Grand River Health Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff developed and updated a care plan consistent with resident's specific conditions and needs which affected two of the 12 sampled residents, (Resident #11, #26). The facility census was 27. A policy regarding care plans was requested but not provided. 1. Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/2/24, showed: - Cognition severely impaired; - Total assist of all Activities of Daily Living; Mobility, Transfers and Hygiene - Diagnosis: Anemia, hypertension (high blood pressure), diabetes, seizure disorder, schizophrenia (mental disorder with a disruption in thought processes), Post Traumatic Stress Disorder (PTSD) (mental health condition from witnessing a traumatic event); Review of the resident's care plan revised, 2/12/2025, showed: - Resident diagnosed with PTSD. - No identified triggers are listed and no interventions for staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff provided services that met professional standards of quality of care when staff failed to have medications available for two of the 12 sampled residents, (Resident #6, #15) and failed to clarify a sliding scale insulin order for Resident #15. The facility census was 27. The facility did not provide a policy for ordering medications. 1. Review of Resident #15's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/15/24, showed: - Cognitive skills moderately impaired; - Independent with eating and transfers; - Diagnoses included diabetes mellitus, depression, high blood pressure, Schizophrenia ( a serious mental illness that affects how a person thinks, feels, and behaves) and Chronic Obstructive Pulmonary Disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's Physician Order Sheet (POS) dated 1/25/25 - 2/25/25 showed:…

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 the residents had fresh water at bedside that was easily accessible to the residents. This affected three of the 12 sampled residents, (Resident #15, #22 and #26). The facility census was 27. Review of the facility's undated policy titled, Hydration, showed staff were directed to do the following: - Each resident is supplied with sufficient fluid intake to maintain proper hydration; - Fresh water is distributed each shift, pitchers and glasses are within reach of the resident and residents who are unable to pour and drink independently will be given assistance by the staff. 1. Review of Resident #15's care plan, revised 11/30/24 showed; - The resident had a diagnosis of constipation; - Will follow diet as ordered by the primary care physician; - Will maintain adequate hydration daily. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/15/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of Resident #22's Quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Independent with eating dressing, personal hygiene and transfers; - Diagnoses included psychotic disorder ( a mental illness that causes a person to lose touch with reality), chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing), and diabetes mellitus. Review of the resident's POS, dated 1/25/25 - 2/25/25, showed; - Start date: 9/27/23 - O2 at 2L/NC (Liters per Nasal Cannula) with ambulation, none required at rest for acute respiratory failure with hypoxia (lack of oxygen to the tissues); - Start date: 8/13/23 - Ipratropium-albuterol solution for nebulization 0.5 mg. -3 mg./3 ml four times a day for shortness of air. Review of the resident's care plan, revised 1/28/25, showed: - The resident had a diagnosis of COPD and required oxygen during the day; - Had nebulizer treatments as ordered. Review of the resident's MAR, dated February, 2025, showed: - O2 at 2L/NC with…

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 staff administered medications with a medication error rate of less than 5%. Facility staff made five medication errors out of 26 opportunities for error which resulted in a medication error rate of 19.23%, which affected four of the 12 sampled residents, ( Resident #2, #22, #15 and #9). The facility census was 27. Review of the facility's undated policy titled, Medication, Administration Guidelines, showed staff were directed to do the following: - It is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies; - Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident; - The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders,…

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 discard expired medications, and biologicals stored within the medication room and the medication cart, failed to date an opened vial of Influenza vaccine, and failed to ensure resident's cigarettes and personal money was not stored in the medication cart. This had the potential to affect all residents within the facility. The facility census was 27. Review of the facility's undated policy titled, Medication Administration Guidelines, showed: - It is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies; - Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident; - The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physician's orders. giving the individual dose to the proper…

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 the required two step tuberculosis (TB, a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered upon hire for seven random sampled, newly hired employees, and failed to use proper handwashing in between tasks, and failed to use enhanced barrier precautions during wound care for resident #79, which affected one of twelve sampled residents. The facility census was 27. Review of the facility's undated Tuberculosis (TB) Control policy showed: -Initial examination: Provide a tuberculin skin test to all employees during pre-employment procedures. -If the initial skin-test result is 0-9mm, a second test should be given at least one week and no more than three weeks after the first test. Review of the facility's policy titled, Enhanced Barrier Precautions to Infection Guidance, showed: - To prevent broader transmission of multidrug-resistance organisms (MDRO)…

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 protect the resident's right to be free from abuse when Resident #12 threatened harm to Resident #9. The facility census was 27. Review of the facility's undated Abuse Prohibition Protocol Policy, showed: - It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion - Additionally, residents will be protected from abuse, neglect and harm while they are residing at the facility; - No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection; - The objective of the abuse policy is to comply with the seven step approach to abuse and neglect detection and prevention. The abuse policy will be reviewed on an annual basis or more frequently and will be integrated into the facility Quality Assurance and performance Improvement (QAPI)…

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 provide the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one of 12 sampled residents (Resident #8) when staff failed to notify the physician of a resident's change of condition in a timely manner. The facility census was 27. A policy regarding physician notification was requested but not provided. 1. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/8/25, showed: -Severe cognitive impairment; -Dependent on a wheelchair for mobility; -Diagnoses included: Diabetes, high blood pressure, dementia, anxiety, and depression. Review of nursing progress notes, dated 2/20/25-2/24/25, showed: -No documentation regarding the resident's upper respiratory condition; -No documentation regarding contacting the resident's physician or guardian of changes. Observation on 2/24/25 at 2:24 P.M. showed: -The resident sitting in the common area with other residents by the TV; -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 and record review, the facility failed to ensure an alleged violation of potential physical abuse was reported immediately, but not later than two hours after the allegation was made, to officials in accordance with State law, including the Survey Agency for one sampled resident (Resident #1) out of four sampled residents. The facility census was 28 residents. Review of the facility provided, Abuse Prohibition Policy dated March 2012 showed: -It is the purpose of this facility to prohibit mistreatment, neglect abuse of resident and misappropriation of resident property; -All employees of this facility are mandated reporters; -All allegations of abuse, neglect,exploitation, mistreatment, injuries of unknown sources, will be reported immediately. Review of the resident's Quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff) dated 11/12/24 showed: -Brief Interview of Mental Status (BIMS) of 99, indicated the resident had severe cognitive deficits; -Understands others and able to make self understood; -Physical behaviors…

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

Based on interview and record review the facility failed to ensure one resident (Resident #1), of three sampled residents, was free from the use of physical restraint when staff members used their bodies to wrap their arms around the resident to entrap the resident's arms down to his/her side, not allowing movement from the resident, while the nurse administered an intramuscular (IM) injection to the resident for aggressive behaviors towards staff. The facility census was 29. Review of the facility policy Behavioral Interventions Catastrophic Reactions (an overreaction or inappropriate behavior associated with a resident who has dementia (a progressive condition that causes a decline in thinking, remembering, and reasoning, that interferes with daily life,)) from the Special Care Unit Manual, Section 6, dated April 2006 showed staff should do the following: -Allow a resident who is experiencing a catastrophic reaction to move freely, except when acting violently to another person. Don't restrain a resident. -Do not restrain the resident or use physical force. Review of the facility…

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

Based on observation, interview, and record review, the facility failed to provide adequate behavioral health interventions for one resident (Residents #1 ) who exhibited behaviors that escalated to a catastrophic reaction, culminating in the use of an antipsychotic (previously known as major tranquilizers: are a class of medication primarily used to manage psychosis: a mental disorder characterized by a disconnection from reality.)medication injection. The facility census was 29. Review of the facility provided policy Behavioral Interventions, dated April 2006 showed: -Catastrophic reaction is the over reactive or inappropriate behavior associated with the resident. This behavior occurs when the resident misunderstands or cannot cope with a distressing physical or environmental situation. A catastrophic reaction can occur when a resident becomes overwhelmed. -Angry and agitated behaviors are part of a brain syndrome and are not deliberate -Do not overwhelm a resident. Usually a calm, private and reassuring show of support will help manage a difficult situation. -Always try to speak…

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 one dietary employee washed his/her hands after touching the lid to the trash can several times. This practice potentially affected the 26 residents who ate food from the kitchen. The facility census was 26 residents. Review of the Handwashing Policy dated May 2015, showed: -If using gloves, remove gloves; -Roll down paper towels (some facilities may have self-dispensing paper towels); -Turn on water and run until warm; -Wet hands and forearms with warm water; -Lather hands with antiseptic soap; -Wash hands, giving particular attention to the areas between fingers, around cuticles, and under fingernails; -Wash forearms as well; -Rinse thoroughly with warm water, beginning at the top of the forearm; -Wipe hands dry with clean paper towel; -Turn off water with paper towel and dispose of paper towel; -Trash cans should either have a foot controlled flip top lid or no lid to prevent re-contamination of the hands. Observation on 4/20/23 at 9:00 A.M. showed: -Cook A hand shredded carrots for the pork fried…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat three of 13 sampled residents (Resident #4, #15 and #21) with dignity and respect when staff did not knock on the resident's door, wait for resident's response before entering, and announcing themselves. The facility census was 26. Review of the undated Resident Rights Policy showed Social Service Department will review Resident Right and Health Care Directives on admission with all residents and annually thereafter, both orally and in writing in a language the resident understands of his rights and rules/regulations including grooming, resident conduct, and responsibilities during facility stay. All residents will be informed of resident rights, regardless of physical, emotional or mental impairment. The rights included treating residents with privacy and respect. 1. Review of Resident #21's quarterly MDS, dated [DATE] showed; - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility and dressing; -…

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 deliver Saturday mail to three of (Resident #21, #3, and #1) 16 sampled residents. The facility census was 26. Review of the undated Resident Rights Policy showed: -Social Service Department will review Resident Right and Health Care Directives on admission with all residents annually thereafter, both orally and in writing in a language the resident understands of his rights and rules/regulations including grooming, resident conduct, and responsibilities during facility stay. All residents will be informed of resident rights, regardless of physical, emotional or mental impairment. RIGHTS: -Resident [NAME] of Rights -Renew annually Resident Rights -To be fully informed -Participate in their own care -Communicate freely 1. Review of Resident #21's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/27/23, showed: -Brief Interview for Mental Status (BIMS) (is a mandatory tool used to screen 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure dependent residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, which affected three of 12 sampled residents, (Resident #4, #6 and #21). The facility census was 26. Review of the facility's undated policy for perineal care, showed, in part: - The purpose is to clean the perineum and to prevent infection and odor; - Assist the resident to lay on their side and flex their knees; - Use one gloved hand to stabilize and separate the perineal folds, with the other hand, wash from front to back; - Rinse and pat dry; - Use a new wash cloth and wash around the anus. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 2/4/23 showed: - Cognitive skills for daily decision making, moderately impaired; - Required extensive…

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 interviews and record review, the facility failed to provide documentation of the pharmacist's recommendations for two of 12 sampled residents, (Resident # 4 and #13). The facility census was 26. The facility did not provide a policy for consultant pharmacy services and/or gradual dose reductions. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/4/23 showed: - Cognitive skills for daily decision making, moderately impaired; - Required extensive assistance of two staff for bed mobility, transfers and toilet use; - Lower extremity impaired on both sides; - Always incontinent of bowel and bladder; - Diagnoses included congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), depression, psychotic disorder ( severe mental disorders that cause abnormal thinking and perceptions). and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions,…

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 staff administered medications with a medication error rate of less than 5%. Facility staff made five medication errors out of 25 opportunities for error, resulting in a medication error rate of 20%. This affected four residents sampled for medication administration (Residents #2, #24, #14, and #1). The facility census was 26. Review of the Cyclosprine eye drops manufacturer's guidelines, dated November 2022 showed: - How to use: Tilt your head back, look upward, and pull down the lower eyelid to make a pouch. Hold the dropper directly over your eye and place one drop into the pouch. Look downward, gently close your eyes, and place one finger at the corner of your eye (near the nose). Apply gentle pressure for 1 to 2 minutes before opening your eyes. This will prevent the medication from draining out. Try not to blink or rub your eye. If directed to use this medication in both eyes, repeat these steps for your other eye. Review of facility's undated Installation of Eye Medication Policy showed: - It'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.

Based on observation, interviews and record review, the facility staff failed to prevent a significant medication error, when staff did not follow standards of practice when staff failed to prime the insulin pens with two units prior to administration and failed to allow the insulin pen to remain in the injection site for at least 6 seconds for three of 12 sampled residents, (Resident #1, #14 and #24) and failed to transcribe a physician order into the resident's electronic chart and into the Medication Administration Record (a record used to document medications given to a resident (MAR), failed to document doses of insulin were given and failed to follow a physician's order as directed for one of 12 sampled residents (Resident #1). The facility census was 26. Review of the facility's undated subcutaneous injection policy showed: - Medications that are injected slowly will absorb more effectively and cause less discomfort. - Expel air from syringe - Inject medication slowly and remove needle quickly. Review of the manufactures instructions for Novolog FlexPen showed: - Before each…

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, record review and interview, the facility failed to ensure medication was not left at a residents bedside which affected one of 12 sampled residents (Resident #17), failed log temperatures on the medication storage room refrigerator and prevent ice buildup, failed to refrain from using the medication storage refrigerator to store staff drinks, failed to destroy medication for a resident who had expired and failed to ensure both staff signed the narcotic count book at shift change. The facility census was 26. Review of the facility's undated Medications, Self-Administration, Self-Storage, Leave at Bedside policy showed: - The resident has a right to self-administer medication unless the interdisciplinary team has determined that this practice is unsafe for an individual resident. - If a resident expresses a desire to self-administer medication, the interdisciplinary team must assess the resident's cognitive, physical and visual ability to carry out this responsibility. The mental status and any psychiatric diagnosis must be taken into account. - 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to follow proper infection control practices during medication pass when staff did not wash or sanitize their hands between residents which affected one of 12 sampled residents (Resident #2), change out their gloves after coming in contact with dirty surfaces which affected one resident(Resident #6), did not sanitize the port of the feeding tube for one resident (Resident #6), and did not place supplies on a clean surface, which affected four resident (Resident #1, #2, #14 and #24) and when staff threw wound supplies directly on the floor which affected one sampled resident (Resident #21). The facility census was 26. Review of the facility's undated Standard and Transmission Based Precautions policy showed standard precautions will be used in the care of all residents regardless of their diagnosis, or suspected confirmed infection status. Standard precautions presume all blood, body fluids, secretions, and excretions, non-intact skin 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement, follow and monitor an antibiotic stewardship program when staff did not monitor infections and antibiotics on a monthly control log, trend the infections and assess to determine if the correct antibiotic was used for the correct length of time for two of 12 sampled residents (#1 and #11). The facility census was 26. Review of the facilities undated Antibiotic Stewardship Program policy showed: -Facility is implementing an antibiotic stewardship program that will help prevent unnecessary use of antibiotics. -The Adverse reaction of using unnecessary antibiotics can result in adverse drug reactions or interactions, the development of Clostridium difficile infections the emergence of multi-drug resistant organisms, antibiotic failure, increased mortality and greatly increased costs. -This program includes tool, policies, and procedures to guide nursing home staff toward more responsible and effective use of antibiotics. - The Goal…

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 record review and interviews, the facility failed to assure they followed their policy when they failed to document the residents' choice of code status in such a way to be readily accessible to staff in the event of an emergency. This affected one sampled resident (Residents #178). The facility census was 26. Review of the undated Advance Directive Policy showed: -Upon admission of a resident to the facility, the social services designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive. -Upon admission of a resident, the social services designee will inquire of the resident; and/or his/her family members, about the existence of any written advance directives. -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab. -Staff will be in-serviced annually to ensure that they remain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer, in writing and in a language they understood. The notice should include the effective date of discharge or transfer; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic mail) and telephone number of the Office of the State Long-Term Care Ombudsman; and for residents with a mental disorder or related disabilities, the mailing, electronic mail (email) address and telephone number of the agency for protection and advocacy for individuals with mental disorders established under the Protection and Advocacy 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 observations, interviews and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents and injuries when transferring one of 12 sampled residents, (Resident #4) during the use of a gait belt (a safety device and mobility aid used to provide assistance during transfers, ambulation or repositioning) transfer and when staff failed to report, document and investigate when staff lowered Resident #4 to the floor. The facility census was 26. Review of the facility's undated gait belt policy, showed, in part: - The purpose is to provide better control and balance while assisting residents with ambulation and transfer; - Apply belt to resident's waist, tighten to fit snugly with the buckle at the side; - Face the resident; - Bend your knees and place your hands around the gait belt on each side of the resident's waist; - Bring resident to a standing position while straightening your knees. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated…

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, record review and interview, the facility failed to assess placement of a gastrostomy tube (g-tube (a tube placed into a patient's stomach through the abdominal wall as a means of feeding them when they are unable to eat) using the current standard of practice, failed to follow proper infection control practices when staff did not change out their gloves after coming in contact with dirty surfaces and failed to ensure correct procedures were followed when medications were administered through the g-tube. This affected one resident (Resident #6) out of 12 sampled residents. The facility census was 26. Review of the facility's undated Standard and Transmission Based Precautions policy showed standard precautions will be used in the care of all residents regardless of their diagnosis, or suspected confirmed infection status. Standard precautions presume all blood, body fluids, secretions, and excretions, non-intact skin and mucous membranes may contain transmissible infectious agents. Staff will be trained in various aspects of standard precautions to ensure…

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 act promptly upon the grievances of the resident council members concerning issues of resident care and life in the facility and failed to communicate back with the resident council regarding their concerns as reported by 15 of 15 residents, who participated in a group interview. The facility census was 37. Review of the facility policy for Residents Rights dated 4/06 showed: -It is the purpose of this facility to meet the Federal and State Mandate in respects to resident rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. A facility must protect and promote the rights of each resident. 1. Review of the Resident Council Minutes dated 12/1/20 showed the residents at the meeting stated that the attitudes of the nursing staff is poor, nursing will not talk to them. No change in the concern. Review of the Resident Council Minutes dated 1/5/21, two residents stated that when staff answered their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' grievances were fully addressed and failed to maintain complete documentation of grievances received, steps taken to resolve the grievance, notification of the residents of the results of the grievance and follow up with the residents to ensure the problem/concern was resolved for two sampled residents (Resident #6 and #32). The facility census was 37. Review of the facility policy for Grievance Protocol dated 4/06 showed: -The purpose of the Grievance/Complaint Report and Grievance Log is to provide a written record of each resident and family concern and to insure proper follow-up through the appropriate discipline. -The Social Service Director (SSD) is responsible for the program, although the Administrator is ultimately responsible for the proper implementation of the program.; -The SSD informs the Administrator of each incident; -Guidelines: any member of the Social Services staff can complete the Grievance Complaint Report. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assure staff provided necessary care and services in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one of 21 sampled residents Resident #25. Staff also failed to respond timely when one resident, Resident #36 had a change in condition. The facility census was 37. 1. Review of the facility policy titled Condition Change, Resident (Observing, Recording and Reporting) dated March 2015 included the following: - Purpose: To observe, record, and report any condition change to the attending physician so that proper treatment can be implemented; - After changes in physical or mental function, monitor for the following (included): o Observe personality changes; o Observe for alterations in consciousness; o Observe for incontinence; o Observe for generalized weakness; o Observe for speech disorder; o Observe for gait, posture or balance disorder, take vital signs and…

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

Based on observation, interview, and record review, facility staff failed to monitor weights, notify the physician of the Registered Dietician's (RD) recommendations and of weight loss for one resident (Resident #16) of 21 sampled residents. The facility census was 37. Review of the facility policy for Dietitian Consultant Reports dated 5/15 showed: -The Dietitian will complete a consultation report prior to completing an exit interview with the Administrator and Dining Services Manager or will fax or email the completed report the next working day; -The consultant report must reflect what was accomplished in the visit which may include, but is not limited to: assessment and monitoring of nutritional needs of the resident; -Recommendations should be completed within five working days of the monthly visit; -A response to the consultant recommendations is to be completed by the dining services manager(DM), in conjunction with the Director of Nursing (DON) 1. Review of Resident #16's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff,…

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 provide care in a manner to prevent infection or the possibility of infection when they did not change gloves and wash their hands between dirty and clean tasks which affected two of 21 sampled residents (Resident #25 and #27) and failed to follow the facility policy for Coronavirus Disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) when staff failed to wear the appropriate personal protective equipment (PPE) when caring for a resident (Resident #36) in the Observation Unit for COVID-19 and failed to wear a facemask while preparing food in the dietary department. The facility census was 37. Review of the facility policy for Gloves, dated 3/15 showed: -Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substance (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus or…

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 record review and interview, the facility failed to notify a resident's physician and guardian immediately when the resident (Resident #36) had a significant change in condition. The resident had a history of being hospitalized while living at the facility. The facility census was 37. Review of the facility policy titled Condition Change, Resident (Observing, Recording and Reporting; includes Fall or Injury), dated March 2015 included the following: - Purpose: To observe, record, and report any condition change to the attending physician so that proper treatment can be implemented; - After all resident falls, injuries or changes in physical or mental function, monitor for the following (included): o Observe personality changes; o Observe for alterations in consciousness; o Observe for incontinence; o Observe for generalized weakness; o Observe for speech disorder, o Observe for gait, posture or balance disorder, take vital signs and include temperature; - Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff provided transfer or discharge notification to residents and their responsible party and the reasons for the transfer/discharge in writing in a language they understood. This affected three of 18 sampled residents (Residents #1, #23 and #36). The facility census was 37. Review of the facility policy for Discharge/Transfer of Resident dated 3/15 showed: -Discharge means to leave the facility without plans or intention to return (i.e., discharge to go home, a lower level of care or another long-term care facility).; -Transfer means to leave the facility with plans or intention to return (i.e., transfer to an acute care facility for appropriate care); -Purpose: to provide safe departure from the facility and to provide sufficient information for the aftercare of the resident: -Needed are: the resident medical record, discharge or transfer order; discharge against medical advice form if necessary, transfer for, discharge summary and post…

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 inform the resident and the resident's family/legal representative of the facility's bed-hold policy at the time of transfer/discharge to the hospital for one of 21 sampled residents (Residents #1). The facility census was 37. 1. Review of the undated facility policy for Bed Hold showed: -The facility will notify all residents, and/or their representative of the bed hold guidelines. This notification shall be given: 1. Upon admission to the facility, 2. At the time of transfer to the hospital or leave, and 3. At the time of non-covered therapeutic leave. Review of Resident #1's face sheet showed the resident was admitted to the facility on [DATE] with the diagnoses of Schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), Schizophrenia (a serious mental illness that affects how a person thinks, feels, and…

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

Based on record review and interview, the facility failed to ensure one resident (Resident #36), who had a history of multiple re-hospitalizations, kept a follow up appointment according to discharge orders from his/her most recent hospitalization. The facility census was 37. 1. Review of Resident #36's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/30/20 showed the following: - admission date 6/7/16; - Moderate cognitive impairment. Review of the resident's medical record showed the resident was hospitalized on the following dates: - 4/13/20 for Urinary Tract Infection (UTI), extended-spectrum b-lactamase (ESBL)-producing Escherichia coli (ecoli) grows from the urine culture - 5/22/20- acute respiratory failure with hypoxia; - 9/20/20- Pneumonia - 11/1/20- UTI, ESBL - 12/14/20- for a Urinary Tract Infection - 1/23/21- for UTI with sepsis Review of the discharge summary from the hospital on 1/23/21 showed the resident had an appointment set up for 2/3/21 at 9:30 A.M. with a gastroenterologist (physicians who are trained 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.

Based on observation, interview, and record review, the facility failed to assure staff identified the cause of an injury and put measures in place for one resident (Resident #27), when the resident developed dark, bruised appearing areas to both outer ankles. The facility census was 37. 1. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 12/2/20 showed: -Alert and oriented and able to make decisions and answer questions appropriately; -Extensive assistance of two staff members with Activities of Daily Living (ADL's) ; -Independent with locomotion in a wheelchair; -Incontinent of bowel and bladder; -No falls or skin impairment; -Diagnoses of hypertension (HTN), diabetes, anxiety, schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation.) Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to change oxygen tubing weekly. This affected three residents (Residents #10, #27, #18) and had the potential to affect all residents who require oxygen while in the dining room. The facility also failed to obtain physician orders for oxygen therapy for two residents (Resident #10 and #27). Facility census was 37. Review of facility policy, Cleaning Guidelines - Oxygen Equipment, dated March 2015, showed: -All oxygen equipment are changed every seven days when heated humidification is used, and monthly when unheated humidification is used. -All concentrator outside surfaces are to be cleaned weekly by nursing personnel, and marked with date an initials; -Tubing, masks, and cannula's used with oxygen therapy should be replaced monthly and as needed (PRN), and marked with date and initials. Review of facility policy, Physician Orders, dated March 2015, showed: -Oxygen orders: specify the rate of flow, route, and rationale. 1. 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 record review and interview, the facility failed to assure two of 21 sampled residents (Resident #15 and #18), who used psychotropic drugs received gradual dose reductions (GDRs) in an effort to discontinue these drugs. The facility also failed to assure as needed (PRN) orders for psychotropic drugs were limited to 14 days. The facility's census was 37. Review of the facility policy for Drug Review dated 3/15 showed: -All medications given to reach resident will be reviewed on a monthly basis in order to; review drug interactions, insure adherence to stop orders, insure accuracy in administration and evaluate medications appropriate to diagnosis; -The pharmacist reviews all federal indicators, and a monthly report is filled out to show any problem areas. The report lists any problems noted, the date and signature of the reporter; -Medications should not show unnecessary or excessive use and should have a diagnosis to support them; -Problems identified shall be addressed according to need in consultation…

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 administer medications with a less than 5% medications error rate. Facility staff made three medication errors out of 25 opportunities for error resulting in a 12.0% medication error rate. This affected two of 21 sampled residents (Residents #6 and #18 ). The facility census was 37. Review of the facility policy for Medication Administration dated 3/15 showed: -Medications are given to benefit a resident's health as ordered by the physician. 1. Review of Resident #6's quarterly Minimum Date Set (MDS), a federally mandated assessment instrument completed by staff, dated 10/20/20 showed; -Alert and oriented and able to make decisions; -Independent with Activities of Daily Living (ADL's); -Diagnoses of heart failure, hypertension and diabetes. Review of the physician orders (POS) for February 2021 showed: -Flonase (is used to relieve symptoms of rhinitis such as sneezing and a runny, stuffy, or itchy nose and itchy, watery eyes caused by hay…

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 staff dated insulins when opened for resident use, failed to discard loose pills, and failed to remove expired medications from the medication cart and the medication storage room. The facility census was 37. Review of facility policy, Storage of Medications, dated March 2015, showed: -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines. Review of Resident #22's physician orders, dated February 2021, showed: -Pazeo drops 0.7% (antihistamine, treats itching and redness in eyes due to allergies); instill one drop in both eyes daily as needed for allergies; order date 01/22/19. Review of Resident #14's physician orders, dated February 2021, showed: -Novolog (a fast-acting insulin to lower blood sugar levels) 10 units subcutaneous (under the skin) three times daily; order date 06/20/20. Review of Resident #14's medication administration review, dated January 8th…

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, record review and interview, the facility failed to prepare and provide each resident with a nourishing, palatable, well-balanced diet that meets the resident nutritional and special dietary needs. This affected two sampled residents Residents #4 and #15. The facility census was 37. 1. Review of the facility policy titled Food Preparation and Distribution, dated May 2015, included the following: - The Dining Services Department will prepare foods by methods that are safe and sanitary while conserving nutritive value as well as enhancing flavor; - Foods are prepared by methods that conserve nutritive value, flavor, and appearance Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/7/21 showed: - Moderate cognitive impairment. During an interview on 2/1/21 the resident said the food was not very good, period. It was too tough, bland and just plain did not taste right. Review of the Lunch menu for 2/2/21 showed smothered Steak with onions, mashed potatoes, green peas, dinner roll,…

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, record review and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff did not keep a clean kitchen. The facility census was 37. 1. Review of the undated facility policy titled Holed and Expiration Policy on Condiments, Dry Spices, etc. included the following: - Spices lose their potency of flavor over time due to dry and excessive holding, causing a quality issue. They are tossed a year after their delivery date, which is standard for spices. Spices never truly expire, but may become outdated and eventually low-quality. Spices are kept in sealed containers and stored in a clean and dry environment; - Leftovers need to be labeled and dated with current date and their expiration date. When putting leftovers in containers, they cannot be left out for no more than two hours at room temperature. By that point bacteria may grow which ma cause foodborne illness. Leftover become outdated and spoiled in three days, which is our holding period. Observation on 2/01/21 beginning at 10:18 AM…

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 record review and interview, the facility failed to develop a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. The facility census was 37. 1. Review of the facility's policies did not addressed foods being brought in to residents by family and other visitors. During an interview on 2/2/21 at 2:34 P.M. the Administrator and Director of Operations said: - The facility did not have an actual policy to address food being brought to residents by family and other visitors. The facility had not been allowing any food to be brought in from family or other visitors due to COVID-19 (a contagious respiratory disease thought to spread mainly from person to person through respiratory droplets produced when an infected person coughs, sneezes, or talks).

Based on observation, interview and record review, the facility failed to assess and provide therapy services for two residents (Residents #15, #4) when the facility placed the resident on a pureed diet due to choking and did not obtain an evaluation from a speech therapist and did not provide physical therapy after Resident #4 requested it. The facility census was 37. The facility did not provide a policy regarding therapy services. 1. Review of Resident #15 quarterly Minimum Data Set (MDS), a federally mandated assessment instrument complete by staff, dated 1/29/21 showed: -Alert and oriented with difficulty making decisions; -Limited assistance of one staff member for Activities of Daily Living (ADL's) and supervision of one staff member for eating; -Has swallowing difficulties with coughing or choking during meals during meals or when swallowing medications; -Received no speech therapy. Review of the residents Physician Orders (POS) for February 2021 showed an order for pureed diet. Review of the medical record showed the resident was receiving speech therapy services in July…

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

Based on observation and interview, the facility failed to maintain the dishwasher in the kitchen in safe operating condition. The facility census was 37. 1. Observation on 2/2/21 at 9:29 A.M. showed the dishwasher in the kitchen was not in working condition. During an interview on 2/2/21 at 10:15 A.M. the Dietary Manager said: - The dishwasher broke on the morning of 1/ 30/21. She heard clanking and the spring that helps the door open broke and the hose was not dispensing sanitizer; - The dishwasher repair man was supposed to come on 2/3/21; - The dishwasher broke down about every four months, the facility needed a new one; - All the residents were being served on disposable dishware because of the broken dishwasher, everything else was being washed in the three compartment sink. Observation on 2/3/21 at 2:43 P.M. showed the dishwasher was still not in operating condition. During an interview on 2/3/21 at 2:43 P.M. the Dietary Manager said the repair man came and would be back on 2/12/21 with the parts needed for the repair. During an interview on 2/3/21 at 2:46 P.M. the…

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

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public when they failed to ensure a shower drain was fastened in the shower and ensure the parking lot was free of large pot holes, potentially causing a tripping hazard. The facility census was 37. The facility did not provide a policy regarding maintenance of the facility. 1. Observation of the shower off of the 300 hall showed a drain cover in the shower was not fastened to the drain line enabling the cover to be moved from the drain line uncovering approximately a two-inch hole. 2. Observation on 2/1/21 at 10:00 A.M. throughout the survey showed seven potholes in the parking lot of various sizes. The sizes ranged from a grapefruit to beach ball size that were approximately three inches deep. 3. During an interview on 2/3/21 at 2:46 P.M. the Administrator said: - The facility did not currently have maintenance staff and had not had one since January 2021, a corporate maintenance staff was coming to the facility to complete…

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.