Pearl Of Elgin, The

Based on observation, interview and record review, the facility failed to employ and schedule a sufficient number of competent food service staff to safely and adequately serve resident meals. This has the potential to affect all 119 residents receiving oral diets in the facility. The findings include: Facility Census and Condition of Residents, dated 9/5/23, show the facility census was 122. Diet Type Report, dated 9/7/23, shows three residents had physician orders for NPO (nothing by mouth). 1. On 9/5/23 at 10:00 AM, the only food service staff working in the kitchen were V3 (Dietary Aide), V4 (Dietary Aide/Cook), and V5 (Cook). V3 stated the day prior the food service had only two employees in the morning working to prepare and serve breakfast to the facility residents. V3 stated the food service often only has a total of three people working in the morning in the food service however the operation requires a total of four staff to be able to effectively prepare and serve food to the residents. 2. On 9/5/23 during observations in the kitchen, several sanitation concerns were…

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

Based on observation, interview and record review, the facility failed to serve the facility menus as planned. This has the potential to affect all 119 residents receiving oral diets in the facility. The findings include: Facility Census and Condition of Residents, dated 9/5/23, show the facility census was 122. Diet Type Report, dated 9/7/23, shows three residents had physician orders for NPO (nothing by mouth). 1. Tray tickets, dated Week 3 Tuesday Lunch, show R10, R104, R5, R82, R15, R34 all received pureed diets. Facility Therapeutic Spread Report 2023 Winter Menu, dated 1/20/23, shows one serving of pureed pork roast was to be served with a #10 scoop (2.75 ounces volume) to equal one regular 3-ounce weight portion of pork roast. On 9/5/23 at 1:00 PM at the conclusion of lunch service, V6 (Corporate Food Service Manager) weighed one serving of pureed of pork as served to pureed diets during the lunch service. The serving of pureed pork weighed a total of only 1.75 ounces. V6 stated the pureed serving should contain no less than three ounces weight of pureed pork not including…

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

Based on observations, interviews, and record reviews, the facility failed to serve palatable meals to facility residents. This has the potential to affect all 119 residents receiving oral diets in the facility. The findings include: Facility Census and Condition of Residents, dated 9/5/23, show the facility census was 122. Diet Type Report, dated 9/7/23, shows three residents had physician orders for NPO (nothing by mouth). 1. On 9/5/23 at 12:02 PM with V6 (Corporate Food Service Manager) in the kitchen during lunch service, the food service staff prepared eight full plates of lunch and left them uncovered sitting on the shelf waiting for lunch servers to arrive to serve the plates to residents. At 12:04 PM, V7 (Food Service Aid) prepared three more plates and placed them on the shelf without lids next to the first eight pre-made plates. At 12:05 PM, V7 requested more tickets and began plating more plates of food and placed them on the shelf with no lids. On 9/5/23 at 12:10 PM, one of the plates sitting on the shelf was removed as a test tray. The foods were tasted, and the…

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

Based on observation, interview and record review, the facility failed to ensure the facility food preparation and storage was performed in a sanitary manner and under sanitary conditions. This has the potential to affect all 119 residents receiving oral diets in the facility. The findings include: Facility Census and Condition of Residents, dated 9/5/23, show the facility census was 122. Diet Type Report, dated 9/7/23, shows three residents had physician orders for NPO (nothing by mouth). 1. On 9/05/23 at 10:00 AM the following observations were made during tour of the kitchen: - There were 4 slabs of cooked ribs uncovered sitting on a sheet pan. The sheet pan of ribs was placed in a rolling rack and above the cooked ribs was a sheet pan of raw ground beef thawing. - A green cutting board was soaking in the third compartment of the three-compartment sink. V5 (Cook) stated the third compartment contained chemical sanitizing solution. V5 tested the chemical sanitizing solution concentration which measured 100 ppm (parts per million). V5 stated the concentration should measure 200…

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

Based on interview and record review the facility failed to identify and implement interventions for performance improvement regarding kitchen sanitation and ADLs (Activities of Daily Living) care. This applies to all 122 residents who reside in the facility. The findings include: On 9/7/23 at 11:35 AM, V1 (Administrator) identified rehospitalization as the only PIP (Performance Improvement Plan) that the facility is currently working on. V1 further stated that during the facility's mock survey in June 2023, by the corporate staff, concerns with sanitation, staffing and following the menus were identified in the kitchen. V1 stated there was no PIP developed nor a plan developed to improve conditions in the kitchen. V1 further stated the Quality Assurance program is not effective and could be improved. On 9/7/23 at 12:00 PM, V21 (Nurse Consultant) stated the facility has one PIP currently for rehospitalization. V21 stated when making rounds in the facility, V21 has identified ADL concerns, specifically grooming, and stated there is no PIP or working plan to address this concern. V21…

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 5. The Electronic Medical Record (EMR) shows that R33, an [AGE] year-old female, with diagnoses of bilateral osteoarthritis, peripheral neuropathy, chronic obstructive pulmonary disease exacerbation, diabetes mellitus type 2, major depressive disorder, obesity, and cerebral infarction. R33 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) assessment dated [DATE] showed that R33 was cognitively intact with a BIMS (Brief Interview Mental Status) score of 14/15. The MDS also showed that R33 required extensive assistance from 1-2 staff for bed mobility, transfer, dressing and hygiene. On 9/05/23 at 10:43 AM, R33 was observed in her room. R33 was sitting in her wheelchair. R33 was observed with a long facial hair surrounding her chin and upper lip and looked like a moustache. When asked how R33 feels about her facial hair, R33 responded I do not like it, I like to have it shaved and I have been asking for it for a while, I even asked for a razor, they (staff) never did anything about it. V11 (Unit…

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 implement physician order regarding the use of compression stockings and compression wrap to treat and manage edema. This applies to four of four residents (R1, R70, R80 and R102) reviewed for edema in the sample of 24. The findings include: 1. On 9/05/23 at 10:53 AM, R1 was observed in the dining room. R1 was sitting in her wheelchair. R1 was wearing a pair of pants and lower legs were visible. R1 was wearing a pair of socks and shoes. R1 was noted with edema to the lower legs/ankles. R1 was not wearing compression stocking. V11 (Unit Charge Nurse) was present during this observation. The Nurses Shift Report dated 9/5/203 shows that R1 was supposed to wear a pair of compression stocking during the day. The compression stockings were to be applied in the morning and removed at night. Review of the POS (Physician Order Sheet) for the month of 9/2023 shows a physician order for R1 to apply the compression stocking in the morning and to take…

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

Based on observation, interview and record review, the facility failed to puree resident food to a smooth consistency per facility policy. This applies to 6 of 6 residents (R5, R10, R15, R34, R82, and R104) reviewed for pureed diets. The findings include: Tray tickets, dated Week 3 Tuesday Lunch, show R5, R10, R15, R34, R82 and R104 all received pureed diets. On 9/5/23 at 11:00 AM during observation of pureed pork preparation for lunch, V5 (Cook) placed portions of ground pork roast into the blender. V5 added broth and pureed the mixture in the blender. V5 turned off the blender and began transferring the pork product from the blender into a steam table pan without tasting the product. V5 stated he was finished with pureeing the product. A sample of the product was tasted, and the sample tasted dry and had lumps of unpureed pork in the mixture. On 9/7/23 at 2:15 PM, V1 (Administrator) stated it was his expectation that purees were to be pureed until smooth (with no lumps) and served at an applesauce to mashed potato consistency. Standards and Guidelines Liberalized Diets, revised…

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

Based on observation, interview and record review, the facility failed to serve residents double protein servings and supplements per physician orders. This applies to 4 residents (R5, R31, R68 and R83) reviewed for therapeutic diets. The findings include: 1. Care plan, revised 9/5/23, shows R5 had a pressure injury on her sacrum, right and left ischium, and right lateral ankle. The care plan intervention, initiated 6/2/23, shows R5 was to be provided supplemental protein, amino acids, vitamins, and minerals as ordered by the physician to promote wound healing (see physician orders). Order Summary Report, dated 9/6/23, shows R5 has a physician order (dated 5/31/23) for Double the protein portions in lunch and dinner. On 9/5/23 at 12:38 PM during lunch service, the food service staff served R5 only one portion of pureed pork and two portions of pureed pasta. On 9/5/23 between 12:45 PM and 1:20 PM, R5 was served a single portion of pureed pork at her lunch table. R5's meal ticket showed R5 was to be a double portion of protein at the meal. 2. Care plan, revised 7/31/23, shows R83 had…

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

Based on observation and interview, the facility failed to ensure that privacy was provided to residents during administration of insulin and eye drops medications. This applies to 2 of 7 residents (R33 and R80) observed during medication pass administration in the sample of 24. The findings include: 1. During medication pass observation on 9/6/23 at 4:46 PM, V24 (Licensed Practical Nurse) administered the insulin injection to R33, inside the resident's room. During the insulin administration, R102 (roommate) was present and saw V24 injecting the insulin to R33's lower abdomen. V24 did not draw the privacy curtain that was hanging in between the two resident beds to provide privacy to R33. 2. During medication pass observation on 9/6/23 at 4:49 PM, V24 administered eye drops to R80 inside the resident's room. During the eye drops administration, R76 (roommate) was present and saw the procedure. V24 did not draw the privacy curtain that was hanging in between the two resident beds to provide privacy to R80. On 9/07/23 at 12:38 PM, V2 (Director of Nursing) stated that privacy should…

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

Based on observation, interview, and record review the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility. This applies to 1 of 6 residents (R55) reviewed for limited range of motion (ROM) in the sample of 24. The finding include: R55's EMR (Electronic Medical Record) showed R55 has been in the facility since 8/26/22. R55's diagnoses included unspecified injury at C7 level of cervical spinal cord resulting in paraplegia, major depression, muscle generalized weakness, contracture of right knee, contracture of left knee, and polyneuropathy. R55's MDS (Minimum Data Set) dated 8/8/2023 showed R55 was cognitively intact and required two staff extensive assistance for bed mobility, transfers, and toilet use. R55 required one staff extensive assistance for dressing and personal hygiene. R55's MDS indicated he was receiving restorative services but did not indicate splint or brace assistance. R55's care plan initiated on 1/6/23 showed [R55] had an ADL (Activities of Daily Living) 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.

Based on observation, interview and record review, the facility failed to clean a resident during incontinence care in a manner that would prevent potential infection. This applies to 1 of 1 resident (R34) reviewed for incontinence care in the sample of 24. The findings include: R34's EMR (Electronic Medical Record) showed R34's most recent admission date was 7/4/22 with diagnoses that included Parkinson's disease, dementia without behavioral disturbances, and peripheral autonomic neuropathy. R34's MDS (Minimum Data Set) dated 7/20/23 showed R34 had severe cognitive impairment and required two staff extensive assistance for all ADLs (Activities of Daily Living). R34's care plan showed [R34] had an ADL self-care performance deficit and was dependent on two staff for toilet use. On 9/6/23 at 1:23 PM, V15 (Certified Nurse Assistant/CNA) came to assist V14 (CNA) with changing R34's incontinence brief. V14 left the room to get some supplies. V16 (Registered Nurse/RN) came to help V15. R34's pants were removed and V15 unfastened and opened up R34's incontinence brief. V15 used a wipe 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 interview and record review, the facility failed to evaluate and put interventions in place to prevent weight loss. This affects 1 resident of 3 residents (R71) reviewed for significant weight loss in the sample of 24 residents. The findings include: According to the facility Face Sheet, R71 had diagnoses that included respiratory failure, congestive heart failure, type 2 diabetes, severe chronic kidney disease, and other diagnoses. R71 was recently discharged from kidney dialysis. R71 is [AGE] years old. On 9/6/23 at 3:13 PM, R71 stated he has not seen the Dietician from the facility. The facility medical record for R71 shows a weight loss of 28 pounds between 6/27/23 and 9/2/23 as shown: 6/27/23 2:44 AM 219.0 pounds 7/5/23 12:27 PM 213.0 pounds 8/2/23 1:47 PM 206.2 pounds 8/2/23 1:53 PM 209.4 pounds 8/14/23 1:35 PM 198.2 pounds 8/28/23 2:43 PM 195.5 pounds 9/2/23 4:34 PM 191.0 pounds This represents an average of 3.1 pounds per week loss. This is a loss of 12.78% of total body weight in 9 weeks. On…

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

Based on observation, interview and record review the facility failed to follow physician's order with regards to administration of continuous oxygen. This applies to 2 of 2 residents (R50 and R61) reviewed for oxygen therapy in the sample of 24. The findings include: 1. R61 had multiple diagnoses which included COPD (chronic obstructive pulmonary disease), asthma, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, based on the face sheet. R61's quarterly MDS (minimum data set) dated 7/6/23 showed that the resident was moderately impaired with cognition and required extensive assistance from the staff with most of her ADLs (activities of daily living). On 9/5/23 at 11:21 AM, R61 was in bed, awake but confused. R61 was receiving five liters of continuous oxygen via nasal cannula as shown in the oxygen concentrator gauge. On 9/6/23 at 1:15 PM, R61 was in bed with the head of the bed elevated. R61 was receiving five liters of continuous oxygen via nasal cannula as shown in the oxygen concentrator gauge. V10 (Licensed Practical Nurse) 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.

Based on observation, interview and record review, the facility failed to provide adaptive equipment to residents as per physician orders. This applies to 2 residents (R10 and R11) reviewed for adaptive equipment. The findings include: Order Summary Report, dated 9/6/23, shows R11 had a physician order (dated 4/17/23) for Plate guard with all meals. Order Summary Report, dated 9/6/23, shows R10 had a physician order (dated 2/6/23) for use plate guard. On 9/5/23 at 12:00 PM with V6 (Corporate Food Service Manager), the food service staff were preparing lunch trays for facility residents. At 12:24 PM, R11's lunch plate was prepared and served. At 12:45 PM during lunch service, R10's lunch tray was prepared and served. Neither resident's plate/tray had a plate guard as per her lunch tray ticket instructions. On 9/06/23 at 2:31 PM, V6 (Corporate Food Service Manager) stated resident assistive devices (such as plate guards) used during meals should be placed on their trays/plates during meal service in the kitchen. Standards and Guidelines Assistive Devices, revised 3/4/21, shows The…

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

Based on observation and interview the facility failed to change gloves and perform hand hygiene during provisions of care. This applies to 1 of 2 residents (R34) reviewed for incontinence care in the sample of 24. The findings include: R34's EMR (Electronic Medical Record) showed R34's most recent admission date was 7/4/22 with diagnoses that included Parkinson's disease, dementia without behavioral disturbances, and peripheral autonomic neuropathy. R34's MDS (Minimum Data Set) dated 7/20/23 showed R34 had severe cognitive impairment and required two staff extensive assistance for all ADLs (Activities of Daily Living). R34's care plan showed [R34] had an ADL self-care performance deficit and was dependent on two staff for toilet use. On 9/6/23 at 1:23 PM, V15 (Certified Nurse Assistant/CNA) came to help V14 (CNA) provide incontinence care to R34. V15 washed her hands with soap and water and put on gloves when V14 said he needed to go get some wipes and more gloves since the box in the room was now empty. V14 returned to the room and put on gloves without washing his hands or using…

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

Based on observation, interview, and record review, the facility failed to ensure food prep areas were free of food debris. The facility also failed to ensure plates were clean and dry before using them for the noon meal. This applies to all 124 residents residing in the facility. The findings include: The CMS 672 census and conditions report dated October 17, 2022 shows, there are 124 residents residing in the facility. On October 17, 2022 at 8:47 AM, during the initial kitchen tour, the stand mixer sitting next to the food prep area by the oven and steamer was dirty with some white powder like substance. The attachments were sitting in the bowl and were dirty with this white powder like substance. There was an opened boxed of barley that appeared to be dusty sitting next to the stand mixer. The table was dirty with a white powder like substance and dried food debris. Underneath the prep tables held the clean pots, pans, and cutting boards. The cutting boards were sitting on top of a baking sheet that was full of food crumbs, debris and old French-fries. The shelf with the pots and…

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

Based on observation, interview and record review, the facility failed to ensure that the kitchen, cooler and freezers were clean and sanitary. This applies to all 124 residents residing in the facility. The findings include: The CMS 672 census and conditions reports dated October 17, 2022 shows, there are 124 residents residing in the facility. On October 17, 2022 at 8:43 AM, both stand-up freezer door handles and doors had dried food debris on them. Inside both freezers, on the floor, were frozen food and food debris (peas and green beans). The cooler had onion peels and other food debris on the floor. A red substance was dried on the wall. The floors were sticky and had a black film on them. There were packets of salt, mayonnaise, coffee creamer on the floor in random places. There were french fries on the floor. The floors appeared to not have been swept and mopped in sometime. On October 17, 2022 at 2:50 PM, V16 (Food Service Manager) stated, they didn't have a cleaning schedules or cleaning logs. She agreed that the kitchen was very dirty and had not been cleaned over the…

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

Based on observation, interview, and record review, the facility failed to ensure residents on mechanical soft and pureed diets received the same menu as the regular diet. This applies to 24 of 24 residents (R6, R27, R127, R19, R64, R22, R82, R80, R43, R75, R44, R60, R38, R24, R182, R93, R3, R15, R88, R115, R51, R90, R36, & R103) reviewed for mechanical soft and pureed diets in the sample of 25. The findings include: The facility's menu with the noon meal for October 17, 2022 shows, Orange glazed chicken, fried rice, oriental vegetable blend, and bread pudding. On October 17, 2022 at 11:22 AM, V17 (Cook) was preparing the pureed diets for the noon meal. He stated, he did not have a pureed recipe for the orange chicken, so he was going to follow the recipe for chicken ala king. He put baked chicken bites in the blender and added some chicken broth. The chicken bites did not have any orange sauce on them. On October 17, 2022 at 12:01 PM, V16 (Food Service Director) was serving the noon meal. Residents' with a mechanical diet (R64, R22, R82, R80, R43, R75, R44, R60, R38, R24, R182,…

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

Based on observation, interview, and record review, the facility failed to ensure pureed diets were served in a smooth, soft texture. This applies to 4 of 4 residents (R6, R27, R127 and R19) reviewed for pureed diets in the sample of 25. The findings include: The facility's menu for the noon meal on October 17, 2022 shows, Orange glazed chicken, fried rice, oriental vegetable blend and bread pudding. On October 17, 2022 at 12:01 PM, the noon meal was served to all of the residents. At 12:46 PM, all residents were served the noon meal. R6, R27, R127, & R19 were served pureed diets. On October 17, 2022 at 1:01 PM, the pureed oriental vegetables were not smooth. There were pieces of the vegetables in it. The pureed rice was not smooth and there were also pieces of rice in it. On October 18, 2022 at 10:20 AM, V16 (Food Service Manager) stated, the pureed diets should be smooth and no chunks of food in it. The facility diet type report provided on October 17, 2022 lists R6, R27, R127, and R19 as having a pureed diet. The facility's liberalized diets last revised on February 19, 2021…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident (R331) was free from physical abuse for 1 of 25 residents reviewed for abuse in the sample of 25. The findings include: R331's face sheet shows he was admitted to the facility on [DATE] with diagnoses including primary osteoarthritis in left knee, infection to left knee, chronic obstructive pulmonary disease, and need for assistance with care. R331's 9/10/22 facility assessment shows his cognition is intact. A nursing progress note completed on 9/3/22 at 7:00 PM, shows R331 is alert was able to answer questions appropriately and his memory is intact. R102's face sheet shows he was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hemiplegia and hemiparesis, dysphagia and aphasia R102's 7/22/22 facility assessment shows he has moderate cognitive impairment. R102's electronic medical record (EMR) shows he communicates by writing on a white board and prefers to speak in Spanish. R102's nursing progress…

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 identify restraining a resident by restricting their movement which applies to 1 of 24 residents (R44) reviewed for restraints in the sample of 25. The findings include: R44's Facility assessment dated [DATE] showed R44 being an [AGE] year old cognitively impairment resident admitted to the facility with diagnoses which include: dementia, history of falls, sequela for pelvis/pubis fracture. On 10/17/22 at 9:05 AM, R44 was sitting inside the nurses' station with no staff present at the desk. R44 was pushed all the way up to the desk counter with both brakes on the wheelchair locked. R44 attempted to get up and push away from the desk but could not move with the wheels locked. On 10/17/22 at 9:10 AM, V22 (Certified Nursing Assistant/CNA) stated R44 is kept at the nurses' station because she is a fall risk. R44 will attempt to get up from her chair by herself. We (staff) keep her at the nurses' station to keep an eye on her, but she cannot…

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 identify, assess, and apply pressure relieving interventions for residents who are high risk for pressure injuries. This applies to 3 of 11 residents (R76, R103 & R106) reviewed for pressure injuries in the sample of 25. 1. R76's electronic medical records (EMRs) list her diagnoses to include: cognitive communication deficit, urine retention, chronic kidney disease, disorientation and dementia. R76's EMR shows she was admitted to the facility on [DATE]. The facility's pressure ulcers as of October 17, 2022 provided on October 17, 2022 shows, R76 has two pressure injuries. Her left heel- DTI (deep tissue injury) and sacrum- DTI. Both were acquired at the facility. R76's initial admission/re-admission nursing note dated August 30, 2022 shows, she was admitted with redness on her sacrum. There was nothing listed about her heels. Additional comments/observations: heels intact, groins intact, Foley catheter 16 fr(french-size)/10ml…

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 2.) R9's face sheet shows she has diagnoses including hemiplegia and hemiparesis following a cerebral infarction. R9's 7/22/22 facility assessment shows her cognition is mildly impaired, and she requires extensive staff assistance with her activities of daily living (ADL's) R9's mobility care plan revised on 8/11/2021 shows that R9 has limited mobility to her left hand and a hand towel roll should be put in her hand each shift. R9's restorative range of motion task charting shows R9 should receive a hand rolled towel in her left hand to prevent further contractures. The chart for R9 is checked off on 10/17/22 at 10:36 AM, and again on 10/18/22 at 11:05 AM, indicating that R9 did have a hand roll towel put into her left hand. On 10/17/22 at 9:56 AM, R9 was in bed her left arm was positioned in front of her and her left hand was in a clenched position with no hand roll in it. On 10/18/22 at 9:24 AM, and again at 1:24 PM, R9 was in bed with her left hand clenched and no hand roll in her hand. On 10/18/22 at 1:24…

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

Based on observation, interview, and record review, the facility failed to ensure a resident with COVID symptoms was placed on isolation precautions. This applies to 1 of 25 residents (R93) reviewed for infection control in the sample of 25. The findings include: On October 17, 2022 at 9:41 AM, R93 was in his room. He was not on any isolation precautions. A CNA (Certified Nursing Assistant) was in the room helping him get up. At 10:45 AM, R93 was still in his room. Therapy was working with him. He practiced walking in the hallway. He was not on isolation precautions. On October 17, 2022 at 2:29 PM, R93 had an isolation bin outside his room and a sign on his door that said contact/droplet precautions. V20 (Registered Nurse/RN) stated, R93 was now positive for COVID-19. He had a cough and loose bowel movements that started last night. Around lunch time they rapid tested him for COVID-19, and he was positive. R93's progress notes dated October 17, 2022 at 7:00 AM show, Resident with LBM x2 (loose bowel movements) and occasional cough . rapid test administered and received negative…

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.