Merriam Gardens Healthcare & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 74 residents. The sample included 18 residents. Two residents were sampled for reasonable accommodations of needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R)47 was given a lipped plate and his meat was cut up into bite-size portions. The facility further failed to ensure R50's call light was within her reach. This deficient practice left R47 and R50 vulnerable to unmet care needs. Findings included: - R47's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hypertension (HTN-elevated blood pressure), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right dominant side,…

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.

The facility identified a census of 74 residents. The sample included 18 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interviews, the facility failed to provide form CMS-10055, Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) for Resident (R) 3 and R132. This deficient practice placed these residents at risk for uninformed decisions. Findings included: - A review of R3 ' s Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 07/09/24 and ended on 7/16/24. R3 remained in the facility for custodial care. The facility issued R3 form CMS-R-131 instead of the required CMS-10055. A review of R132 ' s EMR documented that the Medicare Part A episode began on 01/31/24 and ended on 03/12/24. R33 remained in the facility for custodial care. The facility issued R132 form CMS-R-131 instead of the required CMS-10055. On 10/01/24 at 12:25 PM, Social Services X stated the ABN form the facility had instructed her to use was different from 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 The facility identified a census of 74 residents. The sample included 18 residents with two sampled residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notification of transfer to Resident (R) 45 or their representatives for their facility-initiated transfers. The facility also failed to notify to the long-term care ombudsman (LTCO) for R45. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R45. Findings included: - R45's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia and hemiparesis (weakness and paralysis on one side of the body), and a pressure ulcer (localized injury to the skin and underlying tissue usually over a bony). R45's…

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.

The facility identified a census of 74 residents. The sample included 18 residents with two sampled residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a bed hold policy notice to Resident (R) 45 or their representatives when they transferred to the hospital. This deficient practice had the risk of impaired ability to return to the facility and to his previous room for R45. Findings included: - R45's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia and hemiparesis (weakness and paralysis on one side of the body), and a pressure ulcer (localized injury to the skin and underlying tissue usually over a bony). R45's Annual Minimum Data Set (MDS) dated 07/17/24 documented a Brief Interview for Mental Status (BIMS) score of zero which indicated a severely impaired cognition. R45 had impairment on both sides of his upper and lower…

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.

The facility identified a census of 74 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to fully complete the annual comprehensive Minimum Data Set (MDS) for Resident (R) 45 by not completing documentation analysis for triggered care areas. This placed this resident at risk for inaccurate reflections of the resident's status and an inaccurate care plan. Findings included: - R45's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia and hemiparesis (weakness and paralysis on one side of the body), and a pressure ulcer (localized injury to the skin and underlying tissue usually over a bony area). R45's Annual MDS dated 07/17/24 documented a Brief Interview for Mental Status (BIMS) score of zero which indicated a severely impaired cognition. R45 had impairment on both sides of his upper and lower extremities. R45 required the use 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.

The facility reported a census of 74 residents. The sample included 18 residents with two reviewed for activities of daily living (ADLs). Based on records review, interviews, and observations, the facility failed to provide the required ADL assistance for Resident (R)11 for dressing. This deficient practice placed R11 at risk for impaired independence and a loss of ADL function. Findings Including: - The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of altered mental status, cognitive communication deficit, major depressive disorder (major mood disorder), and unsteadiness on his feet. R11s Annual Minimum Data Set (MDS) completed 08/12/24 noted a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The MDS indicated he required supervision or touch assistance for dressing and personal hygiene. The MDS indicated he required partial to moderate assistance from staff for bathing, transfers, and toileting. The MDS indicated he required set-up assistance from staff for meals. The MDS indicated he was 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.

The facility identified a census of 74 residents. The sample included 18 residents with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician's order for weight monitoring for fluid overload and further failed to ensure Resident (R) 73's as-needed (PRN) diuretic (a medication used to promote formation and excretion of urine) was administered per orders when needed. This deficient practice placed R73 at risk for fluid overload and related complications. Findings included: - R73's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), malnutrition (lack of proper nutrition, caused by not having enough to eat), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain),…

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 The facility identified a census of 74 residents. The sample included 18 residents with one resident reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)47's palm splint was available. This deficient practice placed the resident at risk for discomfort and decreased range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Findings included: - R47's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hypertension (HTN-elevated blood pressure), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right dominant side, aphasia (condition…

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.

The facility identified a census of 74 residents. The sample included 18 residents with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported when Resident (R) 67's blood pressure medication was given outside of the physician-ordered parameter. This placed R67 at risk for unnecessary medication administration and adverse side effects. Findings included: - R67's Electronic Medical Record (EMR) documented diagnoses of respiratory failure (inadequate gas exchange by the respiratory system), and hepatic failure (a condition that can occur when the liver is damaged and can no longer function properly). R67's Annual Minimum Data Set (MDS) dated 04/23/24 documented that R67 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R67 was independent with her functional abilities. R67 used a wheelchair for mobility. R67's Quarterly MDS dated 07/22/24 documented R67 had a BIMS score of 15 which indicated intact…

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.

The facility identified a census of 74 residents. The sample included 18 residents with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 67's blood pressure medication was given within the physician-ordered parameter. This placed R67 at risk for unnecessary medication administration and adverse side effects. Findings included: - R67's Electronic Medical Record (EMR) documented diagnoses of respiratory failure (inadequate gas exchange by the respiratory system), and hepatic failure (a condition that can occur when the liver is damaged and can no longer function properly). R67's Annual Minimum Data Set (MDS) dated 04/23/24 documented that R67 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R67 was independent with her functional abilities. R67 used a wheelchair for mobility. R67's Quarterly MDS dated 07/22/24 documented R67 had a BIMS score of 15 which indicated intact cognition. R67 required set up to partial assistance with her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 74 residents. The sample included 18 residents with two residents reviewed for (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)3. This placed the resident at risk for inappropriate end-of-life care. Finding Included: - R3's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, unsteadiness on her feet, dysphagia (swallowing difficulty), cognitive-communication deficit, dementia (a progressive mental disorder characterized by failing memory and confusion), Cerebral arteriosclerosis (a disease that occurs when the arteries in the brain become hard, thick, 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.

The facility identified a census of 74 residents. The sample included 18 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to administer the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination for Resident (R) 10. This placed the residents at increased risk for complications related to pneumonia. Findings included: - A review of R10 ' s clinical record revealed a Pneumovax was administered on 05/07/15. Upon request for R10 ' s declination or administration of the PCV20 vaccine, the facility provided a signed consent dated 04/30/24. R10 ' s EMR lacked documentation she had received the PCV20. On 10/01/24 at 03:22 PM, Administrative Nurse D, the facility Infection Preventionist, stated she was unable to find documentation R10 had received the PCV20 in April 2024. Administrative Nurse D stated the Infection Preventionist should track the resident vaccination status. The facility ' s Pneumococcal Vaccine policy last reviewed on 01/31/22…

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.

The facility had a census of 75 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to follow-up or resolve resident grievances, placing the residents at risk for unresolved concerns. Findings included: - On 02/14/23 at 10:30AM, during private discussion with the residents of the resident council, residents verbalized an ongoing unpleasant experience with the facility meals, stating the facility does not always have items on the menu, or on the alternate menu. Council members verbalized no resolution from the facility regarding the council's grievances. During the council meeting one of the Residents (R) stated he was given a breadstick instead of the cheeseburger he ordered. Council members verbalized a salad was served for supper and facility did not have any salad dressing for the residents' salads. Review of the council meeting minutes for October, November, December 2022 and January 2023, lacked documentation of the facility's action to resolve menu and food grievances. Review of the facility's grievance log…

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.

The facility had a census of 75 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to prepare and serve their planned menus for 02/13/23 and 2/14/23, due to unavailable food items and failed to update or notify the residents when food items were substituted so they were given the opportunity to change their order on two of the onsite days of the survey . This placed the residents at risk for disappointment and inadequate food intake. Findings included: - The Lunch Planned Menu Sheet, for 02/13/23 documented the lunch meal would Mexican baked chicken, fiesta rice black beans, sour cream, pineapple tidbits, milk, coffee, fruit punch. The Standing Chalkboard located inside the entrance to the dining room read the same as above. On 02/13/23 at 12:00 PM, observation revealed dietary staff served the residents beef stew, cottage cheese, cubed pineapples, and a roll. On 02/13/23 at 12:10PM, observation during dining services revealed four residents seated at a table together, two of the residents asked the dietary aide 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.

The facility had a census of 75 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety and the prevention of food borne illness, for the 68 residents who resided in the facility and received their food from the facility kitchen when the facility failed to ensure clean and sanitary food prep and storage areas, and when staff failed to provide a room tray at the proper temperature for Resident (R) 38. This placed the residents at risk for foodborne illness. Findings included: - On 02/13/23 AM at 09:00 AM, observation in the kitchen revealed the following: A refrigerator had an open bag with a half of a green pepper, onion peelings, and an open bag of celery stalks. The walk-in freezer floor made a crunching noise and felt unstable when stepped on. On 02/13/23 at 9:00 AM, Registered Dietician (RD) DD verified the above finding and stated the bag with the onion peeling and green pepper should be in a closed bag; she said she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 75 residents. The sample included 18 residents. Based on observations, record review, and interview, the facility failed to update two resident care plans, Resident (R) 58 for falls and R63 for a Foley catheter (tube inserted directly into the bladder to drain urine). This placed the resident's at risk for unmet needs and cares. Findings included: - The electronic medical record (EMR) for R58 documented diagnosis of hypertension (high blood pressure), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), unsteadiness on feet, and disorientation (loss of direction). The admission Minimum Data Set (MDS), dated [DATE], documented R58 had severely impaired cognition and required extensive assistance of one staff for transfers, ambulation, dressing, and toileting. The assessment further documented R58 had unsteady balance, no functional impairment, and had falls prior to admission. The Quarterly MDS, dated 01/27/23, documented R58 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 75 residents. The sample included 18 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to idenitfy and implement appropriate, resident-centered interventions for Resident (R) 58, who had multiple falls. This placed the resident at risk for further falls. Findings included: - The Electronic Medical Record (EMR) for R58 documented diagnosis of hypertension (high blood pressure), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), unsteadiness on feet, and disorientation (loss of direction). The admission Minimum Data Set (MDS), dated [DATE], documented R58 had severely impaired cognition and required extensive assistance of one staff for transfers, ambulation, dressing, and toileting. The assessment further documented R58 had unsteady balance, no functional impairment, and had falls prior to admission. The Quarterly MDS, dated 01/27/23, documented R58 had severely…

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 - The Electronic Medical Record (EMR) for R58 documented diagnosis of hypertension (high blood pressure), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), unsteadiness on feet, disorientation (loss of direction), and edema (puffiness caused by excess fluid trapped in the body's tissue. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R58 had severely impaired cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and limited assistance of one staff for ambulation. The assessment further documented R58 was frequently incontinent of bladder and bowel. The Care Plan, dated 01/19/23, directed staff to establish voiding patterns, offer toileting upon rising, before and after meals, before lying down and assist when she voiced the urge to use the bathroom. The care plan further directed staff to provide frequent reminders to call for assistance to ambulate to the bathroom, and check R58 every two 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 The facility had a census of 75 residents. The sample included 18 residents, with one reviewed for hydration. Based on observation, record review, and interview, the facility failed to adequately monitor and ensure staff were aware that Resident (R) 27 was on a 1500 milliliter (ml) daily physician ordered fluid restriction so they could educate the resident and update the providers on his fluid consumption. This placed the resident at risk for fluid overload. Findings included: - The Electronic Medical Record (EMR) for R27 documented diagnoses of chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity ad difficulty or discomfort in breathing), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), chronic myeloid leukemia (a type of blood-cell cancer), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational…

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 The facility had a census of 75. The sample included 18 residents of which one was reviewed for respiratory care. Based on observation, record review, and interview, the facility staff failed to provide cares that included checking oxygen amounts in portable oxygen canister for Resident (R) 5. This placed the R5 at risk for running out of oxygen causing respiratory distress (severe shortness of breath). Findings included: - R5's Electronic Medical Record (EMR) documented the resident had diagnoses of shortness of breath and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R5's Quarterly Minimum Data Assessment (MDS), dated [DATE], documented the resident required extensive staff assistance with transfers, limited staff assistance with dressing and toilet use and staff supervision with bed mobility, locomotion on and off unit, and personal hygiene. The MDS documented the resident received…

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.

The facility had a census of 63 residents. Based on observations, record review, and interview, the facility failed to routinely monitor the food temperatures on the steam table for the 61 residents who received meals from the facility kitchen. Findings included: - On 06/15/21 at 09:05 AM, during the initial tour of the kitchen, Dietary Staff (DS) BB failed to provide daily food temperature logs of foods that were on the steam table and served to residents of the facility for the month of June. On 06/15/21 at 09:30 AM, DS BB stated the food temperature logs disappeared. On 06/21/21 at 01:00 PM, Administrative Nurse D stated she expected the food temperature logs to be completed daily and to be kept on file for one year. The facility's Food Temperatures policy, dated 2017, documented the temperatures of all food items will be taken and properly recorded prior to service of each meal. The facility failed to routinely monitor and log food temperatures for the 61 residents who received meals from the facility kitchen placing the residents at risk for food borne illnesses.

The facility had a census of 63 residents. Based on observations, record review, and interview, the facility failed to provide a certified dietary manager to carry out the functions of food and nutritional services for the 61 residents who resided in the facility and received meals from the facility kitchen. Findings included: - On 06/16/21 at 11:00 AM, observations revealed Dietary Staff (DS) BB participated and provided oversight of the lunch meal preparation and service. On 06/16/21 at 11:00 AM, observations revealed DS BB participated and provided oversight of the lunch meal preparation and service. On 06/15/21 at 09:05 AM, DS BB stated he was not certified but was currently taking classes to become certified. On 06/21/21 at 01:00 PM, Administrative Nurse D stated DS BB was not certified and was taking classes to become certified. The facility's Food, Nutrition, and Dietary Services Policy and Procedure, policy, dated 2020, documented the facility must have a qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant…

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.

The facility had a census of 63 residents. Based on observations, record review, and interview, the facility failed to prepare, store, and serve meals under sanitary conditions for the 61 residents who received meals from the facility kitchen. Findings included: -On 06/15/21 at 09:05 AM, observations during the initial tour of the kitchen revealed the following: Food debris and smashed dried cherry tomatoes on the floor in dry storage area. Food debris and grease smears from shoes all over the kitchen flooring around the food preparation area. Review of the May Dishwasher Temperature Log revealed 24 of 31 missing temperature notations. Upon request, Dietary Staff (DS) BB was unable to provide a cleaning schedule for the kitchen and June temperature logs for the high temperature dishwasher. On 06/17/21 at 01:15 PM, observation revealed DS CC filled cereal bowls for the next days breakfast by taking the bowl with bare hands and scooping the cereal from the dry storage container. On 06/15/21 at 09:30 AM, DS BB stated the cooks and dietary aides just follow the cleaning schedule and he…

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.

The facility had a census of 63 residents. Based on observation, record review, and interview, the facility failed to provide a safe environment for the 15 cognitively impaired, independently mobile residents in the facility. Findings included: - On 06/15/21 at 08:50 AM, observation revealed two janitorial closet doors unlocked on the east side of the building. The closet contained the following items: One bottle of 3M deodorizer Material Safety Data Sheet (MSDS) documented Flammable liquid and vapor. Harmful if swallowed. Causes Severe skin burns and eye damage. Suspected of damaging fertility or the unborn child. One container of I-Shine High Solid Floor Finish. MSDS documented May be harmful if swallowed. May cause eye irritation. May cause skin irritation. Inhalation of vapors or mist may cause respiratory irritation. Keep out of reach of children. One container of Butcher's Baseboard Build-up Stripper. MSDS documented Eye contact: Corrosive. Causes permanent eye damage, including blindness. Skin contact: Corrosive. Causes permanent damage. Inhalation: May cause irritation 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.

The facility had a census of 63 residents. The sample included 16 residents with six reviewed for unnecessary medications. Based on interview, observation, and record review, the facility failed to ensure an appropriate diagnosis for Resident (R) 20 and R34's Seroquel (antipsychotic medication). Findings included: - R20's Physician Order Sheet, dated 05/30/19, documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), , dated 04/13/21, documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, intact cognition, and independent with all activities of daily living (ADLs). The MDS documented the resident received routine antipsychotic medications (class of medication used to treat any major mental disorder characterized by a gross impairment testing) seven of seven days during the look 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.

The facility had a census of 63 residents. The sample included 16 residents. Based on observation, record review, and interview the facility failed to prevent the development of communicable diseases and infections for two of 19 residents who received blood glucose testing (a blood sample test which measures the amount of sugar in the blood), Resident (R) 20, and R35. Findings included: - On 06/15/21 at 09:00 AM, observation revealed License Nurse (LN) G obtained a blood glucose test for R35. After completing the blood glucose test LN G cleaned the blood glucose testing device with an alcohol wipe. LN G went and obtained R20's blood glucose test. After completing the blood glucose test LN G cleaned the blood glucose testing device with an alcohol wipe. On 06/15/21 at 09:15 AM, LN G verified she used alcohol wipes to clean the blood glucose testing device and had not used a disinfectant wipe On 06/21/21 at 09:30 AM, Administrative Nurse D verified LN G should clean the blood glucose testing device with a disinfectant cleaner after each use. The facility's Glucometer Disinfection…

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.