Emerald Care Center Southwest LLC

Based on observation, record review, and interview, the facility failed to ensure: a. hair nets were worn appropriately; b. the kitchen was kept clean and maintained in good repair; c. food items were labeled, dated, and stored according to facility policy; and d. hand washing and glove usage were appropriate. The DON identified 60 residents ate from the kitchen. Findings: A Preventing Foodborne Illness-Employee Hygiene and Sanitary policy, dated 3/20/24, documented food and nutrition service employees would follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. It doucumented employees were to wash their hands after handling soiled equipment or utensils, during food preparation, and as often as necessary to prevent cross contamination when changing tasks. It documented hair nets or caps and/or beard restraints were to be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. A Food Receiving and Storage policy, revised 3/20/24, documented all foods were to be covered, labeled, and dated. On 12/09/24 at 8:40…

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

Based on record review and interview, the facility failed to follow the antibiotic stewardship policy by ensuring a standardized tool for initiation of antibiotics was completed for the treatment of UTI's for one (#37) of three sampled residents reviewed for UTI's. The administrator identified 64 residents resided in the facility. Findings: A Antibiotic Stewardship Policy, dated 01/2024, read in part, The facility will track antibiotic use once ordered. The policy also read, The facility will utilize McGeer and or LOEB Criteria, a practical guide to use in nursing homes. Resident #37 had diagnoses which included congenital occlusion of ureteopelvic junction, hydronephrosis, obstructive and reflux uropathy, crossing vessel, and stricture of ureter. Resident #37's care plan, updated 04/06/24, documented the resident had a nephrostomy tube. The focus documented the resident would have no signs or symptoms of a urinary infection. A physician's order, dated 05/30/24, documented to give Macrobid (antibiotic medication) 100 mg two times a day for UTI for five days. Completed on 06/04/24. A…

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

Based on record review and interview, the facility failed to provide documentation pneumococcal vaccines were offered and/or administered for two (#37 and #216) of five sampled residents reviewed for immunizations. The administrator identified 64 residents resided in the facility. Findings: An Infection Control Immunizations policy, dated 3/20/24, read in part, all residents will be offered pneumococcal vaccines. Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission. A review of Resident #37's immunization record did not document the resident had received or been offered a pneumococcal vaccination. A review of Resident #216's immunization record did not document the resident had received or been offered a pneumococcal vaccination. On 12/12/24 at 10:57 a.m., LPN #1 stated they did not know how the vaccines got ordered, but if an order pops up we did it. They stated they did not skip the vaccinations if they were ordered to be done on their shift. On 12/12/24 at 11:01 a.m., the DON stated on admission, they were to…

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

Based on observation, record review, and interview, the facility failed to maintain effective pest control. The administrator identified 64 residents resided in the facility. Findings: A Pest Control Program policy, dated 11/17/24, read in part, Facility will maintain an effective pest control program that eradicates and contains common household pests. On 12/09/24 at 8:44 a.m., upon initial tour of the kitchen multiple mouse droppings were observed across the tops of four boxes of baking soda in the dry storage area. On 12/09/24 at 8:49 a.m., the dietary manager denied knowing what the mouse droppings were, but stated it was not something that needed to be there. They then threw four boxes of baking soda away. On 12/09/24 at 11:04 a.m., a cockroach was observed crawling on Resident #216's hand and prosthetic leg while sitting in the dining room. On 12/10/24 at 2:01 p.m., housekeeper/CNA #1 stated every once in a while, you see a roach. I know they have someone out for that pretty frequently. On 12/10/24 at 2:03 p.m., CNA #1 stated they had seen roaches and bedbugs. They spray and…

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

Based on record review and interview, the facility failed to ensure residents were free from abuse for one (#2) of two sampled residents reviewed for abuse. The DON identified 58 residents resided in the facility. Findings: The Abuse, Neglect and Exploitation policy, dated 11/17, read in part, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy also read, .Physical Abuse includes, but not limited to hitting, slapping, pinching and kicking. Resident #2 had diagnoses which included other specified depressive episodes. An Initial State Reportable Incident form, dated 07/10/24, documented an allegation of abuse/mistreatment. It was documented Resident #2 was noted standing outside of the BOM doorway yelling [gender withheld] slapped me. It was documented Resident #2 was escorted out of the hallway. It was documented the BOM suspended was immediately pending investigation. A Final State Reportable Incident form, dated 07/29/24, documented an allegation of abuse/mistreatment. It was documented Resident #2 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.

Based on record review and interview, the facility failed to ensure medications were administered as ordered for one (#10) of three sampled residents reviewed for misappropriation of property. The DON identified 58 residents resided in the facility. Findings: The Medication Administration and General Guidelines policy, dated 2021, read in part, Medications are administered in accordance with written orders of the attending physician. Resident #10 had diagnoses which included pain. A physician's order, dated 08/07/24, documented oxycodone HCL (narcotic medication) oral tablet 15 mg give 0.5 tablet via peg tube every four hours for pain. The September 2024 TAR documented a nine on the following days and times; a. 09/03/24 at 8:00 p.m., b. 09/06/24 at 12:00 a.m., 4:00 a.m., 8:00 p.m., and c. 09/24/24 at 4:00 a.m., 8:00 a.m. The September 2024 TAR documented blanks on the following days and times; a. 09/10/24 at 8:00 p.m., and b. 09/24/24 at 4:00 p.m. The September 2024 TAR documented a six on 09/13/24 at 4:00 p.m. A progress note, dated 09/24/24 at 2:02 p.m., documented oxycodone HCL…

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 provide ulcer care as ordered by the physician for two (#1 and #3) of three residents sampled for ulcer care. LPN #1 identified 61 residents resided in the facility. Findings: The Wound Care LPN identified 13 residents received wound care in the facility. 1. Resident #1 admitted to the facility on [DATE] with diagnosis which included non pressure chronic ulcer with unspecified severity (back and right thigh). A Physician's Order, dated 05/25/24, documented, Hibiclens External Solution (Chlorhexidine Gluconate) Apply to back and thighs topically every day shift for use with each dressing change. A May 2024 TAR, had no documentation on 05/26/24 and 05/30/24 for the above treatment. A June 2024 TAR, had no documentation on 06/09/24 for the above treatment. A Physician's Order, dated 05/25/24, read in part, Non-pressure wound of the right flan: cleanse with hibiclense, pat dry, apply calcium alginate sprinkled with collagen powder, cover 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 ensure ADL assistance was provided in a timely manner for one (#7) of four resident call lights observed for staff assistance in a timely manner. The administrator identified 51 residents resided in the facility. Findings: The Call Lights: Accessibility and Timely Response-Physical Environment policy, dated 01/24, read in part, .All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified . A Nursing admission Data Collection dated 05/16/24, documented Resident #7 had functional limitation on both lower extremities and they required one person substantial max assist for bed mobility. On 05/17/24 at 5:23 a.m., two call lights were observed on hall 200. On 05/17/24 at 5:41 a.m., LPN #2 and RN #1 were observed at the nurse's station while the call lights were on. Both call lights on hall 200 were not answered at this time. On 05/17/24 at 5:46 a.m., LPN #2 answered one of the call lights on hall…

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 administer pain and nausea medication as ordered in a timely manner for one (#6) of three sampled residents reviewed for medication administration. The Administrator identified 65 residents resided in the facility. A Medication Administration and General Guidelines policy, read in part, Medications are administered in accordance with written orders of the attending physician. A physician's order dated 05/13/24, documented Norco 10-325 mg every 6 hours as needed for pain. A physician's order dated 05/13/24, documented Ondansetron 4 mg every 6 hours as needed for n/v. Review of Resident #6 MAR did not document the administration of prn pain nor nausea medications. Resident #5 had diagnosis which included senile degeneration of the brain and dysphagia. On 05/17/24 at 5:46 a.m., Resident #6 was observed during incontinent care to slightly moan when moved and to vomit at the end of care. On 05/17/24 at 5:49 a.m., the residents roommate, Resident #5, whom was also the residents family representative, requested CNA…

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

Based on record review and interview, the facility failed to provide pressure ulcer treatment as ordered for three (#3, 5, and #8) of three sampled residents reviewed for pressure ulcers. The Resident Matrix, dated 02/01/24, documented two residents had pressure ulcers in the facility. Findings: 1. Resident #3 had diagnoses which included stage four sacrum wound and intestinal obstruction. A physician's order, dated 11/08/23, documented cleanse sacrum with normal saline, pat dry, apply santyl and calcium alginate, cover with boarded foam dressing every shift. The November 2023 TAR documented blanks for Resident #3's wound care for the day shift treatment on the 21st, 22nd, and 23rd. The November 2023 TAR documented blanks for Resident #3's wound care for the night shift treatment on the 10th. The December 2023 TAR documented blanks for Resident #3's wound care for the day shift treatment on the 17th and 19th. The December 2023 TAR documented blanks for Resident #3's wound care for the night shift treatment on the 13th, 14th, 18th, and 20th. On 02/05/23 at 12:09 p.m., the Wound Care…

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

Based on record review and interview, the facility failed to ensure medications were administered as ordered for two (#5 and #8) of three sampled residents reviewed for medication administration. The Resident Matrix, dated 02/01/24, documented 73 residents resided in the facility. Findings: A Medication Administration and General Guidelines policy, dated 2021, read in part, .Medications are administered as prescribed .Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications .The resident's MAR is initialed by the person administering a medication, in the space provided .Or if using Electronic Medical Record, the initials of the nurse are electronically stamped into the record . 1. Resident #5 had diagnoses which included a stage four pressure wound of the sacrum and GERD. A Physician Order, dated 08/18/23, documented hydrocodone-acetaminophen oral tablet 5-325 mg give 5mg via PEG-Tube every eight hours for pain. A Physician Order, dated 10/23/23, documented…

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

Based on observation, record review and interview, the facility failed to ensure medications were not stored at a resident's bedside for one (#8) of three sampled residents reviewed for medication administration. The Resident Matrix, dated 02/01/24, documented 73 residents resided in the facility. The Administrator identified no residents in the facility with orders for bedside medications. Findings: A Self- Administration of Medications by Residents policy, dated 2021, read in part, .If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety for bedside medication storage is conducted .The following conditions are met for bedside storage to occur .The manner of storage prevents access by other residents .The medications provided to the resident for bedside storage are kept in the containers dispensed by [Pharmacy name deleted] . Resident #8 had diagnoses which included constipation. On 02/02/24 at 10:05 a.m., Resident #8 stated they had their family member bring them in Ex-Lax and a stool softener. The resident was observed…

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

Based on record review and interview, the facility failed to obtain a physician ordered urinalysis for one (#3) of three sampled residents reviewed for a change in condition. The Resident Matrix, dated 02/01/24, documented 73 residents resided in the facility. Findings: The Laboratory Services and Reporting policy, dated 11/17, read in part, .The facility must provide or obtain laboratory services when ordered by a physician .nurse practitioner . Resident #3 had diagnoses which included stage four sacrum wound and intestinal obstruction. A physician's order, dated 12/20/23, documented urinalysis. There was no documentation a urinalysis was obtained. On 02/05/23 at 11:13 a.m., the ADON stated if the urinalysis order was on the order form from the physician's liaison during rounds, they would not know if a urinalysis was ordered or to obtain. The ADON stated they put in the orders prescribed on the order form in the Resident's medical records. On 02/05/23 at 11:37 a.m., the DON provided the physician's order form dated 12/20/23 for Resident #3. The order documented to obtain a…

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

Based on observation, record review, and interview, the facility failed to ensure adequate portion sizes were offered to residents for one of one meal service observed. The DON identified 69 residents received services from the kitchen in the facility. Findings: The Menus and Adequate Nutrition policy, dated 11/17, read in part, .The facility will ensure that menus .be followed . A Diet Spreadsheet, dated 2019, for lunch documented, a. beef stroganoff over egg noodles 6 oz spoodle / 4 oz spoodle noodles, b. baby carrots 4 oz spoodle, c. broccoli 4 oz spoodle, and d. one slice garlic toast. The CDM identified the above menu as scheduled to be served for lunch on 02/02/24. On 02/02/24 at 11:45 a.m., the CDM plated six plates with one grey scoop of beef stroganoff, one spoodle of baby carrots, one spoodle of broccoli, and one slice of bread. On 02/02/24 at 11:49 a.m., the CDM stated the grey scoop was a number eight. The CDM stated the residents were getting more serving size with the number eight. On 02/02/24 at 11:52 a.m., the CDM reviewed the extended menu and scoop sizes. They…

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

Based on record review and interview, the facility failed to ensure wound care treatment was accurately documented for one (#8) of three sampled residents reviewed for pressure ulcers. The Resident Matrix, dated 02/01/24, documented two residents with pressure ulcers resided in the facility. Findings: Resident #8 had diagnoses which included pressure ulcer of sacral region stage four. A Physician Order, dated 10/28/23, documented cleanse sacral wound with normal saline, pat dry, apply Dakin's soaked gauze, cover with a silicone border dressing daily every day shift. The December 2023 MAR was blank for the sacral wound care on 12/21/23 and 12/25/23. The January 2024 MAR was blank for the sacral wound care on 01/22/24. On 02/05/24 at 1:50 p.m., the Wound Care Nurse stated they had worked at the facility on 12/21/23, 12/25/23, and 01/22/24. They stated every day they worked at the facility, they completed wound care. They stated they got pulled to do other things in the facility. They stated they completed the wound care but failed to document it.

Based on record review and interview, the facility failed to notify the physician when: a. a resident's FSBS was out of range and when they administered glucagon for one (#44); b. a resident refused insulin administration for one (#44); c. a resident's routine insulin was held for one (#44); and d. a resident experienced a fall for one (#29) of 16 sampled residents reviewed for physician notification. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility. The facility Resident Matrix, dated 08/14/23, documented 23 residents who received insulin resided in the facility. Findings: A Medications Administration and General Guidelines policy, undated, read in parts, .If a dose of regularly scheduled medication is withheld, refused .The physician must be notified when a dose of medication has not been given . 1. Resident #44 had diagnoses which included type one diabetes mellitus with diabetic chronic kidney disease, type one diabetes mellitus with ketoacidosis with coma, and hypertension. A Physician Order, dated 05/18/23,…

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

Based on record review and interview, the facility failed to: a. intervene per physician's order when a resident's FSBS was out of range; and b. monitor blood pressure for a resident who received two medications to treat blood pressure and who received renal dialysis for one (#44) of eight sampled residents reviewed for medications administered as ordered. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility. The facility Resident Matrix, dated 08/14/23, documented 23 residents who received insulin resided in the facility. Findings: A Medications Administration and General Guidelines policy, undated, read in parts, .Medications are administered as prescribed .Or if utilizing an Electronic Medical Record, the initials of the nurse are electronically stamped onto the record . Resident #44 had diagnoses which included type one diabetes mellitus with diabetic chronic kidney disease, type one diabetes mellitus with ketoacidosis with coma, and hypertension. A discontinued Physician Order, dated 01/14/23, documented the…

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

Based on observation, record review, and interview, the facility failed to provide pressure ulcer treatment as ordered for one (#7) of three sampled residents reviewed for pressure ulcers. The Resident Census and Conditions of Resident report, dated 08/14/23, documented three residents with pressure ulcers, excluding stage one, resided in the facility. Findings: Resident #7 had diagnoses which included a stage four pressure wound of the sacrum. A Physician Order, dated 06/27/23, documented sacrum: cleanse with Dakins 0.125 percent, pat dry, lightly pack with Dakins soaked gauze, cover with four by four/ABD pad, then secure with medical tape two times a day for wound care. The July 2023 TAR documented blanks for Resident #7's wound care for the 7:00 a.m. to 11:00 a.m. treatment on the 6th, 7th, 8th, 13th, 15th, 27th, 28th, 29th, and 30th. Wound Physician Notes, dated 07/14/23 and 07/27/23, documented Resident #7 had a stage four pressure wound of the sacrum. It documented the dressing treatment plan primary dressing Dakins 0.025 percent solution apply twice daily. It documented…

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

Based on observation, record review, and interview, the facility failed to ensure: a. a tube feeding bag administering nutrition and hydration contained the date, time, and name of the staff who hung the feeding for administration for one (#29); b. a resident was provided tube feedings as ordered by the physician for one (#44); c. staff documented by mouth intake for a resident who had tube feeding orders for by mouth intake of less than 50 percent for one (#44); and d. tube feeding water flush order was implemented for one (#53) of four sampled residents reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 08/14/23, documented five residents who received tube feedings resided in the facility. Findings: The facility's Feeding Tubes policy, dated 01/02/19, read in part, Residents that have been identified as requiring nutritional support will receive enteral (tube) feeding per professional standards related to ordering, administering, documenting and assessing nutritional support via tube feeding. Based on the resident's comprehensive assessment, 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 record review and interview, the facility failed to ensure medications were administered as ordered for two (#29 and #44) of eight sampled residents reviewed for medication administration. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility. Findings: A Medications Administration and General Guidelines policy, undated, read in parts, .Medications are administered as prescribed .Or if utilizing an Electronic Medical Record, the initials of the nurse are electronically stamped onto the record .' 1. Resident #29 had diagnoses which included spastic hemiplegia affecting the right nondominant side, unspecified pain, and cerebral infarction. A Physician Order, dated 06/17/23, documented oxycodone 15 mg give one tablet via PEG-tube every eight hours for pain. The July 2023 MAR documented blanks for the 2:00 p.m. oxycodone administration on the 6th, 7th, and 13th. On 08/14/23 at 2:31 p.m., Resident #29 was asked if they received their medications as ordered. They stated, No pain pills. They were asked how often…

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 follow the menu for two of two meals observed. The DON identified 56 residents who received their meals from the kitchen. Findings: An undated facility menu, titled Week at a Glance .[facility name]2019 .week 4, documented residents would be served three cheese penne bake, meadow blend vegetables, sweet pineapple tidbits, breadstick, and beverage for Tuesday's lunch menu on 08/15/23. On 08/16/23 Wednesday's lunch menu, the residents would be served cornflake chicken, garlic mashed potatoes, buttered peas, blueberry crumble bar, dinner roll/margarine, and a beverage. The CDM provided the menu upon request. On 08/15/23 at 11:51 a.m., an observation was made during lunch. The residents were served three cheese penne bake, green beans, a slice of sandwich bread, and a cup of flavored drink. There was no dessert observed on the resident meals trays. On 08/15/23 at 11:54 a.m., the CDM stated the slice of bread was a substitute for the breadstick, and the vanilla cake was a substitute for the sweet pineapple…

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: a. record food temperatures; b. ensure staff wore beard restraint during meal preparation; and c. ensure ice was stored in a manner to prevent cross contamination. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility. The DON reported six residents were NPO. Findings: An Ice Chest and Ice Machine policy, reviewed 01/02/19, read in parts, .To reduce transmission of infection via ice machines within the facility and to ensure that the ice machines and equipment are properly handled and cleaned .All persons handling ice must .Wash hands thoroughly . The facility's Process of Following Menu and Monitoring Food Temperature policy, dated 08/17/23, read in part, .Food temperatures shall be recorded by the cook preparing each meal .The dietary manager is responsible for assuring that the temperature record is utilized at each meal . An undated facility policy, read in part, .Effective hair restraints must be worn when working with or around food…

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 ensure: a. the cap to prevent cross contamination was present on a tube feeding port for one (#29) of four sampled resident's reviewed for nutrition; b. linens contaminated with bodily fluids were removed from a resident's bed for one (#41) of 28 sampled residents observed for clean environment; and c. incontinent care was provided in a manner to prevent cross contamination for one (#1) of three sampled residents observed for incontinent care. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility. Findings: A Linen Handling policy, dated 01/02/19, read in part, .All linen is handled, stored, transported, and processed to contain and minimize exposure to waste products . A Hand Hygiene policy, undated, read in parts, .Purpose: To decrease spread of infection .When to wash hands .When hands are visibly dirty or contaminated or are visibly soiled with blood or other body…

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

Based on observation, record review, and interview, the facility failed to ensure a call light was in reach for one (#29) of 28 sampled residents reviewed for call lights. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility. Findings: Resident #29 had diagnoses which included spastic hemiplegia affecting the right nondominant side and cerebral infarction. Resident #29's Fall Care Plan, updated 06/27/23, documented the resident was at risk for falls related to weakness and stroke with interventions that included be sure the resident's call light was within reach and encourage them to use it. A Medicare 5-day assessment, dated 08/03/23, documented the resident had moderately impaired cognition and required extensive two person physical assistance for bed mobility. It documented the resident had a functional limitation in range of motion impairment on one side for the upper and lower extremity. On 08/14/23 at 2:39 p.m., Resident #29 was asked about their call light. The resident wrote on a communication board I lost…

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 provide a clean, sanitary, homelike environment for one (#29) of 28 sampled residents reviewed for homelike environment. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility. Findings: A Linen Handling policy, dated 01/02/19, read in parts, .All linen is handled, stored, transported, and processed to contain and minimize exposure to waste products .Do not place soiled linen on floor or furniture . A Facility Cleaning Schedule, undated, documented daily Monday through Friday resident rooms: night stands, over bed tables, lights, window blinds, windows, and mop floors. Resident #29 had diagnoses which included spastic hemiplegia affecting the right nondominant side and cerebral infarction. A Medicare 5-day assessment, dated 08/03/23, documented the resident had moderately impaired cognition and required extensive two person physical assistance for bed mobility. It documented the resident had a functional limitation in range of motion impairment…

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 MDS Resident Assessments were accurate for one (#48) of 21 sampled residents reviewed for MDS resident assessments. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility. Findings: Resident #48 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction, aphasia, encephalopathy, flaccid hemiplegia affecting left side. An Annual Resident Assessment, dated 06/26/23, documented Resident #48 had no impairment to upper or lower extremities. On 08/18/23 at 9:15 a.m., MDS Coordinator #1 was asked to review Resident #48's annual resident assessment dated [DATE] and then asked if it documented the resident had impairment to upper and lower extremities. They stated, No. They were asked to review the resident's impairment to upper and lower extremities and determine if the assessment was accurate. MDS Coordinator #1 reviewed the impairment to extremities and 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.

Based on observation, record review and interview, the facility failed to ensure: a. physician ordered weekly weights were obtained for one (#170) of three sampled residents reviewed for weight loss, and b. physician ordered supplement of high protein high calorie was provided for one (#170) of four sampled residents reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 62 residents resided in the facility. Findings: Resident #170 had diagnoses which included pressure ulcer stage 4, diabetes mellitus, surgical aftercare digestive system, gastrostomy status, and artrial fibrillation. An admission Summary progress note, dated 08/04/23, read in part, .to have a high calorie high protein 530 kcal boost shake four times a day and weight of 119.0 pounds . A Nutrition/Weight progress note, dated 08/09/23, read in part, .diet regular, regular texture. Resident is to have high protein, high calorie boost with each meal. 530 kcal boost shake with every meal . An Order Summary report, dated 08/15/23, read in part, .Regular diet, Regular…

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 offer bedtime snacks for one snack service observed. The DON identified 56 residents who received their meals from the kitchen. Findings: The facility's Snacks (Between Meal and Bedtime), Serving policy, dated 12/15/18, read in part, Snacks will be provided to residents for supplemental or between meal nourishment . On 08/14/23 at 1:08 p.m., Resident #42 stated they did not receive snacks. On 08/14/23 at 1:28 p.m., Resident #115 was asked if they received snacks. They stated, No. On 08/14/23 at 1:46 p.m., Resident #7 was asked if they received snacks. Resident #7 stated they had to call for snacks. They stated no one brought snacks. On 08/14/23 at 4:38 p.m., Resident #50 stated they did not receive snacks from the facility. On 08/15/23 at 10:17 a.m., the Resident Council Representative was asked if they received snacks at bedtime or when snacks were requested. They stated snacks were put at the front desk and they had to ask staff to get them. On 08/15/23 10:29 a.m., the Resident Council Representative stated snacks were at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician's orders for four (#26, 46, 47, and #51) of four sampled residents reviewed for following physician's orders. The Census and Conditions of Residents Report documented 65 residents resided in the facility. Findings: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses which included pulmonary embolism, end stage renal disease, congestive heart failure, and diabetes mellitus, insomnia, and atrial fibrillation. The resident's annual Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs), dated 10/26/21, documented the resident's cognition was intact, and required limited to extensive assistance with ADL's. On 12/16/21 at 10:02 a.m., the resident stated that he goes to Dialysis on Monday, Wednesday, and Friday, he leaves the facility at 1:00 p.m. and returns to the facility at 7:15 p.m. The resident's Medication Review Report, dated 12/20/21, documented current physician…

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 a. identify significant weight loss and intervene for one (#47), and b. identify a therapeutic diet preference and intervene for one (#51) of four residents reviewed for nutrition. The Census and Conditions of Residents Report documented 65 residents resided in the facility. Findings: 1. Resident # 47 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, dehydration, and disorientation. The resident's Hospital Discharge Summary, dated 11/20/21, documented the resident weighed 127 lbs on 11/15/21. The resident's Physician's Orders, dated 11/20/21, read in parts, .Obtain and record weekly weight .Regular diet, regular texture, thin consistency. The resident's Care Plan, dated 11/23/21, read in parts, .I am at risk for alteration in nutritional status My goal is to attain and maintain adequate nutritional status and no significant weight changes through next review date .Diet: Regular with no…

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 a. provide a separately locked, permanently affixed compartment for storage of controlled drugs; b. monitor the medication room temperature daily in one of one medication storage room observed for medication storage; c. store drugs in a containers labeled with a resident's name and identification of the drug; and d. discard medications from the medication cart for destruction after a resident was discharged from the facility and discard expired medications for three of four medication carts observed for medication storage. The Census and Conditions of Residents Report identified 65 residents who resided in the facility. Findings: A Storage of Medications policy, read in part, .Medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies .Medications are stored in the containers in which they are received .No discontinued, outdated or deteriorated medications are available for use in the facility. All such medications are destroyed .All…

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 a. remove expired food from the refrigerator, and b. store and label food in a safe manner for two of two refrigerators observed for food storage and labeling. The Director of Nursing reported 65 residents received meals from the kitchen. Findings: On 12/15/21 at 9:15 a.m., the kitchen was observed during the initial tour. Seven, one-gallon containers of milk were in the refrigerator with a 12/12/21 expiration date. A second refrigerator was observed to have a stainless-steel container with bacon covered with plastic wrap that was not labeled and dated. The Dietary Manager (DM) stated the milk should have been discarded. The DM stated the container of bacon should have been labeled to ensure proper storage and use-by dates.