Windsor The Ridge Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure: 1. The recipe for Spinach was followed according to ingredient list for approximately 15 of 96 sampled residents 2. Accurate diets were not served according to resident preferences for two of 96 sampled residents (Resident 36 & Resident 51) These failures had the potential for adverse reactions to foods added to recipes without residents being aware, and for residents to not eat foods according to personal preferences. Findings: 1. During a concurrent observation and interview on 3/26/24 at 11:59 a.m. with [NAME] A, [NAME] A added cooked red bell peppers to the cooked spinach. [NAME] A stated, I am adding them for some more color. During a review of Club Spinach recipe (undated), recipe indicated, Ingredient spinach, chopped, granul [sic] garlic, black pepper, margarine. During an interview, on 3/28/24 at 10:04 a.m. with the Dietary Manager (DM), the DM stated, there are no red bell peppers in the spinach recipe. I told the cook to add them in for extra color. We should follow the ingredient lists. 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.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices in the kitchen when: 1. Dietary Aide (DA) C did not perform hand hygiene after cleaning the floor and touching dirty surfaces; 2. Multiple food items were kept in the freezer after the use by date; and 3. Canned food with major dents were not identified and removed from dry storage shelf These failures had the potential to spread food-borne illness to residents in the facility. Findings: 1. During an observation on 3/26/24, at 11:28 a.m., in the kitchen, DA C cleaned the floors with a broom, then threw trash into the trash can touching the surface of the trash can with his bare hands. DA C then went to the sink and washed his hands with only water for approximately 15 seconds, then dried his hands. DA C then walked over to the dishwasher and began unloading clean utensils with his bare hands. During an interview on 3/26/24, at 11:30 a.m., with DA C, DA C stated, I did not wash my hands with soap after cleaning, I should have used soap before unloading 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.

3. Review of Resident 91's admission Record indicated, Resident 91 was admitted to the facility with diagnoses including aphasia (a language disorder wherein the person is unable to communicate effectively to others) following cerebral infarction (also called stroke), hemiplegia (paralysis of one side of the body/a severe or complete loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body) following unspecified cerebrovascular disease (CVA - also referred to as stroke) affecting right dominant side (more skillful side), and benign prostatic hyperplasia (an enlarged prostate [a gland just below the bladder]) with lower urinary tract symptoms (examples include leaking urine, having sudden and frequent urges to pee, having a weak stream or feeling like unable to empty the bladder). Review of Resident 91's minimum data set (MDS - an assessment tool) Admission/5-day assessment, dated 3/2/2024, indicated, Resident 91's brief interview for mental status…

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 implement their policies on self-administration of medication (resident takes medication without staff assistance) when there were no assessments performed for self-administration of medications, and medications were left at the bedside for 2 of 24 sampled residents (Residents 84 and 3). These failures had the potential for unsafe and improper administration of medications. Findings: 1. Review of Resident 84's admission Record indicated, Resident 84 was admitted to the facility with diagnoses including displaced intertrochanteric fracture of right femur (broken thigh bone), Alzheimer's disease (a progressive disease that destroys memory and mental functions), fall on same level from slipping, tripping, and stumbling, and cognitive communication deficit (problems with a person's ability to think, learn, remember, use judgement, and make decisions). Review of Resident 84's Minimum Data Set (MDS - an assessment tool) Significant change in status and 5-day scheduled assessment, dated 2/10/2024, indicated 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 two of three sampled residents (Resident 13 and 83) with the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, a financial liability notice). This failure could lead to resident unknowingly assume financial liability for receiving services that were not covered by Medicare. Findings: During a review of Resident 13's face sheet (a document that contains a summary of a resident's personal and demographic information) and Notice of Medicare Non-Coverage ((NOMNC, a notice that indicates when a resident's stay at a SNF is no longer paid by Medicare), it indicated Resident 13 was admitted to the facility on [DATE] and his stay was paid by Medicare (federal health insurance for anyone age [AGE] and older, and some people under 65 with certain disabilities) until 12/19/23 and currently resided at the facility. During a review of Resident 83's face sheet and NOMNC, it indicated Resident 83 was admitted to the facility on [DATE] and her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, a clinical assessment tool) for one of 24 sampled residents (Resident 63). Failure to accurately assess the resident had the potential to compromise the facility's ability to provide resident-centered care plan interventions. Findings: During a review of Resident 63's face sheet (a document that contains a summary of a resident's personal and demographic information), it indicated Resident 63 was admitted to the facility on [DATE] with diagnosis of bipolar disorder (a serious mental illness that causes unusual shifts in mood). During a review of Resident 63's level I Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure individuals with mental disorders and intellectual disabilities are not inappropriately placed in nursing homes for long-term care) dated 6/1/22, the PASRR indicated Yes for Section III - Serious Mental Illness Screen: 10. Does the individual have 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 interview and record review, the facility failed to ensure a Level II PASRR (Pre-admission Screening and Resident Review, a federal requirement to help ensure individuals with mental disorders and intellectual disabilities are not inappropriately placed in nursing homes for long-term care) was completed for two of 24 residents (Residents 41 and 61). This failure had the potential to put the residents at risk for not receiving appropriate care and services for their mental health conditions. Findings: Review of Resident 41's clinical record indicated they had diagnoses including paraplegia (the inability to move the lower part of the body, schizophrenia (a mental condition) and morbid obesity (too much body weight). Review of Resident 41's record, indicated Resident 41 had a positive Level I PASRR screen, completed on 9/28/21. Review of Resident 41's record also indicated the Level II PASRR was not completed due to the reason The Individual was isolated as a health and safety precaution, in a letter dated 2/18/22. During an interview on 3/27/24 at 1:52 p.m. with the Minimum…

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 individualized, resident-centered care plans for 3 of 24 sampled residents (Residents 74, 3 and 18) when care plans for: 1. Resident 74's feeling of sadness was not developed and implemented; 2. Oxygen (a colorless, odorless gas) and anticoagulant (sometimes called blood thinning medications) used for Resident 3 was not developed; and 3. Oxygen used for Resident 18 was not developed. These failures had the potential to result in the residents not receiving the care and services necessary to maintain their health, safety and well-being. Findings: 1. Review of Resident 74's admission Record indicated, Resident 74 was admitted to the facility on [DATE] with diagnoses including hypo-osmolality (a condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal) and hyponatremia (low sodium [can be found in table salt or in processed foods] level in blood), adult failure to thrive…

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

Based on observation, interview, and record review, the facility failed to ensure the residents received the necessary care and services for two of six residents (Residents 148 and 15) when licensed nurses did not follow the physician's order for oxygen supplement (a therapy that provides extra air to breathe in) for Residents 148 and 15. These failures had the potential to affect the residents' care and could jeopardize their health and well-being. Findings: 1. Review of Resident 148's admission Record indicated, Resident 148 was admitted to the facility with diagnoses including chronic respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypoxia (occurs when oxygen level in the body organs are low), and chronic obstructive pulmonary disease (COPD - a long lasting lung disease). Review of Resident 148's Order Summary Report, indicated Resident 148 had an order for continuous oxygen administration at 2 liters (L, metric unit of volume) per minute (min) via (thru) nasal cannula (NC, a device that consists of plastic tube 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.

Based on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) reconciled with the corresponding Medication Administration Records (MAR) for four of nine randomly sampled residents (Residents 7 ,37 ,58, and 76). The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but did not document on the Medication Administration Record (MAR) to indicate the controlled medications were given to the residents. This failure had the potential for misuse or diversion of controlled medications. Findings: The CDR for four random residents (Residents 7 ,37 ,58, and 76) receiving as-needed controlled medications were requested for review during the survey. 1. During a review of Resident 7's medical record indicated a physician's order, dated 10/31/23, for Tramadol (a controlled pain medication) Hydrochloride (HCL a salt added to drugs to make them stable) 100 milligrams (mg, unit of measurement), take 1 tablet by mouth every 6 hours…

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 had an eight percent medication error rate when two medication errors out of 25 opportunities were observed during medication pass for one of six residents (Residents 72). These failures had the potential to compromise the health and safety of the residents. Findings: During a medication pass observation on 3/25/24 at 9:54 a.m. with Licensed Vocational Nurse (LVN) I, LVN I was observed preparing and administering ten medications to Resident 72. Review of Resident 72's clinical record indicated a physician's order of Zyrtec (antihistamine to treat allergy, hives, and itching) 10 milligram (mg, unit of measurement) dated 3/11/23 and MiraLAX (laxative to treat constipation) Oral Powder 17 grams (gr, unit of measurement) /scoop dated 2/2/24 for medication to be given. During a concurrent interview and record review on 3/25/24 at 10:40 a.m., with LVN I, LVN I confirmed the order indicated Zyrtec 10 mg tablet and MiraLAX Oral Powder 17 grams and she did not administer those two medication to Resident 72. LVN I further stated…

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

Based on observation, interview, and record review, the facility failed to ensure medications were labeled appropriately when: 1. One opened Refresh Tears lubricant eyedrop without resident's name and an open date was found in medication cart AA; 2. One opened Vyzulta (used to lower intraocular [eye] pressure with open - angle glaucoma [eye condition that can cause blindness] or ocular hypertension) 0.024 % Ophthalmic (used to treat eye infections) Solution was found without an open date; and 3. One opened Brimonidine Tartrate (used to treat open-angle glaucoma or high fluid pressure in the eye) ophthalmic solution was found without an open date. These failures had a potential for residents to receive medications with unsafe and reduced potency from being used past their discard date which could lead to unsafe and ineffective medications for the residents. Findings: During a medication cart inspection on 3/26/24 at 10:54 a.m., on South Wing of the facility, medication cart AA was inspected with Licensed Vocational Nurse (LVN) L. The inspection identified a bottle of opened Refresh…

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 serve food at an appetizing temperature for one test tray food item out of seven sampled food items. This failure had the potential for residents to not wish to eat the sampled food item due to colder temperature. Findings: During an observation on 3/26/24, at 11:59 a.m., [NAME] A added cooked red bell peppers to the cooked spinach, which completed the cooking process for the spinach at this time. During a concurrent observation and interview on 3/26/24, at 1:20 p.m. with the Dietary Manager (DM), the DM tested the internal temperature of 7 food items on the sampled test tray, after all residents in the facility were served the noon meal. One food item, the regular texture Club Spinach's internal temperature read 125 degrees Fahrenheit. DM stated, all hot foods on the tray line should be maintained to 140 degrees Fahrenheit. During a review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 2013, the P&P indicated, B. Hot foods should be held prior to service at 140 degrees…

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 the physician- prescribed therapeutic diet (a diet order as part of treatment for a disease or clinical condition to decrease or increase specific nutrients in the diet) to four of 96 sampled residents when: 1. Three residents (Resident 29, Resident 41 & Resident 57) who were ordered a Controlled Carbohydrate Diet (The focus of the diet is eating the same amount of carbohydrates every day in an attempt to keep blood sugar levels stable) were served the wrong dessert item; and 2. One resident (Resident 92) who was ordered a Fortified Diet ( a diet with additional high calorie items to help prevent or treat weight loss), did not receive the fortified food item for noon meal. These failures had the potential to result in weight loss and/or unstable blood sugar for the residents who did not receive their therapeutic diets as ordered. Findings: 1. During a review of the Facility's Therapeutic Diet Spreadsheet, dated 3/26/24, the spreadsheet indicated, for the noon meal the dessert item for Controlled…

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 proper infection control practices were implemented when: 1. Certified nursing assistant O (CNA O) did not perform hand hygiene while serving and setting up lunch trays in between residents (Residents 14, 71 and 58); and 2. Nasal cannula (NC - a device that consists of plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils for oxygen administration) was not stored properly when not in use (Resident 44). These failures had the potential to compromise resident's health and safety in the facility. Findings: 1. During observation on 3/25/2024 at 12:07 p.m., inside dining room BB (DR BB), CNA O was observed assisting Resident 14 to drink. CNA O held Resident 14's cup of thickened water, pat Resident 14's shoulder and moved the cup of water towards Resident 14's mouth to drink. CNA O placed Resident 14's cup of water back on the table and went to Resident 71's table. CNA O did not perform hand hygiene. CNA O held Resident 71's cup of water, touched Resident 71'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 to provide a safe, functional, and comfortable environment for two of 24 sampled Residents: 1. Resident 94's bed controller was not functioning for two days; and 2. Resident 41's toilet paper holder was broken for three days without being reported and fixed. These failures had the potential to affect the comfort of the residents. Findings: 1. During a concurrent observation and interview on 3/25/24 at 9:21 a.m. in Resident 94's room, Resident 94's bed controller was disconnected from the bed, his head of the bed was elevated. Resident 94 stated, he came back from the hospital two days ago, and he had been sleeping with the head of the bed elevated for two nights now. It was not comfortable for him. During an interview on 3/25/24 at 9:30 a.m. with Occupational Therapist (OT) O, who stopped by Resident 94's room to drop off some clean clothes, she stated she was not aware of the bed situation, but she would let the maintenance know. During an interview on 3/26/24 at 4:14 p.m. with the Maintenance…

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 update the fall care plan for one of 8 residents (Resident 84) when interdisciplinary team (IDT, team composed of members from different departments involved in resident's care) did not review and revised Resident 84's fall risk care plan with subsequent falls. This failure resulted in Resident 84's two more subsequent falls. Findings: Review of Resident 84's admission Record indicated, Resident 84 was admitted to the facility with diagnoses including displaced intertrochanteric fracture of right femur (broken thigh bone), Alzheimer's disease (a progressive disease that destroys memory and mental functions), fall on same level from slipping, tripping, and stumbling, and cognitive communication deficit (problems with a person's ability to think, learn, remember, use judgement, and make decisions). Review of Resident 84's Minimum Data Set (MDS, an assessment tool) Significant change in status and 5-day scheduled assessment, dated 2/10/2024, indicated Resident 84's Brief Interview for Mental Status (BIMS, an assessment 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 observation, interview and record review, the facility failed to ensure fall management policy and procedure were implemented for one of eight residents (Resident 84) when: fall risk assessment was not performed when Resident 84 had a significant change in status and the interdisciplinary team (IDT, team composed of members from different departments involved in resident's care) did not develop and implement appropriate new interventions after a fall. These failures resulted in Resident 84's subsequent falls and had a potential to sustain serious injuries. Findings: 1a. Review of Resident 84's admission Record indicated, Resident 84 was re-admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur (broken thigh bone), Alzheimer's disease (a progressive disease that destroys memory and mental functions), fall on same level from slipping, tripping, and stumbling, and cognitive communication deficit (problems with a person's ability to think, learn,…

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 ensure residents were free from physical abuse for one out of three residents (Resident 1) when Resident 2 (who was of moderate mental capacity) slapped Resident 1 in the mouth causing injury to Resident 1's top lip and first aid being administered. Resident 2's act of slapping Resident 1 in the mouth was a deliberate act to inflict harm or injury, not accidental; therefore, his action was deemed as a willful act and considered abuse. This failure had the potential of both physical and emotional harm to all residents. Findings: On 10/17/22, the facility submitted a facsimile (FAX, a telephonic transmission of scanned printed material) to the California Department of Public Health (CDPH) about an incident between Residents 1 and 2. The FAX indicated Resident 2 slapped Resident 1 in the mouth and Resident 1 sustained a minor injury of the upper gingiva (gums) and upper lip. Review of Resident 1's clinical record indicated she had diagnoses which included metabolic encephalopathy (a problem in the brain caused by a chemical…

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 three sampled residents (Resident 1) received medication as ordered. The facility also failed to notify the physician when Resident 1 did not receive this medication. These failures had the potential to compromise Resident 1's health and well-being. Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE] and had the diagnosis of hyperlipidemia (an abnormally high concentration of fats in the blood). Review of Resident 1's [Hospital] Patient Summary, dated 5/24/23, indicated she received rosuvastatin (medication used to treat hyperlipidemia) while she was in the hospital prior to her admission to the facility. The [Hospital] Patient Summary further indicated Resident 1 was to continue receiving rosuvastatin at the facility. Review of Resident 1's Order Summary Report from the facility indicated she had a physician ' s order, dated 5/24/23, for rosuvastatin 20 milligrams (mg, unit of dose…

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 4. Review of Resident 30's admission Record indicated she was admitted to the facility on [DATE] with anxiety disorder (people with anxiety disorders frequently have intense, excessive and persistent worry and fear about everyday situations) diagnosis. Review of Resident 30's physician order indicated she had an order for buspiron (used to treat anxiety) 15 milligrams (mg, a metric unit of mass) every 12 hours for anxiety started on 5/20/21. Review of Resident 30's medical record indicated there was no side effect monitoring for buspiron. During an interview with the director of nursing (DON) on 8/6/21 at 9:21 a.m., she reviewed Resident 30's clinical record and confirmed there was no side effect monitoring for buspiron. DON stated Resident 30 should have been monitored for the side effects of buspiron. Review of the facility's policy Psychoactive Drug Use, dated 11/28/2017, indicated Assess patient to determine if psychoactive is effective or may be reduced or eliminated by determining: . Whether the patient…

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 served at a palatable temperature for three non-sampled residents (Residents 44, 45, and 77) when the residents complained about the food temperature. This failure had the potential to result in decreased food intake and weight loss, compromising the resident's nutritional status. Findings: During an initial tour with Resident 77 on 8/2/21 at 9:41 a.m., Resident 77 stated the hot food was served cold and cold food was served warm. During an initial tour with Resident 45 on 8/2/21 at 10:31 a.m., Resident 45 stated the hot food was cold. During a group meeting on 8/4/21 at 12:54 a.m., Resident 44 stated the hot food was cold when they served the tray. During an observation and interview with thedistrict dietary manager (DDM) on 8/5/21 at 1:49 p.m., the test tray temperature of the pureed beans was 116 degrees Fahrenheit (°F, unit of measurement), orange juice 60 °F, green bean salad 60°F, coleslaw 50°F,and pureed marinated salad 60°F. DDM stated the cold food should have been served 42°F below…

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 stored, prepared, and served under the sanitary conditions when: 1. An unlabeled big container of sliced bread with cheese dated 7/16/21 was inside the refrigerator; 2. coffee maker machine's daily cleaning was not followed per manufacturer's guidelines; 3. There were three electric fans with grayish black substance; 4. water filter for coffee maker was dated 3/1/2020; 5. undated and unlabeled open bag of chocolate chips; 6. kitchen cook did not perform hand hygiene when changing gloves. These failures had the potential to cause foodborne illness (illness resulting from contaminated food) to the residents who received food from the kitchen. Findings: 1. During an initial kitchen observation on 8/2/21 at 9:15 a.m., an unlabeled big container of sliced bread with cheese dated 7/16/21 was inside the refrigerator. During a concurrent interview with kitchen aide D (KA D), she stated the sliced bread with cheese was more than two weeks old and it was not good to eat. During an interview with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During an observation in the dining room on 8/2/21 at 12:44 p.m., certified nursing assistant N (CNA N) put on gloves without washing her hands, picked up the fried chicken leg and thigh on Resident 43's plate, and shredded it for Resident 43 to eat. During a concurrent interview with CNA N, she stated she should wash her hands and put on gloves before touching the resident's food. Review of the facility's policy Food: Preparation, dated 9/2017, indicated All staff will practice proper hand washing techniques and glove use. 3. During an observation of medication administration on 8/2/21 at 3:53 p.m., after checking Resident 45's blood sugar, licensed vocational nurse J (LVN J) threw the lancet and the strip with blood into a blue cup, removed the glove from one of her hands, held the blue cup in that hand, held the glucometer in the other gloved hand, walked out of Resident 45's room, and threw the blue cup with the lancet and the strip with blood in the trash can of the medication cart which was parked 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 8 residents (37) had informed consent (written permission before implementing a healthcare intervention) prior to initiating psychotropic medication (medication capable of affecting the mind, emotions, and behavior). This failure resulted in the resident receiving psychotropic medications without being informed about their risks and side effects. Findings: Review of Resident 37's admission Record indicated she was admitted to the facility on [DATE] with bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows) diagnosis. Review of Resident 37's physician order, dated 5/27/21, indicated she had an order for valproate sodium (used to treat bipolar disorder) 250 milligrams (mg, a metric unit of mass)/5 milliliters (ml, a metric unit of volume) three times a day related to bipolar disorder, but no informed consent was found for valproate sodium 5 ml three times a day. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accommodate residents' needs for three of 19 sampled residents when: 1. Resident 41 had been waiting 21 minutes for transfer assist in a commode. 2. Resident 64 waited for more than 15 minutes for his perineal care after bowel movement. 3. Resident 74's call light device was not within reach to accomodate his needs. These failures had the potential to result in the residents' needs being unmet and affecting residents' well-being. Findings: 1. During review of Resident 41's clinical record, Resident 41 was admitted on [DATE], with diagnoses included amputation (action of surgically cutting off a limb) of left lower leg, diabetes mellitus (high blood sugar), and muscle weakness. During review of Resident 41's quarterly MDS dated [DATE], indicated Resident 41 was cognitively intact and required limited assist with one person during transfer and toilet use. During concurrent observation and interview on 08/02/21 at 9:50 a.m., Resident 41'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 maintain a clean, safe, orderly, and sanitary homelike environment for two of nineteen sampled residents when: 1. Resident 44's toilet was not working and was clogged with stool; 2. The toilet paper dispenser for Resident 26 had no toilet paper because the roller was broken. These failures had the potential to place the residents at risk for an unsafe and uncomfortable environment. Findings: 1. During an interview with Resident 44 on 8/3/21 at 3:30 p.m., she stated that her toilet was clogged up for a few days now. During a concurrent observation and interview on 8/4/21 at 1:18 p.m., with certified nursing assistant G (CNA G), he verified that Resident 44's toilet would not flush and the toilet bowl still had brown stools. He also stated that he had already reported the incident in the maintenance log, two days ago, 8/2/21. Review of the facility's undated Repair and Preventative Maintenance Log, Resident 44's clogged toilet was reported on 8/2/21 and nobody followed up. During an interview on 8/4/21 at 2:50…

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 the Pre-admission Screening and Resident Review (PASRR, screening for individuals with a mental disorder and individuals with intellectual disability) screening document was accurately completed for one of five residents (27). This failure had the potential for mentally ill residents not to receive the required care and services. Findings: Review of Resident 27's PASRR Level I Screening Document, dated 3/12/21, indicated Resident 27 was noted to have no diagnosis of a neurocognitive disorder or a mental disorder. Review of Resident 27's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and psychotic disorder (severe mental disorder that causes abnormal thinking and perceptions) with delusions (false believes that are based on incorrect interpretations of reality). During…

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. Review of Resident 64's admission Record indicated he was admitted to the facility with chronic obstructive pulmonary disease (COPD, a lung disease that makes it hard to breathe) diagnosis. Review of Resident 64's physician order, dated 7/30/2020, indicated he had an order for Symbicort Aerosol (an inhaler that is used to treat COPD) 160/4.5 micrograms (mcg, a metric unit of mass) 2 puff inhale orally two times a day related to COPD. During an observation of medication administration on 8/3/21 at 9:40 a.m., after administering 2 puffs of Symbicort Aerosol to Resident 64, licensed vocational nurse I (LVN I) gave Resident 64 a cup of water to rinse his mouth. Resident 64 rinsed his mouth and swallowed the water. During an interview with LVN I on 8/3/21 at 10:19 a.m., she stated she should instruct Resident 64 to spit out the water after he rinsed his mouth. Review of the Package Insert (Drug Information) for Symbicort 160/4.5 mcg indicated Advise the patient to rinse his/her mouth with water without swallowing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an on-going activity program to support the resident in her choice of activities for one of 19 sampled residents (Resident 65) when the facility did not provide in-room visits to Resident 65. This failure could potentially affect the physical, mental, and psychosocial well-being of the resident. Findings: Review of Resident 65's clinical record indicated she was admitted on [DATE], with diagnoses of hemiplegia (paralysis of one side of the body), hypertension (increase blood pressure), muscle spasm, and aphasia (loss of ability to express speech). Review of Resident 65's minimum data set (MDS, an assessment tool) dated 7/25/21, indicated she was severely impaired in decision making, required staff assistance for bed mobility, transfer, dressing, eating, toileting, and personal hygiene. The MDS also indicated the resident activity preferences were listening o music and choosing clothes to wear. Review of Resident 65 activities care…

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 appropriate treatment and services for one of 19 sampled residents (Resident 65) when the restorative nursing aide (RNA, helps residents to gain an improved quality of life by increasing their level of strength and mobility) program was not implemented related to contractures (condition of hardening, shortening of muscles and tendons) care plan. This failure had the potential for Resident 65 to decline in activities of daily living (ADL's such as bed mobility, transfer, personal hygiene, toileting, and bathing) and prevent physical deterioration. Findings: Review of Resident 65's clinical record indicated she was admitted on [DATE], with diagnoses of hemiplegia (paralysis of one side of the body), contracture (condition of hardening, shortening of muscles and tendons) of left knee, contracture of left lower leg, contracture of muscle, and abnormal posture. Review of Resident 65's minimum data set (MDS, an assessment tool) dated 7/25/21,…

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 appropriate care to prevent accidents for one of 19 sampled residents (Resident 67) when certified nursing assistant C (CNA C) transferred Resident 67 with Hoyer lift (lifting machine) by herself. This failure had the potential for accidents and injury to the resident. Findings: Review of Resident 67's clinical record indicated he was admitted [DATE] with diagnoses including paraplegia (paralysis of the legs and lower body), morbid obesity (excessive body fat), schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly), and diabetes (increased blood pressure). During an observation with Resident 67 on 8/2/21 at 10:36 a.m., CNA C brought the Hoyer lift to Resident 67's room and CNA C transferred Resident 67 with the Hoyer lift by herself. During a concurrent interview with CNA C, she confirmed she transferred Resident 67 with the Hoyer lift by herself. During an interview with the director…

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 appropriately monitor intravenous (IV, catheter inserted into blood vessel for administration of fluids and/or medication) access/lines for three of 19 residents (Residents 143, 36, and 64). This failure had the potential of losing IV access for the resident and/or the incorrect amount of fluid being administered to the resident, and affecting the residents' health and well-being. Findings: 1. Resident 143 had a peripherally inserted central catheter (PICC) line for access to a large blood vessel to administer antibiotics. During an interview on 8/03/2021 at 10:34 a.m. with licensed vocational nurse M (LVN M), LVN M stated she mainly just monitors Resident 143's PICC line by just looking at Resident 143's arm to make sure it does not look red or swollen. During an interview on 8/03/2021 at 10:40 a.m. with the assistant director of nursing (ADON), ADON stated there were no physician orders for the PICC line dressing changes. ADON stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two residents (Resident 64), who was physician-ordered to receive respiratory services of continuous positive airway pressure (CPAP, machine uses a hose and mask or nosepiece to deliver constant and steady air pressure) received this service and the care was accurately documented. This failure had the potential to result to impact resident's health and well-being. Findings: Review of Resident 64's clinical record, Resident 64 was admitted on [DATE], with diagnoses included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), obstructive sleep apnea (sleep-related breathing disorder) and seizures (sudden, uncontrolled electrical disturbance in the brain). Review of Resident 64's annual MDS dated [DATE], indicated Resident 64 was cognitively intact and required extensive assistance with two-person physical assist during ADLs. During concurrent observation…

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 for two of 19 sampled residents (Resident 84 and Resident 19), were provided with the appropriate and necessary pain management when: 1. Resident 84's left lower back pain was not addressed promptly; 2. The pain medication order for Resident 19 was not followed accurately. These failures had the potential to result in the resident's poor quality of life and discomfort. Findings: 1. During a concurrent observation and interview of Resident 84 on 8/2/21 at 11:06 a.m., the resident was lying in his bed with episodes of facial grimacing when he was trying to move around his bed. When asked if he was ok, the resident stated he had pain on his left lower back, with pain scale of four out of 10 (moderate pain). He stated he had pain for about an hour, and he had left lower back pain for thirty to forty-five days now. During an interview with Resident 84 on 8/2/21 at 1:39 p.m., the resident still complained of pain, and stated the pain…

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 appropriate care to one resident (77) on dialysis (process of removing excess water, solutes, and toxins from the blood in people whose kidneys no longer perform these functions naturally) when the access site for bruit (swishing sound that indicates patency heard by auscultating the dialysis shunt) and thrill (vibration that indicates arterial and venous blood flow and patency felt by palpating the dialysis shunt) for post dialysis were left blank on Resident 77's Dialysis Communication Records, and the licensed nurses did not assess Resident 77's vital signs (reflect essential body functions, including the heartbeat, breathing rate, temperature, and blood pressure) after dialysis as ordered. These failures had the potential for Resident 77 not to receive the appropriate nursing care, delayed detection, and management of complications from the dialysis access site. Findings: Review of Resident 77's admission Record indicated she was admitted…

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 had a 14.29% medication error rate when five medication errors of 35 opportunities were observed during the medication administrations for two sampled residents (49 and 64). These failures had the potential to negatively affect the residents' health and well-being. Findings: During an observation of medication administration with licensed vocational nurse I (LVN I) on 8/3/21 at 9:03 a.m., LVN I instilled 3 drops of artificial tears (eyedrops used to lubricate dry eyes) in Resident 49's right eye and 2 drops in Resident 49's left eye. LVN I also administered 1 tablet of vitamin D3 25 micrograms (mcg, a metric unit of mass) to Resident 49. Review of Resident 49's physician orders indicated she had orders for artificial tears 0.2-0.2-1% instill 1 drop in both eyes four times a day for eye dryness, started on 4/5/21, and vitamin D3 50 mcg two times a day for vitamin D insufficiency, started on 7/3/21. During an interview with LVN I on 8/3/21 at 9:34 a.m., she reviewed Resident 49's physician order and confirmed 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.

Based on observation, interview, and record review, the facility failed to employ staff with the appropriate competency and skills to carry out functions of the food and nutrition service when the kitchen cook (KC) did not properly dip the test strip in the sanitizer water per manufacturer's recommendation. This failure could affect proper washing and sanitation which could cause foodborne illness to the residents in the facility. Findings: During an observation and interview with kitchen cook (KC) on 8/4/2021 at 11:13 a.m., KC was asked to demonstrate the sanitation process using the sanitizer strip when she dipped into sanitized water for two seconds and KC stated she should have dipped the strip for 20 seconds. KC stated the color result was 400 parts per million. During an interview with district dietary manager (DDM) on 8/4/2021 at 11:32 a.m., she stated the sanitizer strip should have been dipped for 10 seconds. Review of the facility's undated policy, Hydrion Quat Dispenser, indicated to dip the strip into the sanitizing solution for 10 seconds and then compare the resulting…

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

Based on observation, interview, and record review, the facility failed to follow the recipe procedure when the cook and kitchen aide did not follow the ingredients for pureed diet. This failure had the potential to decrease food intake and cause weight loss. Findings: During a kitchen observation on 8/4/21 at 11:00 a.m., the kitchen cook (KC) added a scoop of canned ketchup to the blender and the cooked meatloaf for pureed diet. During a concurrent interview with the KC, she stated she added a scoop of canned ketchup to the cooked meatloaf and she did not follow the procedure for pureed diet. During a kitchen observation on 8/5/21 at 11:38 a.m., the kitchen aide added more salad dressing to the blender and marinated mixed vegetables for the pureed diet. During an interview with the director of clinical operation (DCO) on 8/5/21 at 11:59 a.m., she stated the menu procedure should have been followed for pureed diet. During a test tray with the DCO on 8/5/21 at 2:02 p.m., she stated the marinated mixed vegetables was sour. Review of the facility's undated recipe, Salad, Marinated…

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 3. During an observation on 8/2/21 at 1:34 p.m., Resident 390 was sitting in his wheelchair having lunch of sliced bread, noodles, meat, vegetables and a slice of regular cake, by himself and consumed about 20 percent of his meal. Resident 390's dietary menu slip for 8/2/21, indicated he would have pureed dinner roll/bread and pureed chocolate chip cake with white frosting. During a concurrent observation and interview on 8/2/21 at 1:34 p.m., with certified nursing assistant H (CNA H), she verified Resident 390 had a slice of regular cake, not pureed chocolate chip cake and he had no pureed dinner roll, but sliced bread instead. Review of Resident 390's Order Summary Report dated 8/3/21, indicated he had an order of Therapeutic Lifestyle Change (TLC) Diet, Dysphagia Mechanical Soft Texture Diet, Nectar Thick Consistency, and large portion entrée, ordered on 7/29/21. Review of Resident 390's admission Record dated 8/3/21, indicated he was a [AGE] year old male with the diagnoses of unspecified dysphagia,…

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 properly dispose the garbage when the garbage container had no lid to cover it. This failure had the potential to attract pests and transfer harmful microorganism to food leading to foodborne illness to the residents. Findings: During a kitchen observation and interview with kitchen aide D (KA D) on 8/2/2021 at 9:55 a.m., there were garbage bags with flies and no lid for the garbage container. During a concurrent interview with KA D, she stated the garbage container had no lid and should have been covered. During an interview with the maintenance director (MD) on 8/3/2021 at 3:12 p.m., MD stated the garbage container should have a lid to cover the garbage container. Review of the facility's 8/2017 policy, Dispose of Garbage and Refuse, indicated all garbage and refuse will be collected and disposed of in a safe and efficient manner. Appropriate lids are provided for all containers.