Kirkland Court Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #26, Resident #45, and Resident #46) of 17 residents reviewed for infection control. -LVN D failed to use the proper disinfecting wipes when disinfecting equipment used on residents. This deficient practice had the potential to place residents at risk by exposing them to care that could lead to the spread of viral infections, secondary infections, communicable diseases. Findings include: During an observation on 06/09/25 at 06:32 AM, LVN D performed a blood glucose check on Resident # 26 and did not clean glucometer after blood glucose check. During an observation on 06/09/25 at 06:36 AM, LVN D performed a blood glucose check on Resident # 46,. LVN did not clean the glucometer before or after blood glucose check for Resident #46. During an observation on 06/09/25 at 06:43 AM, LVN D…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Residents #1) of 6 residents reviewed for care plans. The facility failed to implement Resident #1's care plan to ensure Resident #1 was transferred and toileted with the assistance of 2 staff in order to ensure resident's safety. Resident #1 was transfered from her bed to wheelchair using a gait belt with the assistance of one person. This failure could place residents at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental, and psychosocial wellbeing. The findings included: Resident #1 was a 69-y o female admitted to the facility on [DATE] with diagnoses of hemiplegia…

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 in accordance with accepted professional standards and practices, the facility maintained medical records on each resident that were complete, accurately documented, and readily accessible for 2 of 5 residents (Residents #1 and #2) reviewed for clinical records. The facility failed to ensure the altercation that occurred on 12/4/2024 between Resident #1 and Resident #2 was documented in their clinical records. This failure could place residents at risk for incorrect or omitted treatment, duplicated treatments, poor self-esteem and self-worth, and a failure to ensure continuity of care. Findings included: 1. Record review of Resident #1's face sheet, dated 01/07/2025, reflected a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #1's current diagnoses included but were not limited to cerebral infarction (stroke), vascular dementia (impaired blood flow to the brain/brain damage), major depressive disorder and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (CNA B and CNA C) of 4 staff and 1 of 1 resident (Resident #1) observed for resident care. CNA B and CNA C did not wear the proper PPE when performing catheter care on Resident #1 per Enhanced Barrier Precautions increasing risk of MDRO contamination. This deficient practice has the potential to affect residents in the facility receiving incontinent care by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene. Findings include: Record review of Resident #1's face sheet printed 11-27-2024 revealed he was a [AGE] year-old male admitted to the facility originally on 1-18-2024 and readmitted on [DATE] with diagnoses to include hemiplegia (partial…

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 immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representatives when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention or a significant change in the resident's physical, mental, or psychosocial status for 1 (Resident #1) of 5 residents reviewed for notification. The facility failed to ensure Resident #1's resident representative was immediately notified when the resident had a change in condition that required he be transported via ambulance to the hospital. This failure could result in residents not having the comfort and company of their families during traumatic times. Findings included: Record review of Resident #1's face sheet revealed that Resident #1 was a [AGE] year-old male, who was originally admitted into the facility on [DATE], with an updated admission date of 07/01/24.…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled and dated. 2. The facility failed to ensure walk-in refrigerator items were stored, labeled, and dated. 3. The facility failed to ensure pantry foods were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the walk-in pantry on 04/24/24 at 8:16 AM revealed the following: 1. (1) Package of turkey gravy mix, opened and sealed in a Ziploc storage bag, with no label or date. 2. (2) Boxes of oatmeal creme pies, 1 opened and the other sealed, with no label or date. 3. (2) cereal boxes, not sealed and open to air with no date or label. 4. (5) cereal bowls covered in plastic wrap with no date or label. 5. (7) loaves of bread were unopened and in their original…

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

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information, for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specification established by CMS for 1 of 4 FY quarters (FY Quarter 1 2024 (October 1-December 31)) reviewed for administration. The facility failed to submit staffing data to CMS for FY Quarter 1 (October 1-December 31). This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Review of the CMS PBJ report for CMS for FY Quarter 1 (October 1-December 31) indicated the facility had failed to submit data for the quarter triggered. In an interview on 04/24/24 at 9:30 AM, ADM stated that IT Corp was responsible for uploading the PBJ. In a phone interview on 4/26/24 at 9:44 AM, IT Corp stated that the PBJ was not uploaded due 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 provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being for 3 of 7 anonymous residents reviewed for quality of life. The facility failed to ensure 3 of the 7 anonymous residents interviewed received adequate notification of activities. The facility failed to ensure activities that were provided met residents' needs or desires. This failure placed residents at risk of boredom and a decline in their quality of life. Findings included: During an observation on 04/24/2024 at 9:56 AM, the AD was coloring in the dining room with two female residents. During an interview on 04/24/2024 at 10:00 AM, the AD stated that Resident Council was scheduled to meet that day at 2:00 PM and that surveyor could meet with residents during that time. An observation on 04/24/2024 at 10:30 AM of Activity Calendar did not reflect Resident Council Meeting at 2:00 PM. Bingo was scheduled at 2:00 PM. During an interview…

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

Based on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional. The facility failed to ensure the AD was qualified to serve as the director of the activities program. This failure placed residents at risk of not having stimulating, engaging activities that are beneficial and meaningful to the residents. Findings included: During an interview on 04/24/2024 at 10:10 AM, the AD said she had worked at the facility for about 6 months and had not taken the classes yet to be certified. The AD said she was waiting on the facility to pay for the classes. During an interview on 04/25/2024 at 11:00 AM, the ADM stated that she was aware of the AD not being certified and that it was a deficiency. The ADM had no answer to a possible negative outcome for uncertified staff. During an interview on 04/26/2024 at 8:20 AM, the ADON stated that she was aware that the AD was not certified and a possible negative outcome for not having a certified AD would be that the AD would not have the training that was needed to provide stimulating…

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, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 medication carts reviewed for medication storage. The facility failed to prevent the following: -1 loose pill was found in medication cart for Hall 300 and part of Hall 200, -medication cart for Hall 300 and part of Hall 200 had 3 insulins with no open dates located on medications. -3 insulin medications were found in Hall 100 & and part of 200 Hall's medication cart that were past their expiration dates. -LVN A left 2 bubble packs of medication on top of the medication cart and left them unattended while she administered medications to a resident. -LVN B did not lock her medication cart while going into a resident's room to administer a medication. The facility's failure placed residents receiving medication at risk for drug diversion,…

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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to prevent the following: -LVN B did not perform HH before performing blood sugar check. -LVN B did not perform HH before or after donning or doffing gloves to administer insulin to resident. -LVN A did not perform HH before preparing medication for resident. -LVN A did not clean bedside table before setting up medication administration for a resident with a gastrotomy tube. -CNA D did not perform HH or glove change after cleaning resident during incontinent care. -LVN A did not perform HH during incontinent care or wound care of resident. These deficient practices have the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary…

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 assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails, and obtain informed consent prior to installation of bed rails with residents or their resident representatives for 1 of 13 (Resident #12) residents reviewed for quality of care in that: The facility failed to ensure Resident #12 did not have (2) one-quarter bed rails, on both sides of his bed with no documentation of physician orders, consent, or a safety assessment prior to installation. This failure could place residents at risk of injury, hindering residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living. Findings included: Record Review of Resident #12's Face Sheet revealed that a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included but not limited to muscle weakness, Vascular Dementia, muscle wasting and atrophy, and…

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

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being for 1 of 5 staff reviewed for nursing services. The facility failed to ensure the following: -LVN A used proper technique when providing wound care. -LVN A used proper technique when providing incontinent care. -LVN A used proper technique when administering medications via gastrotomy tube. This failure had the potential to affect residents receiving wound care and incontinent care by exposing them to infections resulting in poor healing, increased tissue damage, and deterioration in their wounds and health often resulting in IV antibiotic therapy and even hospitalization. This failure had the potential to affect residents with gastrostomy tubes by interfering with the efficacy of the therapeutic level of medications. Findings include: Observation on 04/25/24 at 08:49 AM revealed LVN A administering…

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 residents were free of any significant medication errors for one of 13 (Resident #10) residents reviewed for pharmacy services. -The facility failed to ensure LVN B did not administer insulin to Resident #10 that belonged to another resident. This failure could place residents who receive insulin medications at an increased risk for complications such as increased blood glucose levels, change in cognition, and an exacerbation of symptoms and disease process. Findings include: Observation on [DATE] at 11:39 AM of medication administration performed by LVN B to Resident #10. Revealed LVN B was asked to confirm open date on insulin pen, which also had another resident's name on it. LVN B confirmed that the open date was still valid, and the insulin was not expired. Pen was cleaned with alcohol and a new needle was placed on pen. Novolog 10 units to the RLQ was administered Resident #10. LVN B went back to the medication cart realizing…

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 that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #1 and Resident #2) of 5 Residents reviewed for abuse and neglect. 1. The facility failed to report to the State Survey Agency an unwitnessed fall that Resident #1 had on 1-5-2024 resulting in Hematoma…

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

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility observed for sanitation and infection control in that: The facility did not follow infection control policies when on 01/04/2023 staff failed to use hand hygiene while passing out food, leaving used COVID tests with bodily fluids left on a countertop in an easy accessed location, failed to utilize hand hygiene when entering and exiting resident's rooms, and a staff member not following infection prevention measures when experiencing symptoms This failure could place residents at risk for infections, contamination, and physical and mental decline. Findings included: An observation on 1/4/24 at 7:57 AM revealed two used COVID tests, with swabs still in tests, sitting on countertop. Both tests showed a negative result which indicated the tests had been used. An observation on 1/4/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess residents for risk of entrapment from bed rails prior to installation. The facility failed to review the risks and benefits of bed rails with 1 of 5 (Resident #2) residents or their resident representatives and obtain informed consent prior to installation of bed rails, in that: Resident #2 had (2) one-quarter bed rails, one on each side of her bed with no documentation of consent or safety assessment prior to installation. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living. Findings included: Record Review of Resident #2's Face Sheet revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes(body not being able to produce enough insulin or it resists insulin) with foot ulcer, unspecified open wound, left ankle, end stage renal(kidney) disease,…

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, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete, accurately documented for 1 of 5 residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure Resident #1's physician orders for a bed alarm was documented in the care plan. The facility failed to ensure Resident #1's fall risk assessment was accurately documented in the care plan. The resident's fall risk assessment indicated Resident #1 was a high risk for falls but was inaccurately documented in care plan as a moderate risk for falls. These failures could place residents at risk of not receiving needed care or treatments or duplication of care or treatment by misleading care providers regarding what care or treatments residents have or have not received. Findings included: Record Review of Resident #1's face sheet dated 11/28/2023 revealed a [AGE] year-old male admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for three (Resident #1, Resident #32, and Resident #38) of 49 residents reviewed for misappropriation of property and exploitation. CNA H asked Resident #32 for money. Someone with the same first name as CNA H used Cash App to steal money from Resident #38. Someone with the same first name and half of the same last name as CNA H used Cash App to steal from Resident #1 at the same time Resident #1's wallet was opened and $100 went missing. This failure could place residents at an increased risk for misappropriation of their property. Findings include: 1. Record review of Resident #1's face sheet, dated 03/08/23, revealed an [AGE] year-old female admitted for rehabilitation to the facility on [DATE] with diagnoses that included, but were not limited to, sepsis (the body's extreme response to an infection), muscle wasting,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 3 (Resident #15, #27, and #44) of 18 residents reviewed for advanced directives. Resident #15 had a DNR in her record that was missing multiple required pieces of information. Resident #27 had a DNR is his record that was missing the date and printed signature for the Resident. Resident #44 had a DNR in her record that had no second witness. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings include: Resident #15 Record review of the face sheet dated 3-6-2023 in the clinical record for Resident #15 revealed a [AGE] year-old female resident admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 8 of 17 residents (Resident #12 and all ambulatory residents not residing in the locked unit) reviewed for accident hazards. 1. A razor blade was observed sitting on the countertop of the conference room of the facility. 2. Resident #12 had three towels positioned on the floor around the base of his toilet. He is visually impaired and needs an even floor free of clutter, according to his care plan. These failures could place residents at risk of injury. Findings include: 1. Observation on 03/06/23 at 08:12 AM of countertop in facility conference room revealed a Styrofoam soda cup with lid and straw with a razor blade (the kind used inside a box cutter tool) sitting on the lid of the cup. Observation on 03/06/23 at 11:04 AM of countertop in facility conference room revealed a Styrofoam soda cup with razor blade sitting on the lid of the cup. Observation…

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 that a resident fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings, for 1 (Resident #45) of 1 resident that was reviewed for feeding tubes, in that: -The facility staff failed to verify placement of the feeding tube prior to medication administration. This failure could place residents receiving enteral feedings by placing them at risk for complication such as aspiration pneumonia (occurs when food or liquids is breathed into the airway or lungs, instead of being swallowed), pneumothorax (a condition that occurs when air leaks into the space between the lungs and chest wall), perforations, empyema (one of the diseases that compromises chronic obstructive pulmonary disease), bronchopleural fistula (a sinus tract between the main stem, lobar, or segmental bronchus and the pleural space), and/or hospitalization. Finding include: Record review of the face sheet dated…

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

Based on interview and record review, the facility failed to receive registry verification that the individual has met competency evaluation requirements before allowing the individual to serve as a nurse aide for one of 5 (CNA G) CNA's reviewed for licensure. CNA G was hired by the facility on 08/22/22 and was never certified as a certified nurse's aide despite her current employment as, and title of, CNA. This failure to ensure employee competency in training could affect all residents by exposing them to inadequate care resulting in deterioration of their condition. Findings include: Record review of CNA G's employee file revealed she was hired as a CNA by the facility on 08/22/22. Her file did not contain an EMR or NAR report. It did not contain her CNA license number or expiration date. It did contain an attempt at an NAR report with her first and last name in the appropriate boxes and all other boxes blank, indicating the system did not find any CNA license information for CNA G's name. During an interview on 03/08/23 at 03:20 PM BOM/HR stated CNA G went to a class to get 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.

Based on observation, interview, and record review, the facility failed to prepare, and serve food in accordance with professional standards of food safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to make sure staff (Cook A) was wearing hair restraints while preparing food in the kitchen. This deficient practice could place residents at risk of food-borne illness, weight loss, and a diminished meal experience. Findings include: An observation on 03/06/2023 at 11:03 AM during initial kitchen rounds revealed the following: Cook A was not wearing a beard restraint/net over his goatee while he was preparing and cooking food. During a simultaneous interview, [NAME] A stated he was not aware of the requirements in using a beard net. [NAME] A stated has not been told or coach about the use of a beard restraint. On 03/06/2023 at approximately 11:10 AM in an interview with DM, stated anyone working or being in the kitchen area are expected to wear appropriate hair restraints such as hair nets and beard restraints. DM stated not have any beard nets due to being…

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.