Pebblebrook Health Center at Park Springs

Based on observations, staff interviews, and review of the facility policies titled, Nutritional Lifestyles, Inc., Food Safety Requirements, and Foods Brought in from Outside Sources, the facility failed to ensure food items were properly stored, labeled with expiration dates, and expired foods were disposed of for one of one coolers (Main kitchen) and two of four pantries (Main kitchen and Coastal Hall) observed. In addition, the facility failed to ensure food items was properly labeled in the refrigerator/freezer and failed to ensure cleanliness for one of four refrigerators (Rehab Hall) observed. This deficient practice had the potential to cause foodborne illness for all residents. The deficient practice had the potential to affect 34 of 34 residents (R) who consume an oral diet. Findings include: Review of the facility's policy titled, Nutritious Lifestyle, Inc. dated 12/1/2011 under the section titled Policy: revealed, The consultant dietitian will monitor the storage of foods to ensure that all food served by the facility is of good quality and safe consumption. All food will…

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

Based on observation, staff interviews, and review of the facility's policy titled, Handwashing Guideline for Dietary Employees, the facility failed to perform hand hygiene between residents during meal pass in one of two dining halls (Lodge Dining Hall) observed. The deficient practices had the potential to increase the potential for cross-contamination and spread of infection. The facility census was 34. Findings include: Review of the facility's policy titled Handwashing Guideline for Dietary Employees dated 1/2025 under the section titled Policy revealed, Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illness. Dietary employees shall clean their hands in a handwashing sink or an approved automatic handwashing facility and may not clean hands in a sink for food preparation, ware washing, or in a service sink used for the disposal of mop water or similar waste. Under the section titled Compliance Guidelines: revealed, 1. Dietary employees shall keep their hands and exposed portions of their arms clean. During an observation on 4/29/2025 at…

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, staff interviews, record review, and review of the facility's policy titled Incidents and Accidents, the facility failed to ensure the environment was free from potential accident hazards by not ensuring sharps container was locked, failed to ensure the sharps lid was not left open and failed to ensure the correct size sharps container was secured within the placement holder for one of two medication carts (Coastal Hall). Additionally, the facility failed to ensure two of 34 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) were free from exposure to harmful chemicals and aerosols. Findings include: Review of the facility's policy titled, Incidents and Accidents dated 1/2025 under the section titled Policy Explanation revealed, The purpose of the incident reporting can include: Assuring all appropriate and immediate interventions and implanted and corrective actions are taken to prevent recurrence and improve the management of resident care. Under the section titled Compliance Guideline…

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, staff and resident interviews, record reviews, and review of the facility's policy titled, Administering Medications the facility failed to adequately assess two out of 24 sampled residents (R) (R12 and R141) for self-administration of medication. This failure had the potential to place the residents at risk for adverse consequences. Findings include: Review of the facility's policy titled, Administering Medications dated April 2019 under the section titled Policy Statement revealed, Medications are administered in a safe and timely manner, and as prescribed. Under the section titled Policy Interpretation and Implementation revealed, 27. Resident may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary (IDT) team, has determined that they have the decision-making capacity to do so safely. 1. Review of the Electronic Medical Record (EMR) revealed R12 was admitted to the facility with a diagnoses that included but not limited 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 record review, staff interviews, and review of the facility's policy titled, Resident's Rights Regarding Treatment and Advance Directives the facility failed to ensure one out of 24 sampled Residents (R) (R145) advance directive was documented accurately throughout the medical record. Findings include: Review of the facility's policy titled, Resident's Rights Regarding Treatment and Advance Directives dated January 2025 under the section titled Policy Explanation and Compliance Guideline: revealed, 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive . 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff . 9. Any decision making regarding the resident's choice will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for…

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

Based on observations and staff interviews the facility failed to follow a recipe when preparing puree food. This deficient practice had the potential to result in inconsistent texture modification, nutritional imbalance, and increase risk of aspiration for three of three residents receiving a puree diet. Findings include: Observation and interview on 4/30/2025 at 5:32 pm of pureed foods being prepared in the Coastal kitchen by the Coastal Homemaker DD revealed, there was no recipe being followed when pureeing the dinner meal of baked beef steak, broccoli, and mashed potatoes. Homemaker DD was observed placing three pieces of baked beef steak in the blender then started the blender. She took an ice cream scoop with the broth from the beef steak pan and put it in the blender. When asked what the serving size of the meat was Homemaker DD responded, about 3 ounces per piece she was not able to answer how much broth was added nor the size of the scoop that was used. Observation and interview on 5/1/2025 11:47 am in the Coastal kitchen revealed, Homemaker DD pureeing green peas and baked…

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, staff interviews, record reviews, and review of the facility's policy titled, Nutritional Assessment, the facility failed to provide care and services to prevent significant weight loss and impaired nutritional needs for four of seven Residents (R) (R3, R17, R20, and R21) reviewed for nutrition and weight loss. The facility failed to provide ongoing, consistent Nutritional Assessments, with accurate documentation, provided the correct diet as ordered for R17, and develop a Nutritional Care Plan for R21. The deficient practice had the potential to place the residents at risk for unmet care needs and a diminished quality of life. Findings included. Review of the facility's policy titled, Nutritional Assessment, dated October 2017 revealed, .As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident .The dietician, in conjunction with the nursing staff and healthcare…

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 staff interview and record review, the facility failed to ensure a physician ordered laboratory test was obtained in a timely manner for one of one Resident (R) (R21) reviewed for laboratory testing. The deficient practice had the potential to prevent R21 from receiving laboratory results as ordered by the physician. Findings included. Review of R21's Face Sheet located in the Face Sheet tab of the Electronic Medical Record (EMR) revealed R21 was admitted with diagnoses that included alcohol induced dementia, irregular heart rhythm, and mood disorders. Review of the Minimum Data Set (MDS) located in the RAI (Resident Assessment Instrument) tab of the EMR with an Assessment Reference Date (ARD) of 8/10/2023 revealed R21 had a Brief Interview of Mental Status (BIMS) score that was assessed by staff to be severely impaired in cognition for decision-making. Review of an 8/15/2023 Note to Attending Physician/Provider located in the Resident Documents tab of the EMR revealed a pharmacist recommendation to physician which stated, The resident is receiving medications which need…

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, staff interviews, and policy review, the facility failed to label, and date opened food items; failed to discard food items by use by dates; failed to have appropriate garbage receptacle at hand washing sink; and failed to properly sanitize dishware, to prevent cross contamination. The census was 20. 1. Review of the policy titled Food Safety and Sanitation created 3/17, revealed First In, First Out is to pay close attention to the use by dates and be sure to label and date all opened containers or leftover food items. Continued review of the policy revealed that all leftover food items must be properly covered, labeled with the contents, and dated with a use-by date. The policy also revealed to Prevent Cross Contamination is the transfer of harmful micro-organisms from one food to another by means of a nonfood surface such as cutting boards, utensils, human hands, aprons, or rags. Observation on 7/15/22 at 9:02 a.m. of the walk-in refrigerator revealed two opened one-gallon containers 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 observations, staff interviews, policy review and review of dietary recipe and menu cycle, the facility failed to ensure staff followed food recipes for preparing pureed foods to avoid compromising the nutritive value for peas and meatloaf for two of 20 residents, who received a puree diet. Findings include: Review of the policy titled Standardized Recipes, revised April 2007, revealed the food service manager will maintain the recipe file and make it available to food services staff as necessary. Review of the recipe for Glazed Meatloaf 3 oz PU Number 13. Prepare slurry. Number 14. Process until smooth adding 1 oz (ounce) slurry per portion. Number 16. Reheat to a minimum temperature of 165F (Fahrenheit) or higher for 15 seconds. Hold at 140F or higher for services. Continued review of the recipe revealed measurements as: Food Thickener Bulk - 2 tablespoon 1 1/2 teaspoon and water or stock 1 1/4 cup. Review of the Day 8 Menu Cycle for regular diet revealed portion sizes were indicated. The cycle menu for regular diets did not specify any other diets or diet consistency…

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.