Vmrc, Complete Living Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, and facility document review, the facility staff failed to accommodate food preferences, food intolerance's and/or allergies for two of 21 residents in the survey sample, Resident #71 and Resident #72. Findings include: 1. The facility failed to ensure Resident #71's food preferences were honored. Resident #71's diagnoses included, but were not limited to: diabetes mellitus, thrombocytopenia, chronic atrial fibrillation, gastric reflux and iron deficiency. The resident's most recent MDS (minimum data set) was a quarterly assessment dated [DATE]. The resident was assessed as a 14 cognitively, which indicated the resident was intact for daily decision making skills. The resident was also assessed as requiring supervision with at least one person assist for most ADL's (activities of daily living) and supervision with set up only for eating/meal consumption. On 03/13/23 at approximately 12:00 PM, Resident #71 was observed sitting at the dining room table.…

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, staff interview and facility document review the facility staff failed to ensure food temperatures were obtained prior to serving food and failed to maintain food temperature logs in 4 of six houses ([NAME], [NAME], [NAME], [NAME]). Findings include: 1. The facility staff failed to ensure food temperatures were obtained prior to serving food and failed to maintain food temperature logs for the [NAME] House. On 03/13/23 at 12:13 PM in the [NAME] House, CNA # 1 (certified nursing assistant) was observed plating and serving food to the residents. CNA #1 was asked if she had checked the food temperatures for the food being served. CNA #1 stated that they (staff) had not checked the temps for lunch, but stated, I can do it now. CNA #1 was made aware that the food temperatures should be obtained prior to serving the food. CNA #1 stated, We did temps for breakfast, but not for lunch. CNA #1 was asked for the food temperature logs. CNA #1 presented a book for the [NAME] House. The food temps were…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for one of thirteen residents in the survey sample. The Findings include: The facility nursing staff failed to enter a verbal physician's order into the electronic clinical record regarding Foley catheter placement for one of 21 residents, Resident #9. Diagnoses for Resident #9 included; Urine retention, inguinal hernia, depression, and congestive heart failure. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 2/3/23, Resident #9 was assessed with a cognitive score of 13 indicating cognitively intact. On 3/13/23 12:13 PM during an interview, Resident #9 was asked about his catheter. Resident #9 verbalized that he thought that the staff had placed the catheter because he was having trouble urinating and he possible had a urinary tract infection. Resident #9 went on to say the nurses are taking care of it and was not having any trouble with the catheter. On 3/13/23 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 a medication pass and pour observation, staff interview and facility document review, the facility staff failed to ensure infection control practices were followed for the administration of medications. Findings include: On 03/13/23 at approximately 3:58 PM, LPN (Licensed Practical Nurse) #1 prepared medications for Resident #43. LPN #1 donned (applied) gloves and prepared a glucometer to check the resident's blood glucose level. Once completed, LPN #1 discarded the glucometer strip, wiped off the glucometer, put it away and began to prepare medications for Resident #43. LPN #1 did not remove the gloves used to check the resident's blood glucose level after that task was completed. LPN #1 proceeded to dispense two Tylenol tablets into a plastic dispensing cup, then dispensed one Renvela, when attempting to dispense a second Renvela, the pill dropped to the floor. LPN #1 reached down with a gloved hand and picked the pill up and tossed it in the trash and resumed, by dispensing two more Renvela tablets…

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 staff interview and clinical record review, the facility staff failed to follow physician orders for 2 of 22 residents in the survey sample, Resident #37 and Resident #287. Fluid intake for Resident #37 and Resident #287 was not monitored and documented as ordered by the physician. The findings include: 1. Resident #37 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including lumbar fracture, altered mental status, right pubic fracture, hypo-osmolality, hyponatremia, hypertension, a-fib, congestive heart failure and colostomy. The admission Observation Assessment completed on 07/11/21 assessed Resident #37 as alert, and attentive. Oriented to person, place and time. Having an intact memory (past and present), with clear and organized thinking . On 07/21/21 Resident #37's clinical record was reviewed. Observed on the physician's order report was the following: .Order Type: POC (plan of care) -Task. Start Date: 07/11/2021. End Date: Open Ended. 1200ml…

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

Based on staff interview and facility document review, the facility staff failed to implement a program for prevention of Legionella and other waterborne pathogens and failed to ensure infection control policies were reviewed annually. The facility failed to perform a risk assessment to identify where Legionella and other waterborne pathogens could grow and/or spread; failed to implement a water management program based upon industry standards and/or the CDC (centers for disease control) toolkit and; failed to perform and document specified testing for prevention of Legionella. In addition, the facility had performed no annual review of infection control policies. The findings include: 1. On 11/28/18 at 1:15 p.m., the maintenance director was interviewed about evidence of a water management program to prevent the growth and spread of Legionella and other waterborne pathogens. The maintenance director stated the facility had not set up a program yet to check for Legionella. The maintenance director stated they performed standard testing and maintenance on the boilers and water towers…

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, staff interview and facility document review, the facility staff failed to store, prepare and serve food in a sanitary manner in the main kitchen. [NAME] slaw, which temped at 53 degrees and was made with mayonnaise was served for the lunchtime meal in one of eight houses on the facility campus. Findings were: Initial tour of the facility was conducted on 11/27/2018 beginning at approximately 11:45 a.m. Upon arrival in one of the individual houses on campus, OS (other staff) #5 was observed in the kitchen, preparing to serve lunch. The menu for the day was stuffed pepper casserole, cole slaw and dessert. Lunchtime temperatures were obtained by OS #5. The temperature of the cole slaw was 53 degrees. OS #5 was observed plating the cole slaw and serving it to the the residents residing in the home. OS #5 was questioned about the cole slaw. She was asked if the cole slaw dressing was mayonnaise based. She stated Yes, I fixed it last evening (Monday 11/26/2018) and it has been in 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 staff interview, facility document review and clinical record review, the facility staff failed to honor the right to refuse medications for one of 25 residents in the survey sample. A nurse forced Resident #56 to take medications against her wishes by holding down her arms, pinching her nose closed until her mouth opened and pushing her lips against her teeth. The findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, seizure disorder, anxiety, depression and high blood pressure. The minimum data set (MDS) dated [DATE] assessed Resident #56 with short and long-term memory problems and severely impaired cognitive skills. A facility reported incident form dated 7/12/18 documented certified nurses' aides (CNAs) reported they observed registered nurse (RN) #1 being rough and forceful with Resident #56 when giving oral medications on 7/12/18. This report documented, . [CNA #3] reported to [administrator] on July 12, 2018, that she witnessed…

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 staff interview, facility document review and clinical record review, the facility staff failed to ensure one of 25 residents was free from physical abuse that included restraint. A nurse forced Resident #56 to take medications by holding down her arms, pinching her nose closed until her mouth opened and pushing her lips against her teeth in an attempt to get her to swallow and/or take medications. The findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, seizure disorder, anxiety, depression and high blood pressure. The minimum data set (MDS) dated [DATE] assessed Resident #56 with short and long-term memory problems and severely impaired cognitive skills. A facility reported incident form dated 7/12/18 documented certified nurses' aides (CNAs) reported they observed registered nurse (RN) #1 being rough and forceful with Resident #56 when giving oral medications on 7/12/18. This report documented, . [CNA #3] reported to [administrator]…

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 medication pass and pour observation, staff interview and clinical record review, facility staff failed to administer a medication per manufacturer guidelines for one of 25 residents in the survey sample, Resident #52. Facility staff failed to administer Levothyroxine per manufacturer guidelines, (on an empty stomach) for Resident #52. Findings included: Resident #52 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: Anal Cancer, Macular Degeneration, Depression, Parkinson's Disease, and Hypothyroidism. The most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 10/12/2018. Resident #52 was assessed as impaired in her short and long term memory and moderately impaired in her daily decision making skills. Resident #52 was observed eating breakfast with fellow residents on 11/28/18 at approximately 8:15 a.m. During the medication pass and pour observation conducted 11/28/2018 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.