Tabor Hills Health Care Fac

Based on observation, interview, and record review the facility failed to ensure the hot water dish machine reached 160 degrees Fahrenheit rinse temperature, failed to ensure staff changed gloves between handling soiled and clean dishes and failed to ensure the dry storage area did not contain expired canned food products. This applies to all 63 residents who receive oral diets from the kitchen. The findings include: On May 6, 2024, at 10:11 AM, V6 (Dietary Aide) was washing dishes using the hot water dish machine. V3 (Maintenance Director) and V4 (Dining Room Supervisor) were present and were asked to validate the dish machine temperature, V3 placed the disc thermometer in the dish rack. V3 then placed the rack on the conveyor and ran it through the dish machine. Upon exiting the machine, the thermometer showed a temperature of 153 F (Fahrenheit) degrees. V3 and V4 were both present and aware of the temperature reading. At 10:19 AM, V3 placed the thermometer in the dish rack again, placed the dish rack on the conveyor, and upon exiting the machine the thermometer showed 157.6 F. V6…

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 administer the pneumococcal vaccine to residents according to the CDC (Centers for Disease Control and Prevention). This applies to 4 of 5 residents (R8, R13, R17, and R56) in the sample of 19. The findings include: On May 7, 2024, at 1:22 PM, V7 (Infection Preventionist Nurse) said the facility follows CDC recommendations for pneumococcal vaccine timing. 1. R8's EMR (Electronic Medical Record) showed R8 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including hypertension, pneumonia, and anemia. R8's Immunization Record showed R8 received the PCV13 (13-valent pneumococcal conjugate vaccine) on March 15, 2022. R8's undated Consent to Administer Pneumococcal Polysaccharide (PPSV) Vaccine showed R8's Resident Representative consented for R8 to receive the pneumococcal vaccine. On May 8, 2024, at 1:01 PM, V8 (Infection Control Nurse) said R8 should have received the PPSV23 vaccine one year after receiving 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 provide restorative therapies to a resident scheduled for therapies per her plan of care. This applies to 1 of 1 resident (R41) reviewed for rehabilitation in a sample of 19. The findings include: R41's Medical Record, dated May 2024, shows R41's diagnoses included artificial hip, osteoarthritis right and left shoulders, cerebral infarction and transient ischemic attack, osteoarthritis left shoulder, scoliosis, and osteoporosis. Restorative Joint Mobility Evaluation 3/12/24, shows R41 had limited ROM of the front left shoulder related to stiffness, arthritic digits of the left and right hand. The evaluation shows R41 required AROM (Active Range of Motion) of BUE (Bilateral Upper Extremity) and bilateral ankles. R41 had a diagnosis of osteoarthritis of bilateral shoulders and transferred with a standing lift assisted by two staff. Care plan, initiated 3/12/24, shows R41 had a wedge compression fracture of her thoracic 11-12 vertebrae, thoraco-lumbar anterolisthesis of L4 on L5, osteoarthritis of bilateral knees…

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 apply palm protectors to a resident's contracted hands per her plan of care. This applies to 1 of 3 residents (R14) reviewed for ROM (Range of Motion) in a sample of 19. The findings include: R14's Care Plan, initiated March 20, 2020, shows R14 was at risk for contractures due to decreased strength, impaired coordination, poor endurance and balance, and poor memory. The care plan shows R14 was to wear a palm protector which should be applied in the morning and removed at bedtime. The care plan shows staff should check for redness on the surrounding area. Physician order, dated March 18, 2024, shows R14 was to have Palm Protector applied to her hands every morning and removed before bedtime. The staff were to check for redness in the surrounding areas. On May 6, 2024, at 10:56 AM, R14 was in reclining wheelchair in the dining room. The fingers of both of R14's hands were very contracted and were closing toward palm of each hand. R14 was holding white gauze between her contracted fingers and palm in her left…

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 a resident was properly positioned in a shower chair during a shower. This applies to 1 of 2 residents (R265) reviewed for falls in the sample of 19. The findings include: R265's EMR (Electronic Medical Record) showed R265 was admitted to the facility on [DATE], with multiple diagnoses including encephalopathy, fall, weakness, and dementia. R265's Brief Interview for Mental Status dated May 7, 2024, showed R265 was cognitively intact. R265's Functional Abilities and Goals dated May 1, 2024, showed R265 required maximal assistance from facility staff for transferring to and from the tub/shower. On May 8, 2024, at 11:28 AM, R265 said she got a shower a few days ago and the shower chair tipped over when the CNA (Certified Nursing Assistant) was done washing her. On May 8, 2024, at 11:38 AM, V9 (CNA) said she was giving R265 a shower in her room and R265 attempted to stand up to wash herself. V9 said she instructed R265 to sit back…

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 store food items in sanitary conditions by having unlabeled and undated food items in dry storage and in a walk-in cooler, and ice buildup on food items and the ceiling in the freezer. This affects all 70 residents consuming food from the kitchen. Findings include: On 6/14/23 at 10:10 AM, V2 (Director of Nursing - DON) stated, We have 70 residents on the certified side. Two are on gastrostomy tube (GT) feeding, but they are also on pleasure feeding. So, all 70 residents are eating from the kitchen. On 6/16/23 at 9:40 AM, during the initial kitchen tour with V5 (Assistant Dietary Manager), the dry kitchen storage was observed with a partially used five-pound [NAME] Cracker Crumbs with no label or date. On 6/16/23 at 9:45 AM, the kitchen walk-in cooler was observed with two apple pies with no label or date, and two pounds of sliced ham dated 6/5/23 (11 days earlier), partially covered with plastic wrap. On 6/16/23 at 9:45 AM, V5 stated, Sliced hams are good for seven days and should be fully covered . All 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.

Based on observation, interview, and record review, the facility failed to implement infection control measures to prevent cross-contamination from soiled linens, soiled gloves, incontinence wipes, and resident trays. This applies to 11 of 23 residents (R4, R12, R17, R28, R42, R49, R52, R56, R60, R68, and R278) reviewed for infection control. Findings include: 1. On June 13, 2023, at 11:26 am, V7 CNA (Certified Nursing Assistant) placed a disposable incontinence brief and pants on R278 while R278 was in a standing position, V7 threw R278's soiled under pad onto the floor. R278 was assisted to her wheelchair. While still wearing soiled gloves, V7 walked out of R278's bedroom to the clean linen cart in the hallway. V7 lifted the covering of the linen cart wearing the soiled gloves and removed towels and a pillowcase. V7 returned to R278's room, removed the soiled gloves, and used hand sanitizer. R278's room contained three beds and R278 is assigned to bed #3; beds #1 and #2 were both made and ready for new admissions. V7 moved R278's soiled linen and clothing she had previously placed…

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 kitchen food storage was free of pests which applies to all 81 residents reviewed for sanitary food storage. The findings include: The CMS-672 dated 8/22/22 showed a census of 81 residents. On 8/22/22 at 10:00 AM, upon entering the kitchen's dry storage area, a swarm of flying insects were concentrated on and around the bread and bread cart in the middle of the storage room. Across the storage room there was a smaller swarm of flying insects centralized around bananas stored on a shelf. On 8/22/22 at 10:15 AM, V17 Dietary Manager and V20 Maintenance/Housekeeping Manager (while on kitchen tour) stated the facility has had problems with drain flies for about 2 months. We have had pest control in, but I am not sure what they have done in the storage area. On 8/23/22 at 9:15 AM, flying insects were in and around the bread cart. The food storage room has no drains, bug zappers lights, or other types of insect pest controls (fly traps) devices in it. On 8/23/22 at 10:10 AM, V21 Pest Control Representative…

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 meal intakes were monitored and ordered interventions were followed through for a resident with significant weight loss, failed to initiate dietary recommendations for a resident with significant weight loss and failed to provide dietary supplements for residents with weight loss. This applies to 4 of 15 residents (R20, R21, R12, R26) reviewed for weight loss in the sample of 20. The findings include: 1. R20's Physician Order Sheets (P.O.S.) dated through August 2022 shows she is a [AGE] year old female with diagnoses including esophgeal stricture, irritable bowel syndrome, cerebral infarct, dysphagia following cerebral infarct, encounter for attention for gastrostomy, hemiplegia and hemiparesis following cerebral infarct, and anxiety. The P.O.S. shows orders to give enteral feeding Jevity 1.5 if 50 % or less of meal consumed and hold if 50 % or more of meal consumed. R20's meal intake report from August 1, 2022 to August 23, 2022…

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 oxygen was applied by a licensed professional as ordered and failed to ensure oxygen tubing was changed as ordered for 5 of 8 residents (R12, R21, R26, R50 and R78) reviewed for respiratory care in the sample of 20. The findings include: 1. R21's Care Plan for oxygen shows, I am currently on O2 at 3L/NC Administer my O2 as MD ordered. The position for the intervention says registered nurse or licensed practical nurse. On 8/22/22 at 12:45 PM, V13, Certified Nursing Assistant (CNA) turned off R21's portable oxygen tank to transfer her to bed for care. R21 was provided care and transferred back to her chair. V13 turned the portable oxygen dial to 2 liters and applied the oxygen to R21. On 8/23/22 at 12:14 PM, V14, Registered Nurse (RN) said that CNA's can adjust the oxygen tubing but they should not be turning on the portable tanks and adjusting the liters of oxygen administered. V14 said that the orders should be checked and followed any time oxygen is administered. The facility's Oxygen Therapy Policy…

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 treat a resident with respect and dignity, affecting one of twenty residents (R40) reviewed for dignity in the sample of twenty. The finding include: R40's Minimum Data Set, dated , July 1, 2022, shows, Brief Interview for Mental Status 15/15-Cognitively Intact. On 08/22/22 at 10:06 AM, R40 said, I asked V8 CNA-Certified Nursing Assistant to help me get out of bed. She became very irritated. She took my clothing out of the closet and threw them on my bed. She told me I was a racist; She said I was entitled. On 08/24/22 at 10:28 AM, R40 said, V8 CNA called me a racist. I asked her to help me get up. I reported it to the nurse on duty when it happened. I do not remember the date or the nurse that was working that day. I told the nurse when it happened. R40 said, when V8 CNA called me a racist and was speaking to me rudely I was bewildered. I had never treated her poorly. It was like she was having a bad day and decided to take it out on me. The way V8 CNA acted when calling me a racist made me feel bad. On 08/24/22 at 11:51…

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 verify a resident's code status upon admission to ensure residents wishes were followed for 1 of 20 (R331) reviewed for advance directives in the sample of 12. The findings include: R331's admission Record dated 8/23/2022 shows an admission date of 8/15/2022. R331's admission Record dated 8/23/2022 does not have a code status listed under advance directives. R331's Order Summery Report as of 8/23/2022 does not have a code status order in place. On 8/24/2022 at 9:49, V3 Assistant Director of Nursing said the resident's code status should be addressed upon admission and their wishes should be entered in the computer charting system. V3 said the residents code status should match in all places. V3 said the resident's code status is found in the physician orders.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure staff provided perineal cleansing in a manner to prevent infections for a resident with a history of urinary tract infections. This applies to 1 of 4 residents (R60) reviewed for bladder services in the sample of 20. The findings include: R60's Physician Order Sheets dated through August 2022 shows she is an [AGE] year old female with diagnoses including history of urinary tract infections, dementia and acute cystitis. R60's Minimum Data Set assessment dated [DATE] shows her cognition is severely impaired, requires extensive assist for toileting and frequently incontinent. On 8/22/22 at 1:19 PM, V8 (CNA) transferred R60 from the wheelchair to the toilet using the mechanical stand lift and removed her soiled incontinent brief. V8 cleansed R60's perineal area from front to back and continued to use the same contaminated area of the wipe to cleanse her. V8 did not use a clean area of the wipe with each swipe. On 8/22/22 at 12:15 PM, V9…

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 a resident on contact/droplet isolation remained in the room, and failed to perform hand hygiene and glove exchange during peri care to prevent cross contamination. This applies to 3 of 20 residents (R331, R78, R14) reviewed for infection control in the sample of 20. The findings include: 1. R331's admission Record shows R331 being admitted to the facility on [DATE]. On 8/22/2022 at 12:15AM, R331 was observed in the communal dining room with her mask off sitting at a table waiting for lunch to be served. There were other residents sitting in the same communal dining room as R331. On 8/22/2022 at 1:29PM, V11 Registered Nurse said R331 was on contact/droplet isolation precautions because she didn't have her boosters and wasn't up to date. V11 said R331 has been eating meals in the dining room. On 8/22/2022 at 1:51PM, V4 Infection Control Preventionist said R331 was on contact/droplet isolation precautions for 10 days because 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.