Santa Fe Post-Acute

Based on interview and record review, the facility failed to clarify a physician order related to a resident's fluid restriction and failed to ensure staff did not provide more than the ordered fluids for 1 (Resident #98) of 2 sampled residents reviewed for dialysis. Findings included: An admission Record revealed the facility admitted Resident #98 on 01/11/2024. According to the admission Record, the resident had a medical history that included the diagnoses of end stage renal disease, dependence on renal dialysis, hypertensive heart and chronic kidney disease without heart failure, and dysphagia oropharyngeal phase (difficulty swallowing). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/18/2025, revealed Resident #98 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident required set up or clean up assistance for eating. Resident #98's Care Plan Report included a focus area initiated 08/12/2024 and revised 12/08/2024, that indicated the resident was…

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 facility policy review, the facility failed to ensure medications were not left unattended and the medication cart was not left unlocked with out of sight of the medication nurse for 1 (Cart A Hall A Station 1 medication cart) of 8 medication carts. Findings included: A facility policy titled, Administering Medications, revised 04/2019, indicated, 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The medication must be clearly visible to the personnel administering medications. During an observation on 04/29/2025 at 8:34 AM, the surveyor noted Cart A Hall A Station 1 medication cart was unattended and unlocked. A certified nursing assistant stated she would get the nurse. At 8:43 AM, a nurse appeared and was shown the unlocked…

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 (EBPs) for 1 (Resident #54) of 4 sampled residents reviewed for pressure ulcers and/or urinary catheters. Findings included: A facility policy titled, Enhanced Barrier Precautions, dated 08/2022, revealed, 1. Enhanced barrier precautions are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). The policy specified, 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary…

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 conduct a comprehensive skin assessment on one resident (1) upon return from an Emergency Department (ED) visit after a change of condition As a result, ECG (electrocardiogram-a test that measures electrical activity of the heart; also known as EKG) stickers from a prior ED visit remained undetected on the resident's skin for a period of one week. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder (mental health disorder that affects cognitive abilities) and dysphagia (difficulty swallowing), per the resident's admission Record. The clinical record was reviewed on 1/13/25. According to the Progress Notes, Resident 1 was sent to the ED on 12/24/24 for a change in condition. The resident returned back to the facility the same day. There was no skin assessment documented upon Resident 1's return. The next documented skin assessment was six days later, on 12/30/24, in the Skilled Nursing Weekly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) had a written care plan for falls developed that was individualized with resident-specific interventions. In addition, Resident 1's plan of care to prevent falls was not communicated to all staff responsible for care, monitoring, and supervision of the resident. As a result, there was the potential Resident 1 would fall again and be placed at risk for fall-related injuries. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis to include dementia (a condition characterized by impaired judgement and memory), hallucinations (a false perception of objects or events involving your senses: sight, sound, smell touch, and taste), restlessness and agitation, muscle weakness, and history of falling. On 5/31/24, Resident 1's clinical record was reviewed. Resident 1's progress notes indicated the following: 3/11/24, Resident noted…

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 one of two resident's (Resident 1) physician and/or psychiatrist (a physician who specialized in mental health) when nursing staff observed Resident 1 verbalizing suicidal ideation (SI, thoughts of self-harm or killing oneself). This failure had the potential for Resident 1's change in mental status and/or behavior to go untreated which put the resident at risk for self-harm. Findings: A review of Resident 1's facility admission Record indicated, the resident was admitted on [DATE] with diagnoses to include bipolar disorder (mental disorder with extreme changes in mood, thought, energy, and behavior and characterized by periods of mania and depression) and depression (a mood disorder that caused persistent feelings of sadness, hopelessness, and loss of interest). A review of Resident 1's admitting paperwork from the general acute care hospital (GACH) 2 dated 8/2/23, indicated the resident had a history of SI. A review of facility 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 interview and record review, the facility failed to ensure a care plan intervention was implemented for 1 of 2 residents reviewed for elopement risk. As a result, the well-being of Resident 1 was placed at risk when the resident was able to leave the building unnoticed. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (swelling of the brain) and paranoid personality disorder (a mental health condition marked by a long-term pattern of distrust and suspicion of others without adequate reasons to be suspicious), per the resident's admission Record. The clinical record was reviewed on 8/9/23. According to Resident 1's Elopement Risk Evaluations, dated 2/20/23, 4/12/23, 5/31/23, and 7/21/23, the resident was assessed to be at risk for elopement/wandering (a form of unsupervised wandering that leads to the resident leaving the facility). According to a Nursing Progress Note, dated 7/21/23, staff noticed Resident 1 was not in her room. The note indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to consistently document post (after) dialysis (a procedure for filtering toxins from the blood) assessments for two of two sampled residents (33, 81) and three of seven unsampled residents (49, 79, 96), reviewed for dialysis care. As a result, Resident's 33, 81, 49, 79, and 96 had the potential risk for complications related to delayed assessments from dialysis sessions. Findings: 1. Resident 33 was re-admitted to the facility on [DATE], with diagnoses which included end-stage renal (kidney) failure, per the admission Records. On 7/13/22, Resident 33's clinical records were reviewed: According to the admission MDS, dated [DATE], a cognitive score of 15 (15 out of 15), indicated cognition was intact. According to the physician's order, dated 7/11/22, .Dialysis .Complete post dialysis assessment upon return. In the evening every Tuesday, Thursday, Saturday . The Dialysis Communication Records from 6/2/22 through 7/2/22 were reviewed. Resident 33 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility staff interview, and policy and procedure the facility failed ensure that the following systems were in place for 2 unsampled Residents (35 and 84) out of 4 unsampled Residents and 1 sampled Resident (Resident 54): 1)The facility's medication refrigerated emergency drug kit had not been replaced within 72 hours after opening for the retrieval of one medication for (Resident 54), 2) no expired drugs were available at the facility for administration to any of the facility's residents either in the facility's drug storage rooms or on the facility's medication carts, 3) medications which had been ordered for Resident 35 had been administered as ordered by the resident's physician, and 4) Resident 84's medical record contained documentation indicating why his Gabapentin (Neurontin) had been held. This deficiency had the potential for the residents at the facility to receive expired medications as well as medications which had not been administered in accordance with their physician'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 medication room inspection, interview with facility staff, and review of the facility's policies and procedures the facility failed to: 1) ensure that medication room temperatures had been consistently documented on the facility's temperature logs and 2) that the medication refrigerator on Unit 2, had been secured and locked, as outlined in the facility's policies and procedures. This deficiency had the potential for medications to be stored outside of the drug manufacturer's recommendations and creating the possibility of controlled drug diversion. Findings include: 1) Review of the facility's medication room temperature logs between 5/2022 and 7/2022 revealed several days each month where facility staff had failed to document the medication room temperatures. For the month of 5/2022 the facility's Nursing staff had failed to document the medication room's temperatures. For example, review of the facility's room temperature log for 5/5/2022 on the evening shift, no room temperature had been documented on the facility's log. The same had been true for 5/11/2022, 5/13/2022,…

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 have a consistent method for documenting behaviors and side effects for two of three residents (Residents 54, 577), reviewed psychotropic medications. These failures had the potential for unnecessary medication to be administered when not required, based on the different documentation used for monitoring. Findings: 1. Resident 54 was admitted to the facility on [DATE], with diagnoses which included dementia (declining memory loss) without behavior disturbances, per the admission Records. On 7/14/22, Resident 54's clinical records were reviewed: According to the admission MDS, dated [DATE], indicated a cognitive assessment score of 11 (11 out of 15), indicating moderately impaired cognition. Per the physician's order, dated 5/6/22, .Antipsychotic(s) Monitor side effects: .and tally with hashmarks for each episode on the MAR every shift ., The MAR for antipsychotic side effects was reviewed from 7/1/22 through 7/12/22: The documentation had varied…

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 safe infection control practices when: 1. The shower curtain in one of three resident shower rooms (Station 2's secured unit), had a dried brown substance on the lower interior (inside) curtain. were left in the shower room; 2. Personal care objects and personal clothing was left in one of three resident shower rooms (Station 2's secured unit), and 3. A urinary catheter (a tube inserted into the bladder to aide in urine flow) bag and tubing was lying on the floor for one (Resident 124) of 2 residents, reviewed for urinary catheter care These failures had the potential for cross contamination. Findings: 1. On 7/12/22 at 11:05 A.M., an observation of the shower room in the secured unit was conducted. The shower room was unlocked and adjacent to the main hall used for activities and dining. A brown substance was smeared on the lower interior shower curtain. On 7/13/22 at 8:13 A.M., and On 7/14/22 at 8:35 A.M., the brown smear 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not assure the plan of care for Resident 3's suprapubic catheter (tube inserted into your bladder through a small hole in your belly that drains urine) was implemented for one of three residents (3) with catheters. As a result, Resident 3 had the potential to have a urinary tract infection that was untreated. Findings: Per the admission Record, Resident 3 was admitted to the facility on [DATE] with a suprapubic catheter. Resident 3's record was reviewed. Per Resident 3's physician's orders, dated 1/28/22, the resident was to receive monitoring of his urine for any signs of infection every shift. Per Resident 3's revised plan of care dated, 4/11/22, he was to receive monitoring of urine output for signs of infection such as sediment (white particles) in the urine, foul odor, blood in the urine, lower back pain. The nurses were to monitor the urine output every shift, identify the signs of potential urinary tract infection, and notify the doctor.…

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 resident (Resident 27) received a shower when requested. This failure put the resident at risk for poor hygiene and decreased quality of life. Findings: Resident 27 was admitted to the facility on [DATE], with diagnoses that included Respiratory Failure (a condition affecting the lungs), per the admission Record. On 7/13/22, a review of Resident 27's MDS (a health status screening and assessment tool), dated 4/22/22, indicated a BIMS (Brief Interview for Mental Status-test for cognitive function) score of 15 out of 15, which indicated cognition was intact. In addition, the resident required assistance with activities of daily living (ADL). On 7/13/22 at 10:08 A.M., an interview was conducted with Resident 27. Resident 27 was observed in his room sitting up in a chair dressed in his own clothes, no obvious odors noted, hair was uncombed. Resident 27 stated, he had requested a shower from several staff members and that he had not…

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 three residents' shower rooms (Station 2's secured unit) was free of hazards when: 1. The shower drain was not covered and was left open and exposed; 2. A wall mounted sharp container was full and not replaced in a timely manner; and, 3. Shaving cream canisters were left in the shower room area. These failures had the potential for residents to injure themselves due to the environmental hazards. Findings: 1. On 7/12/22 at 11:05 A.M., an observation of the shower room in the secured unit was conducted. The shower room adjacent to the main hall (used for activities and dining) was unlocked, and no drain cover was present in the shower stall. On 7/13/22 at 8:13 A.M., and on 7/14/22 at 8:35 A.M., the shower drain remained uncovered and exposed. On 7/13/22 at 9:03 A.M., review of the station 2 units' maintenance log was conducted. There was no documentation that the missing shower drain cover was reported for repair. On 7/14/22 at 8:38 A.M., an observation and interview of the secured unit's shower…

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 did not assure that one of five residents (60) reviewed for unnecessary medications received a medication regimen review (a review that promotes appropriate use of medications and compliance with drug therapy) that provided clinical indication for use and need for gradual dose reduction of Resident 60's Seroquel (mood altering medication used for schizophrenia [a disorder that affects a person 's ability to think, feel, and behave clearly]). As a result, Resident 60 potentially suffered side-effects of Seroquel that was not indicated for use in the resident's medical condition. Findings: Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's (progressive mental deterioration leading to an inability to verbalize needs and discomfort) disease. Resident 60's records were reviewed. Per the physician's orders dated 1/31/22, Resident 60 received Seroquel medication 1 tablet by mouth…

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 did not assure one of five residents (60) reviewed for unnecessary medication use received: 1. A psychiatric clinical assessment for a diagnosis of Schizophrenia (inappropriate behaviors and thought processes) 2. Monitoring for side effects such as sedation related to the use of Seroquel (antipsychotic (mind altering) medication used to treat certain mental conditions such as schizophrenia). As a result, Resident 60 received a drug that was not indicated for the resident's condition and was sedated for large amounts of time. Findings: Per the admission Record, Resident 60 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (progressive mental deterioration leading to an inability to verbalize needs and discomfort) disease. Resident 60's records were reviewed. Per the physician's orders, dated 1/31/22, Resident 60 received Seroquel medication 1 tablet by mouth three times a day . for schizophrenia. Per 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 record review, facility staff interview, and policies and procedures the facility had failed to ensure that 1 unsampled Resident (16) of 4 unsampled Residents reviewed, were free of any significant medication errors during the Medication Pass Observation process on 7/12/2022 between 8:30 am and 10:30 am. This medication error had the potential to require that this resident be sent back to the hospital for the treatment of Atrial Fibrillation (A-Fib), an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart. A-fib increases the risk of stroke, heart failure and other heart-related complications which could have also potentially led to this resident's death. Findings include: Review of Resident 16's medical record revealed that this resident had been previously diagnosed with Paroxysmal Atrial Fibrillation (a condition which results in an irregular heart rhythm) along with unspecified Dementia (the loss of cognitive functioning - thinking, remembering, and…

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

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff carried out the tasks of the food and nutrition services department in accordance with the standard of practice for the following kitchen competencies: 1. The kitchen dish washers did not know how to correctly test PPM (parts per million) concentration of the dishwashing solution with the chlorine test strip. 2. Kitchen staff did not follow the facility policy and procedure for fortifying resident diets. These failures had the potential to expose 120 residents who consume food from the kitchen to practices associated with the transmission of foodborne illness. Findings : 1. On 7/12/22 at 9:50 A.M., an observation and interview with DA 6 was conducted. DA 6 pulled out a chlorine test strip from a container and dipped it in the dishwasher machine reservoir water; a color change indicated a reading of 50-100 PPM. DA 6 stated, she saw the chemical representative do it this way and she was just copying what he did. DA 6 further stated, I think it is ok. On 7/12/22 at 10:09 A.M., 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, staff interviews, and record review, the facility failed to follow the facility's policy related to recipes and therapeutic menus as planned. This failure had the potential to result in weight loss of 120 of 126 residents who consumed food from the kitchen due to reduced food intake, and may have further compromised their nutritional status. Findings: 1. On 7/12/22 at 10:29 A.M., an observation, interview, and recipe review in the prep area of the kitchen with the cook was conducted. The cook stated, I have to make pureed chicken for twenty-six (26) residents. The cook put an unmeasured amount of cooked chicken, broth, and food thickener intermittently into a blender, and proceeded to blend all the items together. The cook stated, I just put it in the blender. The cook further stated, I don't understand. On 7/12/22 at 10:31 A.M., a concurrent interview and menu review in the prep area of the kitchen with the CDM was conducted. The CDM stated, the expectation is for the staff to follow the dietary recipes as written. The CDM further stated, the cook did not…

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

Based on observation, interview and record review, the facility failed to maintain sanitary kitchen equipment, safe, proper storage and handling of food practices, were met when: 1. A resident's refrigerator temperature was not within a safe temperature range; 2. A can opener had a build-up black colored substance and residue on it; 3. A utensil storage bin had a build-up of unknown particles and dust; and 4. Expired foods were found in the refrigerator. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illnesses for residents in the facility. Findings: 1. On 7/12/22, at 3:02 P.M., an observation of the residents' refrigerator on Station 1 and a concurrent interview & facility policy review was conducted with LN 7 and the ADON: a. The resident's refrigerator temperature was 62 degrees. The temperature log was signed off by staff as having a temperature of 38 degrees. No documented time was found when the temperature was checked. b. One undated plastic store bag with unidentifiable homemade food labeled 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 facility policy review, the facility failed to implement their policy and procedure related to food brought from the outside to residents for one of two residents' refrigerators when the food inside the refrigerator were not labeled or dated, and expired food was not discarded. In addition, the resident refrigerator temperature was not within a safe range for food storage. This failure had the potential to expose the facility's residents to unsafe food storage practices which could lead to foodborne illness. Findings: On 7/12/22, at 3:02 P.M., an observation of the residents' refrigerator on Station 1 and a concurrent interview & facility policy review with LN 7 was conducted. The following food items were observed: a. The resident refrigerator temperature was 62 degrees. The temperature log was signed off by staff as having a temperature of 38 degrees and no time documented when this temperature was checked. b. One undated plastic store bag with unidentifiable homemade food labeled with resident's name. c. One undated plastic store bag 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 a ceiling suspended privacy curtain, which extended around the bed to provide visual privacy, was provided to one of three residents (Resident 122), reviewed for privacy. This deficient practice violated Resident 122's right to privacy and had the potential for the resident to be exposed to others during personal care. Findings: Resident 122 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (brain disease that alters brain function and structure) and dementia (impaired reasoning and memory). On 7/13/22 at 9:30 A.M., an observation of Resident 122's room was made from the hallway. Resident 122 was in a room with three residents. Resident 122 was assigned to the second bed and a ceiling suspended privacy curtain was not provided for the second bed circumference area. On 7/13/22 at 10:45 A.M., an interview was conducted with CNA 16. CNA 16 stated privacy curtains were important and every 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.

Based on food and nutrition services observations, staff interviews, and record reviews, the facility failed to ensure appropriate departmental supervision and oversight of dietary operations with adequate supervisory staff in the kitchen. This repeated failure to ensure effective oversight of day to day food and nutrition operations may place residents at nutritional risk from exposure to unsanitary practices, and in turn, further compromise their health status. The facility census was 167. (Cross reference F801, F804, F812, F813, F908, and F925) Findings: During the initial kitchen tour on 2/4/19 at 8:28 A.M., multiple observations and concurrent interviews were conducted of the overall kitchen sanitation and cleanliness with food and nutrition services department staff. The kitchen was dirty with trash on the floor, including crumbled plastic wrappers, food debris, plastic utensils and other items. The 2-compartment sink was full of dirty pots and pans and neither compartment had sanitizer or rinse water. Food preparation counters were stained with a clear sticky substance and…

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

Based on observations, interviews, and record reviews, the facility failed to ensure safe and sanitary conditions were met food service and storage, in and out of the Food and Nutrition Services department when: 1) Expired PHF/TCS food items were stored in a reach-in refrigerator, 2) Three staff were not wearing a beard cover and two did not wear a hairnet, 3) Ice machine bin was dirty, 4) Safe food storage conditions were not met for the dry food storage room 5) Dirty, worn down cooking utensils were stored in a drawer with clean utensils 6) Unit refrigerators with resident food were dirty with caked on brown-blackish grime inside the door shelves and racks These failures had the potential to cause widespread foodborne illness in 165 of 167 facility residents who consumed food from the Food and Nutrition Services Department. Findings: 1. During the initial kitchen tour on 2/04/19 at 8:28 A.M., an observation and concurrent interview was conducted with the DSC and DA 1 of the refrigerator units. Inside the reach-in refrigerator were expired PHF/TCS including tuna salad and yogurt.…

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 reviews, the facility failed to ensure food for residents was prepared in a manner that conserved flavor, appearance, attractiveness, and nutritive value. This repeated failure had the potential to affect the meal intake, overall nutritional status, and lead to unintentional weight loss in 48 residents who received a regular, pureed, or mechanical soft diet. (cross reference F801) Findings: On 2/4/19 at 11:45 A.M., an observation and concurrent interview of the lunch trayline was conducted with CK 1 and DSC. A review of the facility therapeutic menu spreadsheet indicated the lunch entrée was 3-bean chili, a tossed green salad, and cornbread with green chilies. CK 1 prepared a ¼ inch metal pan of gravy and placed it on the trayline. CK 1 also poured 1-2 ounces of gravy on pureed and mechanical soft entrées and sides including the 3-bean chili and cornbread items of 34 resident meals. The menu did not include gravy on these food items. CK 1 stated the gravy was poured on the food items because the residents like gravy. The DSC acknowledged…

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, interviews, and record reviews, the facility failed to ensure safe and sanitary practices were followed for residents' food brought in from outside the facility. Failure to ensure safe storage and reheating procedures for residents' food brought in from the outside had the potential to result in widespread foodborne illness for 167 residents in the facility. Findings: On 2/05/19 at 3:02 P.M., an observation of the utility room refrigerator at nurse's station 1 and interview with CNA 7 was conducted. There were five to-go boxes of food with resident's last name and room numbers on them along with a bottle of protein juice with a resident's name on it. None of the food items had dates. CNA 7 acknowledged the undated resident food containers in the refrigerator. stated resident food from outside needed to be checked by the charge nurse to make sure it meets the resident's diet needs. CNA 7 then stated the food is labeled with room number and date and stored in the refrigerator. However, CNA 7…

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, review of the facility assessment plan, and staff interviews, the facility failed to accurately assess the competency of its food and nutrition services supervisory staff and ensure adequate supervisory oversight in the kitchen at all times. This deficient practice had the potential to cause food borne illness and inadequate intake of nutrients for 167 residents who consumed food or received nutrition support from the facility. (cross reference F801, F804, F812, F813, F908, F925) Findings: Observations made during the survey from February 4-7, 2019 identified there were several deficient practices in food and nutrition services related to insufficient supervisory staffing, lack of sufficient staff training by a qualifed individual, and incomplete assessment of the department. A review of the facility's assessment dated [DATE], indicated the skills competency evaluations were not performed for any of the listed dietary services staff. The document titled Facility Assessment Tool, in Part 3.,…

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 essential kitchen equipment, including a walk-in freezer, was in safe operating condition according to standards of practice. This repeated deficient failure had the potential to cause contamination in food storage and sanitation equipment, which could affect overall foodservice operations. The facility census was 167. Findings: During the initial kitchen tour on 2/4/19 at 9:40 A.M., an observation of the walk-in freezer was conducted. There was trash and other debris on the floor. In addition, ice build-up was found on the pipes along the wall and inside the ceiling as well as the cases of ice cream cups. On 2/4/19 at 4:05 P.M., an interview was conducted with the DSC and CK 2 about the ice build-up on the condenser in the walk-in freezer. The DSC stated that she and CK 2 took a blade or other sharp device and shaved the ice down to break and remove the ice from the pipes, wall, and cases. CK 2 acknowledged he took a blade to clear the ice build-up at least twice a week. DSC and CK 2 stated the ice…

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: 1. Four confidential residents (A, B, C, and D) received hair cutting services regularly and, 2. Six confidential residents (A, C, D, E, F, and G) received showers regularly. These failures had the potential to result in a lack of dignity and feelings of low self esteem in the residents. Findings: On 2/5/19 at 10 A.M., a resident council meeting was conducted. Attendees included ten residents of the facility. Six of the ten residents were confined to wheelchairs. Concerns were raised about residents not receiving hair cuts and showers regularly. 1. Three residents (A, B, C) were concerned that residents could not get their hair cut at the facility. Resident D stated the facility had not had a beautician or barber working at the facility for months. Resident A stated residents had to get themselves to a hair salon. Resident C stated several residents had wheeled themselves to a local mall to get their hair cut. Resident C stated there was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not develop a care plan for two of four sampled residents (8, 70) when: 1. Resident 8 did not have a care plan for the use of a Fentanyl patch (a strong narcotic drug applied to the skin which is used to treat severe pain). 2. Resident 70's care plan did not include interventions for turning and repositioning. This failure had the potential for miscommunication between staff members which could lead to harm. Findings: 1. Resident 8 was readmitted on [DATE] with diagnoses including COPD, heart failure and breast cancer, per the facility's admission Record. On 2/6/19 a review of physicians orders and care plans were done. The physician's orders indicated, Fentanyl patch 25 mcg x 72 hours for back pain. Review of Resident 8's care plans were done. There was no care plan for Resident 8's Fentanyl patch. On 2/6/19 at 11:20 A.M., concurrent record review and interview was conducted with LN 1. LN 1 said, We don't have a care plan for Fentanyl. I 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent the development of a pressure injury for one of four residents reviewed for pressure injury (154). This failure resulted in Resident 154 experiencing pain and skin breakdown of her right cheek. Findings: Resident 154 was admitted to the facility on [DATE] with diagnoses which included COPD (chronic obstructive pulmonary disease, involving constriction of the airways and difficulty breathing), per the facility's admission Record. During an observation and interview on 2/5/19 at 7:56 A.M., Resident 154 was observed wearing a nasal oxygen cannula. The plastic tubing from the cannula was pressed into her right cheek which caused redness and skin shedding (approximately the size of a dime). Resident 154 stated the nasal cannula caused her discomfort. On 2/6/19 at 9:11 A.M., an observation was made of Resident 154. The cannula was pressed on her right cheek, and the redness was about the size of a quarter. On 2/6/19 at 9:14 A.M., an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a suprapubic catheter (a device that is inserted into a bladder to drain urine) was changed for one of three residents (37) reviewed for catheters. This failure had the potential for increased risk of infection, and obstruction within the catheter tubing. Resident 37 was admitted to the facility on [DATE], with diagnoses which included Multiple Sclerosis (disease where nerve cells in the brain and spinal cord are damaged) and neuromuscular dysfunction of the bladder (bladder muscles do not function), per the facility's Admissionrecord. During an interview on 2/5/19 at 9:15 A.M., Resident 37 stated she didn't feel her catheter was being changed enough. Resident 37 stated she thought it was monthly and felt it had not been changed in well over a month. A record review was conducted on 2/6/19 at 2:44 P.M. A physician's order indicated the suprapubic catheter was to be changed on the 28th of every month and PRN (as needed). 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 did not ensure one resident's medication was labeled with resident specific information. The lack of labeling created the potential for inappropriate use of the medication and/or use by another resident. Findings: On 2/5/19 at 8:16 A.M., an observation and interview was conducted with LN 17 during medication administration to Resident 73. LN 17 was observed to Resident 73 had one medication without a label. LN 17 stated she could not give the medication without the label because it could cause a medication error. On 2/5/19 at 10:41 A.M., an interview was conducted with LN 17. LN 17 stated Resident 73's medication should have been labeled with the resident's name, directions for use, dispensed date and expiration date. On 2/7/19 at 9:35 A.M., an interview was conducted with the DON. The DON stated resident specific medication should have a label with the resident's name, directions for use, and when it was dispensed. The DON stated all multi dose containers should be labeled with an open date. Per the facility policy,…

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 an effective pest control program was maintained in the Dietary Services department. This failure had the potential to contaminate food stored in the dining area and could cause widespread foodborne illness. Findings: On 2/4/19 at 9:32 A.M., an observation and concurrent interview of the dish machine and trayline area was conducted with the DSC during the initial kitchen tour. Two flies flew above the counter area where the dirty trays and dishes were stored and another fly flew around the dishmachine. The DSC acknowledged the flies in the dishmachine trayline area. On 2/5/19 at 10:00 A.M., during the resident group meeting, a confidential resident reported the residents received a dinner meal a few weeks ago that had a cockroach on the tray. The confidential resident stated the cockroach crawled out of the plate and CNA 11 witnessed it. CNA 11 took the tray and dropped it on the ground but then discarded it. On 2/6/19 at 10:04 A.M., an observation and interview of the kitchen's 2 compartment sink area…

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.