Springs At Monarch Landing, The

Based on observation, interview and record review, the facility failed to sanitize pots and pans per facility policy. This applies to all 81 residents receiving oral diets in the facility. The findings include: Long term Care Facility Application for Medicare and Medicaid, dated July 28, 2024, shows the facility census was 82. Diet Type Report dated July 28,2024, shows one resident did not receive an oral diet at the facility. On July 28, 2024, at 10:18 AM with V6 (Food Service Manager), the dish machine sanitizer temperature was measured using a 180 degree F (Fahrenheit) test strip. The test strip instructions showed the black indicator line on the test strip was to turn completely orange when 180 degrees F was reached during the sanitizing cycle of the dish machine. After running through a full cycle of the dish machine, the test strip indicator line remained gray. During the sanitizing cycle, the dish machine water temperature (as indicated by the dish machine thermometer) did not elevate above 174 degrees F. Instructions posted on the dish machine showed the minimum 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 observation, interview and record review, the facility failed to label medications with the date when opened and failed to remove discontinued eye medication from the medication cart. This applies to 4 of 4 residents (R5, R10, R21, R63) reviewed for medication storage in the sample of 18. The findings include: On July 29, 2024, between 2:32 PM to 4:30 PM, the medication cart inspections were conducted with V3 (Registered Nurse/RN) and V4 (License Practical Nurse/LPN). The following was observed: 1. R63's Insulin Lispro Kwik Pen was opened and not dated. The Pharmacy's undated Insulin Storage Recommendation Beyond Use Date procedure showed to discard the insulin pen 28 days after opened. 2. R10's Humulin Lantus Solostar Injectable 100 ml (milliliters). was opened and not dated. The Pharmacy's undated Insulin Storage Recommendation Beyond Use Date procedure, showed to discard the insulin pen 28 days after opened. 3. R5's Netarsudil and Latanoprost 0.2%/0.005% eye drops were opened and not dated, with instructions to keep refrigerated. The Pharmacy's undated Recommendation 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 observation, interview and record review, the facility failed to ensure a residents urinary catheter tubing was kept off the floor for one resident (R26) reviewed for infection control with urinary catheter in the sample of 18. Findings include: On July 30, 2024, at 10:15 AM, R26 was in her bedroom, sitting in her wheelchair. R26's urinary catheter tube and bag were underneath her wheelchair. While R26 was talking to the surveyor, R26 kept moving her wheelchair back and forth while her indwelling urinary catheter tube was dragging on the floor. On July 30, 2024, at 1:26 PM, V2 (Director of Nursing/DON) stated the catheter tube shouldn't touch the floor to prevent potential infection. The facility's Urinary Catheter Care Policy and Procedure showed: Infection Control: 2. Maintain a clean technique when handling or manipulating the catheter tubing, or drainage bag. b. Be sure the catheter tubing and drainage bag are kept off the floor. 8. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as 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 follow standard infection control practices with regards to hand hygiene and gloving during provisions of care. This applies to 1 of 4 residents (R28) reviewed for infection control in the sample of 18. Findings include: 1. On July 29, 2024, at 4:55 PM, V5 (Certified Nursing Assistant/CNA) provided incontinence care to R28, who was wet with urine. V5 wiped/cleaned R28's perineum from front to back, placed a new incontinence brief, pulled his pants back in place, repositioned R28, placed the motorized wheelchair at bedside and assisted R28 to transfer from bed to wheelchair, while wearing the same soiled gloves all throughout the different tasks. On July 30, 2024, at 1:26 PM, V2 (Director of Director/DON) stated during provisions of incontinence care, staff must perform hand hygiene and change gloves before and after, and in between tasks to prevent cross contamination and spread of infection. The facility's undated Handwashing/Hand Hygiene policy and Procedure, showed: Policy Statement: This facility…

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 residents were assessed for the ability to self administer medications. This failure affects two of residents (R54, R333) reviewed for medication use on the sample list of 30. Findings include: 1. R54's admission Record shows R54 was admitted on [DATE] with diagnoses including gout, right shoulder and left knee pain, and obsessive-compulsive disorder. R54's 12/03/2022 cognitive function care plan showed she has impaired cognitive function related to a diagnosis of dementia, and her [Minimum Data Set] (MDS) scoring does not reflect cognitive fluctuations and forgetfulness that is observed by staff. On 08/22/2023 at 10:29 AM, R54 had an unlabeled tube of topical menthol pain reliever gel and an antifungal powder container on her nightstand on the right side of her bed. On 8/22/2023 at 10:30 AM, R54 said she regularly bought the menthol gel from an online retailer. R54 said she ordered the medication so she can always have and use it…

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 residents' medications were secured and labeled. This applies to 2 residents of 20 residents (R54, R333) reviewed for medication storage on the sample list of 30. Findings include: 1. R54's admission Record shows R54 was admitted on [DATE] and her diagnoses include gout, right shoulder and left knee pain, and obsessive-compulsive disorder. R54's 12/03/2022 cognitive function care plan showed she has impaired cognitive function related to a diagnosis of dementia, and her [Minimum Data Set] (MDS) scoring does not reflect cognitive fluctuations and forgetfulness that is observed by staff. On 08/22/2023 at 10:29 AM, R54 had an unlabeled tube of topical menthol pain reliever gel and an antifungal powder container on her nightstand on the right side of her bed. On 8/22/2023 at 10:30 AM, R54 said she regularly bought the menthol gel from an online retailer. R54 said she ordered the medication so she can always have and use it when 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.

Based on interview and record review, the facility failed to ensure a resident receiving a transdermal medication patch, only had one medication patch in place during transdermal medication administration. This failure affects one of three residents (R1) reviewed for transdermal medication use on the sample list of six. Findings include: R1's face sheet (8/1/23) documents R1's diagnoses including Parkinson's Disease, Dementia, Anxiety Disorder, and Adult Failure to Thrive. R1's current Physician Order Sheet (POS) documents R1's orders including Exelon (Rivastigmine) (reversible cholinesterase inhibitor) transdermal patch 24-hour 4.6 milligram (mg), apply one patch transdermal at a time related to Dementia. On 8/1/23 at 10:58 AM, V5 (R1's husband) was wheeling R1 back to her room. V5 stated he had concerns with R1's Exelon transdermal patch. V5 stated on 7/2/23 and 7/26/23, R1 had two of the Exelon transdermal patches on her. V5 stated R1 is supposed to have only one patch on her at a time. On 8/1/23 at 3:36 PM, V11 (LPN- Licensed Practical Nurse) stated on 7/2/23, V11 took an Exelon…

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 were served menu items from the dietitian approved spreadsheet to meet the resident's nutritional needs. This applies to all 74 residents residing in the facility. The findings include: The Resident Census and Condition Report (Federal Form 672) shows that on 9/6/22, the facility housed 74 residents. The Spreadsheet for Tuesday's lunch includes tilapia, bowtie pasta, kale salad and pear halves for the resident's on a general diet. The Spreadsheet shows pureed tilapia, bowtie pasta, green beans and pears for the resident's on a pureed diet. On 9/6/22 at 10:31 AM, V6 (Cook) pureed the noon meal. V6 pureed fish and green beans. On 9/6/22 at 12:20 PM, V8 (Cook) did not have bowtie pasta on the steam table to be served. V8 served R4, R7, R15, R25 and R62 the prepared pureed meal. V8 stated, They are getting fish, mashed potatoes and peas. R4, R7, R15, R25 and R62 did not receive pureed pears or any dessert substitute. On 9/07/22 at 2:15 PM, V6 said that the spreadsheet showed that the residents…

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 was stored and served in a sanitary manner, dishes were cleaned under sanitary conditions, and food temperatures were taken to prevent foodborne illnesses for all 74 residents residing in the facility. The findings include: The Resident Census and Condition Report (Federal Form 672) shows that on 9/6/22, the facility housed 74 residents. 1. On 9/6/22 at 10:15 AM, there were multiple opened food items in the dry storage area that were not dated with the date opened. These food items include: baking powder, lime gelatin, marshmallows, noodles, strawberry gelatin, brown sugar, 2 bags of pecans and sunflower kernels. A bag of pecans and a box of sunflower kernels were not sealed closed. There was a bag of white chocolate chips that were dated, Use by 2/22. On 9/6/22 at 10:15 AM, V1 (Administrator) said that all food should be labeled with the open date once it is opened. V2 said that it is important to know since different types of foods are only good for a certain amount of time after opening. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to socially distance residents who are on droplet isolation while in the dining room. This applies to two residents (R19, R21) outside the sample reviewed for infection control. This has the potential to affect all 74 residents in the facility. The findings include: The facility face sheet for R19 shows diagnosis to include dementia. The facility assessment dated [DATE] shows moderate cognitive impairment. The facility face sheet for R21 shows diagnosis to include Parkinson's Disease and dementia. The facility assessment dated [DATE] shows her to be cognitively intact. On 9/6/2022 at the noon meal, R19 was observed sitting next to another resident at a table in the dining room. The two residents were not sitting six feet away from each other. On 9/7/2022 during breakfast, R21 was observed sitting at the same dining room table across from another resident. The residents were not sitting six feet from each other. On 9/7/2022 at the noon meal,…

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 treat a resident in a dignified manner by ensuring a resident's urinary drainage bag was covered while in common areas for one of three residents (R15) reviewed for catheters in the sample of 18. The findings include: On 09/06/22 at 10:29 AM, R15 was in her high back wheelchair in a common area during an exercise activity. R15's urinary drainage bag was visible and hanging to right of resident on the chair. The catheter tubing came down through R15's right pant leg. At 12:30 PM, R15 was in the high back chair seated at a dining room table. The dining room was full of residents. R15's urinary drainage bag remained visible and attached to her chair. On 09/08/22 at 08:37 AM, V10 MDS (Minimum Data Set) Coordinator said the purpose of a privacy bag is for dignity. It's meant to preserve the patient's privacy. Everyone doesn't need to know that R15 has an indwelling urinary catheter. Resident's with catheters should have a privacy bag even if…

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.