Autumn Lake Healthcare At Parkville

Based on medical record review and interview with staff it was determined that the facility failed to develop a person-centered Hospice plan of care with individualized needs and preferences. This was evident for 1 (Resident #12) of 1 residents reviewed for Hospice services during the complaint survey. The findings include: Hospice is a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease. Hospice offers physical, emotional, social, and spiritual support for patients and their families. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Resident #12's medical record was reviewed on 4//8/25 at 1:52 PM. Resident #12 was admitted to Hospice Services on 7/11/23. A Hospice Plan of Care was developed by the facility on 7/10/23 with the focus: The resident has a terminal prognosis r/t (relate to) Resident is on [company name] Hospice services. The resident's goals were identified as: Resident #12's comfort…

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 medical record review, interviews, and review of pertinent documentation, it was determined the facility failed to keep residents free from a significant medication error by failing to ensure medication was available in a timely manner for the facility to administer. This was evident for 1 (Resident #16) of 22 residents reviewed for a complaint during the complaint survey. The findings include: On 4/11/25 at 9:00 AM, a review of complaint #MD00195309 alleged Resident #16 was told that his/her medications would be at the facility when s/he arrived at the facility, however it took 2 days to get the medication and the complaint alleged that the nurse attempted to give Resident #16 another resident's insulin. Following the review of the complaint, a review of Resident #16's electronic medical record (EMR) revealed documentation that Resident #16 was admitted to the facility on [DATE], at 7:30 PM, following an acute hospitalization and discharged from the facility in the beginning of September 2023. 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 medical record review and interview with staff it was determined facility staff failed to maintain complete and accurately documented medical records. This was evident for 1 (Resident #12) of 1 residents reviewed for Hospice services during the complaint survey. The findings include: Resident #12's medical record and facility's Hospice contract were reviewed on 4//8/25 at 1:52 PM. The record revealed that Resident #12 was admitted to Hospice services on [DATE]. The facility's contract with Resident #12's Hospice provider included: 2.Responsibilities of Facility (d) coordination of care, (iv) Notification of Change in Condition. Facility shall immediately inform Hospice of any change in the condition of a Hospice Patient. It included but was not limited to the death of a Hospice Patient. A Nursing Progress Note dated [DATE] at 20:04 [8:04 PM] indicated Low blood pressure. Action: Monitoring resident blood pressure, Response: Resident is hospice and declining. There was no documentation indicating 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 interview from residents, record review and interview with facility staff, it was determined that the facility failed to ensure that residents were aware of the current facilities rules and regulations after a change in ownership. This was evident during the resident council meeting and has the potential it effects all residents. The findings include: During the resident council meeting held on 11/3/2022 at 10:30 AM as part of the survey process, surveyor questioned the residents in attendance if they were aware of the facility rules and regulations and their rights under the new ownership that took place May 0f 2021. Five of the five residents in attendance were all residents in the facility prior to the transition of the facility from one company to another. The residents jointly agreed and spoke out that they were not informed or aware of any rule changes, nor were they asked to sign anything acknowledging new ownership of the facility and the expectations of the new owners. The facility Administrator and the Director of Nursing (DON) were interviewed on 11/4/2022 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.

Based on review of resident council meeting minutes and interview with residents and facility staff, it was determined that the facility failed to give adequate responses to grievances presented by the resident council. This was found evident in the review of the monthly resident council meeting minutes and facility responses for the months of February through October 2022. The findings include: Review of the resident council meeting minutes on 11/1/2022 at 9:56 AM revealed repeat concerns 5 of 7 months, regarding failure of staff or significant delay of staff to answer call bells timely and concern regarding the presence of staff specifically geriatric nursing assistance (GNA) to provide care as needed. These concerns were also reported to the surveyors through interviews during the annual survey during initial screening. In the April Resident Council meeting agenda under 'old business' regarding concerns from March documented that residents were informed of recent increased in nursing staff members joining the team. April 2022 concerns also noted continued concerns regarding…

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 clinical record review and staff interview it was determined that the facility staff failed to administer medications according to the physician orders. This was evident for 3 out 6 residents in the survey sample. Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication error and more prone to changes in condition that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers and care givers to evaluate, and represents a failure of basic medication administration principles. Late documentation is a form of inaccurate documentation and is worsened if 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 surveyor observation and interview with staff it was determined that the facility fail to maintain a homelike environment this was evident in four out of four rooms observed. The findings include: On 11/03/22 at 1:33 PM the surveyor entered and began the initial tour of the facility. Observation and Brief walk of second floor hallway with the Maintenance Manager, no issued with lighting, adequate lighting and Comfortable lighting observed. Starting from room [ROOM NUMBER] of second floor hallway observed two 4x4 inch holes on baseboard of room [ROOM NUMBER] and room [ROOM NUMBER] respectively. A distinct smell of urine was observed by surveyor and was persistent throughout this portion of the hallway of the facility on 2nd floor. A 3x3 inches hole was also observed on room [ROOM NUMBER] baseboards. A missing tiles was also observed on room [ROOM NUMBER] by the window ac/heat vent. The baseboards was also observed coming off from the wall, leaky and wet with water inside the Nourishment room located in…

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 medical record review, interview, and review of pertinent facility documents, it was determined that the facility failed to prevent abuse occurring from employees towards residents. This was evident during the review of facility reported incidents occurring between employees and residents, effecting 2 residents (#78 and #79) of 4 reviewed. The findings include: 1. During the initial tour Surveyor interviewed Resident #78 on 10/31/2022 at 9:44 AM regarding any concerns related to abuse. S/he stated that there was an incident with him/her and with his/her roommate #79. S/he elaborated on Resident #79. Resident #78 stated that Resident #79 according to his/her observations is unable to do anything for his/herself including communicate. S/he further stated that there was an incident when staff was providing care to Resident #78 and #79. Resident #78 asked staff to keep the curtain open so that s/he could see the care that was being provided to Resident #79. According to Resident #78, s/he observed GNA #21 slap Resident #79 on the arm while providing care. According to 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 medical record review, review of facility documents and interviews, it was determined the facility staff failed to report an incident of alleged abuse to the Office of Health Care Quality (OHCQ) and local law enforcement in a timely manner (Resident #68). This was evident for 1 out of 18 residents reviewed for abuse allegations during an annual survey. The findings include: Review of Resident #68's medical record on 11/1/22 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include Schizophrenia. Schizophrenia is a serious mental disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning, and can be disabling. Review of a facility investigation regarding Resident #68 revealed Resident #68 reported on 10/22/22 to LPN (licensed practical nurse) #1 that GNA (geriatric nursing assistant) #1 was rough during care. Review of Resident…

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 medical record review and interview with facility staff, it was determined that the facility MDS coordinator failed to complete an assessment within the MDS. This was evident during the review of 1 of 3 hospice residents. The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. The findings include: During the review of Resident #59 on 11/4/2022 at 10:49 AM surveyor noted that the MDS coordinator assessing resident #59 for the 7/6/2022 annual assessment, section 'J' under health conditions, also addresses pain. This area identified that resident #59 has pain, takes as needed pain medications and should be assessed for pain. However, further review failed to reveal that the assessment was completed. Interview was held with MDS coordinator, staff #19 on 11/7/2022 at 11:01 AM regarding the surveyors' findings. She acknowledged the absence of 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 medical record review and interview with facility staff, it was determined that the facility minimum data set (MDS) coordinator failed to submit a significant change assessment within the MDS timely. This was evident during the review of 1 of 3 hospice residents. The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. The findings include: On 10/31/2022 at 9:25 AM, surveyor completed initial screening and interviews with Resident #59. During that interview, Resident #59 notified the surveyor that s/he recently was discharged from hospice. Furether review of Resident #59's medical record on 11/04/22 07:22 AM revealed that on 7/27/2022 a significant change minimum data set was initiated as s/he was picked up for hospice. Further review revealed that on 10/4/2022 s/he was released from hospice secondary to his/her diagnosis. A concurrent review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, it was determined the facility staff failed to administer medications as ordered by the physician (Resident #3,and #42). This was evident for 2 out of 56 residents reviewed during an annual survey. The findings include: 1. Review of Resident #3's medical record on 11/2/22 revealed the Resident was admitted to the facility on [DATE] with a diagnosis of heart disease. Further review of the Resident's medical record revealed the Resident had a cardiology consult on 10/11/22. Review of the Cardiology Office/Clinic Note revealed the Cardiologist ordered the Resident to start on Imdur 30 mg daily. Imdur is used to prevent chest pain in patients with coronary artery disease. Review of Resident #3's Medication Administration Records for October and November 2022 revealed the Resident was not receiving Imdur. Interview with the Director of Nursing on 11/4/22 at 10:05 AM confirmed the facility staff failed to order Imdur for the Resident following his/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.

Based on a review of the clinical records and staff interview, it was determined that the facility staff failed to document the administration of pain medication on the electronic medical record, assess, and monitor the effectiveness. This was true for 1 (#26) out of the 56 residents reviewed for pain management during an annual recertification survey. The findings include: Pain is often regarded as the fifth vital sign in healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than a subjective one. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation that the facility staff assesses pain before and after administering pain medication to determine its effectiveness. On 11/3/22 at 11:00 am a medical record review for Resident #26 the physician ordered 10/03/2022: Oxycodone (pain medication) 5mg, give 1 tablet by mouth every 6 hours as needed for pain.…

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 surveyor observation, it was determined that the facility failed to have adequate ventilation to ensure good air quality circulation to keep the 2nd floor of the facility odor free. This was evident for one of two floors. The findings include: On 11/03/22 at 1:33 PM, immediately upon entering the 2nd floor hallway, an observation and brief walk of second floor hallway with the Maintenance Manager ( Staff #13). All the ventilation duct filters on the hallway were accumulated with dirt and dust. This surveyor's interview with staff #13 about the last time the ventilation duct was cleaned. Staff # 13 stated that they have never been clean during his 8 years employment with the facility. The replacement and cleaning of the ventilation ducts will facilitate good air quality and circulation and prevent the growth of molds. This finding was confirmed with the maintenance manager at the time of the observation. All nursing care centers must provide for adequate and functional operated exhaust ventilation, as necessary to control moisture and odors. The Administrator was made aware…

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 medication cart observations and staff interviews it was determined the facility staff failed to ensure medical records were kept in a confidential manner. This was evident in 2 out of 3 medication carts involving Resident's (R#39) with nursing shift report during the survey process. The finding include: 1. On 12/6/18 at 12:00 p.m. on unit 2 long term care unit surveyor observed an unattended medication cart on the second floor with the nursing shift to shift report document unsecured and in view. This document is used by the facilities nursing staff for assigned nursing task preformed during the nurses shift on assigned residents. On this shift to shift report the surveyor was able to be view resident's names, room numbers for rooms 30A through 59C, residents' vital signs, medical treatments and assigned medications. On 12/6/18 at 12:15 p.m. staff #1 stated to surveyor that he/she was giving care. 2. On 12/7/18 at 9:23 a.m. on unit-2 long term care unit, surveyor observed an open lap top on top of an unattended medication cart with resident #39's medication record visible…

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 medical record review and staff interview it was determined the facility failed to 1. obtain a physician's order to transfer Resident #323 to another facility, and 2. ensure hemodialysis communication record of treatment had the required licensed nurse signatures needed for nursing assessment prior, during and after dialysis treatment. This was evident for 3 of 33 residents (#323, #9 and #75) reviewed during the survey. The findings include: 1). Beginning on 12/7/18 at 1:4 PM, the medical record was reviewed. Review of Resident #323's medical record on 12/7/18 revealed physician documentation for 7/2/18 at 2:06 PM, which stated the following: .Follow/up for agitation .pt with dementia and behavioral issues was requiring a sitter, later d/ced (discharged ) and now discharged to dementia units for further care. Pt seen and examined today, reported to have behavioral disturbance over the weekend requiring ER (Emergency Room) visit and sitter. Per report psych recommended [ a specific psychiatric hospital] transfer for inpatient psych units but [the spouse] refused [his/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.

Based on staff interview with the Director of Nursing (DON) and resident documentation, facility failed to contact Responsible Party (R.P.) to advise them that resident #64 was being transferred to the hospital. This was evident for 1 out of 4 residents transferred to the hospital. Findings include: Medical record review revealed Resident #64 was nonverbal and unable to follow commands. She/he was also noted to be total care for all her/his ADLs (activities of daily living) and had a peg tube. On 10/15/18 resident #64 was transferred from the facility for respiratory distress and hypoxia. Resident was found unresponsive, lethargic, tachypneic, O2 SATs were 75% on room air. The facility called the responsible party on 2 different occasions but was unable to reach him/her. There were no other notes indicating that the responsible party was ever notified. The Director of Nursing was aware and could not confirm whether the RP was notified or not.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on chart review and staff interview, the facility failed to give a bed hold policy for resident #64 who was transferred to the hospital. This was evident for 1 out of 4 residents transferred to the hospital. The findings include: On 12/10/18/at 9:18 AM a chart review conducted for resident # 64. Resident #64 had excess secretions requiring suction, lethargy and not responding appropriately. Resident #64 was admitted to the hospital on [DATE]. Review of nursing notes did not indicate that a bed hold policy was given to the resident or responsible party. Unit Clerk# 5 confirmed that there was no bed hold policy in the resident's chart and could not confirm whether a bed hold policy was sent out or given to resident. The Director of Nursing also could not confirm that a bed hold policy was provided to the resident.

Based on record review, the facility failed to develop a comprehensive care plan for a resident that received Remeron for depression. This was evident for 1 out of 33 residents (#110) reviewed for care plans. Findings include: Record review for Resident #110 on 12/10/18 at 12:50 PM revealed he/she had a history of recurrent depression and was placed on Remeron 15 mg tab per day at bedtime. Further record review did not indicate a comprehensive care plan that was completed for the resident being prescribed Remeron, a medication for depression. The Director of Nursing was made aware and confirmed there was no care plan available.

Based on observation, medical record review and resident, family and staff interview it was determined the facility failed to ensure Resident #107 was shaved consistently. This was evident for 1 of 33 residents observed and investigated during the survey. The findings include: On 12/7/18 at 9;46 AM Resident #107 was observed unshaven and with what appeared to be several days growth. When asked if he/she liked to be shaved daily, she/he stated a preference of every other day but was told yesterday that the staff were busy and they would try to get to her/him today. Interview of Resident #107's spouse at 2:27 PM revealed that the resident is shaved by staff but not consistently. The resident's spouse also said the Geriatric Nursing Aides (GNAs) don't come in and offer to shave her/him but they will shave her/him when asked. During an interview with Unit Manager #4, she confirmed it is a GNA responsibility to shave the residents daily or according to their personal preferences. A review of the resident's Nursing Care Plan revealed Resident #107 required assistance with activities of…

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

Based on medical record review and staff and resident interview it was determined the facility failed to ensure nursing staff clarified the definition of pain for as needed medications and failed to indicate the location and type of pain prior to administering as needed medications for Resident #77. This was evident for 1 of 33 residents assessed during the survey. The findings include: On 12/6/18 at 2:54 PM, Resident #77 was interviewed. When asked if he/she was having any pain issues, he/she stated sometimes he/she has pain in the hip and thigh and then asks for pain medication. When asked to rate pain on a scale from 0-10 with '0' being no pain and '10' being the worst imaginable, he/she stated it sometimes goes up to a 6 or an 8. Beginning on 12/11/18 at 3:05 PM, the medical record for Resident #77 was reviewed. It was noted that nursing staff had failed to clarify the definition of severe pain for an as needed medication and were not documenting the location and type of pain when administering as needed medication. A review of the Medication Administration Record (MARs)…

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 the facility failed to 1. label and store drugs/biological's in the 2nd floor Med room, and 2. secure the medication cart on the second floor. This was evident for 1 out of 6 medication carts inspected and 1 medication room out of 1 medication room checked. Findings include: On [DATE] at 11:19 AM, the following observations were made: 1). Medication cart labeled Med. Cart Team 1 CMA on second floor was stored in the resident lounge area with resident's present. The front of medication cart was facing the wall. When this surveyor moved the cart, it was found open with no staff present. The Unit Manager #9 was made aware and shown these findings. 2). The medication storage room had an open bottle of Clorpactin (1/4 filled) with no date of when opened, and a vial of Tuberculin was opened and not dated. Unit Manager #9 was made aware of these findings. 3). Medication Cart labeled team 2 CMA had three drugs that were not dated when opened or expired. Two bottles of Latanoprost eye drops 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 interview with acting dietary manager of the kitchen (Staff #6) it was determined that the facility failed to ensure that the acting dietary manager and full time dietary manager of the facility, (Staff #7) had completed required CDM (certified dietary manager) certification. The findings include: A tour of the facility kitchen was completed on December 6, 2018 at 9 AM. This surveyor was told by Acting Dietary manager Staff #6 who came from a sister facility, that the required certification was in process, but not complete. On 12/7/18 the facility Dietary Manager came back from vacation and was notified at 10:00 AM of the findings of the kitchen inspection the day before. At that time, he reported he was not a licensed CDM, but was waiting to schedule the test. The Administrator and Director of Nursing were made aware.

Based on observations and tour of the kitchen, the facility failed to properly store food and other items in the kitchen area. The findings included: On December 6, 2018, at 10 AM, this surveyor toured the facility kitchen with the food service acting manager staff #6. The following observations were made: 1) In the small dry storage area located in the kitchen two dry goods bins used for storing flour and breadcrumbs and were found with the date of 9/18. There was no year and no other dates noted. 2) In the large dry storage room located outside the kitchen, a plastic bag of cake mix was split open and sitting on the shelf. The contents of bag were spilling over other bags and onto the shelf. Additionally, empty soda cans were laying on shelves and dirty paper towels were thrown on the shelves. Boxes were on the floor toward the back of the storage room, blocking what was on the shelving unit. 3) Three unlabeled pitchers of orange juice, cranberry juice and fruit juice were in the refrigerator with no labels of when poured or expired. The manager (Staff #7) of the kitchen,…

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 review of facility records and staff interviews, the facility staff failed to include a required section of the Facility's Assessment Plan. The findings include: On 11/30/18 the facility's Assessment Plan was reviewed. The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents require. Part of that plan must include competencies/education needed by the staff to care for its listed patient population. Review of the plan did not include the training needed. The Director of Nursing was made aware.

Based on observation and staff interview it was determined the facility failed to ensure personal hygiene equipment was stored and labeled appropriately in a bathroom shared by Residents #70 and #74. This was evident for 2 of 33 residents investigated during the survey. The findings include: On 12/7/18 at 10:02 AM, the bathroom shared by Residents #70 and #74 was inspected. A commode urine specimen collector was found lying directly on the floor. A washbasin containing a toothbrush, toothpaste, denture cream, denture cup, razor, body wash/shampoo and shaving cream were noted on the back of the toilet. Neither the washbasin nor the items it contained were labeled with the resident's name or room and bed number. The findings were confirmed by Unit Manager #4.