Wickliffe Country Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review, and review of facility policy revealed the facility failed to implement fall interventions as identified in the resident's plan of care. This affected one resident (#32) of four residents reviewed for falls and/ or accidents. The facility census was 126. Findings included: Review of medical record for Resident #32 revealed an admission date of 12/02/22 and diagnoses included schizophrenia, diabetes, moderate protein-calorie malnutrition, and hypertension. Review of care plan dated 07/08/24 revealed Resident #32 was at risk for falls due to impaired mobility, generalized weakness, Schizophrenia, and neuropathy. Interventions included assist with transfers, locomotion and mobility, grab bar to bed, commonly used items within easy reach, and protective floor mat next to bed that was added on 08/29/24. Review of the care plan dated 07/08/24 revealed Resident #32 had a self-care performance deficit related to impaired mobility, generalized weakness, and neuropathy.…

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, observation, record review, and review of facility policies the facility did not ensure weights were obtained and monitored timely. This affected two residents (#16 and #32) of seven residents reviewed for nutrition. The facility census was 126. Findings included: 1. Review of medical record for Resident #32 revealed an admission date of 12/02/22 and diagnoses included Schizophrenia, diabetes, moderate protein-calorie malnutrition, and dysphagia. She had a legal guardian. There was no documentation in the medical record regarding the physician, and legal guardian was notified of Resident #32's significant weight loss of 17.1 percent from 02/01/24 to 05/08/24. Review of weight record for Resident #32 from 01/08/24 to 09/24/24 revealed she had the following weights: 01/08/24 her weight was 197.6 pounds, 01/30/24 her weight was 202.3 pounds, 02/01/24 her weight was 193 pounds, and 05/08/24 her weight was 160 pounds which indicated a 17.1 percent significant weight loss. The weight record also…

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, observation, record review, and review of facility policy the facility failed to ensure Resident #108's enteral tube feeding (a method of providing nutrition to patients who are unable to eat or drink safely by mouth) was infusing at the correct rate per physician order. This affected one resident (#108) of two residents reviewed for tube feeding. Findings included: Review of the medical record for Resident #108 revealed an admission date of 12/08/23 and diagnoses included heart failure, diabetes, cerebral infarction, and protein-calorie malnutrition. Review of care plan dated 12/08/23 revealed Resident #108 had a feeding tube to assist in maintaining or improving nutritional status related to cerebral infarction, and difficulty swallowing. Interventions included tube feeding per dietary recommendation and physician order, check placement of feeding tube, keep head of bed elevated and monitor for complications. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #108 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.

Based on interview, observation, policy review and review of the medical record revealed the facility failed to ensure enteral feedings were labeled and dated appropriately. This affected one resident (#93) of two residents reviewed for enteral feedings. The facility census was 126. Findings include: Review of the medical record for Resident #93 revealed an admission date of 10/06/22. Diagnoses included but were not limited to encephalopathy, gastrostomy, dysphagia, and history of transient ischemia attack (TIAs). Review of the 09/02/24 annual Minimum Data Set (MDS) 3.0 for Resident #93 revealed a Brief Interview for Mental Status (BIMS) revealed severe cognitive impairment. Resident #93 and was dependent for all Activities of daily living (ADLs) and received a tube feeding. Review of physician orders dated 11/10/23 for Resident #93 revealed an order to change enteral feeding bag and syringe every night shift for routine care and label with date. Review of physician orders dated 09/01/24 for Resident #93 revealed an order for Isosource 1.5 calorie enteral feed at 50 milliliters (mL)…

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, observation, record review and review of facility policy revealed the facility failed to ensure enhanced barrier precautions were utilized for a resident during high contact resident care. This affected one resident (#108) of two residents observed for enhanced barrier precautions. Findings included: Review of the medical record for Resident #108 revealed an admission date of 12/08/23 and diagnoses included heart failure, diabetes, cerebral infarction, and protein-calorie malnutrition. Review of care plan dated 12/08/23 revealed Resident #108 had a feeding tube to assist in maintaining or improving nutritional status related to cerebral infarction, and difficulty swallowing. Interventions included enhanced barrier precautions with high contact care including using a gown and gloves for dressing change and tube feeding care, check placement of feeding tube, keep head of bed elevated and monitor for complications. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, menu spreadsheet review, and policy review the facility failed to serve palatable meals at appetizing temperatures. This affected 117 residents receiving meals from the kitchen as two residents (#67 and #108) were ordered nothing-by-mouth (NPO). The facility census was 119. Findings include: Review of a menu for week two, Tuesday corresponding to 03/26/24 revealed the following for the lunch meal: barbeque pork shoulder, tater tots, coleslaw, biscuit, and a spiced pear bar. Interview on 03/25/24 at 10:20 A.M. with Resident #116 revealed food was terrible, did not taste good, and was often cold. Interview on 03/25/24 at 10:32 A.M. with Resident #68 revealed the food sometimes was not warm. Interview on 03/25/24 at 10:42 A.M. with Resident #5 revealed the food was sometimes cold. Observation of the lunch meal on 03/26/24 starting at 11:30 A.M. revealed [NAME] #414 took temperatures of the foods to be served with the facility's self-calibrating electronic thermometer as follows:…

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 have sufficient staff to provide the necessary care and services including restorative nursing, getting assistance to bed per preference and timely manner, timely incontinence care, showers per schedule and preference, changing of clothing, and meeting the minimum daily staffing requirement of 2.50 hours per resident. This had the potential to affect all 137 residents residing in the facility. Findings include: 1. Review of the staffing tool with Scheduler/ State Tested Nursing Assistant (STNA) #725 on 09/22/22 at 11:57 A.M. revealed the facility did not meet the minimum daily staffing requirement of 2.50. On 09/18/22 the facility had 2.42 hours of direct care staff per resident. Interview on 09/22/22 at 11:57 A.M. with Scheduler/ STNA #725 verified on 09/18/22 there was 2.42 hours of direct care staff per resident. She revealed there were several call offs on 09/18/22, and they were unable to cover all the call offs to meet the daily…

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 interviews, the facility failed to serve hot and palatable foods. This had the potential to affect all 132 residents receiving food from the facility kitchen. Five (Resident's #25, #48, #38, #50, and #127) did not receive food from the facility. The facility census was 137. Findings include: Interview with Resident #67 on 09/19/22 at 12:57 P.M. revealed the food was usually not hot. Sometimes the facility used plates and sometimes the facility used Styrofoam. Interview with Resident #441 on 09/19/22 at 12:08 P.M. revealed the food was often cold, and there was not anything I would eat at home. Interview with Resident #71 on 09/19/22 at 12:43 P.M. revealed the food was cold sometimes. Interview with Resident #1 on 09/19/22 at 1:24 P.M. revealed the food was often cold. Interview with Resident #72 on 09/19/22 at 3:11 P.M. revealed the food was cold. Interview with Resident #27 on 09/19/22 at 4:51 P.M. revealed the food was terrible and never hot when it arrives to the 300-hall. Interview with Resident #12 on 09/20/22 at 8:42 A.M. revealed the food was bad,…

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, record review, and facility policy review the facility failed to provide consistent and timely assistance with activities of daily living (ADL) for incontinence care and showers. This affected four (Resident's #17, #116, #441 and #453) of eight residents reviewed for ADL. The facility census was 137. Finding included: 1. Review of the medical record for Resident #116 revealed an admission date of 10/23/17 with diagnoses including cervical disc disorder, polyneuropathy, contracture right and left knee, and contractures of the right and left hip. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #116 had intact cognition. The resident required the extensive assistance of two staff for bed mobility and dressing. The resident was totally dependent on two staff for transfers, toilet use, and personal hygiene and required the extensive assistance of one staff for locomotion and eating. Interview on 09/20/22 at 8:51 A.M. Resident #116 stated she…

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, record review, review of Centers for Disease Prevention and Control (CDC) guidance, and review of the facility policy the facility failed to ensure two (Resident's #1 and #450) were placed on contact precautions timely. The facility failed to ensure appropriate hand hygiene during and after care the of one (Resident #1) who was on contact precautions. The facility failed to ensure tuberculin screening tests were administered and read within the required time frame for two (Resident's #3 and #453). This affected two (Resident's #1 and #450) of three residents reviewed for transmission-based precautions, one (Resident #1) of three residents reviewed for hand hygiene, and two (Resident's #3 and #453) of five reviewed for tuberculin screening. The facility census was 137. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 05/24/22 with diagnoses including encounter for surgical aftercare following surgery on the digestive system, unspecified…

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, observation, record review, and facility policy review the facility failed to ensure water temperatures were maintained in a safe manner at or below 120 degrees Fahrenheit (F). This affected eight residents (Resident's #12, #15, #20, #45, #95 #109, #116 and #136) and had the potential to affect 101 residents who resided on the 100, 200, 300, and 500 halls (Resident's #1, #2, #3, #4, #5, #6, #7, #9 #12, #13, #15, #16, #17, #20, #21, #25, #27, #30, #31, #33, #35, #37, #38 #41, #43, #44, #45 #47, #48, #49, #51, #52, #54, #55, #57, #59, #60, #61, #62, #63, #65, #66, #67, #68, #89, #70 #71, #72, #73, #74, #75, #77, #79, #80, #82, #86, #87, #93, #95, #96, #97, #99, #102, #104, #106, #108, #109, #111, #114, #116, #117, #118, #119, #121, #123, #125, #127, #130, #131, #133, #134, #135, #136, #139, #140, #391, #392, #442, #443, #444, #445, #446, #447, #448, #449, #450, #451, #452, #453, #454 and #455) reviewed for physical environment. The facility census was 137. Findings included: Review of the facility form labeled Logbook Documentation: Water Temperature, dated from…

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 neglect did not occur. This affected two (Resident's #452 and #453) of three residents reviewed for neglect. The facility census was 137. Findings include: 1. Review of Resident #453's medical record revealed an admission date of 09/06/22 with diagnoses including cellulitis of the right and left lower limbs, heart failure, type two diabetes mellitus with diabetic neuropathy, and morbid obesity. Review of Resident #453's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #453 was cognitively intact and required extensive assistance of two staff for bed mobility, transfers, and toilet use. Resident #453 was always incontinent of urine and frequently incontinent of bowel. Review of Resident #453's care plan dated 09/07/22 included Resident #453 was a fall risk characterized by impaired balance, impaired mobility, incontinence, and cellulitis to lower extremities. The goal was to prevent, minimize fall…

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, record review, and facility policy review the facility failed to implement a care plan intervention after a fall for Resident #122. This affected one (Resident #122) of two Resident #62 and Resident #122) reviewed for accuracy of care plan fall interventions. The facility census was 137. Findings include: Review of the medical record for Resident #122 revealed an admission date of 09/05/18 with diagnoses including diabetes, chronic obstructive pulmonary disease, hypertension, congestive heart failure, and history of falling. Review of the care plan dated 11/3/21 revealed Resident #122 was a fall risk related to impaired mobility, unstable health conditions, unsteady gait, weakness from chronic obstructive pulmonary disease, and history of falls. Interventions included analyze previous resident falls to determine whether pattern, bariatric bed, bed in low position, and reinforce need to call for assistance. The care plan revealed on 08/10/22 the facility implemented an intervention 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 interview, observation, record review, and facility policy review the facility did not ensure Resident's #10 and #116 received their restorative programs per recommendation. This affected two (Resident's #10 and #116) of two (Resident's #10, and #116) reviewed for restorative nursing programs. This had the potential to affect 38 (Resident's #5, #10, #12, #14, #15, #16, #22, #23, #25, #28, #32, #35, #39, #40, #42, #43, #45, #51, #52, #53, #56, #59, #60, #64, #65, #70, #80, #87, #89, #99, #104, #106, #112, #116, #117, #121, #122, and #126) who received a restorative nursing programs. The facility census was 137. Findings included: 1. Review of the medical record for Resident #10 revealed an admission date of 11/23/20 with diagnoses including chronic kidney disease, diabetes, dementia, asthma, and major depression. Review of the care plan dated 02/12/21 revealed Resident #10 had a restorative nursing program due to impaired physical mobility in locomotion related to activity intolerance and weakness.…

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 ensure Resident #45 had orders in place to receive appropriate indwelling catheter care. This affected one (Resident #45) of three residents reviewed for indwelling catheter care orders. The facility census was 137. Findings include: Review of the medical record for Resident #45 revealed an admission date of 11/04/21 wit diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dementia, benign prostatic hyperplasia, and neuromuscular dysfunction of bladder. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 was cognitively intact and required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS revealed Resident #45 had an indwelling urinary catheter. Review of the September 2022 physician orders for Resident #45 revealed there were no active orders for Resident #45's indwelling catheter care. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to ensure two (Resident's #136 and #450) were administered oxygen as ordered by the physician. This affected two (Resident's #136 and #450) of seven residents reviewed for oxygen administration. The facility census was 137. Findings include: 1. Review of Resident #136's medical record revealed an admission date of 08/30/22 with diagnoses including acute respiratory failure with hypoxia, malignant neoplasm of ascending colon, and end stage renal disease. Review of Resident #136's oxygen saturations summary in the medical record from 09/05/22 through 09/19/22 revealed Resident #136 had oxygen via nasal cannula, and her oxygen saturations ranged from 95 to 100 percent. Review of Resident #136's physician orders from 09/05/22 through 09/19/22 did not reveal orders for oxygen administration. Review of Resident #136's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #136 was cognitively intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review the facility failed to complete dialysis assessments before and after dialysis and send a dialysis communication form to dialysis. This affected one (Resident #93) of one resident reviewed for dialysis. This had the potential to affect 17 additional residents (Resident #2, #6, #26, #31, #35, #54, #74, #82, #84, #87, #111, #119, #133, #134, #139, #443, and #446) who received dialysis. The facility census was 137. Findings include: Review of the medical record for Resident #93 revealed an admission date of 08/05/22 with diagnoses including end stage renal failure, dependence on renal dialysis, spinal stenosis, major depression, and muscle weakness. Review of the physician orders for August 2022 and September 2022 revealed Resident #93 received dialysis three times a week on Monday, Wednesday, and Friday in house, and had a physician order dated 08/10/22 to complete and lock dialysis assessment and dialysis communication forms before and after dialysis.…

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, record review, and review of facility training the facility failed to ensure appropriate supervision for one resident with dementia. This affected one (Resident #455) of three residents reviewed for supervision. The facility census was 137. Findings include: Review of Resident #455's medical record revealed an admission date of 09/14/22 with diagnoses including Alzheimer's disease with late onset, dementia, and delusional disorders. Review of Resident #455's admission assessment dated [DATE] included Resident #455 had cognitive impairment with poor decision-making skills. The resident displayed the following behaviors: easily distracted, periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy, mental function varies over the course of the day, wanders, abusive, and resistant to care. Resident #455 verbally expressed a desire to go home. Resident #455 ambulated without problem and with devices 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, record review, and interview the facility failed to maintain the nursing unit refrigerators and microwaves in a clean and sanitary condition. This had the potential to affect all residents except Residents #136 and #17, who received nothing by mouth. Findings include: Observations of the nursing unit refrigerators on 09/23/19 from 9:40 A.M. to 10:00 A.M. with Food Service Director (FSD) #500 revealed the A wing nursing unit freezer had various spills. The B wing nursing unit refrigerator contained a small green bowl with a white plastic lid with no label or date, a carton of nectar thickened cranberry juice without a top and handwritten date of 9/15 on the side of the container. Both the freezer and refrigerator had various food spills. The C wing nursing unit refrigerator had a clear plastic container of what appeared to be apple juice without a lid, label, or date. The D wing nursing unit freezer had a brown colored splatter on the back wall of freezer and on the bottom shelf. The refrigerator also had other various food splatters. The E wing nursing unit…

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 use alcohol-based hand sanitizer within dispensers mounted in resident rooms and resident care areas throughout the facility, ensure contact precautions were maintained, and ensure contaminated dressings were handled in a manner to prevent the spread of infection. This had the potential to affect all 150 residents residing within the facility. Findings include: 1. During tour of medication storage rooms on 09/24/19 between 2:29 P.M. and 2:57 P.M., five hand sanitizer dispensers were observed mounted within resident care areas outside the medication storage rooms, and were observed to contain hand sanitizer gel labeled no alcohol. Review of Centers for Disease Control Guidelines for Healthcare Providers for Hand Hygiene, located at https://www.cdc.gov/handhygiene/providers/index.html, last reviewed 04/29/19, revealed alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare…

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 mechanical soft meat was prepared to the appropriate consistency. This had the potential to affect 36 of 36 residents who received mechanical soft diets (Residents #102, #40, #202, #21, #71, #76, #41, #89, #87, #68, #91, #75, #70, #109, #20, #11, #150, #143, #33, #83, #57, #47, #122, #14, #43, #154, #8, #53, #121, #51, #101, #131, #208, #4, #38, #206) and 36 of 148 residents who ate meals prepared in the kitchen. Residents #136 and #17 received nothing by mouth. Findings include: Observation on 09/24/19 from 4:30 P.M. to 4:35 P.M. of tray line with Dietary [NAME] (DC) #806 revealed the mechanical soft meat appeared to be chopped chicken roast. Review of the menu extension sheet revealed the chicken roast should have been ground. DC #806 stated the chicken came chopped up and he just chopped it up more with a spoon. At this time Dietary Manager (DM) #804 verified on the menu extension the chicken roast should be ground. Interview on 09/24/19 at 4:45 P.M. with Registered Dietitian (RD) #805 confirmed 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 interview and record review the facility failed to provide an individualized activity plan and activities for Resident #149. This affected one of three residents (Resident #25, Resident #107 and Resident #149) reviewed for activities. The census was 150. Findings include: Review of the medical record revealed Resident #149 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, unspecified visual loss and end stage renal disease with dependence on dialysis. Review of the 5-day minimum data set (MDS) assessment dated [DATE] revealed the resident required extensive two-person assist for bed mobility, transfers, dressing, eating and personal hygiene. The resident was totally dependent on staff for locomotion and toilet use. The brief interview mental status (BIMS) score of 04 indicated severe cognitive impairment. A care plan, dated 08/09/19 and revised 08/25/19, relative to activities revealed generic interventions including: the resident will express satisfaction with type 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.