Glenbridge Health And Rehabilitation

Based on observations and staff interviews, the facility failed to remove expired food and failed to date perishable food stored for use in 1-of-1 walk-in cooler. This practice had the potential to affect food served to residents. The findings included: During the initial tour of the kitchen on 4/01/25 from 10:45 AM to 11:00 am an observation with the Assistant Dietary Supervisor of the walk-in cooler revealed the following: - a plastic container sealed with plastic wrap dated 3/28/2025 that was one quarter full of chicken breasts with seasoning dated 3/28/25 - a plastic container sealed with plastic wrap dated 3/27/2025 that was half full of chicken noodle soup that had started to separate - a plastic container sealed with plastic wrap dated 3/26/2025 that was half full of creamed corn - a metal tray of seven tuna salad sandwiches sealed with aluminum wrap with no date - a metal tray of 10 bologna sandwiches sealed with plastic wrap dated 3/27/2025 The Assistant Dietary Supervisor observed on 4/01/25 at 11:15 AM the food stored inside of the walk-in cooler that were expired 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 record review, Nurse Practitioner and staff interviews, the facility failed to notify the provider when five daily doses of Metoprolol Succinate ER (medication to treat heart failure) and Quetiapine Fumarate (an antipsychotic medication that helps regulate mood behaviors and thoughts) was not administered for 1 of 1 resident reviewed for notification (Resident #36). The findings included: Review of the hospital Discharge summary dated [DATE] revealed orders for Metoprolol Succinate 25 milligrams 24 hr tablet. Take 0.5 tablets (12.5 milligram total) by mouth nightly, and Quetiapine 25 milligram tablet. Take 1 tablet (25mg total) by mouth nightly. Resident #36 was admitted to the facility on [DATE] with diagnoses that included chronic systolic (congestive) heart failure, type 2 diabetes mellitus with diabetic peripheral angiopathy (the presence of diabetes which involves damage to the blood vessels particularly to the extremities), hypertensive heart disease with heart failure, unspecified dementia 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Pharmacist, Nurse Practitioner, and staff interviews, the facility failed to prevent a significant medication error when they failed to administer five daily doses of Metoprolol Succinate (medication to treat heart failure) and Quetiapine Fumarate (an antipsychotic medication that helps regulate mood behaviors and thoughts) for 1 of 3 residents reviewed for medications (Resident #36). The findings included: Review of the hospital Discharge summary dated [DATE] revealed orders for Metoprolol Succinate 25 milligrams 24 hr tablet. Take 0.5 tablets (12.5 milligram total) by mouth nightly, and Quetiapine 25 milligram tablet. Take 1 tablet (25mg total) by mouth nightly. Resident #36 was admitted to the facility on [DATE] with diagnoses that included chronic systolic (congestive) heart failure, type 2 diabetes mellitus with diabetic peripheral angiopathy (the presence of diabetes which involves damage to the blood vessels particularly to the extremities), hypertensive heart disease with heart…

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 staff interviews, the facility failed to employ a director of food and nutrition services that met the minimum qualifications, and it affected 106 of 109 residents. Findings included: On 01/27/2025 at 10:10 AM, the Dietary Manager was interviewed and revealed that he did not have any of the following: certification as a dietary manager or food manager, national certification for food service management and safety, an associate's or higher degree in food service management or in hospitality, 2 or more years of experience in the position of Director of Food and Nutrition Services in a nursing facility setting. The Dietary Manager stated that he does have a dietician that he can consult, but he did not know her name. He stated that he could call her if needed. He revealed that he had been at this facility in this kitchen for a total of six months and that he left for a while and then came back. On 01/28/2025 at 10:50 AM, a Dietary Manager at a sister facility was interviewed and stated that she was a Certified Dietary Manager and a Certified Food Protection…

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 and staff interviews, the facility failed to remove loose and unsecure pills of various shapes, sizes and colors and failed to ensure a medication cart was clean and free of debris for 2 of 3 medication carts reviewed for medication storage (100/200 split hall and 300 hall medication carts). The findings include: a. On 01/29/25 at 1:31 PM an observation was made of medication cart 100/200 hall split along with Nurse #2 which revealed 41 loose and unsecure pills of various shapes, sizes and colors and debris of paper shavings and rubber bands in the bottom of the cart drawers. An interview was conducted with Nurse #2 on 01/29/25 at 1:31 PM who explained that everyone was responsible for keeping the medication carts clean and orderly. The Nurse stated she should have vacuumed the medication cart out prior to the observation. During an interview with Unit Manager (UM) #1 on 01/29/25 at 1:42 PM she explained that the condition of the medication cart was unacceptable and that it was the nurses' responsibility to vacuum the medication carts out once a week. b. An…

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, observations, and resident, visitor and staff interviews and test tray, the facility failed to provide food that was appetizing in temperature, texture and palatability for 3 of 3 residents sampled for food palatability (Resident #59, Resident # 15, and Resident # 57). The findings included: a. Resident #59 was admitted on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #59 was cognitively intact. An interview with Resident #59 occurred on 01/27/2025 at 1:05 PM he stated the food was terrible. They don't give us much breakfast. This morning the eggs were runny and cold. There was no meat. The bread was hard. He said he knew that he could have asked for something different, but he knew it would take a long time and wouldn't be much good either. He stated that he tries to keep a few snacks in his drawer, and the nutrition room never had anything. During an interview with Resident #59 on 01/29/2025 at 5:28 PM, he stated regarding lunch hate them chicken…

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 and staff interviews, the facility failed to store food items off the floor in the dry goods storage area, remove food items with signs of spoilage stored for use in 1 of 2 walk-in freezers and failed to ensure ice cream stored for use in an upright freezer did not have signs of freezer burn in 1 of 3 nourishment rooms (100 Hall nourishment room). The practices had the potential to affect food served to residents. The findings included: a. An observation on 01/27/2025 at 10:02 AM of the dry goods storage room revealed a mesh bag of onions and a wrapped package of water bottles sitting on the storeroom floor. They were pointed out to the Dietary Manager who stated that they should not be on the floor. An item with a split plastic bag on it on the storeroom floor was pointed out, and the Dietary Manager said that it was an old mixer and didn't need to be on the floor. b. Observations of the freezer shelves on 01/27/2025 at 10:07 AM revealed an expired bag of iceberg lettuce dated 01/21, a container of lettuce covered in plastic wrap with a date of 1/23 that…

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, record review and staff and Resident interviews, the facility failed to treat a dependent resident in a dignified manner when Nurse Aide (NA) #2 failed to change Resident #39's soiled brief upon request of the Resident before she ate her lunch meal for 1 of 1 resident reviewed for dignity and respect (Resident #39). Resident #39 stated she felt belittled and treated like a child. The findings included: Resident #39 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39's cognition was severely impaired, and the Resident was dependent (helper does all the effort) for toileting. The MDS indicated Resident #39 was always incontinent of bladder and bowel. On 01/27/25 at 2:20 PM during an observation and interview with Resident #39 the Resident was lying in bed on her back. The Resident explained that she could not go to the bathroom by herself and that she wore a brief which had to be changed by the staff. Resident #39…

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, record review and interviews, the facility failed to maintain the bed remote in good repair for 1 of 21 rooms on 200 hall (room [ROOM NUMBER]-B) reviewed for environment. The findings included: On 01/27/25 at 11:40 AM an observation of room [ROOM NUMBER] revealed bed B was raised approximately waist high and the bed remote was attached to the right-side rail. The coiled cord to the bed remote was missing approximately 8 inches of the rubbery outside covering exposing the wire inside the cord. The bed was occupied by a resident during the observation. On 01/27/25 at 3:10 PM an observation was made of the bed which was in low position. The Resident was not in the bed and the bed remote was attached to the right-side rail and remained unchanged. An observation was made of the bed remote in room [ROOM NUMBER]-B on 01/28/25 at 1:45 PM which remained unchanged. On 01/28/25 at 3:49 PM an interview was conducted with Nurse Aide (NA) #1 who explained the resident in bed 205-B was not able 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 observations, record review, and staff and Consultant Pharmacist interviews, the facility failed to protect a resident's right to be free of misappropriation of controlled medications for 1 of 3 residents reviewed for misappropriation (Resident #28). The findings included: Resident #28 was admitted to the facility on [DATE]. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #28 was cognitively intact and received as needed pain medication during the assessment reference period. A physician order dated 08/05/24 read Oxycodone/Acetaminophen (controlled pain medication) 10/325 milligrams (mg) by mouth every 6 hours as needed. Review of a facility reported incident dated 09/11/24 read in part, it was brought to the attention of the facility that a card of narcotics was unaccounted for. The accused employee was listed as Medication Aide #1. The report was signed by the Assistant Director of Nursing (ADON). Medication Aide #2 was interviewed on 01/29/25 at 10:06 AM. She stated…

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. Resident #92 was admitted to the facility on [DATE] with diagnoses that included alcoholic cirrhosis of liver, chronic kidney disease, heart failure, and protein-calorie malnutrition. A review of Resident #92's weights were as follows: 7/18/2024- 191.6 pounds (lbs.) 8/13/2024- 183.0 lbs. 9/13/2024- 157.6 lbs. Review of Resident #92's most recent nutritional assessment dated [DATE] revealed the following statement: significant weight loss noted at 30 days, at 90 days, and at 180 days with weight trending down since admission. A review of Resident #92's quarterly Minimum Data Set assessment dated [DATE] revealed him to be cognitively impaired. He was coded as not having had any significant weight loss. Review of Resident #92's weights at the time the Minimum Data Set assessment was completed revealed he had a 16.04% weight loss from 7/2024 to 9/2024. During an interview with MDS Nurse on 01/30/25 at 4:02 PM he acknowledged that Resident #92's quarterly Minimum Data Set assessment from 12/21/24 was inaccurate…

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 staff interviews the facility failed to request a Preadmission Screening and Resident Review (PASARR) Level II evaluation for a resident with a new mental health diagnosis for 1 of 3 residents reviewed for PASARR (Resident #23). The findings include: A Preadmission Screening and Resident Review (PASARR) Level I evaluation was completed at the time of admission on [DATE] for Resident #23. Resident #23 was readmitted to the facility on [DATE] with diagnoses, in part, of Type 2 diabetes mellitus, vascular dementia, and cognitive communication disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #23 was cognitively intact. The Psychiatric Nurse Practitioner (NP) evaluated Resident #23 on 11/25/2024, 12/05/2024 and 12/20/24 and diagnosed her with depression. The NP continued the medication regimen of Doxepin (an antidepressant) and trazodone (an antidepressant), On 01/24/2025 the NP diagnosed Resident #23 with major depressive disorder and psychosis…

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, record reviews, and staff interviews, the facility failed to develop a person-centered comprehensive care plan that reflected the need for supervised visitation for 1 of 22 residents reviewed for care plans (Resident #4). The findings included: Resident #4 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was moderately cognitively impaired with no behaviors. Review of Resident #4's care plans revealed none that addressed supervised visits with a family member. Supervised Visits documentation for Resident #4 revealed the family member had visited on 12/17/2024 at 1:00 pm with supervision for approximately 1 hour. Resident #4 had supervised visits on 1/14/2025 at 12:00 pm, 1/27/2025 at 1:00 pm, and on 2/4/2025 at 12:00 pm with her family member. An interview was conducted on 1/30/2025 at 9:59 am with the Social Worker (SW). The SW stated Resident #4 was placed on supervised visitation after Resident #4's family member was found…

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 reviews and staff, Resident Representative and Nurse Practitioner interviews, the facility failed to implement a treatment for an area of skin impairment for 1 of 4 residents (Resident #181) reviewed for pressure ulcers. The findings included: Resident #161 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD) requiring hemodialysis, diabetes mellitus, severe protein calorie malnutrition, dysphagia (difficulty swallowing) and cerebral infarction. Resident #161 discharged to the hospital on [DATE]. A review of Resident #161's care plan dated 05/16/24 indicated the Resident was at risk of pressure ulcers related to severe malnutrition, hemodialysis, impaired mobility due to cerebral vascular accident and dysphagia. The interventions included: follow the facility's policy regarding preventing/treating skin breakdown, informing caregivers of any new skin breakdown and monitor/document/report any changes in skin status to include appearance, color, would…

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, record reviews, and resident and staff interviews, the facility failed to provide incontinence care to a resident upon request (Resident #39) and failed to shave a dependent resident (Resident #27) for 2 of 5 dependent residents reviewed for activities of daily living (ADL). The findings included: 1. Resident #39 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident (CVA) and atrial fibrillation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39's cognition was severely impaired, and the Resident was dependent (helper does all the effort) for toileting. The MDS indicated Resident #39 was always incontinent of bladder and bowel. A review of Resident #39's care plan dated 10/29/24 revealed the Resident had bladder and bowel incontinence related to CVAs, history of urinary tract infections and impaired mobility. The goal was that the risk for urinary tract infections will be minimized/prevented through utilizing…

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, record review, and staff interviews, the facility failed to provide a physician ordered treatment for a resident (Resident #36) with a stage 2 (open sore or ruptured blister) pressure ulcer. The deficit practice was identified for 1 of 5 residents (Resident #36) reviewed for pressure ulcers. The findings included: Resident #36 was admitted to the facility on [DATE]. An annual minimum data set (MDS) dated [DATE] revealed Resident #36 was severely cognitively impaired with no behaviors or rejections of care. There was no pressure ulcers coded for Resident #36. A wound care note dated 1/24/2025, authored by the Wound Care Nurse, revealed Resident #36's high risk area to sacrum (area near the lower back/pelvis) was now a stage 2 (open sore or ruptured blister) pressure injury. There was not a cushion noted in Resident #36's wheelchair on 1/23/2025 when wound care was provided. Therapy provided a high-density foam cushion, and an air mattress overlay was placed on Resident #36's bed 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 observations, record reviews and interviews, the facility failed to secure an oxygen cylinder stored in a resident's bathroom and failed to ensure an oxygen vent was free from dust and debris for 2 of 2 residents reviewed for respiratory care (Resident #19 and #1). The findings included: 1. Resident #19 was admitted to the facility on [DATE] with diagnoses that included hypoxia (low oxygen saturation). A review of Resident #19's physician orders revealed an order dated 04/29/24 for supplemental oxygen at 2 liters per minute continuous for hypoxia. A review of Resident #19's care plan revised 09/18/24 revealed the need for oxygen related to hypoxia with the goal of having no signs or symptoms of poor oxygenation. The interventions included monitoring for signs and symptoms of respiratory distress and providing supplemental oxygen at the prescribed rate. Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was severely impaired and she had supplemental oxygen. 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 observations, record review, and staff interviews, the facility failed to ensure accurate medical records when a resident's sacral dressing was incorrectly documented as applied for 1 of 1 resident (Resident #36) reviewed for medical record accuracy. The findings included: Resident #36 was admitted to the facility on [DATE]. A wound care note dated 1/24/2025, authored by the Wound Care Nurse, revealed Resident #36's high risk area to sacrum (area near the lower back/pelvis) was now a stage 2 (open sore or ruptured blister) pressure injury. A physician's order dated 1/24/2025 revealed Resident #36 was ordered to have a foam dressing applied to her sacrum, placement checked daily, and dressing to be changed every 3 days or as needed. Review of the January 2025 Treatment Administration Record (TAR) revealed the Wound Care Nurse had documented Resident #36's foam dressing to sacrum as completed for dayshift on 1/29/2025. An observation was conducted on 1/29/2025 at 5:32 pm of Nurse #3 and Nurse Aide (NA)…

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 and staff interviews the facility failed to ensure bread was dated and not stored for use after the use by date in the dry storage area. This deficient practice had the potential to affect the food served to the residents. The findings included: During an observation of the dry storage area on 12/12/23 at 3:30 PM along with the Dietary Director the observation yielded 3 packs of 12 hotdog buns with a date of 12/10/23 and 3 packs of 12 hamburger buns that had no date printed on the packages. An interview was conducted with the Dietary Director at 3:40 PM on 12/12/23 who explained the hotdog buns should have been pulled from the shelves on the expiration date printed on the packages and there should have been a clarification date for the expiration date for the hamburger buns. The hamburger buns should not be used unless there was a known expiration date. During an interview with the Dietary Manager on 12/12/23 at 4:15 PM the Manager explained that he tried to check the expiration dates on the breads about every day and he missed the dates because he was not…

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, record reviews and interviews the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following a recertification and complaint survey dated 10/05/23. This was for two repeat deficiencies that were cited in the areas of F-804: Nutritive Value/Appearance/Palatable/Preferred Temp, and F-812: Food Procurement/Storage/Preparation/Serve/Sanitary that were originally cited during the recertification and complaint survey dated 10/05/23. The continued failure of the facility during 2 federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is crossed referenced to: F-804 Based on observations, record review, test trays, staff and resident interviews, the facility failed to provide meals that were palatable and appetizing in temperature and appearance for 2 meals served to 1 of 3 residents (Resident #1). The practice had the potential to affect other residents receiving meals from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, staff and resident interviews the facility failed to treat residents in a dignified manner when they served the resident's supper meals in Styrofoam containers for 2 of 3 residents reviewed for dignity (Resident #2 and Resident #3). The findings included: 1. Resident #2 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #2's cognition was moderately impaired. On 12/12/23 at 5:30 PM during an observation of the supper meal tray line in process of plating the food, [NAME] #1 obtained 7 black Styrofoam containers to utilize for the residents' meals to complete the plating process. An interview conducted with [NAME] #1 on 12/12/23 at 5:30 PM who explained that they often had to use the containers because they did not have enough plate covers to use for the meals. The [NAME] continued to explain that they normally had enough for breakfast but throughout the day they had to resort to the containers because 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 observations, record review, test trays, staff and resident interviews, the facility failed to provide meals that were palatable and appetizing in temperature and appearance for 2 meals served to 1 of 3 residents (Resident #1). The practice had the potential to affect other residents receiving meals from the kitchen. The findings included: Resident #1 was admitted to the facility 01/02/23. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #1 had moderately intact cognition. a. An observation and interview were conducted with Resident #1 on 12/12/23 at 11:00 AM. The Resident explained that the food was not good but some days it was better than others. The meat, especially chicken, was overcooked and tough and the pasta was not good. She stated the broccoli was always so overcooked and mushy that she informed the kitchen not to bring her broccoli anymore with her meals. The lunch meal served on 12/12/23 was roasted chicken thigh, mashed sweet potatoes, lima beans and pears. 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 staff interviews the facility failed to employ a qualified director of food and nutrition services with the competencies and skills required to carry out food and nutrition services for 88 of 88 residents. The findings included: An interview was conducted with the Dietary Manager on 10/04/23 at 12:04 PM and revealed that he had been employed by the facility for three months and was appointed the Dietary Manager position at the end of August 2023. He stated that the facility had sent him to a sister facility for three days for some training, but he had not gone through the certified dietary manager class and had no education in food and nutrition. The dietary manager stated that prior to working at the facility he worked in retail and again confirmed he had no educational training in food and nutrition. He added that the plan was to get him through the certified dietary manager program as well as serve safe certification but due to the staffing challenges in the dietary department he had been unable to attend either of those classes. The Registered Dietician (RD) was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to maintain the final rinse cycle of the high temperature dish machine according to manufacturer's recommendations, failed to remove expired food items from the dry goods storage area, failed to maintain a clean floor free from grease build-up and clean vent on the reach-in cooler and failed to keep the food preparation area free of chemicals and personal drinks. In addition, the facility failed to maintain the walk-in freezer free of ice build-up and failed to discard frozen food with signs of freezer burn. The facility also failed to ensure dietary staff wore hair coverings in the food preparation area. This deficient practice had the potential to affect the food served to residents. The facility census was 88 residents. The findings included: 1. The manufacturer recommendations for the high temperature dish machine read in part, operating temperature for high temperature sanitizing rinse cycle was 180 degrees Fahrenheit (F). An…

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 and staff interviews the facility failed to remove expired medications from 3 of 5 medications carts and 1 of 2 medication rooms observed for medication storage. The findings included: 1a. An observation of the 100/200 hall split medication cart was conducted on 10/03/23 at 10:58 AM along with Nurse #2. The observation revealed the following expired medications were on the cart and available for use: Aspart Insulin flex pen that was opened on 04/27/23 and Levothyroxine (used to treat thyroid issues) 88 micrograms (mcg) open bottle of 90 tablets that expired on 07/31/23. Nurse #2 was interviewed on 10/03/23 at 11:14 AM and confirmed that she was responsible for the 100/200 split medication cart. She stated that the insulin had been discontinued on 05/04/23 and just never pulled off the medication cart. Nurse #2 explained that the pharmacy had just been at the facility and gone through the medication cart and Nurse #2 thought the Unit Managers also went through the medication carts, but she could not say for sure. Nurse #2 added that she had gone through her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, test tray, and resident and staff interviews the facility failed to provide palatable food that was appetizing in appearance and temperature for 4 of 6 residents reviewed with food concerns (Resident #3, Resident #8, Resident #18, and Resident #76). The findings included: 1a. Resident #3 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #3 was moderately cognitively impaired and required supervision with eating. An observation and interview were conducted with Resident #3 on 10/04/23 at 2:43 PM. Resident #3 lunch tray sat in front of her with approximately 25% of the meal gone. Resident #3 stated that she had eaten what she could eat because the chicken alfredo was cold and dry and had one small piece of chicken in it and the asparagus was also cold. She did say that she was able to eat the top portion of the asparagus stalks but that was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff and resident interviews the facility failed to provide a dependent resident with his choice of showers for 1 of 2 residents (Resident #145) reviewed for providing assistance with activities of daily living. The finding included: Resident #145 was admitted to the facility on [DATE] with diagnoses that included heart failure and diabetes mellitus. A review of the nursing admission assessment dated [DATE] revealed that Resident #145 was alert. A review of the facility's shower schedule indicated Resident #145 was scheduled to receive showers on Tuesday and Friday on evening shift. A review of Resident #145's shower/bathing record since his admission on [DATE] revealed documentation of morning and evening wash ups and two occasions of bed baths given. There were no showers documented for Resident #145. During an interview and observation of Resident #145 on 10/02/23 at 2:14 PM the Resident was sitting in his wheelchair at his bedside. He was dressed in street clothes…

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, record reviews and interviews the facility failed to post cautionary and safety signs that indicated the use of oxygen for 2 of 2 residents reviewed for respiratory care (Resident #46 and #145). Findings included: 1. Resident #46 was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease and respiratory failure. A review of Resident #46's physician order dated 05/19/23 indicated oxygen at 2 liters continuously by nasal cannula. The quarterly Minimum Data assessment dated [DATE] indicated Resident #46 was cognitively intact and used supplemental oxygen. On 10/02/23 at 12:33 PM an observation was made of Resident #46 wearing oxygen via nasal cannula at 3 liters per minute. There was no warning sign posted on the outside of the door or door frame to indicate oxygen was in use. A subsequent observation on 10/03/23 at 9:43 AM revealed Resident #46 wore oxygen via nasal cannula at 2 liters per minute. There was no warning sign posted on the outside…

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.