Main West Postacute Care

Based on interview, record review, document review, and facility policy review, the facility failed to implement the pharmacist's recommendation for 1 (Resident #93) of 5 sampled residents reviewed for unnecessary medications. Findings included: An undated facility policy titled, Consultant Pharmacist Reports, revealed, The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing and the attending physician, and if appropriate, the medical director and/or the administrator. The policy further revealed, G. Recommendations are acted upon and documented by the facility staff and or the prescriber. 1) Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. An admission Record revealed the facility…

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

Based on observation, interview, record review, document review, and facility policy review, the facility failed to address dental needs for 1 (Resident #39) of 1 sampled resident reviewed for dental. Findings included: A facility policy titled, Availability of Services, Dental, dated 01/2018 indicated the following, Oral healthcare and dental services will be provided to each resident. PROCESS 1. Dental services are available to all residents requiring routine and emergency dental care. The policy continued, 3. Social services will be responsible for making necessary dental appointments. 4. All requests for routine and emergency dental services should be directed to social services to assure that appointments can be made in a timely manner. An admission Record indicated the facility admitted Resident #39 on 02/15/2024. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/2024, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #39's Care Plan Report, included a…

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

Based on observation, interview, record review, and facility policy review, the facility failed to implement enhanced barrier precautions (EBP) for 2 (Resident #93 and Resident #252) of 21 sampled residents. Findings included: A facility policy titled Enhanced Barrier Precaution, dated 06/2022, revealed, Enhanced Barrier Precautions expand the use of PPE [personal protective equipment] and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [multidrug-resistant organism] to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact activities. The policy specified, 1. Enhanced Barrier Precautions can be applied to residents with any of the following: a. Wounds or indwelling medical devices, regardless of MDRO colonization status such as but not limited to central line, urinary catheter, feeding tubes, tracheostomy/ventilator care). B. Infection or colonization with an MDRO. 2. Use EBP for high-contact resident care activities by using gown and glove…

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 interventions indicated in the plan of care were being provided by the nursing staff for Resident 1 in accordance with professional standards of practice for one of four sampled residents (Resident 1), when Resident 1 ' s splint and finger sleeve was not available for Resident 1. This failure failed to meet the medical needs of Resident 1 and had the potential to contribute to contractures (perment tightenting of joints that casues stifness) Resident 1 ' s right hand. Findings: During a review of Resident 1's admission Record (AR) (document containing resident demographic information and medical diagnosis), dated 1/27/25, the AR indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included but are not limited to .TYPE 1 DIABETES MELLITUS WITH UNSPECIFIED DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) .ESSENTIAL…

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, record review, and observation, the facility failed to ensure sufficient preparation and orientation for a safe and orderly discharge from the facility for one of one sampled resident (Resident 1) when the facility planned to discharge Resident 1, a [AGE] year-old female with medical and physical needs, to a homeless shelter. This failure resulted in emotional stress, increased anxiety, an increase in antipsychotic medication (used to treat mental health disorders), and near daily episodes of mood swings as evidenced by angry outbursts from Resident 1 and potential for an unsafe discharge. Findings: During a review of Resident 1 ' s admission Record (AR), dated 8/6/24, the AR indicated Resident 1 was a [AGE] year-old female admitted to the facility six years ago. Resident 1 ' s diagnoses included Multiple Sclerosis (MS, a chronic neurological disorder), Type 2 Diabetes Mellitus (chronic condition regarding the inability to control blood sugar), Chronic Obstructive Pulmonary Disease (COPD, 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 interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) had an accurate Minimum Data Set Assessment (MDS, a set of comprehensive, standardized assessments), when her MDS assessment dated [DATE] was not accurate. This failure had to potential to affect the care and facility placement of Resident 1. Findings: During a review of Resident 1 ' s admission Record (AR), dated 8/6/24, the AR indicated Resident 1 was a [AGE] year-old female admitted to the facility six years ago. During a review of an email from Resident 1 ' s insurance provider, dated 7/3/24, at 2:44 PM, and addressed to the facility ' s Social Services Director, the email indicated Resident 1 . does not have needs that require this level of care [care required by a Skilled Nursing Facility] . the member is appropriate to discharge to a lower level of care. During a review of Resident 1 ' s Progress Notes (PN), dated 8/5/24, at 4:33 PM, the PN indicated, SSD, joined by DON [Director 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the policy and procedure titled, Hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) Program for one of three sampled residents (Resident 1) when the facility failed to collaborate with the facility and hospice provider regarding Resident 1 ' s request to receive HIV (human immunodeficiency virus - virus that attacks cells that help the body fight infection) treatment. This failure resulted in Resident 1 not receiving HIV treatment and increasing his chances of weakened immunity (protecting the body against an infectious). Findings: During an interview on 5/7/24 at 2:00 p.m. with Family (FM 1), FM 1stated that the facility informed him that hospice was responsible to provide HIV medication. FM 1 stated when he spoke to hospice they informed him that the facility was responsible to provide the HIV medication and that there was no reason that he couldn ' t receive it.…

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) maintained acceptable parameters of nutritional status when the Registered Dietitian (RD) was not notified of Resident 1's weight loss of 6.8 pounds (9.6%) in 3 weeks and by mouth (PO) intake was 60% to obtain recommendations to prevent unplanned and further weight loss. As a result of this failure, Resident 1's compromised nutritional status was not addressed which had the potential to lead to further medical complications. Findings: During a review of Resident 1's admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included hypertension (high blood pressure), long term use of insulin (controls amount of sugar in the body) and muscle weakness. During a review of the facility document titled, Weights and Vitals Summary (WVS), dated 4/29/24,…

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NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents environment remained free of accidents and hazards when: 1. Four of 41 residents' rooms (Residents 6, 54, 64 and 73) had unsecured, exposed electrical cable wires and were hanging from the ceiling within arm's reach. 2. Six of 41 residents' rooms (Resident 3, 4, 63, 67, 68 and 71) had water leaking in the bathroom from a clogged swamp cooler line. These failures had the potential to place residents and staff at risk for accident hazards such as electrocution, skin burns, slip and fall, ceiling collapse and avoidable resident and staff injury. Findings: 1. During a concurrent observation and interview on 8/22/23 at 10:22 a.m. with Resident 73 in her room, unsecured exposed cable wires hung from ceiling tiles within arm's reach were observed. Resident 73 sat in her wheelchair next to her bed and stated the cable wires have been hanging for as long as she can remember. Resident 73 stated it was unsafe. During a concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the policy and procedure titled, Hospice Program for eight of eight sampled residents (Residents 25, 26, 47, 54, 55, 81, 85, and 291) when the facility failed to ensure hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) personnel caring for residents under hospice services were provided orientation to the facility's policies and procedures. This failure had the potential to place Residents 25, 26, 47, 54, 55, 81, 85, and 291 at risk of not receiving appropriate medical, physical, psychosocial, and spiritual support to manage symptoms associated with terminal illness. Findings: During an interview on 8/23/23, at 8:09 a.m., with Hospice Registered Nurse (RNCM), in Station 1 hallway, RNCM stated, she was the assigned RNCM for Resident 25 and Resident 54 for over a month. RNCM stated, she performs skilled nursing assessment for Resident 25 and Resident 54 and collaborates with…

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

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) assessment accurately reflected resident's current status for one of three sampled residents (Resident 64) when MDS assessments failed to accurately code the functional limitations according to the Resident Assessment Instrument (RAI- guidelines on gathering definitive information on a resident's strengths and needs) guidelines. This failure had the potential for Residents 64 not being provided with the necessary care and services to meet his healthcare needs. Findings: During a concurrent observation and interview on 8/22/23 at 11:09 a.m. with Resident 64, Resident 64 was observed in his wheelchair with a contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) left hand. Resident 64 stated, he had left sided weakness related to previous stroke (damage to the brain from interruption of its blood supply). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide routine dental care for one of three sampled residents (Resident 79) according to the facility's policy and procedure titled, Dental Services, when Resident 79 had not been seen for routine dental services since being admitted to the facility on [DATE]. This failure resulted in Resident 79 not having a dental appointment since admission and wanting dentures. Findings: During a record review of Resident 79's admission Record (AR), dated 8/25/23, the AR indicated, Resident 79 was admitted to the facility on [DATE] and had .Unspecified Protein-Calorie Malnutrition . (a disorder caused by lack of proper nutrition or an inability to absorb nutrients from food). During a record review of Resident 79's Minimum Data Set (MDS), assessment (an evaluation of a resident's cognitive and functional status) dated 7/11/23, the MDS indicated the Brief Interview for Mental Status (BIMS) score (an assessment of a resident's cognitive status for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to provide the correct diet for one of ten sampled residents (Resident 54) during lunch tray assembly when Resident 54 was on a fortified diet (an enrichment of food to increase calorie and protein to sustain or gain weight) and dietary staff did not follow the facility's policy and procedure titled, Fortification of Food: Increasing calories and/or protein in the diet to provide Resident 54 with 1 tablespoon (Tbsp - unit of measurement) of extra tartar sauce (a condiment made of mayonnaise mixed with other ingredients) and 2 teaspoons (tsp - unit of measurement) of extra salad dressing. This failure had the potential to result in Resident 54 to not receive the adequate nutritional requirement to sustain or gain weight. Findings: During a record review of Resident 54's admission Record (AR), dated 8/24/23, the AR indicated, Resident 54 was admitted to the facility on [DATE] and was on hospice (palliative care for terminally ill residents)…

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 store food according to the facility's policy and procedure titled, Storage of Food and Supplies, when two of four sampled plastic bin containers with ready to eat dry cereal were labeled with incorrect use by dates (date in which the item must be used). This failure did not meet the professional standards for food safety, had the potential to cause foodborne illness (sickness due to eating contaminated food), and loss of nutritional efficacy (value). Findings: During a concurrent observation and interview on 8/22/23 at 10:00 a.m., with the Dietary Supervisor (DS), in the facility's kitchen pantry (area where dry goods are stored), one 20 liter (L-unit of measurement) plastic bin container with [brand name] ready to eat dry cereal was labeled, Received date: 8/21/23. Use by date: 8/13/24. The second 20 L plastic bin container with [brand name] ready to eat dry cereal was labeled, Received date: 8/21/23. Use by date: 6/8/24. The DS stated, the use by dates were incorrect. The DS stated, ready to eat dry cereal…

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 an appropriate discharge for one of two sampled residents (Resident 1), when the facility issued a 30-day advance notice of discharge to Resident 1 and did not specify a location to which the resident would be discharged . This failure had the potential to result in an unsafe discharge and resulted in Resident 1 experiencing anxiety. Findings: During an interview on 7/27/21 at 4:20 p.m. with the Director of Nursing (DON), the DON stated the facility issued a 30-day discharge notice to Resident 1 because Resident one was not compliant with the facility's smoking policy. During an interview on 7/28/21 at 10:55 a.m. with the social worker (SW), the SW stated a 30-day discharge notice was issued by the IDT (interdisciplinary team) on 6/29/21 after a staff member stated she observed Resident 1 outside smoking without supervision. During an interview on 7/28/21 at 11:45 a.m. with Resident 1, Resident 1 stated she had been a resident at the facility since 2018. Resident 1 stated she is a smoker and for three years she did…

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 dietary supervisory supervisor (DSS) possessed the appropriate competencies and skills sets to carry out the functions of the food and nutrition service department in accordance with her job description when: 1. Evaluations of dietary staff competency were not conducted and Dietary Aide (DA)1 and [NAME] 1 were unable to accurately identify the correct level of sanitizer used to sanitize food preparation surfaces, food utensils and dishware; (cross-reference F802) 2. Evaluations of dietary staff competencies were not conducted for [NAME] 1, [NAME] 4 and DA 2 in relation to food service, therapeutic diets and menu compliance and dietary staff were unable to cool down cooked foods and monitor food temperatures according the Food Code standards and the facility policy and procedure; (cross-reference F803, F805 and F812 a. ) 3. The DSS did not provide the necessary oversight of food safety, sanitation, and storage in the kitchen when: a. Dietary staff were not implementing or accurately documenting safe…

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 two dietary staff, Dietary Aide (DA) 1 and [NAME] 3 possessed appropriate competencies and skills sets to perform the duties in the kitchen when DA 1 and [NAME] 3 did not follow manufacturer's guidelines for testing the sanitizer chemical strength used to clean food preparation surfaces and in the 3-compartment dishwashing sink. This failure had the potential to cause food borne illnesses for residents who received meals from the kitchen. Findings: During a concurrent observation in the kitchen and interview with DA 1, on 12/9/19, at 3:38 p.m., DA 1 demonstrated how to test the quaternary ammonium (quat) sanitizer concentration that was used to sanitize food preparation areas. DA 1 stated he was responsible for preparing the sanitizer buckets. DA 1 took a quat test strip and immersed the strip into the red bucket of sanitizer for 4 seconds and stated that it read a concentration of 400 parts per million (ppm). The test strip was compared to a color chart on the test strip container which indicated the…

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

Based on observation, interview, and record review, the facility failed to store, prepare, sanitize and serve food in accordance with professional standards for food service safety affecting residents who received meals from the kitchen when: 1. Dietary staff were not implementing or accurately documenting safe food cool down methods. 2. The ice machine was not maintained according to manufacturer's cleaning recommendations and contained a pinkish/red residue inside the evaporator next to the ice tray on the inner right side. 3. The vegetable washing sink and ice machine did not have air gaps (is an amount of space that separates a water line from a drain to a sewer). 4. Cooking equipment and plastic ware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze were not discarded. 5. The food service utensils, food preparation areas, equipment and kitchen floors had residue and were soiled. 6. [NAME] 2 and Dietary aide (DA) 3 prepared food and did not cover their facial hair. 7. Food storage containers were soiled, stacked wet and not air dried. These…

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 observations, interviews, and record review the facility failed to ensure safe and sanitary practices were instituted for food brought in to residents by family or visitors from outside the facility when food saved for resident consumption was stored in employee refrigerators without temperature controls. The food stored was unlabeled and undated. This failure could result in consumption of food that is unsafe and cause foodborne illness in residents who received food from outside sources. Findings: During an interview on 12/10/19, at 2:55 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated food brought in from home or a restaurant would have to be thrown away by the end of the day. During an interview on 12/10/19, at 2:59 p.m., with CNA 2, she stated stored resident's food would be kept in the staff refrigerator located in the staff breakroom. CNA 2 stated the food kept in the refrigerator in the resident dining room were snacks prepared by the kitchen for Licensed Nurse to use if a resident experienced low blood sugar levels. During an observation on 12/10/19,…

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 effectively implement their infection control and prevention program when the Director of Staff Development/Infection Preventionist (DSD/IP) had incomplete infection surveillance logs for the monitoring, tracking and trending of facility infections for September 2019, October 2019, and November 2019, for 22 of 22 sampled residents (Resident 4, Resident 22, Resident 39, Resident 45, Resident 49, Resident 52, Resident 63, Resident 76, Resident 78, Resident 83, Resident 85, Resident 334, Resident 384, Resident 486, Resident 487, Resident 488, Resident 489, Resident 490, Resident 491, Resident 492, Resident 493 and Resident 494. These failures placed the 22 residents at risk for adverse reactions from the prescribed antibiotics and/or develop an antibiotic-resistant (not effective to treat an infection) organisms from the potentially unnecessary or inappropriate antibiotic use and had the potential to place other residents, staff and visitors to experience infection from the inadequate surveillance of infections…

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 staff consistently developed and implemented the comprehensive person focused care plan for three of five sampled residents (Resident 23, Resident 27 and Resident 334) when: 1. Resident 23 was transferred from bed to wheelchair by one Certified Nursing Assistant (CNA) 4 using the mechanical lift instead of two staff members as indicated on the care plan. 2. Resident 27 had known self-feeding difficulties and would spill food on herself. A Comprehensive Care Plan was not developed to optimize Resident 27's self-feeding independence and prevent food spillage. 3. Resident 334's fall prevention care plan interventions were not implemented. These failures placed Resident 23, Resident 334 at risk for falls and injuries and Resident 27 at risk for weight loss and decreased eating independence. Findings: 1. During a concurrent observation and interview on 12/9/19, at 10:49 a.m., in Resident 23's room, there was a Mechanical Lift sitting…

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 menus were followed for residents on fortified diets and No Concentrated Sweets (NCS) diet served on 12/9/19 during the lunch meal service when fortified diets and NCS diets were not served in accordance with residents physician prescribed diet. This failure had the potential to result in residents not receiving the amount of calories and nutrients prescribed by their physician which could lead to unplanned weight loss and further compromise their medical status. Findings: During a concurrent meal service observation and interview on 12/09/19, at 11:30 a.m., in the kitchen, [NAME] 4 prepared pureed chili. [NAME] 4 poured 3 bean chili into blender to puree (nothing else was added). During tray line on 12/9/19 at 11:50 a.m., [NAME] 2 called out diets on the tray tags and [NAME] 1 plated (serve or arrange (food) on a plate or plates before a meal) the food according to what was called out. [NAME] 2 called out fortified diets when it was listed on the tray tickets. When questioned about what was different…

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 residents received a dignified dining experience when Certified Nursing Assistant (CNA) 3 stood while he fed Resident 7, who laid in bed. This failure violated Residents 7's rights to be treated with respect and dignity while receiving assistance with his meal. Findings: During an observation on 12/10/19, at 12:40 p.m., in Resident 7's room, Resident 7 laid in his bed while CNA 3 stood by Resident 7's bedside as he fed Resident 7 his lunch. During an interview with CNA 3, on 12/10/19, at 12:55 p.m., CNA 3 stated the facility allowed staff to stand while feeding residents and that it was his own preference to stand instead of sitting while feeding residents. During an interview with the Interim Director of Nursing (IDON), on 12/11/19, at 11:38 a.m., she stated staff should be at residents' eye level when feeding the resident. The IDON stated standing over a resident while feeding could make Resident 7 feel uncomfortable. During a review of the facility's policy and procedure titled, Assistance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set assessment (MDS- assessment of physical and psychological functions and needs) accurately reflected resident's healthcare and functional status for one of three sampled residents (Resident 66) when a diabetic ulcer (a sore that usually forms on the foot of a person who has diabetes - is a disease that causes high blood sugars) was inaccurately coded on Resident's 66's quarterly MDS assessment. This failure had the potential to result in Resident 66's care needs going unmet. Findings: During a review of Resident 66's face sheet, dated 12/12/19, the face sheet indicated Resident 66 was re-admitted on [DATE] with diagnosis which included peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block), type 2 diabetes mellitus (high levels of the sugar in the blood) and heart failure. During a review of Resident 66's MDS assessment, 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.

Based on observation, interview, and record review the facility failed to ensure residents were free of significant medication errors when Registered Nurse (RN) 1 administered Metoprolol Tartrate (medication use to treat high blood pressure) to Resident 65 without conducting an assessment of Resident 65's heart rate. This failure had the potential for Resident 65 to experience bradycardia (slow than normal heart rate) and an increased risk for falls. Findings: During a medication administration observation on 12/12/19, at 8:14 a.m., RN 1 administered Metoprolol Tartrate 25 milligrams (mg) (unit of measure) tablet by mouth to Resident 65 without conducting an assessment of Resident 65's heart rate. During a review of Resident 65's clinical record, the Face Sheet (a document containing resident profile information) dated 12/19, indicated Resident 65 was admitted to the facility with a diagnosis of Essential Hypertension (high blood pressure that does not have a secondary cause), muscle weakness (generalized) and unsteadiness on feet. During a review of the Order Summary Report for…

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

Based on observation, interview, and record review, the facility failed to ensure drugs were labeled with open date in accordance with the facility Administering Medications policy and procedure for two of six sampled residents (Resident 31 and Resident 32) when Resident 31 and Resident 32's Proheal Oral Protein medication bottle was available for use without an opened date labeled on the medication container. This failure had the potential to place Resident 31 and Resident 32 at risk of receiving expired medications which could lead to medication ineffectiveness and experience adverse reactions from potentially expired medication. Findings: During a medication pass observation on 12/10/19, at 12:04 p.m., with Licensed Vocational Nurse (LVN) 6, LVN 6 administered medications from Station One's Medication Cart. The medication cart contained one bottle of Proheal Oral Protein without an open date written on the bottle. LVN 6 stated the Proheal Oral Protein medication bottle had been opened and belonged to Resident 32 and Resident 31. LVN 6 verified the Proheal Oral Protein medication…

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 prepare and serve food appropriate to meet the needs of one of ninety residents (Resident 355) when dietary staff served hard corn bread for Resident 355 on a mechanical soft diet (a diet prescribed to residents by a physician that is soft or mechanically altered food and is easy to chew) on the lunch tray. This failure had the potential to place Resident 355 at risk for choking and possible death. Findings: During a concurrent observation of tray line food service and interview with Registered Dietitian (RD) 1, and [NAME] 2, on 12/9/19, at 11:42 a.m., [NAME] 2 called out diets on a tray ticket and [NAME] 1 placed the foods that pertained to the diets called out on a plate to serve to the resident. [NAME] 2 called out .mechanical soft . for Resident 355. [NAME] 1 placed a piece of corn bread on Resident 355's plate. The corn bread was a side piece and had dark brown colored, hard edges and was very hard to the touch. The plate with the cornbread and other foods was placed on a tray on the food cart ready 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.