Atterdag Care Center

Based on observation, interview, and record review, the facility failed to ensure food safety requirements were met when:1) Two dietary aides (DAs 1 and 2) did not completely cover their hair, with the required hair restraint, while in the food preparation area. 2) Dietary staff did not follow the facility's policy and procedure when cleaning and sanitizing kitchen surfaces. 3) Contaminated food was not removed from dry food storage area. These failures had the potential to cause food borne illness to the residents. 1) During an observation on 1/9/26 at 9:41 a.m. with Director of Nutrition Services (DNS), in the food preparation area, DAs 1 and 2 hair restraints were noted not properly covering the hair area. During a review of facility's policy and procedure (P&P) titled, Hair Restraints, dated 2020, the P&P indicated, Hair restraints, hats and beard covers will be worn in the food production area by all staff to prevent hair from falling into food. 2) During a review of the facility's P&P titled, Cleaning Instructions for Work Tables and Counters, dated 2020, the P&P indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the informed consent [a resident's right to make an informed voluntary decision about their care, requiring providers to clearly explain their health status, treatment risks/benefits, alternatives (including refusal)] for psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) had accurate information for one of three sampled residents (Resident 8).This failure had the potential to result in Resident 8 receiving inappropriate care and treatment.Findings:During a review of Resident 8's admission Record (AR), dated 1/8/26, the AR indicated, Resident 8 was a [AGE] year-old female who was admitted to the facility on [DATE] with admission diagnoses including, Alzheimer's disease (a progressive brain disorder that primarily affects memory, thinking, and behavior), dementia with mood disturbance (a pattern of mental decline caused by different diseases or conditions), major depressive 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 infection control practices were implemented when: Laundry washing machine water temperatures were below the minimum required temperature for infection control. Personal protective equipment (PPE - protective equipment such as gloves, gowns, masks, and eye protection that creates a barrier to protect patients, healthcare workers from infectious materials, bloodborne pathogens, and other hazards, and to prevent the spread of illness to others) was not readily available in four out of four residents (Residents 6, 27, 36, and 48) on enhanced barrier precautions (EBP - Infection control measures the involves wearing PPE for specific high-contact tasks such as bathing, transfers, and wound care for at-risk residents to stop germ spread). These facility failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable HAIs (Healthcare…

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 documentation by Social Services Designee (SSD) was completed for one of three sampled residents (Resident 1) medical records regarding allegations of abuse involving Resident 1.This facility failure resulted in Resident 1's medical record not accurately reflecting SSD follow-up on abuse allegations, potentially impacting the adequacy of care for Resident 1.During a review of Resident 1's admission Record, [undated], the admission Record indicated, Resident 1 was 94 years-old, admitted to the facility on [DATE] with the following diagnoses: senile degeneration of brain (decline in cognitive abilities that occurs with aging), generalized anxiety disorder (mental condition with excessive or unrealistic anxiety about two or more aspects of life), schizoaffective disorder bipolar type (a mental health condition that combines symptoms of schizophrenia [chronic mental health condition that affects a person's thoughts, feelings, and behavior] 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 interview and record review, the facility failed to ensure that the personal property inventory list was updated for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1's belongings to be lost or unaccounted for. Findings: During an interview with the Social Services staff (SS) on 7/2/25 at 11:08 a.m., the SS stated that Resident 1 had complained she could not locate a pair of pants she purchased (online store name). The SS assisted Resident 1 and located the missing pants, which had a tag with the resident's name. During an interview with Licensed Nurse 1 (LN1) on 7/2/25 at 11:22 a.m., LN1 stated that when a resident brings in new clothing, facility staff should label the items and update the inventory list kept in the resident's closet. During an interview with Certified Nursing Assistant 1 (CNA1) on 7/2/25 at 11:30 a.m., CNA1 stated that when a resident brings in new clothes, staff should label them and update the resident's inventory list when placing them in the closet. During a concurrent interview and record review with…

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

Based on observation, interview and review of facility documents, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety when: 1. The high temperature dish machine was not reaching 150 degrees Fahrenheit (F) for the wash cycle and 180 degrees F for the rinse cycle and the facility did not have a mechanism to verify the plate level temperature was reached according to their policy and procedure; and 2. [NAME] 2 (C2) did not change gloves after touching raw meat then touching other items. These failures resulted in equipment, utensils, dishware and silverware not being properly cleaned and sanitized and had the potential to result in the growth of microorganisms which can cause foodborne illness for the 49 residents eating food from the kitchen. Findings: 1. During a concurrent observation and interview on 1/21/25 at 10:35 a.m. with Dishwasher 1 (DW1), the last rack was observed being placed in the dish machine. DW 1 stated he knows the dish machine is working properly when the wash temperature…

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 review of the medical record for resident and interview with the facility's Director of Nursing (DON) on 1/23/2025, regarding resident 20's blood pressures, the facility had failed to ensure that this resident's blood pressure monitoring had been ordered by the resident's physician and not by the facility's nursing staff. The facility also failed to develop a policy and procedure which identified hypotension for the nursing staff. The facility's failure had the potential to put this resident at risk of severe hypotension which could result in ultimate organ failure and shock. Findings: Review of resident 20's clinical record revealed that this resident had been admitted to the facility on [DATE]. On revealed that this resident's physician had ordered, Coreg 6.25mg (a blood pressure medication) to be given twice daily for hypertension, please give with meals. without any blood pressure or pulse parameters on 9/11/2024. This resident continued to receive his Coreg from 9/12/2024 to 10/13/2024 without…

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 monitor the medication refrigerator temperature twice a day and maintain the temperature within acceptable range. This failure had the potential for the residents to receive ineffective medications due to improper storage. Findings: During an interview on 1/21/25 at 3:26 p.m. with the Director of Nursing (DON), in the medication storage room, the DON stated the temperatures of the refrigerator in the medication storage room are monitored once a day in degrees Fahrenheit (F). During a concurrent interview and record review on 1/21/25 at 4:20 p.m., with the DON, Medical Room Refrigerator Temperature Monitoring Log (MRRTML), for October 2024, November 2024, and December 2024 were reviewed. The MRRTMLs indicated the following temperatures in Farenheit (F): 12/8/24: 34 degrees 11/14/24: 34 degrees 11/22/24: 34 degrees 11/24/24: 30 degrees 11/27/24: 32 degrees 11/28/24: 34 degrees 11/29/24: 34 degrees 11/30/24: 34 degrees 10/12/24: 32 degrees Additionally, the MRRTML indicated Report all temperatures that do not meet standards.…

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, record review, and interview the facility failed to ensure residents were provided a well-balanced, physician prescribed diet that met their nutritional needs when meal ticket and diet order did not match for seven (7) residents (Residents 7, 23, 29, 34, 35, 37, and 38). This failure had the potential for residents to receive incorrect diets and have nutritional deficits. Findings: During a concurent observation and interview in the kitchen on 1/21/25 starting at 11:45 a.m. with the Director of Dining Srvices (DDS), a lunch meal service was observed. Resident 33's meal ticket showed the resident was on a puree small portion diet. Further review of the meal ticket indicated, the resident was to receive a #6 scoop (5.33 ounces) of lamb. The DDS stated was not sure why the meal ticket showed #6 scoop, but they use half portions on all items when serving a small portion diet. During a concurrent interview and record review on 1/23/2025 at 10:56 a.m. with Registered Dietitian (RD), 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 the menus were followed when: 1. The incorrect portion sizes for meat and vegetables were served for the puree diet during the lunch meal on 1/22/25 for four residents (Residents 2, 3, 29, 35); and 2. The incorrect portion sizes were served for one resident (Resident 30) for the lunch meal on 1/21/25. This failure has the potential to result in residents not having their nutritional needs met. Findings: 1. During a review of the facility document titled, Daily Spreadsheet, dated 1/22/25 for the lunch meal, the Daily Spreadsheet indicated, for the puree diet, #6 scoop (2/3 cup) [NAME] broil (red meat), 1 ounce gravy, #8 scoop (1/2 cup) puree potatoes, and #10 scoop (3/8 cup) puree zucchini. During a concurrent observation and record review on 1/22/25 at 11:49 a.m., the lunch meal service steamtable contained puree meat ([NAME] broil) with a #8 scoop (1/4 cup), puree zucchini with a #8 scoop and mashed potatoes with a #8 scoop. [NAME]…

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 Physician Orders for Life-Sustaining Treatment (POLST- a form that documents a resident's treatment wishes in the event of a medical emergency) matched the electronic medical record (EMR) in one of one sampled resident (Resident 23). This failure had the potential to cause a delay in receiving or incorrectly administering life-sustaining treatments. Findings: During a review of Resident 23's admission Record (AR), the AR indicated, Resident 23 is a [AGE] year-old female admitted on [DATE] with diagnosis of senile degeneration of the brain (a brain and nerve disorder characterized by a progressive decline in cognitive function [how a person thinks, behaves, and their ability to remember things], impacting memory, reasoning, and the ability to perform everyday activities). During a concurrent interview and record review on [DATE] at 10:01 a.m. with the Minimum Data Set Coordinator (MDS 1), Resident 23's POLST was reviewed. The POLST dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan to address Restorative Nursing Assistant (RNA) services for one of three sampled resident (Resident 27). This failure had the potential for care and services not to be provided to Resident 27 that could potentially cause a decline in mobility and muscle strength. Findings: During a review of Resident 27's admission Record (AR), the AR indicated, Resident 27 was admitted on [DATE] with diagnoses including muscle weakness (generalized), other abnormalities of gait (the way a person walks) and mobility, and repeated falls. During a concurrent interview and record review on 1/24/25 at 9:36 a.m. with the Minimum Data Set Coordinator (MDS 1), Resident 27's order summary report (OSR) was reviewed. The OSR indicated, RNA Range of Motion (active) right upper extremity AROM (active range of motion) / PROM (passive range of motion) exercises to maintain mobility RNA: Range of Motion (passive) right upper extremity AROM/PROM exercises 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 review of the medical record for resident, interview with the resident's nurse, and interview with the facility's Director of Nursing (DON) on 1/23/2025, regarding resident 247, the facility failed to ensure that Standards of Practice regarding Tachycardic pulses which resulted in abnormal results, had been addressed by the facility and medical staff. The facility also failed to develop a policy and procedure which identified tachycardia. This failure had the potential to put this resident at risk for a heart attack or a stroke. Findings: Review of resident 247's clinical record revealed that this resident, had an elevated Pulse recorded in the resident's medical record on the evening of 1/22/2025. This resident's pulse had been recorded as 103 beats per minute, which had been flagged in the nurse's computer as being highlighted in red by the facility's computer system to help bring this resident's elevated pulse to the nurse's attention. Review of the textbook, the Fundamentals of Nursing, 11th edition, which had been dated, 2023, (which represents the Standard of Nursing…

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 and validate the dishwashing machine was functioning properly and was in safe operating condition when the temperatures of the wash and rinse were not reaching manufacturer's directions. This failure had the potential to result in temperatures not reaching proper temperature levels which led to all the dishware, silverware, utensils, pots and pans not being sanitized to which can result in the growth of microorganisms which can lead to food borne illness for the highly susceptible population that was eating at the facility. The facility census was 49. Findings: During an observation on 1/22/25 at 9:17 a.m. in main kitchen at dishwashing station, dishwashing rinse temp gauge read 124F and dishwashing wash temp gauge read 128F. During an interview on 1/22/25 at 9:30 a.m. with Director of Dietary Services (DDS), the DDS states staff use display gauges on front of machine to confirm machine temperatures. DDS states they have no other method for temperature validation. During a concurrent observation 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 ensure safe food handling and sanitation when: 1.Expired pizza sauce per the facility's refrigerated shelf- life guidance was available for use in the walk-in refrigerator. 2. Opened bag of cheese was not dated when opened to have a system to follow the facility's Refrigerated Storage Chart, shelf-life guidance. 3. The dry food storage room stored an undated opened bag of pasta, multiple large, unopened canned foods not dated with a received date, ingredient bins containing flour, and thicken-up were not dated, and a dented can of tuna was available for use. 4. The wall located by the clean side of the high temperature dish machine had extensive black colored substance on the surface of the wall. And the covers to the light fixture in the dish machine room were cracked and broken which posed a risk for foreign object cross-contamination. 5. The preparation of cantaloupe was not done in accordance with food safety standards of practice. 6. The facility lacked temperature monitoring of the refrigerator located…

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 standard infection control practices were followed when: 1. A Housekeeping Staff (HK 1) did not use gloves while sweeping and collecting trash inside a resident's room (room [ROOM NUMBER]), and did not perform hand hygiene after contact with potentially contaminated items. 2. A Licensed Nurse (LN 1) did not sanitize the handheld inhaler of one unsampled resident (Resident 34) before and after use and did not perform hand hygiene after contact with the resident. 3. LN 5 did not sanitize a glucometer test kit (a kit containing test strips and a device used to measure blood sugar) and perform hand hygiene after checking the blood sugar of one of 14 sampled residents (Resident 24). 4. Expired catheter stabilization device (a device, alternative to tape, used to secure catheters in place) and an opened, non-reusable wound care dressings were found in the treatment cart (storage for medical and treatment supplies). These failures had 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 initiate a care plan for one of 14 sampled residents (Resident 19), to prevent a pressure ulcer (an injury that breaks down the skin and underlying tissue) on the buttocks from developing or getting worse. This failure resulted in the development of two stage I (first stage- shearing off of the first layer of the skin ) pressure ulcers to the left and right buttocks. Findings: During a review of facility's policy and procedure (P&P) titled, Care Planning, dated 2/11/20, the P&P indicated in part, .To assure all residents care needs are identified through continuous assessments and those needs are care planned .All residents will have a comprehensive care plan to meet their individual needs . During a review of Resident 19's admission Record, dated 3/2/23, the record indicated, resident is a [AGE] year-old with admitting diagnoses including Multiple Sclerosis (nervous system disease that affects your brain and spinal cord) and is confined…

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 an accurate, and effective system for monitoring parameters of nutritional status when: 1. An order for a therapeutic (to cure or restore to health) liquid nutritional supplement (Mighty Shake) was not documented as being provided and lacked documentation of quantity of consumption of the therapeutic nutrition supplement for effective monitoring pertaining to parameters of nutritional status for one of ? sampled residents (Resident 41). 2. Speech therapist (ST) recommendation for 1:1 supervision during mealtimes was not communicated via an order to ensure the recommendation based on ST assessment would be implemented for Resident 41's health and safety when the texture of a diet order was modified. Failure to consistently ensure nutrition interventions were carried out and monitored had the potential to ineffectively evaluate nutrition interventions and delay an alternative nutrition approach, if necessary, to help prevent or…

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

Based on observation, interview, and record review, the facility failed to ensure a nutrition services employee had the appropriate competency and skill set to carry out the function of accurately completing the Dishmachine Temperature Log. The facility failure to have accurate documentation of dish machine temperatures and lack of monitoring of the dishmachine temperature log impeded the facility's ability to identify temperature problems that could have occurred for prompt resolution to ensure the health and safety of residents. Findings: During a concurrent observation and interview on 07/25/23, at 10:36 a.m., with Nutrition Services employee (NS) 4, in the main kitchen, NS 4 was observed running resident dishes through the high temperature dish machine. NS 4 stated, he was responsible for completing the Dishmachine Temperature Log (DTL). In the presence of the Director of Nutrition Services (DNS), who translated in Spanish to NS 4, NS 4 was asked to show or explain how he documented the temperature for the Wash Temp [temperature] column located on the DTL. NS 4 showed the wash…

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 menu as planned when: 1. The SB 6 (Soft, Bite Sized Food) diet was not followed related to the size of meat in accordance with the facility's planned menu, and Diet Manual for SB 6 diet for two of 14 sampled residents (Resident 35 and Resident 3). 2. A regular portion diet was not followed per the planned menu, and diet order, for one of 14 sampled residents (Resident 8) when small portions were served by a cook in the main kitchen. This failure had the potential to not meet the resident's nutritional needs per the planned menu as approved by the facility's Registered Dietitian. In addition, not following the correct size of meat for a SB 6 diet had the potential to place resident's at an increased risk of choking. Findings: 1. During a concurrent observation and interview on 07/25/23, at 12:19 p.m., in the kitchenette next to the main dining room, licensed nurse (LN) 1 was observed lifting the lid that covered Resident 3's lunch plate and compared it to Resident 3's diet order listed on 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 ensure its required QAA (Quality Assessment and Assurance) Committee (a committee organized by the facility which is responsible for developing and implementing corrective action plans for identified quality deficiencies) members included a credentialed Infection Preventionist [(IP - a staff trained to have oversight of the facility's infection prevention and control program (IPCP)]. This failure had the potential to result in the facility's IPCP not getting implemented effectively which could lead to misinformation, inadequate surveillance and reporting, and spread of healthcare associated infections. Findings: During a review of the facility's policy and procedures (P&P) titled, QAPI (Quality Assurance Performance Improvement - an ongoing process that guides the facility's efforts in assuring care and services are maintained at acceptable level of performance), dated 11/6/17, the P&P failed to indicate the facility-designated IP as a member of the…

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

Based on interview, and record review, the facility failed to designate a credentialed Infection Preventionist [(IP - a staff trained to have oversight of the facility's infection prevention and control program (IPCP)]. This failure had the potential for no coordination of infection control practices, increasing the risk of infections for residents, staff, visitors and others in the facility. Findings: During a review of the CMS (Center for Medicare and Medicaid Services) Memorandum QSO-19-10-NH, dated 3/11/19, the memo indicated in part, The CMS and CDC collaborated on the development of a free on-line training course in infection prevention and control for nursing home staff in the long-term care setting . Effective November 28, 2019, the final requirement includes specialized training in infection prevention and control for the individual(s) responsible for the facility's IPCP. The memo indicated further, . The course if approximately 19 hours long and is made up of 23 modules and submodules . In order to receive continuing education for the course and a certificate of…

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