Westgate Gardens Care Center

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was evaluated to self-administer medication when lidocaine (medication used to relieve pain) was left at the bedside. This failure resulted in Resident 1 having medication at bedside and the potential to self-administer medication incorrectly. Findings: During a concurrent observation and interview on 4/7/25 at 11:10 a.m. with Resident 1 in Resident 1's room, Resident 1 was holding a washcloth up to her mouth and appeared in pain. There was a medication cup with a clear gel looking substance on Resident 1's over bed table. Resident 1 stated she had a bad tooth, and was provided the lidocaine in the medication cup from the nurse so she could use it when she was in pain. During a concurrent observation and interview on 4/7/25 at 11:18 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, LVN 1 stated the medication cup that was on Resident 1's over bed table contained lidocaine. LVN 1 stated when a resident was to self-administer medication 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.

Based on interview and record review, the facility failed to ensure the Ombudsman (government-appointed official who investigates and attempts to resolve complaints in the long-term care facility) was notified when one of three sampled residents (Resident 1) was provided a 30-day notice to discharge the facility for non-payment. This failure had the potential for Resident 1 to experience an inappropriate discharge. Findings: During a review of Resident 1's Notice of Proposed Transfer/Discharge (NPTD) dated 3/11/25, the NPTD indicated, Reason(s) for transfer/discharge: non-payment of share of cost assigned by medi-cal. You have failed, after reasonable and appropriate notice, to pay for your stay at the facility. If you became eligible for Medi-cal after admission to the facility the facility may charge you only allowable charges under Medi-cal.4/9/25 effective date of transfer/discharge.(signature of facility representative).3/12/25.(signature of Resident 1).3/12/25. During an interview on 3/28/25 at 12:23 p.m. with Administrator, Administrator stated Resident 1 was issued a 30-day…

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 Advance Directives (AD-a legal document indicating resident preference on end-of-life treatment decisions) were offered and completed for two of 32 sampled residents (Resident 19 and Resident 103). This failure had the potential for residents' healthcare wishes to not be honored. Findings: During a concurrent interview and record review on 2/20/25 at 9:25 a.m. with Nursing Consultant (NC), NC was unable to provide documentation of an AD for Resident 19. NC stated there is no AD on file or no documentation of AD being offered or discussed with Resident 19 or Resident 19's responsible party. During a concurrent interview and record review on 2/24/25 at 11:28 a.m. with Social Services (SS), Resident 103's Advance Directive (AD), dated 6/06/24 was reviewed. The AD indicated, on 6/06/24 Resident 103 was interested in executing an AD. SS stated Resident 103 had checked that he was interested in the AD per the paperwork and there was no documentation on file that it was followed up. During a review of Resident 103'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 interview and record review, the facility failed to ensure its arbitration agreement explicitly indicated that the resident or his or her representative had the right to rescind the agreement within 30 calendar days of signing the arbitration agreement. This failure had the potential for 92 of 138 residents who signed arbitration agreements not to understand their right to rescind the arbitration agreement within 30 days. Findings: During a concurrent interview and record review on 2/24/25 at 9:30 a.m. with the Admissions Director (AD), the facility's list of current residents who signed arbitration agreements was reviewed. A review of the list of current residents who signed arbitration agreements indicated 92 of 138 residents had signed it. The AD stated the facility offered arbitration agreement to all its residents. During a concurrent interview and record review on 2/24/25 at 11:34 a.m. with the Administrator, the facility's Arbitration Agreement (Agreement) (undated) was reviewed. The Agreement indicated, This Agreement may be rescinded by written notice within thirty…

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 document the attendance of Quality Assurance and Performance Improvement (QAPI) committee meetings during ten of 12 meetings in 2024. This failure prevented the verification of attendance of the required QAPI committee members (Administrator, Director of Nursing, Medical Director, and Infection Preventionist). Findings: During a concurrent interview and record review on 2/24/25 at 3:22 p.m. with the Administrator, the facility's QAPI committee meeting minutes (the minutes) for 2024 were reviewed. The minutes indicated monthly meetings during 2024 but attendance sheets only for the November 2024 and December 2024 meetings. There was no documentation of who attended the meetings held from January 2024 to October 2024. The Administrator stated the facility started documenting the attendance of QAPI committee meetings in November 2024. The Administrator stated there was no documentation of who attended the meetings from January 2024 to October 2024. During a review of the facility's policy and procedure (P&P) titled, Quality…

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 three of 12 sampled residents (Resident 97, Resident 34, and Resident 13) were treated with dignity when they had to wait up to two hours for their call light request to be answered. This failure resulted in residents experiencing discomfort and feeling upset and the potential for skin breakdown. Findings: During a concurrent observation and interview on 2/19/25 at 7:48 a.m. with Resident 97 in Resident 97's room, Resident 97 was sitting up in bed. Resident 97 stated the longest she's waited for staff to answer her call light was approximately two hours for someone to help her and she needed her brief to be changed because she had soiled her brief. Resident 97 stated she needs two people to help her change her brief. Resident 97 stated, It made me feel like crap. During a review of Resident 97's admission Record, (AR) dated 3/28/24, the AR indicated Resident 97 had a diagnosis of Unspecified Sequelae of Cerebral Infarction…

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 call lights were within reach for two of 64 sampled residents (Resident 42 and Resident 101). This failure had the potential to result in residents' needs not being met. Findings: During a concurrent observation and interview on 2/18/25 at 10:14 a.m. with Resident 42 in Resident 42's room, the call light was tied to the right side rail close to the top of the bed. When Resident 42 was asked how she would call for assistance, Resident 42 tried to reach the call light but could not. Resident 42 stated she could not reach the call light. During a concurrent observation and interview on 2/18/25 at 10:15 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 42's room, Resident 42's call light tied to the right side rail close to the top of the bed. CNA 1 stated Resident 42 could not reach the call light. CNA stated the call light should be within reach. During an observation 2/18/25 at 10:19 a.m. in Resident 101's room, Resident 101's call light was attached to the bed and not within reach. 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.

Based on observation, interview, and record review, the facility failed to ensure a functioning overhead light was provided for one of eight sampled residents (Resident 37). This failure resulted in Resident 37 to not have a light available for personal use. Findings: During a concurrent observation and interview on 2/18/25 at 9:44 a.m. with Resident 37 in Resident 37's room, there was a light on the wall above Resident 37's bed, the string to turn on the light was detached. Resident 37 stated she has been unable to turn on the light and the string had been broken for a couple of weeks. During a review of Resident 37's Minimum Data Set [MDS - a federally mandated resident assessment tool], dated 1/30/25, the MDS indicated Resident 37 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 11 (score of 8-12 means moderate cognitive impairment). During an interview on 2/18/25 at 9:57 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the string to turn on 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 follow one of eight sampled residents (Resident 103) care plan for smoking. This failure had the potential to result in Resident 103 to not meet his psychosocial (a person's well-being) needs. Findings: During a review of the facility's Smoking Times and Location (STL), (undated), the STL indicated, Smoking Times are 9:00 a.m. - 9:10 a.m. (CNA St [station] 1), 11:00 a.m. - 11:10 a.m. (CNA St 2), 1:15 p.m. - 1:25 p.m. (CNA St 3), 4:30 p.m. - 4:40 p.m. (CNA St 2), 8:00 p.m. - 8:10 p.m. (CNA St 3). Resident will need to be by the smoking door ready to go out at smoking times. During a concurrent observation and interview on 2/19/25 at 10:44 a.m. with Resident 103 in Resident 103's room, Resident 103 was dressed and lying in bed. A wheelchair was parked on the left side of bed. Resident 103 stated, No one has come to offer to get me ready for a smoke break. During a concurrent observation and interview on 2/19/25 at 11:07 a.m. with Resident 103 in Resident 103's room, Resident was dressed and still lying in bed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled for one of seven residents (Resident 83) when two of Resident 83's medications were labeled with the wrong type of insulin and the wrong resident's name. These failures had the potential for Resident 83 to receive the wrong insulin, another resident's insulin or another resident to receive a medication without a physician order. Findings: During a review of Resident 83's admission Record (AR), dated 2/24/25, the AR indicated Resident 83 was admitted on [DATE] with diagnoses including diabetes mellitus (inability to control blood sugar levels). During a review of Resident 83's Order Details (OD), order date 11/21/24, the OD indicated the following medication order: HumaLOG Kwikpen Subcutaneous [under the skin] Solution Pen-Injector 100 UNIT/ML (Insulin Lispro) [a fast acting insulin] Inject subcutaneously before meals for DM [Diabetes Mellitus]. During a review of Resident 83's OD, order date…

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 of eight sampled residents (Resident 93 and Resident 103) meal consumption percentages were documented accurately. This failure had the potential to resulted in Resident 93 and Resident 103 to experiencing unplanned weight loss or weight gain. Findings: During a concurrent observation and interview on 2/18/25 at 11:41 a.m. with Resident 93, Resident 93 was sitting in bed eating her lunch in her room. Resident 93 stated, There has not been anything on the food menu that has been tasteful. I end up with those chicken nuggets all the time and I am tired of it. I have never eaten 80% of my meals. During a review of Resident 93's Minimum Data Set [MDS - a resident assessment tool] Brief Interview for Mental Status [BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident], dated 12/18/24, the MDS indicated Resident 93's BIMS was 15 [13-15 able to make decisions for self]. During an observation on 2/18/25 at 12:24 p.m. in Resident 93'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 interview and record review, the facility failed to provide a written report of an allegation of sexual abuse to the proper authorities for two of three sampled residents (Resident 1 and Resident 2). This violated Resident 1 and Resident 2's rights. Findings: During an interview on 1/28/25 at 9 a.m. with Ombudsman (an advocate for residents of nursing homes), Ombudsman stated they did not receive an SOC 341 (a required form used to report suspected abuse of dependent adults and elders) from the facility regarding the allegation of sexual abuse between Resident 1 and Resident 2. During a review of Resident 2 ' s Progress Notes (PN), dated 1/12/25 at 2:06 p.m., the PN indicated, Writer made aware by CNA (Certified Nursing Assistant) that resident [Resident 2] was found in between station 2 & 3 inappropriately touching a female resident [Resident 1]. During an interview on 1/29/25 at 12:05 p.m. with Licensed Vocational Nurse (LVN), LVN stated on 1/12/25 at approximately 12:45 pm, CNA was passing in between stations when Resident 2 was observed with his hands on top of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the care plan was implemented for one of two sampled residents (Resident 1) when non-skid strips were not placed on the bathroom floor after a fall. This failure had the potential to result in further falls. Findings: During a review of Resident 1's care plan (CP), dated 1/11/24, the CP indicated, Fall in restroom [ROOM NUMBER]/22/24.interventions/tasks.non skid [sic] strips on restroom floor.date initiated: 12/23/24. During a concurrent observation and interview on 1/2/25 at 1:57 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 1's restroom, there were no non-skid strips on Resident 1's restroom floor. CNA 1 confirmed there were no non-skid strips on the restroom floor. During a concurrent observation and interview on 1/2/25 at 2:10 p.m. with Maintenance Director (MD), in Resident 1's restroom, there were no non-skid strips on the restroom floor. MD stated he was responsible to put the non-skid strips on the restroom…

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 promptly resolve one of three sampled residents (Resident 1) grievance when Resident 1 requested for Certified Nursing Assistant (CNA 1) to not return to his room and provide care. This failure resulted in violation of Resident 1 ' s rights and potential for emotional distress. Findings: During an interview on 9/6/24 at 11:11 a.m. with CNA 2, CNA 2 stated on 8/26/24, after CNA 1 had provided care for Resident 1 and left the room, Resident 1 reported being uncomfortable with CNA 1 and requested for CNA 1 to not return to his room and care for him again. CNA 2 stated she immediately reported Resident 1 ' s request to the nurse on-duty (License Vocational Nurse-LVN). During an interview on 9/6/24 at 12:20 p.m. with CNA 1, CNA 1 stated when he went back to work on 8/30/24, he was assigned to provide care for Resident 1. CNA 1 stated Resident 1 yelled at him stating, I don ' t want you in here. During an interview on 9/9/24 at 10:14 a.m. with LVN, LVN stated on 8/26/24, CNA 2 had reported Resident 1 not being comfortable 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 interview and record review, the facility failed to notify the physician when there was a change in the discharge plan for one of three sampled residents (Resident 1). This failure resulted in the physician being unaware of Resident 1's transfer to the hospital. Findings: During a review of the Physician Order (PO) dated 5/9/24 (two days prior to discharge) at 1:44 p.m. the PO indicated, [Physician 1]; Resident to discharge on [DATE] with HH [home health], PT [physical therapy] OT [occupational therapy] RN [registered nurse], wound nurse, HHA [home health aide], msw [master of social work], NOMNC [notice of Medicare non-coverage] LCD [last covered day] 5/10. During a review of Resident 1's PN, dated 5/10/24 at 4:15 p.m. the PN indicated, SS office spoke with Rp (responsible party).informing her resident NOMNC appeal was denied. RP informed SS discharge plan is a request for resident to be sent out to [hospital name] . During a review of Resident 1's PN, dated 5/11/24 at 2:13 p.m. the PN 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.

Based on interview and record review, the facility failed to revise and implement an appropriate plan of care for falls for one of three sampled residents (Resident 1). This failure had the potential to cause serious harm. Findings: During a concurrent interview and record review on 3/26/24 at 11:57 a.m. with Director of Nursing (DON), Resident 1 ' s Electronic Medical Record (EMR), was reviewed. The EMR indicated Resident 1 had a fall in which he hit his head on 3/16/24. Resident 1 was sent to the acute hospital and returned with an acute (new) to subacute (not new) fracture (break) of L3 (lumbar-area of the spine). DON stated Resident 1 had previous falls in the facility including a fall earlier in the month (no specific date given). DON stated Resident 1 can walk but is generally confused. During a review of Resident 1 ' s admission RECORD (AR), dated 3/26/24, the AR indicated Resident 1 diagnosis including Shortness of breath, Hypotension (low blood pressure), Abnormality (abnormal) of gait and walking, Unspecified Dementia (impaired ability to remember, think, or make decisions…

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 care plan was implemented when the call light was not within reach for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to be unable to call for assistance. Findings: During a review of Resident 1's Care Plan (CP), dated 1/5/24, the CP indicated, Falls: Resident is at risk for falls with or without injury.Intervention/Tasks.Keep call light within reach.Date initiated.1/5/24. During a concurrent observation and interview on 4/17/24 at 2:28 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 1's room, Resident 1 was lying in bed. The call light push button was clipped to the call cord where it was attached to the wall. CNA 1 unclipped the call light and placed it on top of Resident 1's abdomen where he could reach it. When Resident 1 was asked what the call light push button was used for, Resident 1 stated it was used when he needed help. CNA 1 stated Resident 1 could not reach the call light push button when it was clipped to the wall, and it should…

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 of three sampled residents (Resident 1 and Resident 2) were provided a pest free environment when a spider and spider webs were on the bedroom furniture. This failure resulted in an unclean environment. Findings: During a concurrent observation and interview on 10/25/23, at 3:30 p.m., with Administrator, in Resident 1's room, Resident 1 was lying in A bed. Over B bed, noted a spider on the ceiling, spider webs under a metal chair in the corner of the room, and under two night stands there were spider webs, and one night stand had a living spider in the web. Administrator stated the resident rooms should have been cleaned everyday by the housekeeper. During a concurrent observation and interview on 10/25/23, at 4:16 p.m., with Environmental Services Supervisor (EVS), in Resident 1's room, EVS stated in Resident 1's room, there was a recent repair done to a hole in the wall and when it was being repaired there were dead spiders noted in the room. EVS stated when the housekeepers cleaned the rooms…

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

Based on observation and interview, the facility failed to clean and appropriately store one of four sampled residents (Resident 1) bed pan. This failure had the potential for contamination and the spread of infection. Findings: During a concurrent observation and interview on 7/25/23 at 12:37 p.m. with Central Supply (CS) in Resident 1's room, a used uncovered bed pan was found in Resident 1's drawer. CS stated the used bed pan should have been cleaned and wrapped in a plastic bag before storing in Resident 1's drawer. During an interview on 7/25/23 at 1:35 p.m. with Director of Staff Development (DSD), DSD stated, Bed pan were to be clean after each use, placed in a plastic bag, and stored in residents drawer. During an interview on 7/27/23 at 9:56 a.m. with Director of Nurses (DON), DON stated, the facility did not have a specific policy on bed pan storage. DON stated, it was the facility's practice to clean a bed pan after use, place in a plastic bag, and place inside resident drawer for storage.

Based on observation, interview, and record review, the facility failed to ensure expired foods were not available to be served when there was molded Hawaiian rolls and expired rice vinegar in the dry food storage area. This had the potential to be served to the residents and cause food borne illness. Findings: During a concurrent observation and interview, on 7/14/23, at 8:28 a.m., with Director of Dietary Services (DDS), in the kitchen dry storage room, the bread storage area contained two packages of Hawaiian rolls. Each package contained 12 Hawaiian rolls for a total of 24 Hawaiian rolls. Out of 24 Hawaiian rolls approximately 18 had mold on them. DDS stated, 18 out of 24 of the Hawaiian rolls were molded and they should have been thrown out. During a concurrent observation and interview, on 7/14/23, at 9:44 a.m., with DDS, in the dry food storage area, there was a bottle of rice vinegar that had an expiration date of 6/23/23. DDS stated, the rice vinegar should have been thrown out. During a review of the facility policy and procedure (P&P) titled, Storage of Food and Supplies…

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 one of three sampled residents (Resident 1) was served a palatable meal. This resulted in Resident 1 eating a molded hamburger bun. Findings: During an interview on 7/14/23, at 8 a.m., with Resident 1, Resident 1 stated, two days prior (7/12/23) she received a hamburger bun on her meal tray that was molded. Resident 1 stated, the area of mold was approximately the size of a fingernail and she could smell the mold on the hamburger bun. During an interview on 7/14/23, at 9:44 a.m., with Director of Dietary Services (DDS), DDS stated, Resident 1 had received an alternate food item that was served on a hamburger bun. DDS stated, the hamburger bun Resident 1 was provided was molded. DDS stated, the molded bun should have been caught by the cook that served the sandwich and it should have been thrown out. During a review of the facility policy and procedure (P&P) titled, Food and Nutrition Services dated 10/2017, the P&P indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his…

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 Advance Directive (AD-health care preferences, including decisions for end-of-life care) acknowledgement form was completed for nine of 13 sampled residents (Resident 13, Resident 71, Resident 64, Resident 106, Resident 33, Resident 17, Resident 66, Resident 70, and Resident 82). This failure had the potential for the licensed staff to be unaware of the desired medical treatment when residents' are no longer able to make decisions in the event of an emergency. Findings: During a concurrent interview and record review, on 4/18/23, at 11:05 AM, with Medical Records Assistant (MRA), Administrative Assistant (AA), and Regional Consultant for Clinical Services (RCCS), Resident 13's medical record was reviewed. MRA, AA, and RCCS were unable to find a completed AD acknowledgement form. RCCS stated, It's [AD acknowledgement form] not there. During a review of Resident 71's admission Packet (AP), dated 1/20/22, the AP indicated, that AD did not have questions about whether Resident 71 had an AD, wanted information about…

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 refer promptly three of five sampled residents (Resident 17, Resident 41, Resident 108) for a level II mental health services as indicated in the positive pre-admission screening and resident review report I (PASRR Level I identifies if an individual has a suspected Mental Illness [MI] or an intellectual/Development Disability or Related Condition [ID/DD/RR]. It's an evaluation data requirement to determine whether a resident with mental illness requires specialized services). This failure had the potential for residents to decline in their mental capacity and not receive specialized services. Findings During a review of Resident 17's admission Record (AR), dated 4/19/23, the AR indicated, Resident 17 was admitted to the facility on [DATE] with a diagnosis of Schizophrenia, Unspecified (a serious mental disorder in which people interpret reality abnormally) and Bipolar Disorder, unspecified (a mental illness that causes dramatic shifts in a person'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 its medication error rate was less than 5% for three of 14 sampled residents (Resident 36, Resident 45, Resident 335). This failure had the potential for adverse health outcomes related to incorrect medication administration. Findings: During an observation on 4/19/23, at 7:38 AM, outside Resident 36's room, Licensed Vocational Nurse (LVN) 11 prepared Resident 36's medications. LVN 11 crushed all of Resident 36's medications scheduled for 8 AM including Protonix (medication used to reduce stomach acid), then administered them to Resident 36. During a review of Resident 36's Order Summary Report (OSR), dated 4/19/23, the OSR indicated, Resident 36 had an order for Protonix Tablet Delayed Release 40 MG [milligrams, unit of measure] The OSR indicated, an order May crush medications unless contraindicated [not indicated] During an observation on 4/19/23, at 7:58 AM, with LVN 11, in Resident 45's room, LVN 11 gave Resident 45 his Breo Ellipta inhaler (inhaled medication used to open airways) to self…

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: 1. Ensure medications were properly labeled and stored in one of three sampled medication carts (Cart 2). This failure had the potential to result in medications being administered to the wrong resident and not being stored in accordance with manufacturers recommendations. 2. Ensure that controlled substances were stored in accordance with federal and state laws and regulations. This failure had the potential to result in drug diversion (transfer of a legally prescribed controlled substance from the individual for whom it was prescribed to another person for illegal use). 3. Maintain the recommended temperature range for medications stored in one of two medication refrigerators. This failure had the potential to result in medications losing their effectiveness. Findings: 1. During a concurrent observation and interview on 4/18/23, at 9:06 AM, with Licensed Vocational Nurse (LVN) 4, at the medication cart on Station 2, an unlabeled…

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 professional standards for food service safety and sanitary kitchen conditions. This failure had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) for at-risk vulnerable residents. Findings: During an observation on 4/17/23, at 10:04 AM, in the kitchen, [NAME] 1 was washing hands in the 3-compartment sink(requires 3 separate sink compartment that wash, rinse and sanitize) that had dirty trays and utensil cookware close to the preparation area for the egg salad lunch menu item. During an interview on 4/17/23, at 11 AM, with Dietary Manager (DM), DM stated, the staff should use the designated hand washing sink and not wash their hands in the 3-compartment sink. During a concurrent observation and interview on 4/17/23, at 10:56 AM, with Dietary Aide (DA) 1, in the kitchen, DA 1 was washing dirty pots, serving pans, and cookware utensils in the 3-compartment sink. DA 1 stated, the pots, serving trays, and cookware utensils were air drying after…

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 standard infection control practices when: 1. Used linens were not handled correctly for one of one sampled resident (Resident 92). 2. Handwashing was not performed before and after treatment/procedure for two of two sampled residents (Resident 9 and Resident 107) These failures had the potential for the spread of infections to residents, staff and visitors. Findings: 1. During a concurrent observation and interview on 4/17/23, at 9:39 AM, with Certified Nursing Assistant (CNA) 1, in Resident 92's room, a pile of bed linen was noted on the floor. CNA 1 stated, the linens were dirty and should not be on the floor. CNA 1 stated, dirty linen should have been placed in a bag. During an interview on 4/17/23, at 9:53 AM, with the Infection Preventionist (IP), IP stated, when the clothing or linen is removed from the resident or bed, it should be placed in a clear bag. IP confirmed the finding and stated, They should not be placed on the floor. During a review of the facility's policy and procedure (P&P)…

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 notify the physicians of a change in condition for two of two sampled residents (Resident 74 and Resident 33). This failure had the potential for a delay in appropriate patient care for Resident 74 and Resident 33. Findings: During a concurrent observation and interview on 4/18/23, at 12:30 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 tested Resident 74's blood sugar and blood sugar results were 366 milligrams per decilitre (mg/dL, unit of measure, normal range 70-100mg/dl). LVN 1 asked Resident 74 if she wanted to take her insulin (medication used to lower blood sugar), Resident 74 refused the insulin. LVN 1 stated, Resident 74 had refused her insulin for several days. LVN 1 stated, if residents refused three or more medications in a row, the facility should inform the physician and the responsible party. During a concurrent interview and record review, on 4/19/23, at 10:32 AM, with Director of Nursing (DON), Resident 74's Medication Administration Record (MAR), dated 4/2023, was reviewed. The MAR…

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 routinely assess depression (mental illness marked by persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) for one of seven sampled residents (Resident 66). This failure had the potential for Resident 66's depression to go untreated. Findings: During an interview on 4/18/23, at 10:25 AM, with Family Member (FM) 1, FM 1 stated, Resident 66 was diagnosed as having depression but was taken off anti-depressant medication about a year ago. FM 1 stated, she felt her mom still had depression. During a concurrent interview and record review, on 4/19/23, at 11:20 AM, with Medical Records Assistant (MRA), Resident 66's clinical record was reviewed. Medical Diagnoses included Major Depressive Disorder, Recurrent [multiple episodes of depression of varying lengths]. The Psychotropic [medications that affect a person's mental state] Gradual Dose Reduction [decreasing the dosage or discontinuing a medication] (GDR) Review form, dated 1/25/22, at 2:11 PM, indicated, Resident 66'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 interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR- assessment to ensure facility services are appropriate for people with mental illness, developmental disabilities, substance abuse disorders, or have a conservator) was completed for one of one sampled resident (Resident 70). This failure had the potential for not providing the appropriate care and treatment to Resident 70. Findings: During a concurrent interview and record review, on 4/20/23, at 12:17 PM, with Minimum Data Set Coordinator (MDSC), Resident 70's Preadmission Screening and Resident Review (PASRR) Level I Screening Document (PASRRLID), dated 5/19/20, was reviewed. The PASRRLID indicated, Level I - Negative and Section V - Mental Illness 26. Does the resident have a diagnosed mental disorder such as Schizophrenia [mental illness characterized by delusions and hallucinations]/Schizoaffective Disorder [schizophrenia with depressed or manic mood changes], Psychotic/Psychosis, Delusional Depression, Mood Disorder, Bipolar, or Panic/Anxiety? Neither Yes 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.

Based on observation, interview, and record review, the facility failed to ensure one of one visually impaired resident (Resident 82) was properly oriented to her meal tray and hot drink. This failure had the potential to negatively impact Resident 82's dignity and for her to accidentally spill her hot drink on herself. Findings: During an interview on 4/17/23, at 9:48 AM, with Resident 82 and her family member (FM) 2, FM 2 stated, Resident 82 had been blind four years due to diabetes (disease marked by high blood sugar levels which can lead to cardiac, vascular, kidney, and visual, and other health problems). FM 2 stated, Resident 82 was weak on her right side due to a stroke. FM 2 stated, the certified nursing assistants (CNA)s deliver her food trays, set the tray up, but do not orient Resident 82 to the items on the tray. During an observation on 4/17/23, at 12:02 PM, in Resident 82's room, Resident 82 was seated in a high-back wheelchair with her overbed table positioned over her lap. CNA 4 placed a mug of coffee on the overbed table but did not orient Resident 82 to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a fully continent (aware and able to control bowel and bladder function) resident was assisted with toileting needs to maintain continence for one of one sampled resident (Resident 118). This failure had the potential for Resident 118 to lose bowel and bladder continence and to negatively impact her dignity. Findings: During an interview on 4/17/23, at 2:54 PM, with Resident 118, Resident 118 stated, she was fully continent of bowel and bladder when she was admitted to the facility on [DATE]. Resident 118 stated, when she was at home, she walked to the bathroom to empty her bowel and bladder. Resident 118 stated, she was placed in briefs (adult diapers) when she was admitted to the facility. During a concurrent interview and record review, on 4/20/23, at 10:20 AM, with Medical Records Assistant (MRA), Resident 118's clinical record was reviewed. Minimum Data Set (MDS- resident assessment tool) Section H Bladder and Bowel, dated 2/27/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a Registered Dietitian's (RD) nutrition intervention recommendation was communicated to the physician in a timely manner for one of four sampled residents (Resident 50). This failure resulted in Resident 50's unplanned weight loss. Findings: During a concurrent observation and interview on 4/17/23, at 12:05 PM, with Resident 50, in Resident 50's room, an opened carton of health shake and nutritional juice supplement (to increase calories and protein) were observed. Resident 50 stated, he had lost weight previously. During a review of Resident 50's Weights and Vitals Summary (WVS), dated 2/2/23 to 4/2/23, the WVS indicated: 2/03/23 - 145 lbs (pounds [#]; a measurement of weight) 2/11/23 - 126 lbs 2/18/23 - 122 lbs 2/25/23 - 117 lbs 3/4/23 - 120 lbs 3/11/23 - 118 lbs 3/18/23 - 121 lbs 4/1/23 - 122 lbs During a review of Resident 50's Nutritional Risk Assessment (Admission/Annual) (NRA), dated 2/16/23, the NRA indicated, Resident 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 observation, interview, and record review, the facility failed to ensure a physician's order for oxygen therapy was followed for one of six sampled resident (Resident 33). This failure had the potential for Resident 33 to have complications related to inadequate oxygen administration. Findings: During a review of Resident 33's admission Record (AR), dated 4/19/23, the AR indicated, Resident 33 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation including shortness of breath) and Acute Respiratory failure with hypoxia (when your lungs cannot release enough oxygen into your blood). During an concurrent observation and interview on 4/17/23, at 11:13 AM, with Resident 33, in Resident 33's room, Resident 33 was observed laying in her bed without her oxygen on. Resident 33 stated, she only uses her oxygen at night. During a review of Resident 33'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 interview and record review, the facility failed to clarify with RD/Physician a duplicate order for a protein supplement for one of one sampled resident (Resident 103). This failure resulted in Resident 103 receiving more than the intended amount of the protein supplement and had the potential to result in undesired weight gain. Findings: During a review of Resident 103's Order Summary Report (OSR), the OSR indicated, there were two active orders for Prostat (protein supplement, wound healing). There was an order on 3/25/23, to give 30 ml (milliliters-metric unit of volume) two times a day and another order on 4/14/23, to give 30 ml three times a day. During a concurrent interview and record review, on 4/18/23, at 2:48 PM, with Licensed Vocational Nurse (LVN) 7, Resident 103's Medication Administration Record (MAR), dated 4/2023, was reviewed. The MAR indicated, Prostat was signed as given 5 times a day on 4/15/23, 4/16/23, and 4/17/23 between both orders. LVN 7 confirmed the findings and stated, MAR shows I signed for it, I must not have been paying attention. 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.

Based on observation, interview, and record review the facility failed to follow the ordered diet menu to meet the nutritional needs for three of 133 sampled residents (Resident 24, Resident 58, and Resident 93). This failure resulted in unmet nutritional needs for at-risk vulnerable residents. Findings: During a concurrent observation and interview on 4/18/23, at 11:50 AM, with Registered Dietician (RD), in the kitchen during tray line, Resident 24's lunch meal tray was prepared with a bread roll and placed in the delivery food cart by Dietary Aide (DA) 2. The RD reviewed the tray ticket with the lunch therapeutic spreadsheet for Consistent Carbohydrates (CCHO; a diet that provides a consistent amount of blood sugar balance intended for persons with diabetes [a disease of blood sugar imbalance]) and stated, Resident 24's diet should not include a bread roll food item for lunch tray. During a review of Resident 24's Physician's Order (PO), dated 3/10/23, the PO indicated, CCHO Diet. During a concurrent observation and interview on 4/18/23, at 12:05 PM, with RD, in the kitchen 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.

Based on observation, interview, and record review, the facility failed to notify the physician regarding refusal of treatment for one of 44 sampled residents (Resident 339). This failure had the potential to result in unmet care needs. Findings: During an observation and interview with a family member (FM) 2, on 10/22/19, at 3:40 PM, in Resident 339's room, there was a Bi-level Positive Airway Pressure machine (BiPAP machine - a non-invasive form of therapy for patients suffering from sleep apnea [temporary cessation of breathing during sleep]) on Resident 339's nightstand. FM 2 stated She [Resident 339] got a BiPAP but nobody knows how to use it. During an interview with the MDS (an assessment tool) Coordinator (MDSC) and review of clinical record for Resident 339, on 10/23/19, at 11:31 AM, she reviewed the Treatments Administration History dated 10/11/19 - 10/23/19 and noted the following: BiPAP with medium full face mask on @ [at] HS [bedtime] 10:30 PM and off in AM [morning] was ordered on 10/11/19. Resident 339 refused the BiPAP treatment and/or did not receive treatment on…

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

Based on observation, interview, and record review, the facility failed to administer medication via gastrostomy tube (G-tube - a tube inserted through the abdomen directly into the stomach, used to provide nutrition, fluids, and medication to people unable to take these things orally) as per the physician's order (PO) for one of 44 sampled residents (Resident 112). This failure had the potential to result in inadequate medication absorption for Resident 112. Findings: During a medication pass observation and interview with Licensed Vocational Nurse (LVN) 1, on 10/22/19, at 11:53 AM, LVN 1 poured 50 milliliters (mL - a unit of measurement) of water into a cup. She flushed Resident 112's G-tube with approximately 13 mL of water from the cup. She then mixed approximately 7 mL of water from the cup with crushed clonidine hcl (medication to treat high blood pressure) 0.2 milligrams (mg - a unit of measurement) tablet and administered it via G-tube. She then mixed approximately 7 mL of water from the cup with a crushed Vitamin C 500 mg tablet and administered it via G-tube. LVN 1 then…

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 one of 44 sampled residents (Resident 129) received routine bathing. This failure had the potential to negatively impact Resident 129's health and dignity. Findings: During an observation on 10/23/19, at 3:09 PM, in Resident 129's room, he was lying in his bed and appeared to be unshaven. During an interview with the Director of Nursing (DON), on 10/23/19, at 3:36 PM, she reviewed the clinical record for Resident 129. She stated Resident 129 was on a shower schedule of Wednesdays and Saturdays on the evening shift. She stated Resident 129 refused showers. The Point of Care dated 10/1/19 - 10/23/19 indicated Resident 129 was only given one shower during October 2019, on 10/23/19, at 2:24 PM. The document indicated Resident 129 was Total Dependence [relies on staff to meet his bathing needs]. The only dates of documented shower refusal were 10/5/19 and 10/12/19. The DON confirmed the finding. During a review of the facility policy and procedure titled Activities of Daily Living (ADLs), Supporting 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 food preferences were honored for one of 44 sampled residents (Resident 130). This failure had the potential to result in decreased nutritional intake for Resident 130. Findings: During an observation, interview with the Registered Dietitian (RD), and review of Resident 130's meal tray ticket, on 10/21/19, at 12:16 PM, in the dining room, Resident 130 had a sandwich on a plate in front of her. She had eaten approximately two bites of her sandwich. The meal tray ticket in front of her indicated Dislikes: pork. The RD stated the sandwich on Resident 130's plate was a ham sandwich. The RD confirmed Resident 130's tray ticket indicated a dislike of pork, and stated a ham sandwich should not have been served to her. During a review of the facility's policy and procedure titled Food Preferences dated 2018, it indicated Resident's food preferences will be adhered to within reason.

Based on observation, interview, and record review, the facility failed to ensure usable assistive devices were available to one of 44 sampled residents (Resident 3). This failure had the potential to negatively impact Resident 3's nutritional status. Findings: During an interview with Resident 3, on 10/22/19, at 9:06 AM, he stated he needs modified utensils to eat his food. During an observation and interview with Resident 3, and Certified Nursing Assistant (CNA) 1, on 10/22/19, at 12:20 PM, in his room, he was eating his lunch. The adaptive utensils on his meal tray had a foam material around the handles of the fork and spoon. The fork, from the neck through the tines, were bent at an almost 90-degree angle to the right. Resident 3 indicated the fork was unusable to feed himself. CNA 1 verified the fork was not usable for Resident 3's needs. During an interview with Occupational Therapy Assistant (OTA) 1 and OTA 2, on 10/23/19, at 10:07 AM, they confirmed the bent assistive device would not meet Resident 3's feeding needs. During a review of the facility policy and procedure…

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 infection prevention and control practices when: 1. Hand hygiene was not performed prior to assisting one of 44 sampled residents (Resident 46) with eating; 2. Resident care equipment was not maintained in a sanitary manner for one of 44 sampled residents (Resident 37). These failures had the potential to result in the spread of infection. Findings: 1. During an observation on 10/21/19, at 12:10 PM, in the dining room, Certified Nursing Assistant (CNA) 2 grasped a chair with both hands and pulled it up to the table for residents who require assistance with eating. She did not perform hand hygiene after touching the chair. She then picked up Resident 46's spoon and his sandwich and helped feed him. During an interview with CNA 2, on 10/21/19, at 12:46 PM, she stated she did not perform hand hygiene before assisting Resident 46 with eating after touching the chair. During an interview with the Registered Dietician (RD), on 10/21/19, at 12:50 PM, she stated it is the facility's expectation hand hygiene is…

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.