Garden View Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure expired testing supplies and medications not in use by two residents including one current resident Resident #10) and one discharged resident (Residents #100), were destroyed or returned as directed by facility policy. The facility census was 48. Review of the facility's policy, Storage of Medications, last revised [DATE], showed the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 1. Review of Resident #100's physician orders, dated [DATE], showed an order for fluticasone-salmeterol (a combination of two medicines that are used to help control the symptoms of asthma and improve breathing) aerosol powder breath activated 250-50 microgram (mcg)/dose, one inhalation - inhale orally every 12 hours (original order 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, interview, and record review, the facility failed to maintain an effective pest control program to ensure staff responded timely to reports of pests in the building. The facility census was 48. Review of the facility's policy, Pest Control, revised May 2024, showed the following: -The facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents; -Pest control services are provided by the pest control service/vendor; -Maintenance services assist, when appropriate and necessary, in providing pest control services. Review of the facility's policy, Sanitation, revised November 2024, showed all kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 1. Review of the pest control company's service summary report, dated 12/31/24, showed the company treated the exterior of the facility for rodents and ants. Observation on 1/13/25 at 2:30 P.M. showed a light brown insect crawled along the wall by the heated carts, 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 observation, interview, and record review, the facility failed to assess residents for risk of entrapment prior to placement of bed rails, document alternatives attempted prior to bed rail placement, complete entrapment zone measurements, or obtain written consent from the residents and/or their guardians prior to use for one resident (Residents #11), who used side rails, in a review of 14 sampled residents. The census was 48. Review of the facility's Bed Safety /Bed Rails policy, last revised in July 2024, showed the following: -The facility shall strive to provide a safe sleeping environment for the resident and after evaluation, if need be, appropriate bed rails will be used for bed mobility as necessary: -The resident's sleeping environment should be assessed by the Nursing Supervisor/ Administrator/ DON (interdisciplinary team), considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -The facility will attempt to utilize appropriate…

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 complete inspections of bed frames, mattresses and bed rails, as part of a regular maintenance program, to identify areas of possible entrapment for one resident (Resident #11), in a review of 14 sampled who used bed rails/assist bars. The facility census was 48. Review of the facility's Bed Safety /Bed Rails policy, last revised in July, 2024, showed the following: -The facility shall strive to provide a safe sleeping environment for the resident and after evaluation, if need be, appropriate bed rails will be used for bed mobility as necessary; -To try to prevent injuries from the use of bed rails and related equipment, the facility should promote the following approaches: -The maintenance department will complete an inspection on bed rail and bed components routinely and should provide a copy of inspections to the Administrator. These inspections will be incorporated into Safety Committee; -Ongoing evaluation of resident and bed rails will occur to assess the ongoing need for use of bed rails and resident'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 interview and record review, the facility failed to ensure individuals employed by the facility did not have a federal indicator for misconduct. Review of Licensed Practical Nurse (LPN) B's employee file showed he/she had a federal indicator for misconduct. LPN B was employed by the facility as a charge nurse with access to all residents. The facility census was 29. Review of the facility policy, Background Screening Investigation, revised November 2015, showed the following: -Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on direct access employees; -For the purposes of this policy direct access employee means any individual who has access to a resident or patient of a long term care facility or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact with a patient or resident of the facility or provider, as determined by the State for purposes of the National Background Check Program; -The Personnel/Human Resources Director, or other…

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 develop a policy and procedure to address reviewing the state Certified Nurse Aide (CNA) Registry for all new employees. This has the potential to affect all residents of the facility. The facility census was 29. Review of the facility policy, Background Screening Investigation, revised November 2015, showed the following: -For any individual applying for a position as a Certified Nursing Assistant (CNA), the state nurse aide registry will be contract to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file. Review of the facility policy showed it did not include that all individuals employed by the facility will be checked against the state nurse aide registry. During an interview on 07/11/23 at 11:26 A.M., the Administrator said she was aware that the policy did not instruct for the CNA registry check to be completed on all new hires, including any potential non-CNA staff.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety when it failed to appropriately store and handle food products to maintain quality and free from potential contaminants, and label and date opened food items. The facility also failed to ensure dietary equipment was free of an accumulation of grease, dust and debris. The total facility census was 60 and the certified census was 29. Review of the facility's policy, Preventing Foodborne Illness, Employee Hygiene and Sanitary Practices, revised October 2017, showed the following: -Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness; -Employees must wash their hands after handling soiled equipment or utensils, during food preparation as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; -Gloves are considered single-use items and must be discarded after completing the task for which they are used.…

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 develop an antibiotic stewardship program as a part of their infection prevention and control program that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 29. Review of the facility policy, Antibiotic Stewardship, dated December 2018, showed the following: -The facility would educate and train staff and practitioners about the antibiotic stewardship program, including appropriate prescribing, monitoring, and surveillance of antibiotic use and outcomes. Antibiotic usage and outcome data would be collected and documented using a facility approved antibiotic surveillance tracking form. The data would be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship; -As part of the program, all clinical infections treated with antibiotics would undergo review by the director of nursing (DON); -The designee would review antibiotic utilization as part of the antibiotic stewardship program and identify…

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 designate a qualified individual(s) onsite who was responsible for implementing programs and activities to prevent and control infections. The facility census was 29. Review of the facility's Infection Preventionist policy, dated 12/2018, showed the following: -The Infection Preventionist is responsible for coordinating the implementation and updating of our established infection and prevention and control policies and procedures; -The Infection Preventionist will collect, analyze and provide infection and antibiotic usage data and trends to nursing staff and health practitioners; consult on infection risk assessment and prevention control strategies; provide education and training; and implement evidenced-based infection prevention and control practices. During an interview on 06/23/23 at 10:30 A.M., the Director of Nursing (DON) said the following: -She was employed as the Director of Nursing in January 2023; -The Administrator and DON work together on the Infection Control and Prevention Program; -Neither one had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow policies and procedures for immunization of residents against pneumococcal disease. The facility failed to offer and vaccinate nine eligible residents (Resident #24, #5, #8, #18, #19, #13, #17, #3, and #4), in a review of 15 sampled residents, and 10 additional residents (Resident #501, #21, #504, #6, #2, #15, #16, #12, #20 and #503) with the recommended doses of the pneumococcal vaccine as indicated by the Centers for Disease Control and Prevention (CDC) recommendations. The facility also failed to ensure the facility policy followed current CDC guidelines for pneumococcal vaccine administration. The facility census was 29. Review of the undated facility policy for Influenza/Pneumococcal Vaccines showed the following: -It is the facility's policy that residents will receive the vaccinations listed below, unless documentation can be provided showing that he/she has received them within the appropriate time frame allowed for each vaccination;…

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 that enhanced resident dignity for four residents (Resident #1, #9 #13, and #24), in a review of 15 sampled residents. Staff stood while assisting three residents (Residents #1, #9, and #13) to eat in the dining room, and did not answer one resident's (Resident #24's) call light promptly, causing the resident to be incontinent. The facility census was 29. Review of the facility policy, Answering the Call Light, revised October 2010, showed the policy directed staff to answer a resident's call light as soon as possible. Review of the facility's Assistance with Meals policy, dated December 2018, showed residents who cannot feed themselves shall be fed with attention to safety, comfort and dignity. This includes not not standing over resident while assisting them with meals. 1. Review of Resident #24's care plan, dated 01/25/23, showed the following: -The resident requires assist with activities of daily living…

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 create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for two residents (Residents #3 and #24) in a review of 15 sampled residents, when staff woke residents according to staff preference or based off of a get up list. The facility census was 29. Review of the facility's admission agreement form, residents' rights and responsibilities, dated 4/20/21, showed the following: -Rights to freedom from control; -Residents shall not have their personal lives regulated or controlled beyond reasonable adherence to meal schedules and other written policies which may be necessary for the orderly management of the facility. 1. Review of Resident #24's care plan, dated 01/25/23, showed the following: -The resident requires assistance with activities of daily living (ADLs) related to stroke with left side paralysis. Resident is able to make needs known; -Requires one assist to transfer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's choice of code status was consistent throughout the resident's medical record and the Outside The Hospital Do-Not-Resuscitate (OHDNR) Order form was completed for three residents (Resident #1, #13, and #16), in a review of 15 sampled residents. Also, staff responsible for the care of one resident (Resident #11) did not accurately review the resident's chart to ensure the proper code status and two other care staff did not know where a resident's code status would be located. The facility census was 29. Review of the facility policy, Advanced Directives, dated 12/2018, showed the following: -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directives. 1. Record review of Resident #1's (OHDNR) form, undated, showed 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 provide the necessary care and services for incontinence care for three residents (Resident #3, #4, and #17), in a review of 15 sampled residents, who required assistance to perform activities of daily living. The facility census was 29. Review of the facility policy, Perineal Care, dated 12/2018, showed the following: -The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -Review the resident's care plan for any special needs of the resident. 1. Review of Resident #17's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/22/23, showed the following: -The resident had short and long term memory loss; -He/She did not reject care; -He/She was incontinent of bladder and bowel. Review of the resident's care plan, last updated 04/26/23, showed 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 reposition three residents (Resident #3, #4, and #17), in a review of 15 sampled residents, who were at risk for developing pressure ulcers. The facility's census was 29. Review of the facility's repositioning policy, dated May 2013 showed the following: -The purpose was to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair-bound residents and prevent skin breakdown, promote circulation, and provide pressure relief for residents; -Review the resident's care plan to evaluate for any special needs; -Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief; -Repositioning was critical for a resident who was immobile or dependent upon staff for repositioning; -Check the resident's care plan, assignment sheet, or the communication…

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 sufficient nursing staff to meet residents' needs including toileting, meal assistance and supervision for five residents (Resident #2, #24, #1, #13, and #17), in a review of 15 sampled residents on a secured dementia unit. The facility census was 29. Review of the facility policy, Staffing, revised April 2007 showed the following: -Our facility provides adequate staffing to meet needed care and services for our resident population; -Our facility maintains adequate staffing on each shift to ensure that our residents' need and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services; -Certified Nursing Assistants (CNAs) are available on each shift to provide the needed care and services of each resident as outlines on the resident's comprehensive care plan; -Other support services (e.g. dietary, activities/recreational, social, therapy,…

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 medication carts and treatment cart were secured when unattended. The facility census was 29. Review of the facility policy, Storage of Medications, dated 12/2018 showed the following: -The facility shall store all drugs and biologicals in a safe, secure and orderly manner; -Nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Observation on 06/23/23 at 8:22 A.M., at the C wing nurses station, showed the following: -The medication cart sat at the nurses station unlocked; -The treatment cart sat across from the nurses station unlocked. The cart contained multiple tubes of prescription ointments/creams/medications; -A housekeeper walked by the medication cart; -The medication cart contained a narcotic box, three bottles of Atropine (medication used to dry up secretions), and multiple insulin pens. Observation on 06/23/23 at 8:35 A.M., at the C wing nurses station, showed the following: -The medication cart sat at the nurses…

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 washed their hands after each direct resident contact and when indicated by professional standard of practice during personal care for three residents (Resident #1, #2, and #4) in a review of 15 sampled residents. The facility census was 29. Review of the facility policy, Handwashing/Hand Hygiene, dated 08/2015, showed the following: -Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after direct contact with residents; b. Before performing any non-surgical invasive procedures; c. Before moving from a contaminated body site to a clean body site during resident care; d. After contact with a resident's intact skin; e. After contact with blood or bodily fluids; f. After handling used dressings, contaminated…

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 provide required in-service training for nurse aides that included dementia management training as part of the required minimum 12 hours of training per year. The facility census was 29. Review of the facility assessment dated [DATE] showed the following: -Required in-service training for certified nurse assistants CNAs must be sufficient to ensure that continuing competence of nurse aides, but must be no less than 12 hours per year; -Include dementia management training and other individuals with cognitive impairments; -For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. During an interview on 6/23/23 at 9:05 A.M., Activity Aide N said the following: -He/She worked at the facility for four years; -He/She went to dementia care lectures and training, but the last one was prior to COVID-19 (Coronavirus pandemic) restrictions. During an interview on 06/23/23 at 9:15 A.M., CNA I…

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 appropriate use of a gait belt for two residents (Resident #1 and #13), in a sample of 15 residents, when staff pivot transferred the residents. The facility census was 29. The facility did not provide a policy for gait belt use or resident transfers. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/05/23, showed the following: -The resident had short and long term memory problems; -He/She required extensive assistance of two staff members for transfers; -He/She had diagnoses of dementia, seizure disorder, traumatic brain injury, and post-concussional syndrome (when concussion symptoms last months or even a year or more after initial injury that affect how the body and brain function, as well as how a person experiences emotions). Review of the resident's care plan, dated 04/11/23, showed the following: -The resident required assistance 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 and interview, the facility failed to follow proper sanitation and food handling practices in the kitchen. The total facility census was 73. 1. Observation on 9/10/19 at 10:42 A.M. showed the external thermometer of the three-door freezer showed a temperature of 0 degrees Fahrenheit (F) while the interior thermometer showed a temperature of +10 degrees F. Observations on 9/10/19 between 2:49 P.M. and 3:22 P.M. showed the three-door freezer had not been opened. At 3:22 P.M., the exterior thermometer read 0 degrees F and a calibrated thermometer was placed inside the freezer. Observations on 9/10/19 between 3:22 P.M. and 3:32 P.M. showed the freezer door had not been opened. At 3:32 P.M. the external thermometer of the freezer read 0 degrees F and the calibrated thermometer inside the freezer showed +10 degrees F. The facility's internal thermometer was not observed in the freezer at this time. Further observation showed the freezer held potentially hazardous food items such as, fish, ground beef, sausage, bacon, beef patties, chicken breast, chicken strips, 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 ensure staff provided three residents (Residents #3, #10 and #16), who were unable to perform their own activities of daily living, in a review of 12 sampled, the necessary care and services to maintain good personal hygiene and prevent body odor. The total facility census was 73 with a certified census of 24. 1. Review of the facility's policy, Perineal Care, dated December 2018, showed the following: -The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition; -For a female resident: wet washcloth and apply soap or skin cleansing agent. Separate labia and wash area downward from front to back. Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. Do not reuse the same washcloth or water to clean the urethra or labia. Rinse perineum…

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

Based on observation, interview, and record review, the facility failed to store all medications in locked compartments when staff left the medication carts unlocked and left the medication keys unattended on top of the medication cart. The total facility census was 73 with a certified census of 24. 1. Review of the facility's policy, Security of Medication Cart, dated December 2018, showed the following: -The medication cart shall be secured during medication passes to ensure medications are kept in a controlled environment, to restrict access by unauthorized personnel/residents, and to maintain resident safety; -The nurse must secure the medication cart during the medication pass to prevent unauthorized entry; -Medication carts are to be kept locked when not in use, or when not in direct line of sight of staff members; -Schedule II controlled substances must be stored behind two locks, requiring two separate keys to open. 2. Review of the Certified Medication Technician Student Manual, 2008 revision, showed the following: -Access control - access should be limited to persons…

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 ensure staff served meals to meet residents' needs by not serving correct portion sizes of protein to residents on a mechanical soft diet. The total facility census was 73. Review of a list of residents and their physician-ordered diets, provided by the facility, showed 12 residents had physician orders for mechanical soft diets. Review of the facility's menu for the lunch meal on 9/10/19 showed residents on a mechanical soft diet were to receive ground pork steak. During interview on 9/10/19 at 10:42 A.M., the dietary supervisor said there are no spreadsheets to show serving sizes. Observation on 9/10/19 at 12:10 P.M. showed Dietary Aide W prepared six plates for residents on a mechanical soft diet. He/she used a pair of tongs to place an unmeasured amount of ground pork steak onto each of the plates. During interview on 9/11/19 at 2:40 P.M., Dietary Supervisor said he expected staff to use a 3 ounce scoop, spoodle, or ladle to serve mechanical soft protein. He would not expect to see tongs used for mechanical soft because…

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 report two allegations of resident to resident physical abuse to the state survey agency for one resident (Resident #13), in a review of 12 sampled residents. The facility's total census was 73, with a certified census of 24. 1. Review of the facility policy Freedom from Abuse, Neglect, and Exploitation Reporting and Response, dated December 2018, showed the following: -Abuse allegations (abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law; -The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made; -If the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result 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 observation, interview, and record review, the facility failed to follow standards of nursing practice for one resident (Resident #18), in a review of 12 sampled residents. Nursing staff mixed a prescription cream with a barrier cream, placed the cream in the resident's room for certified nursing assistants (CNAs) to apply to the resident's skin. The nursing staff documented their initials on the treatment record (indicating they had applied the medication) when the CNAs applied the cream to the resident's skin. The facility did not have a policy to direct staff on how to properly mix the medication. The facility also failed to administer liquid medication to one resident (Resident #6) in a manner that would ensure an accurate dose of the ordered medication. The facility census was 73 and the certified census was 24. 1. Review of the policy Administering Topical Medications, dated December 2018, showed the following: -Perform hand hygiene; -Arrange supplies in the medication room or move the medication cart outside the resident's room; -Select the drug from the unit dose…

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 used a gait belt (special belt, used to provide assistance during transfer, ambulation, or positioning in a chair) during transfer for one resident (Resident #10), in a review of 12 sampled residents, and failed to ensure staff used proper technique when repositioning two residents (Residents #10 and #16) in the wheelchair. The total facility census was 73 with a certified census of 24. 1. Review of the facility's undated policy, Ambulate Resident Using Gait Belt, showed the following: -Purpose is to provide safety to residents and nursing staff during ambulation and transfers; -Lower bed to lowest level; assist resident to sit on edge of bed; -Assist resident in putting on nonskid shoes and socks; -Put gait belt around the resident's waist; -Assist the resident to a standing position; -Assist resident to stand by straightening legs as you lift with the gait belt as resident pushes down with hands on mattress. 2. 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.

Based on observation, interview, and record review, the facility failed to provide one resident (Resident #6), in a review of 12 sampled residents, sufficient fluid intake to maintain proper hydration and health. The facility census was 73, with a certified census of 24. 1. Review of the facility policy Resident Hydration and Prevention of Dehydration, approved December 2018, showed nurses aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report any change in fluid intake to nursing staff. 2. Review of the Nurse Assistant in a Long-Term Care Facility manual, 2001 Revision, showed the following: -Water is essential to life. A person can live only a few days without water. It provides minerals but no other nutrients. The body requires 2000 to 3000 milliliters (ml) daily; -The human body is 60 percent water; -Illness may upset water balance; -Dehydration is an excessive loss of water from body tissues. Symptoms may include thirst, dryness of 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 and record review, the facility failed to ensure staff washed their hands after each direct resident contact and when indicated by professional practices during personal care for two residents (Residents #3 and #16), in a review of 12 sampled residents. The total facility census was 73 with a certified census of 24. 1. Review of the facility's policy, Standard Precautions, dated December 2018, showed the following: -Standards precautions will be used in the care of all residents regardless of their diagnosis, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents; -Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) OR using alcohol-based hand rubs (gels, foams rinses) that do not require access to water; -Hands shall be washed with soap and water whenever visibly soiled with dirt, blood, 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.