., the DON was observed in resident care areas, conversing, and assisting residents and interacting with other staff members without a surgical mask or other facial covering over her nose or mouth. During an observation on 12/14/23 at 7:30 a.m., the DON was observed in resident care areas, conversing, and assisting residents and interacting with other staff members without a surgical mask or other facial…

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 food services observations, staff interview and departmental document review the facility failed to ensure a Registered Dietitian and Dietetic Services Supervisor comprehensively evaluated the effectiveness of food service operations as evidenced by lapses in the delivery of services associated with meal distribution accuracy and nutritional value of menus (Cross Reference F803, F805, and F808 ), and food safety (Cross Reference F812). Failure to ensure food and nutrition services systems are accurately and effectively delivered may result in compromising the nutritional status of residents through the potential transmission of foodborne illness and incorrect plating of physician ordered therapeutic diets for the 52 residents at the facility. Findings: During the annual recertification survey from 7/13 - 7/16/21, there were multiple lapses in the delivery of food services including incorrect portion sizes, food in the improper form, not providing physician prescribed therapeutic diets and in relation 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 observation, interview and facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety when: 1. Time/Temperature Control for Safety (TCS) foods (food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation) were not properly monitored for cool down; 2. TCS foods were not properly labeled and expired items were in the refrigerator; 3. Cups for resident drinks were stored wet and stacked or wet with lids on; 4. A utensil storage drawer, cabinets, and walls were not clean; and 5. Air gaps were not present in the ice machine and food preparation sink. These failures had the potential to cause the growth of microorganisms which could cause foodborne illness or cross contaminate food (cross contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness) for the 49 residents eating at the facility.…

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 Assurance and Performance Improvement (QAPI, a program that enables the facility to evaluate and improve the quality of resident care and services through data collection, staff input, and other information) program failed to implement their action plans which include monitoring and sustaining the appropriate plan of actions to correct the identified quality deficiencies in accordance with their plan of correction from the last re-certification survey completed on 1/30/2020 when: 1. Quality care issues were not identified with an appropriate action plans developed to correct the identified deficient practices (cross reference F656, F801, F808, F812, F880); and 2. When four of ten interviewed facility staff were unable to identify the purpose of QAPI and current QAPI projects. These failures resulted in an ineffective QAPI program to improve quality of care for all residents in the facility. Findings: During an interview on 7/16/21, at 1:43 p.m., with Administrator (ADM) and Director of Nursing (DON), ADM stated, 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, the facility failed to maintain an essential equipment in a safe operating condition when one of two laundry washer (washer 1) had unreadable water temperature control to detect and measure recommended water temperature for laundry process of soiled resident's linens and clothes. This failure had the potential for residents to be exposed to unclean linens and microorganisms (bacteria, viruses, and fungi). Findings: During a concurrent observation and interview, on 7/15/21, at 8:45 a.m., with Housekeeper (HK) 2, in the laundry room, the two washers (washer 1 and 2) were running in washing and rinsing cycle with loads of linens. The washer 1 temperature screen was not readable to detect the water temperature in ongoing wash cycle mode. HK 2 stated, The machine [washer 1] is off. We [laundry staff] can't read the temperature of [washer 1]. It's been like this [washer 1] for a month. We can still use it [washer 1]. HK 2 stated, the defective temperature control of washer 1 had been reported to their office (outside source). 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 observation, and staff interviews, the facility failed to provide a safe, sanitary, comfortable working environment for residents, staff, and the public when: 1. the kitchen's temperature readings exceeded 83 degrees F (Fahrenheit [temperature measure). This failure resulted in an unsuitable working environment for kitchen staff. 2. a rubber strip across doorway of a resident room came loose when it was walked on. This failure had the potential to cause tripping and injury to a resident, staff, or the public. 3. the paint from the walls of the laundry room, inlcuding above the laundry sink was peeling. The laundry sink, faucet, faucet handles, and surfaces of the sink were stained with grime (dirt ingrained on the surface). Findings: 1. During an observation on 7/13/21 at 11:27 AM, the Surveyor Thermometer in kitchen by stove across from tray line area showed 88.7 degrees F. During an observation on 7/13/21 at 11:31 AM, the Surveyor Thermometer showed 120 degrees F at stove in the kitchen. During an observation on 7/13/21 at 11:43 AM, in front of stove on steam table the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs of the residents for three of five sampled residents (Resident 2, Resident 28 and Resident 31) when: 1. Resident 28 and 31 did not have a resident-centered care plan intervention for safe handling, humidification (process to provide moisture content to the air), and cleaning of oxygen (O2 - supplemental oxygen to supply oxygen to the lungs) therapy use; and 2. Resident 2 did not have the use of fall prevention signs implement in her room as one of the interventions to prevent falls. These failures had the potential to result in Resident 2, 28, and 31's identified care needs to go unmet. Findings: During an observation with Resident 31, on 7/13/21, at 12:19 p.m., in Resident 31's room, Resident 31 laid comfortably on the bed with O2 concentration at 4.5 liters…

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: 1. Controlled (drugs with high abuse potential subject to special handling, storage, disposal, and record keeping) drug accountability, when Resident 197's medication, a controlled medication was only accessible to authorized personnel 2. Provider's orders were carried out for Resident 46 These failures increased potential for drug diversion by allowing unauthorized access to Resident 197's controlled medication, and delayed the administration of medication for Resident 46. Findings: 1. During a concurrent observation and interview on 7/13/21, at 9:20 a.m. in the facility's medication room, with Licensed Vocational Nurse (LVN) 2, tramadol, a controlled medication for pain, was observed in a black bag on top of the counter. LVN 2 stated when the tramadol was discontinued for Resident 1, and acknowledged it should not have been left on the counter. LVN 2 stated, controls should not be left in bag, someone did not go through bag .…

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 had proper storage and labeling when: a. Medication room and fridge temperature not monitored consistently; b. For Resident 1, an eye drop that required to be dated when opened, did not have an expiration date/date open sticker; c. For Resident 37, a morphine (pain medication) solution was incorrectly labeled with another resident's identifier These failures had the potential to decrease medication potency that could compromise the therapeutic effectiveness of stored medications, medications for Residents 1, and 37. Findings: a. During a concurrent observation and interview on 7/13/21, at 9:40 a.m., in the facility's medication room, with Licensed Vocational Nurse (LVN) 2, the temperature log for medication/vaccine refrigerator and room temperature was noted to be incomplete, with entries missing for 7/2/21 night shift; 7/4/21 pm shift; 7/6/21 am and pm shift; 7/10/21 night and am shift; 7/11/21 am and pm shift. LVN 2…

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, staff interview, and facility document review, the facility failed to ensure the planned menu was followed for: 1) a. 14 out of 14 residents (Residents # 6, 8, 12, 15, 16, 17, 19, 26, 38, 39, 41, 42, 45, 97) on Regular Controlled Carbohydrate diets, b. One out of one residents (Resident #1) on Small Controlled Carbohydrate diet; and 2) Three out of three residents (Residents #15, 20, 33) on Pureed diets did not receive the correct portion sizes of foods. This failure had the potential to result in not meeting the nutritional needs further compromising the medical status of the residents. Findings: 1. Review of the facility menu titled Summer Menus Cooks Spreadsheet for Week 2 Tuesday 7/13/21 indicated for the Regular and Small CCHO (Carbohydrate controlled diet -therapeutic diets designed for people with diabetes to keep the carbohydrate levels in meals evenly spaced throughout the day), the following items: Regular: Chicken with [NAME] Sauce 3 oz (ounce), 1 oz sauce, Diced Fried Potatoes…

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, staff interview, and facility document review, the facility failed to ensure food was served in the proper size for five of five residents (Resident #19, 30, 38, 47, 297) on chopped meat diet when they received chicken cut in approximately 1 inch squares during the lunch meal service on 7/13/21. This failure had the potential to place residents on a chopped meat diet at an increased risk for choking. Findings: During an observation of the lunch meal service starting on 7/13/21at 11:50 am, when Resident #19, 30, 38, 47, 297's tray tickets were called out for chopped diet, Food Service Worker 2 (FSW 2) placed Chicken with [NAME] Sauce on a plate and cut it in half then in thirds with the serving tongs. Food Service Worker 1 (FSW 1) and Dietary Services Supervisor (DSS) then placed the plates on trays in the meal delivery cart for delivery. During an interview with FSW 2 on 7/13/21 at 12:17 pm once the lunch meal service was completed, FSW 1 indicated for chopped meat diets she cuts the meat…

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, staff interview, and facility document review, the facility failed to ensure residents are receiving therapeutic diets as prescribed by the physician when: 1. Two residents (Resident # 2 and 40) did not receive carbohydrate controlled diets (a therapeutic diet designed for people with diabetes to keep the carbohydrate levels in meals evenly spaced throughout the day), and 2. Six resident's (Resident # 3, 9, 45, 197, 297, 298) tray tickets did not match their physician prescribed diets. This failure could result in further compromising resident medical status or unnecessarily restricting a resident's diet. Findings: 1. Review of the facility menu titled Summer Menus Cooks Spreadsheet for Week 2 Thursday 7/15/21, indicated for the Regular CCHO diet (carbohydrate controlled diet) the following items: Roast Pork Loin 3 oz (ounce), Spiced Apples 1 oz, Ranch Style Beans #12 (#12 scoop= 1/3 cup), Southern Style [NAME] Beans #12, Cornbread (2 x 2 ½ inch square) ½ serving, Vanilla Mousse No…

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 and maintain an infection control procedures when: 1. Licensed Vocational Nurse (LVN) 2 failed to observe infection control measures by failing to properly disinfect resident's glucometer for one randomly selected resident (Resident 41) according to manufacturer's specifications 2. two (Resident 28 and Resident 31) of four sampled residents' nasal cannula and humidifier container of oxygen therapy (also called supplemetal oxygen) were not changed and not labeled with date changed in accordance to facility's policies and procedures. These deficient practices had the potential for the development and the spread of infection to all residents, and for Resident 28, and Resident 31's nasal cannula build up of bacteria which could lead to infections and result in adverse reactions on Resident 28 and 31's respiratory treatments. Findings: 1. During a review of Resident 41's admission Records, dated 7/15/21, the admission Records…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a sampled resident (Resident 17) was free from an unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication when licensed nurses administered sertraline (medication for depression) without consistently doing a monthly monitoring and evaluation of resident-specific behavioral symptoms, and did not attempt non-pharmacological interventions prior to the intiation of mirtazapine (medication for depression). These failures increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss. Findings: During a review of Resident 17's admission Record, dated 7/15/21, the admission Record indicated, Resident 17 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted to 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.