Nspire Healthcare Lauderhill

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs is maintained and periodically reconciled for 2 of 6 sampled residents reviewed for medication reconciliation, Residents #19 and #306. The findings included: 1. Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses that included the following: Obesity, Other Abnormalities of Gait and Mobility and Muscle Weakness (generalized). Review of the physician's orders for Resident #19 revealed an order for Tramadol HCL 50mg give 50mg by mouth every 12 hours as needed for pain. Review of the Medication Monitoring / Control Record for Resident #19 for the medication Tramadol HCL 50mg documented the medication was given on 07/15/24 at 9:00 PM and again on 08/25/24 at 4:33 PM. Review of the MAR for Resident #19 for the month of July 2024 revealed no documentation for the medication Tramadol HCL 50mg being administered on 07/15/24. Review of the MAR for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide the appropriate diet consistency for a Mechanical soft diet for 2 of 27 residents, Residents #7 and #41, during dining observation. This had the potential to affect 27 residents who were on a mechanical soft diet. The findings included: Review of the facility's 'National Dysphagia Diet Level 3 Advanced' revealed the following: The advanced diet consists of food of varying textures except for very hard, sticky, or crunchy foods. Foods need to be served moist and ground, chopped, or in bite-size pieces less than 1 inch long. It further showed foods to avoid, such as undercooked fibrous, tough, or stringy vegetables, such as cabbage, asparagus, and celery. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had a Brief Interview of Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Review of orders revealed an order, dated 02/8/23, for a No Added Salt (NAS) diet 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 and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This was observed during 1 of 3 visits conducted in the Main Kitchen. The findings included: In a tour of the Main Kitchen conducted on 09/09/24 at 9:00 AM with the Kitchen Manager, the following were noted: a. Small flying insects were noted in the dishwashing area near an opened round garbage dumpster. A Drainage treatment system that was not connected was noted underneath the dishwashing machine. In this observation, the Kitchen Manager said that she called an outside company to come and treat the flying insects that were observed last week in the kitchen. She did not know why the treatment system was disconnected and said, It is not connected to the main tube. She then proceeded to connect the treatment system to the correct tubing. b. The walk-in refrigerator had an internal thermometer, which showed a temperature of 55 degrees Fahrenheit and not the recommended 40 degrees Fahrenheit or below. The walk-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 observations, interviews, and record review, the facility failed to treat residents in a dignified manner for 1 of 1 sampled resident reviewed for dignity, Resident #13. The findings included: Resident #13 was admitted on [DATE] with diagnoses of Dementia and Cerebral Atherosclerosis. The care plan dated 07/10/23 revealed that Resident #13 is rarely understood with communication problems related to Dementia. In an observation conducted on 07/10/23 at 9:55 AM, Resident #13 was observed in her bed with her shirt lifted and fully exposing her bare breast, visible from the doorway. Closer observation showed that her curtain was fully opened. Staff members were observed walking by the opened door and not making any attempts to close the door or pull the curtains around Resident #13. In another observation conducted on 07/10/23, at 10:20 AM, 25 minutes later, Resident #13 was observed in her bed with her shirt lifted and fully exposing her bare breast, visible from the doorway. Closer observation showed that…

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 and interview, the facility failed to provide a safe, clean, and homelike environment on 1 of 4 units, the 400 unit. The findings included: During observations of residents' rooms conducted on 07/10/23 and 07/11/23, and a subsequent facility observation tour conducted on 07/12/23 at 8:09 AM with the Maintenance Director, the following environmental concerns were noted: 400 rooms unit: (a) 413 - bathroom floor linoleum was bubbling up and was uneven, bathroom sink cabinet was damaged, and the door was broken, overhead lights were not working and the closet wood was broken. (b) 412 - bathroom sink was loose, and the floor was stained. (c) 408 - bathroom sink cabinet was damaged and the baseboard around was loose. (d) 406 - the wall behind the bed was in disrepair. (e) 405 - baseboard behind the dresser was loose. (g) 402 - bathroom wall paint needed a touch up; bathroom cabinet was damaged and baseboard around it was loose. (h) 400 - the room television was on, and no picture noted. During 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, record and policy review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) form for 2 of 2 sampled residents reviewed for PASRR, Residents #46 and #299. The findings included: Review of the facility's policy, titled, Pre-admission Screening revised on 11/30/14 documented .the pre-admission screening is completed by the referring human service agency .the company will review the pre-admission screening upon receipt . 1. Review of Resident #46's clinical record documented an admission on [DATE], and no readmissions. The resident's diagnoses included Unspecified Malignant Neoplasm of Skin, Diabetis Mellitus (DM), Anxiety, Parkinson's Disorder, Dementia, Depression and Psychosis. Review of Resident #46's Minimum Data Set (MDS) significant change assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 3 indicating the resident had severe cognition impairment. Review of Resident #46's revealed a hand written…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, observation, interview and record review, the facility failed to secure over-the-counter (OTC) medication packets for 1 of 24 sampled residents observed during initial pool process, Resident #75; failed to secure OTC nasal spray and chest rub for 1 of 24 sampled residents observed during initial pool process, Resident #71; failed to secure an unidentified, unsecured, loose pill capsule outside of the main dining room floor in the hallway; failed to secure an unlocked and unattended medication cart for 1 of 4 medication carts on North wing, cart 300 hallway; failed to properly dispose a controlled substance during Medication Administration for Resident #83; and failed to keep the medication cart trash-can lid closed on the North wing 400 hallway. The findings included: Review of the facility policy and procedure on 07/13/23 at 10 AM, titled, Medication Storage in the Facility, revised January 2018, provided by the Director of Nursing (DON), documented, in part: In 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 interviews and record review, the facility failed to have a qualified Registered Dietitian to supervise and monitor the Dietetic Technician Register (DTR) scope of practice for high nutritional risk residents for 2 of 2 sampled residents reviewed for tube feeding initial assessments, Resident #251 and Resident #42. The findings included: A review of the Academy of Nutrition and Dietetics: Scope of Practice for the Dietetic Technician, Registered (DTRs) dated June 2013, showed, in part, the following: For DTRs, the scope of practice focuses on food and nutrition and related services provided by DTRs who work under the supervision of an RD when in direct patient / client nutrition care, and who may work independently in providing general nutrition education to healthy populations, consulting to foodservice business and industry, conducting nutrient analysis, data collection and research, and managing food and nutrition services in a variety of settings (https://www.jandonline.org/article/S2212-2672(12)01935-1/fulltext). Record review showed that Resident #251 was on tube…

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 review, the facility failed to ensure that a system was in place to ensure residents received the correct enhanced food items on their meal trays as per physicians' orders during dining observations for 3 of 3 sampled residents observed, Resident #13, Resident #23 and Resident #25. The findings included: A review of the facility's recipe book showed they have four food items that may be used as Enhanced foods: Enhanced Pudding, Enhanced Potatoes, Enhanced Cereal, and Enhanced Scrambled Eggs. 1. Record review showed Resident #13 was admitted to the facility on [DATE]; and had a physician order for an enhanced diet, pureed texture, dated 10/05/20. In an observation conducted on 07/11/23 at 8:31 AM, Resident #13 was noted in her room with her breakfast tray. Closer observation showed a tray with a meal ticket for Enhanced Pureed. The tray was noted with different types of pureed texture food items, but no identification was noted on which food item was the enhanced food…

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 chart review, facility staff failed to practice adequate hand hygiene for 2 of 2 sampled residents during dining observations, Resident #13 and Resident #6. The findings included: Review of the facility policy, titled, Dietary, revised on 09/18/2018, showed that Staff must sanitize before passing each tray and wash hands before delivering the next tray if they have handled room items or Resident clothing. 1. Record review showed Resident #13 was admitted on [DATE] with diagnoses that included Dementia and Cerebral Atherosclerosis. The care plan dated 07/10/23 revealed that Resident #13 is rarely understood. The Quarterly Minimum Data Set (MDS) dated [DATE] showed that under section G for eating, Resident #13 needs extensive assistance with one-person physical assistance. In an observation conducted on 07/10/23 at 12:50 PM in the memory lock unit, Resident #13 was noted in her room. Continued observation showed Staff A, Certified Nursing Assistant (CNA), looking at 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 interviews and record review, the facility failed to ensure that the binding arbitration agreement explicitly granted the resident or their representative the right to rescind the contract within 30 calendar days of signing it for 3 of 3 sampled residents reviewed for arbitration agreements, Resident #61, Resident #38, and Resident #399. The findings included: 1. Record review showed that Resident #61 was admitted to the facility on [DATE] and that she had entered into a binding arbitration agreement. Further review showed that the agreement needed to be signed and dated by Resident #61. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed that Resident #61 has a Brief Interview of Mental Status (BIMS) score of 05, which indicated moderate to severe cognitive impairment. Review of the arbitration agreement that the facility provided did not show that the resident / family had the right to rescind the contract within 30 calendar days of signing it. 2. Record review showed that Resident #38…

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 inform the physician in a timely manner when a change in condition was identified for 1 of 1 sampled resident reviewed for Change in Condition, Resident #71, as evidenced by a delay in notification Resident #71 was experiencing acute right hip pain as a result of a right hip fracture. The findings included: Review of the facility policy for Notification of Change in Condition, dated and revised 12/16/20 stated in part, 'The Center to promptly notify the Patient / Resident, the attending physician, and the Resident Representative when there is a change in the status or condition. Procedure: The nurse to notify the attending physician and Resident Representative when there is an Accident; Significant change in the patient's/resident's physical, mental, or psychosocial status.' Review of the clinical record revealed Resident #71 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, Dementia, Depression 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessments related to discharge MDS and Quarterly MDS for 2 of 24 sampled residents, Residents #2 and #239. The findings included: 1. Chart review showed that Resident #2 was readmitted on [DATE] with Psychosis, Depressive Disorder and Muscle Weakness. The last Quarterly Minimum Data Set (MDS) compled was on 10/03/21. Further review showed that no Quarterly MDS was completed for Resident #2, which should have been done in January 2022. 2. Chart review showed that Resident #239 was admitted to the facility on [DATE] and was discharged on 11/20/21. Further chart review did not show that a discharge MDS was completed for Resident #239 before discharge. An interview conducted on 03/02/22 at 3:45 PM with the MDS coordinator who stated that she is the only MDS coordinator in the facility and that another consultant MDS overlooks her work daily. She further noted that every day the electronic system would give…

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 review, the facility failed to revise the care plan according to the resident's needs and follow the care plan according to the resident's needs for dining assistance for 2 of 24 sampled residents, Resident #56 and Resident #33. The findings included: 1. Record review showed that Resident #56 was readmitted on [DATE] with diagnoses, in part, of Dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) dated [DATE] showed that for eating under Section G, Resident #56 needed extensive assistance with one person assist. A review of the Care Plan, dated 02/25/22, showed Resident #56 has impaired cognitive function / dementia or impaired thought process related to Dementia. In an observation conducted on 02/28/22 at 12:52 PM, Resident #56 was noted in his room eating the lunch meal. Closer observation showed that staff was in the room assisting with the lunch meal. In an observation conducted on 03/01/22 at 8:10 AM, Resident #56 was noted in his room waiting…

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 interviews and records review, the facility failed to develop a discharge summary which included a complete recapitulation of residents stay and reconciliation of all the pre/post-discharge medications; and failed to develop a post-discharge plan of care that included discharge instructions for 1 of 3 sampled residents reviewed for discharge, Resident #238. The findings included: Record review revealed Resident #238 was admitted to the facility on [DATE] and was discharged from the facility on 11/24/21. The diagnoses included, Unspecified Dementia without Behavioral disturbance among others. A family member was delegated as the representative / durable power of attorney. During an interview conducted with Resident #238's authorized representative (AR) / Power of Attorney (POA) on 03/03/22 at 9:58 AM, the POA stated that Resident #238 was discharged from the facility on 11/24/21. She was contacted by the Social Services Director (SSD) of the facility who informed her that the nurse had forgotten to give…

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 1 of 4 sampled residents reviewed for Activities, Resident #54, was offered and provided with preferred activities as evidenced by Resident #54 was not provided with activities of his choice. The findings included: Review of the clinical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses to include Traumatic Subdural Brain Hemorrhage, Parkinson's Disease, Anxiety Disorder, Seizures, Aphasia (inability to communicate verbally) and Dysphagia (inability to eat or drink by mouth). Resident #54 has a feeding tube for all his nutrition and hydration needs, with the tube feeding commencing at 2:00 PM daily and infusing over a 20-hour period. Resident #54 is dependent on staff for all activities of daily living. Review of the facility's Activity Program Policy and Procedure, revised 11/01/15, stated in part, 'An ongoing wide range of therapeutic programs, interventions and techniques designed and offered 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 observation, interview and record review, the facility failed to ensure measures were implemented to prevent the development of pressure ulcers for 1 of 1 sampled resident, Resident #68, reviewed for Pressure Ulcer/Injury, as evidenced by physician recommendations for pressure ulcer prevention were not followed, increasing the risk of pressure ulcer development for Resident #68. The findings included: On 02/28/22 at 9:45 AM, an initial observation was conducted of Resident #68 seated in his wheelchair in the hallway outside of his room. In an attempt to conduct an interview, it was noted the resident was cognitively impaired and was not able to provide appropriate answers to the questions asked. An observation was then conducted inside of the resident's room and his bed was observed to have an air mattress on it with the air mattress compressor box attached to the foot board of the bed. Further observation revealed the air mattress compressor box was not turned on. When the end of the mattress 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 observations, interviews and record review, the facility failed to follow up on tube feeding regimen changes in a timely manner for 1 of 1 sampled resident reviewed for tube feeding, Resident #64. The findings included: A review of the facility's policy, titled, Nutritional Assessment, dated 09/17/18, showed that Residents at high nutritional risk will be assessed in a timely manner by the Dietitian. It further showed that the nutritional care plan is communicated to the rest of the interdisciplinary team. In an observation conducted on 02/28/22 at 10:13 AM, Resident #64's tube feeding was observed running with Jevity 1.5 (formulary) at 50 millimeters (ml) an hour. It further showed that the tube feeding bottle was started at 2:00 AM the night before. A review of the chart showed that Resident #64 was readmitted to the facility on [DATE] with diagnoses to include Dysphagia, and Schizophrenia. A review of the Physician's orders showed the following tube feeding changes: On 01/12/22, the tube feeding…

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 review, the facility failed to follow the residents' approved menu during dining observation for 2 sampled Residents #51 and #56, of the 13 residents receiving puree diets. This could affect all 13 residents receiving pureed diets. The findings included: A review of the Cycle 1, Week 2 Regular Diet menu showed the following: Glazed meatloaf, new potatoes, red cabbage, wheat roll, margarine, and apple pie. In an interview conducted on 02/28/22 at 1:50 PM with Staff E, Cook, he stated that because he didn't have enough red cabbage for all of the residents, he decided to substitute the menu on the pureed diet for green beans. 1. In an observation conducted on 02/28/22 at 1:24 PM, Resident #51 was observed with her lunch meal. Closer observation showed the following: pureed glazed meatloaf, pureed potatoes, and pureed green beans. A record review was conducted for Resident #51. She was originally admitted to the facility on [DATE]. Noted in her Quarterly Minimum Data Set…

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 review, the facility failed to provide food and drink that is palatable, attractive, and at a safe and appetizing temperature for 3 residents of 3 sampled residents observed during dining, Resident #27, Resident #51, and Resident #20. The findings included: 1. In an observation conducted on 02/28/22 at 12:45 PM, the first tray cart arrived on the 100's unit with the lunch meals. The cart was placed in the hallway, and the staff was observed passing the lunch trays to all residents. Continued observation showed that Patient #51's lunch tray was left on the meal cart while all the other lunch trays were given to the residents. At 1:25 PM, 40 minutes later, the staff took the lunch meal from the meal cart and brought it into Resident #51's room. A record review was conducted for Resident #51. She was originally admitted to the facility on [DATE]. Noted in her Quarterly Minimum Data Set completed on 01/15/22 in the section regarding cognitive patterns, it shows that 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, and record review, the facility failed to provide the correct consistency for the mechanical soft diet during dining observation for 4 sampled residents, Residents #49, #17, #29, and #70, of the 14 residents ordered to receive mechanical soft diets. The findings included: Review of the Nutrition Care Manual under section Dysphagia Level 3: Advanced or Mechanical Soft, showed the following: no hard sticky or crunchy foods, foods should be moist, meat cut up and chopped, food particles are served in bite-sized pieces and less than 1 inch, and crunchy bread are not allowed (https://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=273657). 1. A record review was conducted for Resident #49 that showed initially being admitted to the facility on [DATE]. The Quarterly Minimum Data Set was completed on 01/17/22 in the section regarding cognitive patterns. It is shown that a Brief Interview for Mental Status was unable to be conducted due to her mental status. She has a medical history…

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 and interviews, the facility failed to keep food safety requirements with storage, preparation, and distribution that is in accordance with professional standards for food service safety that included failure to maintain sanitary conditions. The findings included: An initial tour of the kitchen was conducted on 02/28/22 at 8:51 AM with Staff F, Dietary Manager (DM), Staff E, Cook, and the Maintenance Director (MD). The following observations were noted: 1. In the food preparation area, 1 bin containing a bag of thickener powder was left open to air (Photographic evidence obtained) 2. Also in the food preparation area, a garbage can lid was left open (Photographic evidence taken) 3. In the plate warmer were 5 discolored scoop plates and 5 discolored plates noted (photographic evidence obtained) 4. In the walk-in refrigerator, it was noted that the ceiling had a moderate amount of black, spotty residue. 5. In the dry storage room, it was noted that a box of split bananas were on a shelf (Photographic evidence obtained); and there was a heavy accumulation of…

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

Based on observation and interviews, the facility failed to dispose of garbage and refuse properly to ensure a potential health hazard. The findings included: During the initial kitchen / food service observation tour conducted on 02/28/22 at 9:10 AM, the outside dumpster area was noted with the following: 1. 1 large green garbage dumpster was noted to be overflowing with clear garbage bags on top. 2. The area surrounding the dumpster had dirty used gloves, debris, and broken glass with a flying insect around it. In an interview conducted on 02/28/22 at 9:11 AM, the facility's Maintenance Director stated that the garbage gets picked up 3 or 4 days a week but was unsure of the times and days of the week. In another interview conducted on 02/28/22 at 10:00 AM, the facility's Maintenance Director stated that he checked the schedule and that the garbage gets picked up 3 days a week.