Stone Bridge Center For Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and review of facility policies and procedures for 1 sampled resident (Resident #4) who had a diagnosis of diabetes and was at risk for skin breakdown and for one sampled resident (Resident #14) who was incontient of urine, required incontinence care, and often refused incontinent care, the facility failed to develop a comprehensive care plan for foot care for an individual with a diagnosis of diabetes and failed to develop a comprehensive care plan with person centered interventions for incontinence care and care refusals. The findings include: 1. Resident #4 was admitted to the facility with diagnoses that included Parkinson's disease, weakness, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #4 was totally dependent for bed mobility, at risk for developing pressure injuries (no active pressure injuries), had no signs of pain, and was severely impaired in cognitive functioning (Brief interview for mental status (BIMS) score of 5). The Resident Care Plan (RCP)…

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 clinical record review, review of facility documentation, review of facility policy and interviews for two of four residents (Resident #4 and #7) who were at risk for the development of pressure ulcers, the facility failed to promote the prevention of pressure ulcer/injury development; failed to promote the healing of existing pressure injuries (including prevention of infection to the extent possible); and failed to prevent development of an additional pressure ulcer/injury; and failed to conduct an initial skin assessment as a baseline when a reddened area of the left hip was identified to determine if the area was healing or deteriorating. The findings include: Resident #4 was admitted to the facility with diagnoses that included Parkinson's disease, weakness, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #4 was totally dependent for bed mobility, at risk for developing pressure injuries (no active pressure injuries), had no signs of pain, and was severely impaired in…

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 clinical record review, review of facility policies and procedures, and interviews with facility staff for 1 sampled resident who was assessed as a nutritional risk (Resident #4), the facility failed to provide a timely nutritional assessment for a resident with a documented pressure injury. The findings include: Resident #4 was admitted to the facility with diagnoses that included Parkinson's disease, weakness, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #4 was totally dependent for bed mobility, at risk for developing pressure injuries (no active pressure injuries), no signs of pain, and severely impaired in cognitive functioning (Brief interview for mental status (BIMS) score of 5). The assessment noted weight loss, a therapeutic diet (e.g., low salt, diabetic, low cholesterol) and no indication of a mechanically altered diet (e.g., pureed food, thickened liquids) was noted. The RCP dated 3/5/21 identified Resident #4 had a potential for impaired nutritional status,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policies and procedures, and interviews with facility staff for 1 of 2 residents who were reporting/demonstrating pain, (Resident #4), the facility failed to assess pain for a resident with a deteriorating facility acquired pressure injury and failed to assess efficacy of the pain regimen. The findings include: 1. Resident #4 was admitted to the facility with diagnoses that included Parkinson's disease, weakness, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #4 was totally dependent for bed mobility, at risk for developing pressure injuries (no active pressure injuries), experienced a weight loss, and was severely impaired in cognitive functioning (Brief interview for mental status (BIMS) score of 5). The assessment noted Resident #4 was rarely/never understood and had no signs of pain. The Resident Care Plan (RCP) dated 3/5/21 identified Resident #4 was at risk for skin breakdown, required extensive assistance from 2 staff members…

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

Based on review of facility policy, interviews, and review of employee files for 6 of 6 Nurse Aides (NA #1, NA #2, NA #3, NA #4, NA #5 and NA #9), the facility failed to ensure performance evaluations were completed in a timely manner. The findings include: 1. Review of NA #1's employee file identified that date of hire was 2/8/2016 and last Employee Performance Evaluation was completed on 3/2/21. 2. Review of NA #2's employee file identified that date of hire was 11/4/2002 and last Employee Performance Evaluation was completed on 10/25/2017. 3. Review of NA #3's employee file identified that date of hire was 8/8/11 and last Employee Performance Evaluation was completed on 10/8/2020. 4. Review of NA #4's employee file identified that date of hire was 3/24/03 and last Employee Performance Evaluation was completed on 10/10/2020. 5. Review of NA #5's employee file identified that date of hire was 12/11/17 and last Employee Performance Evaluation was completed on 9/30/2020. 6. Review of NA #9's employee file identified that date of hire was 3/30/20 and last Employee Performance…

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 clinical record reviews, staff interviews, and review of facility documentation for three of six residents reviewed for social service needs (Resident #1, #8 and #31), the facility failed to ensure the residents were assessed after allegations of abuse were reported: 1. Resident #1's diagnoses included Parkinson's disease, adjustment disorder, cerebral ischemic attack, difficulty in walking, depression and Alzheimer's disease. The Psychological Supportive Care progress note dated 12/27/19 identified Resident #1 with adjustment difficulty (illness, decline, loss), inappropriate behaviors and interactive skills, short tempered and easily annoyed. Interventions included coping skills training, supportive psychotherapy and validation therapy. The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition, required limited one person assistance with transfer and walking in the room. The care plan dated 1/21/20 identified Resident #1 with behavior and mood patterns. Interventions…

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, review of facility policies and procedures, and interviews with facility staff for 1 sampled resident, (Resident #4), who required specialized rehabilitative services, the facility failed to conduct a timely speech therapy evaluation in the presence of weight loss and failed to perform a provider directed physical therapy evaluation for heel offloading with a knee contracture in the presence of a facility acquired left heel pressure injury. The findings include: Resident #4 was admitted to the facility with diagnoses that included Parkinson's disease, weakness, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #4 was totally dependent for bed mobility, at risk for developing pressure injuries (no active pressure injuries), no signs of pain, and severely impaired in cognitive functioning (Brief interview for mental status (BIMS) score of 5). The assessment noted weight loss, a therapeutic diet (e.g., low salt, diabetic, low cholesterol) and no indication of 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 observations, interviews, review of the clinical record, facility documentation, and facility policy for one resident (Resident #13) reviewed for facility transportation, the facility failed to include and have available consultations from outside vendors available in the paper or electronic chart and have nursing documentation available regarding outside consultations. The findings include: Resident #13's diagnoses included malignant neoplasm (abnormal tissue growth) of the right breast, epilepsy (seizures), anxiety disorder, unsteadiness on feet, and weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was cognitively intact, exhibited no behaviors, and required extensive assistance for bed mobility, transfers, toileting, and personal hygiene. The Resident Care Plan dated 5/13/22 identified Resident #13 was diagnosed with breast cancer and was undergoing chemotherapy. Interventions included to follow-up with the oncologist as ordered and treatments/diagnostics…

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 facility documentation, facility policy, and interviews for all residents who are served meals, the facility failed to provide a dignified dining experience as evidenced by serving meals on paper products since 4/1/24 due to a dishwasher that is unusable related to the need for a water softener product which is required for the dishwasher to function effectively. The findings include: The facility dishwasher has not been used since 4/1/24 when the temperature probe malfunctioned preventing the water temperature of the dishwasher from reaching the acceptable temperature for sanitation. The facility has been serving meals on paper products since 4/1/24. Two (2) vendor work order forms identified the cause of the temperature probe malfunction was due to poor water quality and the facility required a water softener replacement to correct this. The forms indicated the temperature probes would continue to malfunction until the water softener was replaced. Interview with the Food Service Director on 5/23/24 at 11:00 AM identified he submitted a vendor quote and request for a water…

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 facility documentation, observation, and interviews, the facility failed to provide a safe, homelike environment as evidenced by sticky floors due to the facility's inability to purchase the necessary chemicals required to prevent the floors from becoming sticky when washed due to financial issues. The findings include: The facility utilized a vendor company to secure floor washing supplies and has been unable to purchase the chemical 3A which was utilized as a ph neutralizer in combination with the other floor washing chemicals to prevent a sticky residue from building up on the floors. Interview with the Director of Housekeeping on 5/23/24 at 10:36 AM identified the 3A chemical neutralizes the chemicals utilized to clean the floors and removes the stickiness that builds up from the cleaning residue. The Director of Housekeeping identified each time he attempted to order the chemical from the vendor that had been providing the supplies he was told the company owed them money so they wouldn't send the supply. The Director of Housekeeping stated he contacted all sister…

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 clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who were reviewed for an injury of unknown origin, the facility failed to ensure a resident was free from staff to resident physical abuse. The findings include: Resident #1's diagnoses included senile degeneration of the brain, unspecified dementia, and stage three chronic kidney disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, was always incontinent of bowel and bladder, required extensive assistance with bed mobility, dressing, and personal hygiene and was totally dependent on staff with transfers and toileting. The Resident Care Plan dated 8/22/23 identified a self-care deficit, requires assistance with activities of daily living related to cognitive deficits, and deficits in balance, ambulation, mobility, strength, weakness, high fall risk, poor safety, and poor insight.…

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 clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who were reviewed for an injury of unknown origin, the facility failed to ensure staff reported an observation of physical abuse from a staff member to a resident immediately. The findings include: Resident #1's diagnoses included senile degeneration of the brain, unspecified dementia, and stage three chronic kidney disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, was always incontinent of bowel and bladder, required extensive assistance with bed mobility, dressing, and personal hygiene and was totally dependent on staff with transfers and toileting. The nurse's note dated 11/1/23 at 9:01 PM identified Resident #1 was screaming in pain and holding his/her chest while eating dinner in the dining room. The note identified Resident #1 was brought to his/her room and upon assessment…

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 clinical review, interviews, and facility policy review for one resident (Resident #1) reviewed for Cardiopulmonary Resuscitation (CPR), the facility failed to ensure that an Automatic External Defibrillator (AED) was accessible when a resident required CPR. The finding included: Resident #1's diagnoses included a history of acute and chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), Congested Heart Failure (CHF) and atrial fibrillation. Advance Directives signed by Resident #1, dated [DATE], indicated Resident #1 requested to be a full code (receive CPR). A physician order dated [DATE] directed Resident #1 was a full code (per medical directives) Review of a quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and was dependent for ADLs and personal hygiene. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 requested to be a full code. Interventions directed to follow resident's wishes for CPR. A nursing note…

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 clinical record review, observations, facility documentation review, facility policy review and interviews for one of five residents (Resident #1) reviewed for neglect, the facility failed to ensure care was provided in a timely manner for a resident who required assistance with personal hygiene. The findings include: Resident #1's diagnoses included wedge compression fracture, osteoporosis, peripheral neuropathy, and atrial fibrillation. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented and required extensive assistance with one-person for personal hygiene, toilet use, dressing, bed mobility and transfers, and was frequently incontinent of urine and bowel. The Resident Care Plan dated 7/26/23 identified Resident #1 is incontinent of bowel and bladder. Interventions directed to provide incontinent care approximately every two hours and as needed, offer bedpan/toilet assistance approximately every 2 hours and as needed and before leaving his/her room.…

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 clinical record reviews, facility documentation, facility policy and interviews for two of four sampled residents (Resident #1 and #2) who were reviewed for an allegation of inappropriate sexual contact, the facility failed to monitor the residents when they were first observed together to prevent an inappropriate sexual encounter. The findings include: Resident #1's diagnoses included unspecified dementia and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living and was independent with ambulating on the unit. The Resident Care Plan dated 6/24/23 identified Resident #1 had impaired cognition related to dementia and exhibited wandering behaviors. Interventions directed to use simple, direct communication, verbal cues, task segmentation and provide specific diversional activity. The nurse's note dated 7/8/2023 at 10:31 PM identified at approximately 8:45 PM Resident #1 was found with his/her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the kitchen , facility policy review, and interviews, the facility failed to ensure the date of the juice stored in the emergency food supply was not beyond the best before date and failed to monitor food temperature in accordance to standard practice. The findings included: 1. Initial tour of the kitchen with the Food Service Manager (FSM) on 3/12/23 at 10:30 AM identified multiple boxes of bottle juice in the emergency food supply were kept past beyond the best before date. a) 1 box contained of 8 bottles of 64 ounces of ocean spray 100% concentrate orange juice with best before date of 11/4/22. b) 1 box contained of 8 bottles of 64 ounces of tropicana 100% orange juice with best before date of 8/24/22. c) 1 box contained of 8 bottles of 64 ounces of ruby [NAME] lite cranberry with best before date of 1/23/23. d) 1 box contained of 12 boxes of 32 ounces of soy silk 8-gram protein with best before of 1/30/23. e) 1 box contained of 8 bottles of 64 ounces of ocean spray light cranberry…

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 clinical record review, facility documentation review, facility policy review, and interviews for four residents of six residents (Residents #6,# 18,# 95 and # 100) reviewed for immunizations, the facility failed to obtain consent for immunization non Covid 19. The findings included: 1. Resident #6's diagnoses included type 2 diabetes mellitus, hypotension, lower left extremity amputation, osteomyelitis, gout, post-polio syndrome and hypothyroidism. The quarterly MDS assessment dated [DATE] identified resident had moderate cognitive impairment with no behavioral issues , the resident was independent with eating but required extensive assistance or was totally dependent with all other activities of daily life. The MDS assessment further identified the resident was not offered an influenza or pneumococcal vaccine. A review of immunization record identified Resident #6 did not receive influenza or pneumococcal vaccine. 2. Resident #18 's diagnoses included Parkinson's disease, pulmonary fibrosis, type 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility grievance file and staff interview for 1 resident (Resident # 94), the facility failed to follow up on the resident's grievance for missing clothing in accordance to facility practice. The findings include: Resident # 94's diagnoses included Alzheimer's disease, glaucoma and Chronic Obstructive Pulmonary Disease ( COPD) , atrial fibrillation and Benign Prostatic Hyperplasia ( BPH). The Minimum Data Set ( MDS) dated [DATE] identified the resident was severely cognitively impaired, had memory problems , required extensive two person assistance with bed mobility and transfers. On 3/12/23 11:20 AM Person # 3 indicated Resident # 94 had several pieces of clothing missing such as 2 blankets missing since admission (10 months ago). Person # 3 notified the unit nurses, Nurse Aides ( NA) and front desk receptionist but has received no response as of today's date. A review of the facility grievance file for Resident #94 on 3/21/23 regarding identified Person # 3 reporting Resident # 94'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and interviews for 1of 3 residents (Resident # 92) reviewed for Advanced directives, the facility failed to ensure the resident's Advanced directive paperwork was completed timely. The findings include: Resident # 92's diagnoses included genetic disorder, paraplegia, and dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 92 had a severe cognitive impairment. The Resident Care Plan (RCP) initiated [DATE] identified the Resident/Guardian had established and advanced directive to receive Cardiopulmonary Resuscitation (CPR)with the intervention to support the decision made by the Resident/Responsible party. A physician's orders directed Full Code status on [DATE], [DATE] [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 12:10 PM an interview and review of the admission paperwork with the Director of Nursing Services ( DNS) identified she was unable to find any paperwork signed regarding advanced directives from 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 clinical record reviews, facility documentation review, facility policy review, and interviews for 2 of 6 residents (Resident #59 and Resident #92) reviewed for abuse, the facility failed to implement the facility abuse policy for investigating and reporting to state agency injury of unknown origin . The findings included: 1. Resident 59's diagnoses included Alzheimer's disease, dementia, diabetes mellitus, chronic obstructive pulmonary disease, cerebral infarction, osteoarthritis, anxiety, seizures, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident # 59 had severely impaired cognition, had no behavioral symptoms, required total assistance with personal hygiene, dressing and two-person physical assist with bed mobility and transfers. The Resident Care Plan dated 1/3/23 identified a risk for pressure ulcer development and skin breakdown. Interventions directed to pad bed rails at all times, apply Geri sleeves to upper extremity's as tolerated, inspect skin for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for 1 of 6 residents (Resident #59) reviewed for abuse, the facility failed to report injury of unknown origin to the state agency. The findings include: Resident 59's diagnoses included Alzheimer's disease, dementia, diabetes mellitus, chronic obstructive pulmonary disease, cerebral infarction, osteoarthritis, anxiety, seizures, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident # 59 had severely impaired cognition, had no behavioral symptoms, required total assistance with personal hygiene, dressing and two-person physical assist with bed mobility and transfers. The Resident Care Plan dated 1/3/23 identified a risk for pressure ulcer development and skin breakdown. Interventions directed to pad bed rails at all times, apply Geri sleeves to upper extremity's as tolerated, inspect skin for redness, irritation or breakdown during care and position with pillows. a. Review…

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 clinical record reviews, facility documentation review, facility policy review, and interviews for 2 of 6 residents (Resident #59 and Resident # 75) reviewed for abuse, the facility failed to conduct a thorough investigations regarding allegations of abuse/neglect. The findings included: 1. Resident 59's diagnoses included Alzheimer's disease, dementia, diabetes mellitus, chronic obstructive pulmonary disease, cerebral infarction, osteoarthritis, anxiety, seizures, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident # 59 had severely impaired cognition, had no behavioral symptoms, required total assistance with personal hygiene, dressing and two-person physical assist with bed mobility and transfers. The Resident Care Plan dated 1/3/23 identified a risk for pressure ulcer development and skin breakdown. Interventions directed to pad bed rails at all times, apply Geri sleeves to upper extremity's as tolerated, inspect skin for redness, irritation or breakdown during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for 1 of 3 residents (Resident #59) reviewed for following physician medication orders, the facility failed to ensure medications were administered as ordered and the facility failed to ensure that the narcotic count was accurate at the end of the shift to meet professional standard of practice. The findings included: 1. Resident #59's diagnoses included Alzheimer's disease, dementia, diabetes, chronic obstructive pulmonary disease, cerebral infarction, osteoarthritis, anxiety, seizures, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #59 had severely impaired cognition, had no behavioral symptoms, required total assistance with personal hygiene, dressing and two-person physical assist with bed mobility and transfers. The Resident Care Plan (RCP) dated 1/3/23 identified Resident #59 used anti-anxiety medications related to anxiety disorder. Interventions directed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations and interviews for 3 of 6 residents (Residents # 75, # 89 and # 92) reviewed for ADL, the facility failed to ensure the residents received assistance with grooming and hygiene to meet the resident need. The findings included: 1. Resident # 75's diagnoses included COPD, nuclear bilateral cataract, hypertension, chronic atrial fibrillation, and aphasia following nontraumatic intracerebral hemorrhage. The RCP dated 12/5/22 for assistance with ADL secondary to CVA with right sided weakness. Interventions included to provide assist of one person with ADL, to break tasks down to simpler sub task, to explain purpose and expected task to resident, to give resident sufficient time to accomplish each task and to transfer the resident via Hoyer lift with the assistance of two staff members. The quarterly MDS assessment dated [DATE] identified the resident was severely cognitively impaired, no behavioral symptoms, required extensive one-person physical assist for bed mobility…

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 clinical record reviews, observations, review of facility policy and interviews 1 of 3 residents ( Resident # 92) reviewed for accident the facility failed to conduct an assessment post fall. The findings include. Resident # 92's diagnoses included a genetic disorder, paraplegia, contractures of multiple sites and dementia. The Significant Change MDS assessment dated [DATE] identified Resident # 92 had a severe cognitive impairment and required extensive assistance of two persons for bed mobility and total assistance of 2 for transfer. The Resident Care Plan (RCP) dated 1/10/23 identified a deficit in functional mobility with interventions in part to provide assistance with bed mobility and transfers. A progress note dated 2/26/2023 at 11:05 AM identified Resident #92 had a witnessed fall without hitting his/her head, the supervisor was contacted, and the nurse and supervisor conducted assessment. The resident was noted with no injuries. On 3/16/2023 and interview with the DNS at 9:45 AM indicated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview for 1 of 2 resident (Resident # 94), reviewed for at risk for pressure ulcer development, the facility failed to ensure the resident's pressure reducing device for the seat of the wheelchair did not have multiple layers on top of the chair in accordance with facility practice. The findings include: Resident # 94's diagnoses included Alzheimer's disease, glaucoma and Chronic Obstructive Pulmonary Disease (COPD), atrial fibrillation and Benign Prostatic Hyperplasia (BPH). The quarterly MDS assessment dated [DATE] identified the resident was severely cognitively impaired, had memory problems , required extensive two person assistance with bed mobility and transfers and total dependence two person physical assist with personal hygiene. The assessment also noted no pressure ulcer at time of the assessment period. The physician's order dated 2/27/23 directed Roho to customize wheelchair and to check inflation every shift and for specialty air- mattress…

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 clinical record review, observations, and interviews for 1 of 3 residents (Residents #35) reviewed for ADL, the facility failed to refer the resident to podiatry to ensure good foot care. The findings include: Resident #35's diagnoses included congestive heart failure, unspecified dementia with other behavioral disturbance, and weakness. The physician's orders dated 1/23/23 directed staff to perform a weekly body audit on shower day. The MDS assessment dated [DATE] identified the resident's Brief Interview for Mental Status (BIMS) was two out of fifteen, indicating severe cognitive impairment. The resident required the extensive assistance of two people for ADL and the resident was totally dependent on one person with bathing and hygiene. The resident was always incontinent of bowel and urine. The Resident Care Plan (RCP) dated 3/7/23 identified a need for assistance with ADL. Interventions directed to assist the resident with bathing and hygiene, to perform weekly skin checks on shower day, and to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observation and interviews for 1 of 6 sample resident ( Resident # 75) who required assistance with ADL, the facility failed to ensure the resident was transferred via Hoyer lift according to professional standards to prevent a potential accident and for 1 of 3 residents reviewed for accidents ( Resident # 81), the facility failed to ensure supervision was provided during the mealtime and the facility failed to ensure that a housekeeping cart was secure to prevent a potential accident. The findings included: 1. Resident # 75's diagnoses included COPD, nuclear bilateral cataract, hypertension, chronic atrial fibrillation, and aphasia following nontraumatic intracerebral hemorrhage. The RCP dated 12/5/22 for assistance with ADL secondary to CVA with right sided weakness. Interventions included to provide assist of one person with ADL, to explain purpose and expected task to resident and to transfer the resident via Hoyer lift with the assistance of two staff members. The quarterly…

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 clinical record review, facility documentation review, facility policy review, and interviews for 1 of 3 residents (Resident #10) reviewed for ADL, the facility failed to ensure staff was trained in the use of a plastic commode liner used as a bedpan liner. The findings include: Resident # 10's diagnosis include dementia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 10 had severe cognitive impairment, required extensive assist of one person for bed mobility and extensive assistance of two persons for toileting. The Resident Care Plan (RCP) date 2/7/2023 identified Resident #10 was incontinent of bowel and bladder. Interventions included in part to offer the bedpan/toilet approximately every two hours and as needed and to provide incontinent care. An observation on 3/21/23 at 9:21 AM identified NA#5 completing incontinent care after use of a bedpan by Resident # 10. The bedside curtain was pulled with privacy maintained and NA #5 explained the procedure to the 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 clinical record review, facility documentation review, facility policy review, and interviews for 1 of 3 residents (Resident #32) reviewed for pain, the facility failed to ensure medications were available for administration as ordered by the physician. The findings include: Resident #32's diagnoses included spondylosis (age related wear and tear of the spinal disks) cervical region, heart failure, intra-abdominal and pelvic swelling mass, anxiety, and migraine. The Resident Care Plan dated 12/1/22 identified Resident #32 was on pain medication therapy. Interventions directed to administer analgesic medications as ordered by the physician, monitor and document side effects and effectiveness every shift. A physician's order dated 2/6/23 directed to administer Hydrocodone-Acetaminophen 7.5-300 mg (milligrams) one tablet by mouth two times a day for pain. The Pain Evaluation dated 2/8/23 identified Resident #32 was able to verbalize pain. The location of pain was back and neck with intermittent pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation review, facility policy review, and interviews for 2 of 5 residents (Resident #4 and Resident # 94) reviewed for dental, the facility failed to ensure the residents were evaluated by a dentist after a broken tooth and for missing dentures. The findings included: 1. Resident #4 's diagnoses included dementia, malnutrition, type 2 diabetes mellitus and hypothyroid. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident # 4 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicative of severe cognitive impairment and required extensive assist of 1 to 2 people with transfer, hygiene and toileting and non-ambulatory. The nurse's note dated 1/4/23 at 11:41PM identified Resident #4 had a broken tooth and lost his/her tooth on the right side. He/she may need dental consult. A physician's order dated 1/5/23 directed for dental consult related to broken tooth. The Resident Care Plan (RCP) dated 1/9/23 identified…

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 and staff interviews, the facility failed to ensure that the NA removed gloves after touching a dirty object on the floor to prevent the spread of infection. The findings include: Resident # 94's diagnoses included Alzheimer's disease, glaucoma, and Chronic Obstructive Pulmonary Disease (COPD), atrial fibrillation and Benign Prostatic Hyperplasia (BPH). The quarterly MDS assessment dated [DATE] identified the resident was severely cognitively impaired, had memory problems , required extensive two person assistance with bed mobility and transfers and total dependence two person physical assist with personal hygiene. Observation on 3/16/23 at 11:15 AM during Resident # 75's incontinent care identified NA # 13 going to bathroom to obtain water in a basin with gloves on. NA # 13 then proceed to place the basin on the overbed table and pick up the resident's left floor mat with her gloved hand. NA # 13 then went to begin incontinent care to Resident # 75 without the benefit of changing her…

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

Based on observation of a tour of kitchen, interviews and review of policy, the facility failed ensure that staff preformed hand-hygiene and ensure that hair restraints were used during kitchen preparation duties in accordance to facility policy and practice. The findings included: 1.an Observation during the kitchen tour with the Dietary Manager identified on 4/13/21 at 10:03 A.M. identified Dietary Aid (DA # 1) with a baseball cap without the benefit of covering all hair from the mid back while performing kitchen prep duties. Subsequent to surveyor inquiry DA #2 DA # 1 applied a hair net. b. In addition, DA # 2 was observed to continue touching her surgical face mask to reposition above her nose without the benefit of hand hygiene and continue to serve and prepare puree food items. In addition DA # 2 was observed with her hair covering not positioned to enclose all hair therefore leaving part of her back hair exposed. Subsequent to surveyor inquiry, DA #2 was identified to apply a hair net and perform hand hygiene. Interview with the Dietary Manager at 10:11 A.M. at the time of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based clinical record reviews, review of facility documentation, facility policy, and interviews for three of six residents (Residents # 4, 40, and #89) reviewed for abuse, the facility failed to ensure the resident was free from physical abuse during resident to resident altercation. The findings included: 1. a Resident #4's diagnoses included dementia with behavioral disturbance, Alzheimer's disease, anxiety disorder, hypotension, metabolic encephalopathy, unsteady on feet, abnormality of gait, and muscle weakness. Resident #4's quarterly Minimum Data Set ( MDS) assessment dated [DATE] identified Resident # 4 had severe cognitive impairment, required extensive assistance of one for transfers and limited assistance of one for walking in the room and the corridor. The quarterly assessment MDS further identified the resident normally used a rolling walker and wheelchair and did not have a wander/elopement guard. Resident #4's care plan dated 10/26/20 identified a problem of a long history of quarreling 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 clinical record reviews, review of facility documentation, review of facility policy and interviews for three of six resident (Residents #73 #89 and # 297) reviewed for abuse, the facility failed to report the results of an investigation in accordance with State law and to the State Agency within 5 working days of the incidents. The findings included: 1a. Resident #73 was admitted on 1/17/ 20 with diagnoses that included type 2 diabetes mellitus, schizoaffective disorder, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified severe cognitive impairment, the resident required limited one person assist with ambulation on and off the unit and wandered daily. The care plan dated 10/7/20 identified Resident #73 had a concern related to behavior and mood patterns and would wander in and out of peers' rooms. Interventions included: redirection, to provide verbal diversions/redirection when appearing agitated and to provide assistance back to the room or bathroom as needed. b.…

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 clinical record review, review of facility documentation, facility policy, and interviews for one of five residents (Resident #39) reviewed for unnecessary medications, the facility failed to accurately transcribe a laboratory blood test in accordance to physician's order and professional standards. The findings included: Resident#39's diagnoses included cardiovascular disease (CVD), congestive heart failure, atrial fibrillation, hypertension, peripheral vascular disease, cerebrovascular accident, diabetes mellitus, chronic kidney disease, and dementia. Review of Resident# 39's laboratory result dated 2/14/20 identified the resident's digoxin serum level was out of range at 0.6 mcg/L (normal range 0.8 - 2.0 mcg/L). Resident #39 was receiving Digoxin 125 (Antiarrhythmic) mcg by mouth daily. Physician's order dated 8/13/20, directed to administer Digoxin 125 mcg by mouth daily. Review of the Pharmacy Consultant Medication Regimen Review dated 9/7/20 identifying that Resident#39 who had atrial…

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, clinical record reviews, review of facility documentation, review of facility policy, and interviews for two sampled residents (Resident #57) reviewed for supervision during dining and (Resident # 296) reviewed for accidents, the facility failed to provide care and services in accordance with the resident's care plan and physician's orders and failed to ensure an RN assessment was conducted upon the resident's return from receiving treatment at a hospital emergency department, and failed to ensure the emergency department physician recommendation was addressed timely. The findings included: 1. Resident #57's diagnoses included bacterial pneumonia, Schatzki ring, dysphagia, pneumonitis due to inhalation of food and vomit, chronic obstructive pulmonary disease, heart disease, diabetes, anxiety, major depression, Alzheimer's disease and dementia. The Speech Therapy Discharge summary dated [DATE] identified that resident was receiving dysphagia level 2 diet with nectar thick liquid and 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 clinical record review, observation, and interviews for one resident in survey sample reviewed for contractures (Resident # 81) the facility failed to follow physician's orders to provide the resident with a hand splinting device to prevent further contractures. The findings include: Resident #81's diagnoses included Traumatic Brain Injury (TBI). A quarterly MDS assessment dated [DATE] identified Resident #81 with severe cognitive impairment and noted the resident required extensive assistance with ADL. The physician's orders dated 3/2021 and 4/2021 directed to provide Resident#81 with a palm roll to the right hand, twenty-four (24) hours a day, with skin checks and hand hygiene every shift. Additionally directed to report all skin integrity issue to therapy immediately every shift. Resident care plan (RCP) dated 3/26/21 identified a problem with contracture management with a goal to prevent further contracture of bilateral hands. Interventions included: to apply right palm roll as ordered and bilateral…

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 facility policy for two of three sampled residents (Residents # 87 and Resident # 88) who required assistance with medication administration, the facility failed to ensure the residents' medications were safely secured. The findings included: Resident #87 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, alcoholic cirrhosis of liver, chronic obstructive pulmonary disease and adjustment disorder with depressed mood. The admission MDS assessment dated [DATE] identified Resident #87 was cognitively intact and required limited assistance with the assist of 1 person for personal hygiene. The care plan dated 4/08/21 identified Resident #87 has impaired cognition related to metabolic encephalopathy, alcohol withdrawal and abuse. Resident will answer questions appropriately until next review. Interventions include: to encourage socialization and recreational activity, to have a call bell within reach, identify self, speak slowly…

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 of the kitchen and interview, the facility failed to maintain the refuse dumpster area in a clean and sanitary manner. The finding include: During a tour of the facility dietary department with the Dietary manager on 4/13/21 10:37 A.M. included the garbage dumpster area. During observation of garbage/dumpster area environment noted debris on the ground. The debris included eighteen (18) medical type exam gloves strewn on the ground around the dumpster and the adjacent areas, as well as empty rusted metal food cans, plastic, paper, cardboard as well as other empty food containers. Interview with the Dietary Manager at that time of the observations identified that housekeeping was responsible for maintaining the area as well as any staff who noticed debris. Subsequent to surveyor inquiry, the facility staff cleaned the area. Interview with the Administrator on 4/20/21 10:03 A.M. identified the garbage/dumpster area is usually well maintained.

Based on observation, review of facility policies, facility education, and documentation, the facility failed to wear Personal Protective Equipment (PPE) in accordance with infection control standards. The findings include: Observation of kitchen during the facility tour with the Dietary Manager identified on 4/13/21, at 10:15 A.M. Dietary Aide (DA) # 2 and DA # 3 wearing their surgical mask without the benefit of covering the nose while prepping resident food items. In addition, DA # 2 and DA # 3 were observed to continue touching the face mask to reposition without the benefit of performing hand hygiene. Interview with DA #2 at time of observation identified the position of her mask frequently falls on its own and demonstrated hand hygiene upon inquiry. Subsequent to surveyor inquiry observation of the Dietary Manager identified him/her providing a KN95 mask to DA # 2 and DA# 3 to replace the surgical mask as well as educating the staff that the mask may be a better fit and stay in position. Interview with the Dietary Manager at 10:11 A.M. identified the expectation of staff is to…

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