Grant Rehabilitation And Care Center

Based upon record review and staff interview, the facility failed to perform a drug regimen at least once a month by a licensed pharmacist. This was found to be true for one (1) of five (5) residents reviewed under the unnecessary drug pathway during the long-term care survey process. Resident identifier: #4. Facility census: 90. Findings included: a) Policy Review The facility policy entitled, Monitoring Medication Regimen Review, dated 12/17, stated, The ACP (AlixaRx Clinical Pharmacist) performs a comprehensive review of each resident's medical record at least monthly. The medication regimen review (MRR) is a thorough evaluation of the medical regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. b) Resident #4 A record review revealed the facility did not have documentation in the electronic medical record showing the necessary monthly drug regimen reviews had been completed for the following months: -January 2025-February 2025-March 2025-April 2025-May 2025-June 2025-July…

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 staff interview, the facility failed to ensure dietary staff had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. The facility did not ensure all Dietary Staff received their food handlers card within 30 days after being hired. This was found during the Annual Long-Term Care Survey Process. Facility census: 90.Findings include: a) Guidelines Per local health department guidelines for Grant County, the employee should earn a food handlers card within 30 days of starting work. b) Review of Staff Records Two (2) of (15) dietary records reviewed found the food handler cards were not obtained within the (30) day guideline after hire date. - Dietary Employee #71 had a hire date of 07/23/25. A food handlers card was obtained on 09/16/25. - Dietary Employee #119 had a hire date 08/18/25. A food handler card was obtained on 10/14/25. c) Interview with Dietary Supervisor During an interview, on 02/10/26 at around 1:30PM the Dietary Supervisor verified the food handler cards for the above-mentioned employees…

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

Based on observation and staff interview, the facility failed to ensure all garbage and dumpsters were properly contained and that the dumpsters were covered with lids (or otherwise covered.) This was true for three (3) of the four (4) dumpsters observed. This was a random opportunity for discovery during the Long-Term Care Survey Process. Facility Census 90.Findings include: a) Policy Review The policy for Sanitation reads in part under interpretation and Implementation-14. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered.)-15. Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests. Guidelines for garbage and refuse containers reads in part:-Garbage and refuse containers need to be in good condition (no leaks) and is waste properly contained in dumpsters with lids or otherwise covered. b) Observations and Interview On 02/10/2026 at 8:30 AM, three (3) of the four (4) dumpsters observed were found with lids open and trash hanging over…

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 facility record review and staff interview, the facility failed to complete final internal food temperatures and ensure food was held prior to food service at appropriate temperatures. This has the potential to affect all residents that receive their nutrition form the kitchen. Facility census: 82 Findings include: a) Food tempetures On 04/15/24 at12:20 PM during a tour of the kitchen it was discovered the Food temperatures were not completed on: -evening meal 04/01/24 -evening meal 04/02/24 -evening meal 04/03/24 -evening meal 04/04/24 -all meals 04/05/24 -all meals 04/08/24 -evening meal 04/10/24 -all meals 04/11/24 -evening meal 04/12/24 -all meals 04/13/24 -evening meal 04/14/24 During an interview on 04/15/24 at 12:23 PM the Certified Dietary Manager verified the food temperatures were not being completed daily as required.

Based on observation and staff interview the facility failed to complete labeling and dates in a unit refrigerator and complete refrigerator temperature log unit refrigerator and freezers on the 100, 200 and Sub halls and main dining room in accordance with professional standards for food service safety related to storage. This has the ability to affect all Residents that get their nutrition from the kitchen. Facility Census: 82. Findings Include: a) 100 Hall Unit Refrigerator Observation during the Unit tour on 04/15/24 at 12:44 PM found 3 sodas open, cherry pie, and plastic container in the resident refrigerator with no labeling or dates. During an interview on 04/15/24 at 11:44, the Dietary Manager (DM) verified there was no labeling or dates on the items in the 100-hall resident refrigerator. b) Refrigerator / Freezer Temperature Log On 04/15/24 at 12:58 PM facility record review of the refrigerator temperature log for unit refrigerator and freezers on the 100, 200 and Sub halls and main dining room found the temperatures was not completed on the log at this time on: -04/01/24…

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 record review and staff interview, the facility failed to implement appropriate interventions for quality deficiencies of which it was aware. This deficient practice had the potential to affect all residents residing in the facility. Facility census: 82. Findings included: a) Skin assessments. On 04/16/24 at 3:40 PM, the Director of Nursing (DON) was interviewed and asked about the facility form called a, SHOWER BODY AUDIT for Residents. The DON said the Nurse Aides do skin assessments when they give showers. If they find a concern, they mark it on the shower body audit sheet and the nurse will go and assess it, then sign the shower body audit. The DON was asked if a Licensed Nurse does routine skin assessments on everyone. The DON said no they go by what the Aides find. Also, at this same time the Licensed Practical Nurse/Treatment Nurse (TN) #120 was present for this interview via phone. TN #120 stated she does not do routine skin assessments. The DON agreed that while it is good practice for the Nurse Aides to report any skin issues they find, a licensed nurse has 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 staff interview, the facility failed to document the attendance of the Medical Director or designee at all quarterly Quality Assurance Performance Improvement (QAPI) meetings. This deficient practice had the potential to affect all residents residing in the facility. Facility census: 82. Findings include: a) Meeting attendance by medical director On 04/16/24 at 4:21 PM, the Administrator stated Quality Assurance Performance Improvement (QAPI) meetings were held every month. The Administrator stated the facility's Medical Director attended the quarterly meetings held on January, April, July, and October. However, the Administrator was unable to locate the QAPI attendance record for April 2024 to document the Medical Director's attendance at the meeting. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to ensure a new Preadmission Screening and Resident Review (PASARR) was completed for Resident #68, #67, and #18 when the residents developed a new mental illness diagnosis during their stay at the facility. This was true for three (3) out of five (5) residents reviewed for care area of PASARR during the long term care survey process. Resident Identifier: #68, #67, and #18. Facility census: 82. Findings include: A) Resident #68 At approximately 2:30 PM on 04/15/24 a record review was conducted for Resident #68. The record noted the resident was admitted to the facility with a PASARR dated 09/01/23. A review of Resident #68's diagnoses noted the resident was diagnosed with Major Depressive Disorder on 10/30/23. Further review indicated the facility had not completed a new PASARR for Resident #68. At approximately 2:01 PM on 04/16/24, the Director of Nursing (DON) acknowledged the facility had not yet completed a new PASARR for Resident #68 after the diagnosis was added. The DON stated they were not aware a new PASARR…

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, medical record review and staff interview the facility failed to ensure skin assessments were done at a professional standard of practice and failed to administer Immunizations recommended by the CDC in a timely manner. This failed practice had the potential to affect more than a limited number of residents who currently reside at the facility. Resident Identifier: #52, #19, #18, and #12. Facility census 82. Findings include: a) Skin assessments. On 04/16/24 at 3:40 PM, the Director of Nursing (DON) was interviewed and asked about the facility form called a, SHOWER BODY AUDIT for Residents. The DON said the Nurse Aides do skin assessments when they give showers. If they find a concern, they mark it on the shower body audit sheet and the nurse will go and assess it, then sign the shower body audit. The DON was asked if a Licensed Nurse does routine skin assessments on everyone. The DON said no they go by what the Aides find. Also, at this same time the Licensed Practical Nurse/Treatment Nurse (TN) #120 was present for this interview via phone. TN #120 stated she…

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

Based on observation and staff interview the facility failed to ensure the resident environment over which it had control was as free of accident hazards as is possible . These failed practices were random opportunities for discovery and was true for Resident #65 and #26. Resident identifiers: #65 and #26. Facility census 82. Findings include: a) Resident #65 Resident #65 was observed on 04/16/24 at 11:55 AM, being lifted from his Geri chair in the Day room by Nurse Aide (NA) #50 and #55. It was noted the residents' pants were not pulled up over his brief and he was exposed to everyone in the Day room. There were 14 residents in the day room and two (2) visitors. The white brief on Resident #65 appeared to be very heavy and was hanging very low, while the resident was hanging in the air being pushed to the bathroom. Resident #65 was transported approximately 10-12 feet into the bathroom via a mechanical lift. The two (2) NA's used the lift to transport Resident #65 to the bathroom. At 12:02 PM the same two (2) NA's pushed Resident #65 out of the bathroom with the lift back 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.

Based on record review, and staff interview, the facility failed to insure the physician documented the actions or rational if no action taken for monthly drug regimen reviews. This was true for three (3) of five (5) reviewed for unnecessary medications. Resident identifier #65, #7 and #43. Facility census: 82. Findings include: a) Resident #65 A medical record review for Resident #65 revealed monthly drug regimen reviews response without actions or rational if no action taken by the physician. --06/07/23 Recommendation to consider reducing Zyprexa 2.5mg and 1.25mg dose by 50%. Physician response -Stable. --03/06/24 Recommendation to consider reducing Zyprexa 2.5mg and 1.25mg dose by 50%. Physician response -Needs this. During an interview on 04/16/24 at 11:02 AM the Director of Nursing verified that the physician did not document the action or rational. b) Resident #7 On 04/17/24 at 10:10 AM a record review of Resident #7's medical diagnosis showed the following: Unspecified Dementia, moderate with anxiety, unspecified dementia, moderate with mood disturbance, and conduct disorder,…

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 staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. Insulin pens were not dated when opened. Additionally, controlled substances were not properly secured in medication rooms. Also, expired medications were found in the medication room. This deficient practice had the potential to affect more than a limited number of residents. Resident identifiers: #70, #8, #72. Facility census: 82. Findings Include: a) Insulin pens Review of the facility's policy titled Administering Medications, with implementation date 2001 and revision date 2009, stated when a multi-dose container is opened, the opening date should be recorded on the container. On 04/17/24 at 8:16 AM, the 400 hallway medication cart was inspected with Registered Nurse (RN) #18 in attendance. Three (3) multi-dose insulin medications had not been dated when opened. It is important to label multi-dose medications for injection with the opening date because they must be discarded within 28 days of…

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

Based on observation, policy review and staff interview the facility failed to ensure each resident had a dignified existence. This was a random opportunity for discovery and was true for Resident #37, #65, #40, #57, #330 and #44. Resident identifiers: #37, #65, #40, #57, #330, and #44 . Facility census 82. Findings include: a) Assisting Resident with eating On 04/16/24 at 12:27 PM, Licensed Practical Nurse (LPN) # 35 was standing over Resident #37 while feeding her. LPN #35 was asked if she always feeds residents while standing? LPN #35 said, I just feed, however, I can. LPN #35 went on to say, I do not always feed Residents. The Facility Policy titled, Assistance with Meals Revision date: 03/22, stated, * Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: -Not standing over residents while assisting them with meals. On 04/16/24 at 2:00 PM, the Assistant Director of Nursing (ADON) was informed of the above and no further information was provided. b) Resident #65 Resident #65 was observed on 04/16/24 at 11:55 AM, 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.

Based on observation, record review and resident and staff interview the facility failed to promote and facilitate resident self-determination through support of resident choices in regards to the resident's preference as to how many showers they would like per week. This was true for one (1) of three (3) residents reviewed for self-determination. Resident identifier: Resident #60. Facility Census: 82. Findings Include: a) Resident #60 During an interview on 04/15/24 at 1:23 PM, Resident #60 stated they had asked the staff for three (3) baths per week and was told the facility did not have enough help. The resident reported their shower days are scheduled for Wednesdays and Sundays but they would like to shower on Fridays in addition. The resident reported they have a condition which causes them to itch and believes they may feel better with more frequent showers. On 04/16/24 1:08 PM, a review of the Psychosocial Note dated 02/19/24 stated the resident asked for (their) care plan team to allow (them) to have an additional shower during the week on Fridays. Review of resident's 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 staff interview the facility failed to develop a personalized centered care plan for a focus of respiratory relating to Chronic Obstructive Pulmonary Disease (COPD). This was true for one (1) of twenty six (26) care plans reviewed during the long term care process. Resident Identifier: #12. Facility Census: 82 Findings Include: a) Resident #12 On 04/15/24 at 12:40 PM and 2:40 PM and on 04/16/24 at 8:24 AM it was observed that Resident #12 had a respiratory nebulizer mask at bedside. On 04/16/24 at 1:30 PM, a record review found Resident #12 had a medical diagnosis of Chronic Obstructive Pulmonary Disease (COPD). There was also physicians orders as follows: Ipratropium Albuterol Solution 0.5-2.5 (3) milligrams (MG)/3 milliliters (ml) 1 application inhale orally two times a day related to Chronic Obstructive Pulmonary Disease. and Ipratropium Albuterol Solution 0.5-2.5 (3) milligrams (MG)/3 milliliters (ml) 1 application inhale orally every 12 hours as needed for COPD. On 04/16/24 at 1:30 PM, a record review found Resident #12 had no personalized care plan…

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

Based on observation and staff interview the facility failed to store respiratory equipment in a clean sanitary manner consistent with professional standards of practice. This was a random opportunity for discovery. Resident Identifiers: #12 and #13. Facility Census: 82 Findings Include: a) Resident #12 On 04/15/24 at 12:40 PM and 2:40 PM and on 04/16/24 at 08:24 AM it was observed that Resident #12's respiratory nebulizer mask was not stored in a clean sanitary manner. It was on the bedside table outside of the plastic storage bag. Resident #12 had a physicians order for: Ipratropium Albuterol Solution 0.5-2.5 (3) milligrams (MG)/3 milliliters (ml) 1 application inhale orally two times a day related to Chronic Obstructive Pulmonary Disease. and Ipratropium Albuterol Solution 0.5-2.5 (3) milligrams (MG)/3 milliliters (ml) 1 application inhale orally every 12 hours as needed for COPD. The facility policy for departmental (respiratory Therapy) prevention of infection states Infection control considerations related to medication nebulizer/continuous aerosol: 7. Store the circuit in…

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 staff interview, the facility failed to ensure an order for a PRN (as needed) psychotropic medication did not exceed 14 days for Resident #43, and failed to attempt a Gradual Dose Reduction (GDR) for an antidepressant for Resident #7. This was true for two (2) of five (5) residents reviewed for the care area of unnecessary medications during the long-term care survey process. Resident identifiers: #43,and #7. Facility census: 82. A) Resident #43 At approximately 11:00 AM on 04/15/24, a record review of orders for Resident #43 was conducted. During the review, it was determined the resident had the following order for Ambien: Ambien oral tablet 10 MG (Zolpidem Tartrate) Give 10 mg by mouth as needed at bedtime for insomnia. The hours listed on the order are PRN. The order was written on 12/06/23 and was the current order at the time of this review. Pharmacy recommendations were found for the PRN order of Ambien during a record review, however, appropriate rationales were not given and a specific duration of use was not provided. The following recommendation…

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, policy review, and staff interview the facility failed to ensure establish and 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 infection. This was a random opportunity for discovery and had the potential to affect a limited number of residents who currently reside at the facility. Facility census 82. Findings include: a) No hand hygiene While monitoring dining in the day room at the end of the 100 halls on 04/16/24 at 11:55 AM. It was noted that Nurse Aide (NA) #55 was opening each tray on a a counter putting cream and sugar in the coffee, butter on the rolls cutting up food etc NA #55 served eight (8) residents and failed to use any hand hygiene between the residents. On 04/16/24 at 12:45 PM, NA #55 was asked if she used hand hygiene between serving residents. NA #55 said no. The facility policy titled, Handwashing/Hand Hygiene, revision date 08/2019. *Use hand hygiene before and after eating or handling 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 staff interview, the facility failed to ensure the environment over which it had control was free from accident hazards. The 300 Hall of the facility was being remodeled and there were multiple identified accident hazards readily accessible to residents. The 400 Hall had dangerous chemicals stored on top of an isolation cart. These were random opportunities for discovery. Facility census: 80. a) 300 Hall On 11/14/23 at 1:40 PM, a random opportunity for discovery found the 300 Hall of the facility was under construction and in the process of remodeling resident rooms. The two (2) double doors to the 300 Hall were open. Additionally, the doors to the resident rooms under construction were open. There were no posted room numbers at this time. The following accident hazards were observed: - The sixth room on the left, at the end of the 300 Hall, had a one (1) gallon AC/NA air conditioner coil cleaner. The container read, Danger. Corrosive. Keep out of reach of children.…

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 medical record review, facility record review, policy review and staff interview, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and prevent the transmission of communicable diseases. The facility did not follow their policy and isolate Covid positive residents in their rooms. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #41 and #67. Facility census: 75. Findings included: a) Covid Policy The facility Covid-19 Prevention and Control Policy last updated 09/28/22, states all residents who test positive will be moved to the designated Covid-19 isolation unit or placed in isolation separate from other residents. b) Covid Outbreak Line List The facility line listing identifies a Covid-19 outbreak on 08/14/23 with five (5) residents and two (2) positive staff. The last positive resident was on 08/25/23 and the last positive staff was on 08/27/23. A total of 24 residents and 23 staff were listed as Covid positive. c) Resident (R) #41 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.

c) Resident #66 On 08/10/22 at 10:25 AM, after reviewing the treatment administration record (TAR) found resident #66 to have 12 blank holes for month of June for treatments for wounds, (apply Silver alginate to wound bed on sacrum with each dressing change after cleaning and prior to applying mepilex dressing until further notice. every shift). Four (4) blank holes for July for treatments,(apply Silver alginate to wound bed on sacrum with each dressing change after cleaning and prior to applying mepilex dressing until further notice. every shift). These treatment to wound were to be done by midnight shift as well. On 8/10/22 at 10: 40 AM, Interview with assistant director of nursing (ADON) after observing TAR showed 12 blank holes for June and four (4) blank holes for July of where treatment and observations were to be done on night shift. ADON stated, yes they are blank holes and treatments were not done by night shift nurse. Based on observation, staff interview and record review the facility failed to provide care as stated within the physician's orders. Medications for 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.

Based on facility documentation review, staff interview and policy review the facility failed to obtain current and active food handler cards for all dietary staff. This was true for four (4) of 13 dietary staff reviewed. The failed practice had the potential to affect more than a limited number of Residents. Staff identifiers: #55, #56, #59 and #137. Facility census 71. Finding included: Record review of the facility's policy titled, Preventing Foodborne Illness: Employee Hygiene and Sanitary Practices, dated 10/2017, stated, New hire employees will obtain a food handler's card within thirty (30) days of being hired. a) Food Handler Cards Record review of the facility's food handler cards showed that two (2) food handler cards were expired and two (2) dietary staff did not have food handler cards available. 1) Dietary Staff (DS) #55 A review of Dietary Staff (DS) #55's food handler card showed no available food handler card on record. During an interview on 08/08/22 at 12:20 PM, Director of Food Services (DFS) stated that DS #55's food handler card was thrown away as it expired in…

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 staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form and Notice of Medicare Non-Coverage (NOMNC) form to one (1) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed all skilled care residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifier: #370. Facility census: 71. Findings included: a) Resident #370 On 08/09/22 at 2:45 PM, a review was completed regarding the beneficiary protection notification liability notices given to Resident #370 who remained at the facility following the last covered day of Medicare Part A services. - Resident #370 began Medicare Part A skilled services on 05/11/22. The last covered day of Part A service was 06/27/22. There was no evidence that the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms were provided. 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 medical record review, staff interview, and policy review, the facility failed to ensure Resident #34, who lacked the capacity to consent, was free from sexual abuse. The facility also failed to ensure Resident #23 was free from verbal abuse. This was true for two (2) out of two (2) residents reviewed for the abuse pathway. This failed practice had the potential to affect a limited number of residents in the building. Resident identifiers: #34 and #23. Facility census: 71. Findings included: Review of the facility's policy Reporting Abuse to Facility Management outlined it was the responsibility of all employees to promptly report any incident or suspected incident of neglect or resident abuse. The policy defined sexual abuse as non-consensual sexual contact of any type with a resident. a) Resident #34 During a medical record review, completed on 08/09/22 at 8:45 AM, the following details were found: FIRST SEXUAL ABUSE INCIDENT ON 01/09/22 -Resident #34 is an [AGE] year-old female resident with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed implement written abuse and neglect policies and procedures for reporting in order to prevent all types of abuse. The facility failed to report an incident of sexual abuse with Resident #34. The facility failed to report an incident of verbal abuse with resident #23. This practice affected two (2) of three (3) residents reviewed using the abuse pathway in the survey process. Resident identifiers: #34 and #23. Facility census: 71. Findings included: a) Resident #34 Review of the facility's policy Reporting Abuse to Facility Management outlined it was the responsibility of all employees to promptly report any incident or suspected incident of neglect or resident abuse. The policy defined sexual abuse as non-consensual sexual contact of any type with a resident. The policy defined mental abuse as humiliation, harassment, threats of punishment, or withholding of treatment or services. Additionally, review of the facility's Abuse Prohibition Policy…

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 policy review, record review, and staff interview the facility failed to ensure employees reported a suspicion of a crime against another resident to law enforcement. This was true for one (1) of three (3) residents reviewed under the Abuse Pathway. This failed practice had the potential to affecta limited number of residents. Resident Identifier #34. Facility Census: 71. Findings included: a) Resident #34 Reivew of the facility's Abuse Prohibition Policy, with a revision date of 06/22/22, revealed the facility, and all employees, have an obligation to notify local law enforcement of actions that may be considered criminal in nature. During a medical record review, completed on 08/09/22 at 8:45 AM, the following details were found: -Resident #34 is an [AGE] year-old female resident with a diagnosis of Dementia, Major Depressive Disorder, and Anxiety. -Section C1000 of the Quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 11/16/21, documented Resident #34's cognitive…

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, staff interview, and policy review, the facility failed to ensure that an allegation of sexual abuse and an allegation of verbal abuse were reported immediately, but not later than 2 hours after the allegations were made, 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. The facility did not report a witnessed sexual abuse incident for Resident #34. The facility did not report within a two-hour timeframe a second witnessed sexual abuse incident for Resident #34. The facility did not report an allegation of verbal abuse made by Resident #23. This practice affected two (2) of three (3) residents reviewed using the abuse pathway in the survey process. Resident identifiers: #34 and #23. Facility census: 71. Findings included: Review of the facility's policy Reporting Abuse to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure that an incidents involving sexual abuse and verbal abuse were thoroughly investigated. The facility did not investigate a witnessed sexual abuse incident for Resident #34. The facility did not investigate an instance of verbal abuse for Resident #23. This practice affected two (2) of the three (3) residents reviewed using the abuse pathway in the survey process. Resident identifiers: #34 and #23. Facility census: 71. a) Resident #34 During a medical record review, completed on 08/09/22 at 8:45 AM, the following details were found: FIRST SEXUAL ABUSE INCIDENT ON 01/09/22 -Resident #34 is an [AGE] year-old female resident with a diagnosis of Dementia, Major Depressive Disorder, and Anxiety. -Section C1000 of the Quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 11/16/21, documented Resident #34's cognitive skills for daily decision making as severely impaired -A Nurses Note, dated 01/09/22 at 1:05 PM, noted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility inaccurately assessed a non-insulin medication as an insulin on the minimal data set (MDS). This was true for one (1) of two (2) Residents reviewed for insulin. Resident identifier: #64. Facility census: 71. Findings included: a) Resident #64 A review of Resident #64's medical record showed a diagnosis of Type (two) 2 Diabetes Mellitus with hyperglycemia. The physician orders showed prescribed diabetic medications to include Jardiance Tab 10 milligrams (MG) give one (1) tablet by mouth one (1) time a day , Metformin Tablet 500 MG give one (1) tablet by mouth two (2) times a day and Ozempic Solution Pen-injector two (2) MG inject 0.5 MG subcutaneously in the morning every Monday. The care plan showed a focus that stated, Diabetes Mellitus, takes oral diabetic medications and Ozempic. Further review of Resident #64's medical record showed a Quarterly minimal data set (MDS) dated [DATE] that stated Resident #64 received insulin for one (1) day. During an…

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

Based on record review and staff interview, the facility failed to revise the comprehensive care plan for one (1) of 26 residents reviewed during the long-term care survey process. Resident Identifier: #34. Facility census: 71. Findings included: a) Resident #34 Review of Resident #34's comprehensive care plan showed the following focus, [Resident #34's First Name] may express fear, crying, be easily startled, and/or display emotional numbness related to a male resident and inappropriate contact. The focus was initiated on 06/14/2022. One of the interventions listed was Remain with the resident at all times when levels of anxiety are high; reassure client of her safety and security. During an interview on, 08/10/22 at 11:44 AM, the Director of Social Services acknowledged Resident #34's care plan was not updated / revised following the first instance of inappropriate sexual contact on 01/09/22 but that it had been updated / revised following the second instance of inappropriate sexual contact on 05/18/22. The Director of Social Services stated, That was an oversight. The care plan…

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 deliver respiratory care services consistent with professional standards of practice. Oxygen supplies were not stored safely or properly for residents reviewed during the Long-Term Care Survey Process (LTCSP). This was a random opportunity for discovery. Resident identifier #268. Facility census: #71. Findings include: a) Resident #268 An observation on 08/08/22 at 3:05 PM found, Resident #268's nebulizer machine mask and tubing were laying on the bed side stand without being placed in a protective bag. During an interview on 08/08/22 at 3:05 PM, Resident #268 stated that they never put it in a bag. An interview on 08/08/22 at 3:16 PM with Licensed Practical Nurse (LPN) #104 confirmed that Resident #268's nebulizer mask should be placed in a protective bag when not in use. LPN #104 stated that she would have to go to supplies for a protective bag. .

Based on observation, staff interview and food tray temperatures the facility failed to serve food to residents that was at an appetizing temperature. This was a random opportunity for discovery. The failed practice had the potential to affect a limited number of residents. Facility census: 71. Findings included: a) Test Tray Temperature An observation on 08/09/22 at 8:10 AM showed an open-air food tray cart located on 200-hall with breakfast trays waiting to be served to Residents. During an interview on 08/09/22 at 8:10 AM, Nurse Aide (NA) #107 stated that the food tray cart arrived at 200-hall at 7:30 AM. A test tray temperature was taken on 08/09/22 at 8:25 AM of the last food tray on the 200-hall food cart. The test tray temperatures showed the following temperatures: French Toast Sticks- 93 degrees Sausage Patty- 95.2 degrees Milk- 57.3 degrees Orange Juice- 58.2 degrees During an interview on 08/09/22 at 8:25 AM, Director of Food Services (DFS) stated the food on the test tray was not within appropriate temperatures. .