Glenwood Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to 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 infections. These were random opportunities for discovery: a half-consumed bottle of diet soda was on the medication cart, and an improper wearing of a mask in a resident care area. Facility census: 78. Findings included: a) Housekeeper #30 On 12/18/23 at 10:20 AM on [NAME] Hall it was noted that Housekeeper #30 was standing inside the doorway of room [ROOM NUMBER] with her mask not covering her nose and upper lip. When asked about the mask not being worn properly Housekeeper #30 shook her head back and forth before placing the mask over her nose and mouth. On 12/19/23 at 1:04 PM, ED #56 was informed of the above findings. b) Medication cart on [NAME] Hall On 12/18/23 at 10:30 AM it was noted a half-consumed bottle of diet soda was on 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 observations, and staff interviews, the facility failed to ensure the environment remains as free of accident hazards as is possible. These were random opportunities for discovery and had the potential to affect more than an isolated number of Residents. Facility census 76. Findings included: a) Housekeeping Closet During a tour on 08/29/23 at 8:23 AM, the keys to the housekeeping closet were noted to still be in the keyhole on the door knob. There was not a housekeeper in sight looking down two (2) hallways. At 8:39 am on 08/29/23 Infection Control Staff (ICS) #55 walked by and removed the keys from the door knob on the housekeeping closet. On 08/29/23 at 11:00 AM, the Administrator was informed of the above events. On 08/29/23 at 3:11 PM, the Administrator provided sign-in sheets with staff signatures regarding educational information about hazardous materials and storage. b) admission Observation Unit During the initial tour of the admission Observation Unit (AOU) on 08/29/23 beginning at 8:12 AM the treatment cart was observed unlocked and unattended. During the…

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

Based on observation, record review and staff interview the facility failed to provide nutritional adequacy by providing inconsistent portions of the food. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen. Facility Census: 76 Findings Included: a) Appropriate Portions During a review of the facility menu provided by the Culinary Director (CD) the noon meal on 08/29/23 read as follows: Meatsauce Spaghetti Noodles Caesar Salad Garlic Bread Deluxe Fruit Salad During a tour of the kitchen on 08/29/23 at 11:32 AM, the CD was assisting with serving the noon lunch meal. The CD was using a pair of tongs to serve spaghetti which according to the menu should have been served with a six (6) ounce scoop, The CD was asked what size scoop should be used to serve the spaghetti, she stated It should be six (6) ounce, but I just eyeball it. The CD and this Surveyor looked at the menu and confirmed the residents should be getting six (6) ounces of spaghetti. The CD was also serving spaghetti sauce. When asked if the menu called…

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 and staff interview 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. These failed practices were a random opportunity for discovery. Resident identifier: #14. Facility census 76. Findings included: a) Resident #14 While on the tour of the facility on 08/29/23 at 8:34 AM, it was noted Registered Nurse (RN) #79 was seen from the hallway providing wound care for Resident #14, without using any Personal Protection Equipment (PPE). There was a sign on the door for Enhanced Barrier Precautions (EBP). The signage read staff providing direct care are to wear gowns and gloves while providing care. As RN #79 was leaving the room without using hand hygiene she asked why she was not using any PPE. RN #79 said she did not think Resident #14 was still in EBP anymore. This surveyor pointed out the signage on the door. RN…

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 residents receive treatment and care in accordance with professional standards of practice, by failing to follow physician orders regarding weights and medication administration. This was true for four (4) of sampled residents reviewed during the complaint survey. Resident identifiers: #51, #29, #42, and #43. Facility census 76. Findings included: a) Resident #42 A review of the Medication Administration Audit Report (MAAR) found Resident #42 received scheduled medication outside of the hour before and hour after timeframe on more than one (1) occasion. In addition, the nursing staff failed to document why the medication was administered late. On 08/02/23, License Practical Nurse (LPN) #3 failed to administer Insulin Lispro injector pen scheduled to be given after meals at 6:30 PM. The documented time of administration was 8:11 PM. On 08/02/23, LPN #3 failed to administer Insulin Lispro injector pen scheduled to be given after meals at 6:30 PM. The documented time of administration was 8:54 PM. On 08/07/23, LPN…

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 provide residents with a diet that met the needs of each resident and conserved the nutritional value, and met the preferences of each resident. This was true for one (1) of one (1) sampled residents reviewed for nutrition during a complaint survey . Resident identifier: #56. Facility Census: 76. Findings Included: a) Resident #56 During a tour of the kitchen on 08/29/23 at 11:32 AM, the Culinary Director (CD) was assisting with serving the noon meal. The CD was using a four (4) ounce scoop to serve pureed spaghetti, which according to the menu should have been served with a eight (8) ounce scoop. The CD was not measuring the scoops properly. One(1) of the scoops served was half full, and one(1) was a quarter full. The CD was asked what size scoop should be used to serve the spaghetti, she stated It should be eight (8) ounce that is why I have to do two (2) scoops. Resident #56 name receives double portions so the resident would get six (6) total. During an interview on 08/29/23 at 11:47 AM, the…

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

Based on observation, record review, resident interview and staff interview the facility failed to provide the residents with menu items according to their preferences. This was a random opportunity for discovery and was true for Resident #29 and Resident #35. Resident identifiers: Resident #29 and Resident # 35. Facility Census: 76 Findings included: a) Resident #29 During the initial tour of the admission Observation Unit (AOU) 08/29/23 at 8:12 AM, an observation of Resident #29's breakfast tray meal ticket dated 08/29/23 read as follows: Biscuit and gravy 1 serving Hashbrown ½ cup Hot cereal ½ cup An observation of Resident #29's meal tray found they had a Biscuit with gravy and tater tots. There was no hot cereal on the tray. During an interview on 08/29/23 at 8:12 AM, Nurse Aide (NA)#78 acknowledged Resident #29 did not receive hot cereal on the breakfast meal tray. b) Resident #35 During the initial tour of the admission Observation Unit (AOU) 08/29/23 at 8:12 AM, an observation of Resident #35's breakfast tray meal ticket dated 08/29/23 read as follows: Biscuit and gravy 1…

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 a complete and accurate line listing for surveillances to ensure Antibiotic Stewardship is being used. This was a random opportunity for discovery and was true for Resident #65. Resident identifier: #65. Facility census 76. Findings included: a) Resident #65 During a review of the line listing it revealed, Resident #65 with given a complete round of Augmentin for seven days despite the fact she did not meet McGeer's criteria and had no growth on the results of the Urine Analysis (UA). On 08/29/23 at 1:48 PM Infection Preventionist (IP) was asked why Resident #65 got seven (7) days of antibiotic. IP said the daughter of Resident #65 threw a fit and would not let her stop it and the attending physician could be shown the Antibiotic Stewardship, but he refused to follow it.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to offer an eligible resident the Pneumococcal conjugate vaccine 20 (PVC 20). This was true for one (1) out of five (5) residents reviewed for immunizations. Resident identifier: #53. Facility census 76. Findings included: a) Resident #53 A review of Resident #53's medical record found Resident #53 was admitted on [DATE] with a history of type two (2) diabetes and Chronic respiratory failure. Resident #53's record showed they received the Pneumococcal 23 on 09/28/18. During an interview on 09/29/23 at 12:43 PM, Infection Preventionist was asked if Resident #53 was offered the Pneumococcal 20? IP said she thought Resident #53 refused it and would look for the refusal. On 08/29/23 at 4:10 PM, the IP stated she did not have a signed refusal from Resident #53.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility inappropriately completed and implemented the Physicians Order for Scope of Treatment (POST) form for one (1) one of (1) residents reviewed for advanced directives. The facility changed the resident's wishes for full code to a do not resuscitate. The resident had not granted permission for her wishes for end of life care to be changed. This failed practice had the potential to affect only limited number of residents. Resident identifiers: #30. Facility census: 78. Findings included: Observation on [DATE] at 11:49 AM showed Resident #30 coughing and wheezing and very short of breath. Resident was only able to speak in fragmented sentences. Resident was yelling, Oh, Oh every time she coughed. Resident stated, Help me. I can't breathe and it hurts. Surveyor left the resident's room informed Licensed Practical Nurse (LPN) #50 of resident complaints of shortness of breath and pain. LPN #50 stated Yea she didn't look good this morning and I called the doctor…

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 the Hospice agency developed a care plan with measurable goals. In addition, the facility failed to implement their Hospice care plan for notification of the Hospice agency when the resident experienced nausea and vomiting. The facility failed to implement their care plan for urinary catheter care. This was true for one (1) of 18 residents whose care plans were reviewed during the long-term care survey process. Resident identifier: 58. Facility census: 78. Finding included: a-1) Resident #58- Hospice care plan Record review found the resident was accepted for Hospice services on 11/15/22 for a diagnosis of Parkinson's disease. A Hospice agency care plan, dated 11/15/22 was located in the electronic medical record. On 01/24/23 at 8:41 AM, an interview with the DON, confirmed that the most recent documentation the facility had in house from the Hospice agency was a care plan dated 11/15/22. Handwritten on the care plan was the first name of the Hospice social worker, the last name of the Hospice chaplain, as…

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 have evidence of collaboration with the Hospice agency providing services for one (1) of one (1) resident reviewed for the care area of Hospice. In addition, the facility failed to assess patient's needs and notify the Hospice agency of a change in condition. Resident identifier: #58. Facility census: 78. Findings included: a-1) Resident #58 Record review found that resident was accepted for Hospice services on 11/15/22 for a diagnosis of Parkinson's disease. On 01/24/23 at 8:37 AM, Registered Nurse (RN) #122 was asked where to locate a resident's Hospice agency notes. She responded that she would look for them under the nurses notes but that she is not sure and she would have to find out. On 01/24/23 at 8:39 AM, Licensed Practical Nurse (LPN) #114 stated she would look for a resident's Hospice agency notes under the miscellaneous tab of the electronic medical record. On 01/24/23 at 8:41 AM, the DON (Director of Nursing) stated that they would have to request the Hospice notes from the Hospice agency. Record review…

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 pressure ulcer care was provided consistent with professional standards of practice. A Registered Nurse (RN) failed to assess and stage the pressure areas within 24 hours of admission and/or after the development of pressure ulcers. This was true for two (2) of three (3) residents reviewed for the care area of Pressure Ulcers. Resident identifiers: # 42 and #327. Facility census: 78. Findings include: a) Resident #42 Review of Resident #42's medical records found the resident was noted on 12/26/22 to have a stage IV (4) pressure ulcer on sacrum by Employee #133, a Licensed Practical Nurse (LPN). On 01/01/23, Employee #71, a Registered Nurse (RN), measured and staged Resident #42's pressure ulcer on the sacrum. Additionally, the wound assessments completed on 1/3/23 by, RN #71, documented the wrong date the pressure ulcer was first observed and the wound assessments completed on 1/10/23 and 1/17/23 by RN #124, documented the wrong date…

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 follow the current standards of practice for indwelling Foley catheter's for two (2) of four (4) residents reviewed for the care area of catheter during the long-term care survey process. Resident identifiers: #58 and #327. Facility census: 78. Findings included: a) Resident #58 Observation of the Resident on 01/23/23 at 11:30 AM, found the resident was in bed. The catheter drainage bag was laying in the floor beside the bed. Registered Nurse (RN) #46 observed the catheter and said she would take care of the issue. On 01/24/23 at 10:56 AM, the observation was discussed with the Director of Nursing (DON) and the Assistant DON. No further information was provided at the close of the survey. b) Resident #327 Observation on 01/23/23 at 12:45 PM, found the Resident was in bed. The Resident's catheter bag and tubing were laying on the floor. Nursing Assistant (NA) #40 immediately fixed the issue when notified by the surveyor. On 01/24/23 at 10:56 AM, the observation was discussed with the Director of Nursing (DON) and 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 ensure each resident's drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for one (1) of five (5) residents reviewed for unnecessary medications. The resident was prescribed a antipsychotic medication in absence of appropriate indication / rational for use, and absence of non-pharmacological interventions attempted before prescribing the medication. Resident identifier: #58. Facility census: 78. Findings included: a) Resident #58 Record review found the resident was receiving the antipsychotic medication, Risperdal 0.25 milligrams (mg), give 1 tablet by mouth at bedtime for sexual urges with hallucinogenic fantasies of sexual episode. (Hallucinogenic is defined as producing hallucinations, such as a hallucinogenic drug.) Further review found Risperdal was prescribed on 06/07/22. The following is the nursing note prompting the start of the medication: 06/07/22 at 11:36 Nurses Note Note Text: Please note 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 observation, resident interview and staff interview the facility failed to promote and facilitate resident self-determination through support of resident choice in regards to having access to and choosing their own clothes. This failed practice had the potential to affect more than a limited number of residents that currently reside at the facility. Resident identifiers: Resident #63, # 49, # 61, #12, #17, and #3. Facility census 66. Findings included: a) Resident # 63 On 10/11/21 at 10:40 AM, Resident # 63 was sitting in a wheelchair wearing a yellow facility gown. A facility thin, white blanket covered the front of her body. The resident was shaking and saying she was cold. On 10/11/2021 at 11:00 AM, Nurse Aide (NA) #80 said she is only given a gown to dress everyone in and as far as she knows Resident # 63 has not had her own clothing for three to four weeks. While interviewing this nurse aide, a female staff person walked by (but would not stop to give her name) and stated, I called the Social Worker, and she is going to come and talk to you about this. Moments later…

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, resident interview and staff interview the facility failed to ensure comfortable and safe temperature levels for the residents. This was a random opportunity for discovery. This failed practice had the potential to affect more than a limited number of Residents that currently reside in the facility. Resident identifiers: #63, #66, #58, #37, and #15. Facility census 66. Findings included: a) Rooms 13-28 On 10/11/21 at 10:40 AM, Resident # 63 sitting in wheelchair wearing a yellow facility gown and a facility thin white blanket covering the front of her body. Resident # 63 stated she was cold. On 10/11/2021 at 10:47 AM, Resident # 66 stated she was cold and only has one warm sweater. On 10/11/2021 at 10:50 AM, Resident #58 was looking inside of boxes for her shoulder wrap because she was cold. On 10/11/2021 at 10:55 AM, Resident #37 was wearing a long sleeve shirt, a sweater and a fleece blanket. The resident stated she was cold. On 10/12/2021 at 8:30 AM Maintenance Assistant # 79 was asked…

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, staff interview and record review, the facility failed to prevent the spread of infections when staff failed to complete hand hygiene, in between passing meal trays to residents on the 400 hallway. In addition, Resident #57's nebulizer and supplies were not stored in a sanitary manner to prevent the spread of infections. This failed practice had the potential to affect a limited number of residents. Resident identifier: #57. Facility census: 66 Findings Included: a) Meal observation on 400 hallway On 10/11/21 at 11:45 AM, an observation of the lunch time meal, found Nursing Assistant (NA) #74 passing meal trays in the rooms. NA #74 failed to use hand sanitizer in between meal tray passes. NA #74 was asked, Should hand hygiene be completed when passing meal trays? No response was given. After surveyor intervention, NA #74 used the hand sanitizer located on the wall of the 400 hallway. Review of the policy, Infection prevention and control program, found: Under hand Hygiene Protocol: All staff shall wash their hands when coming on duty, between patient contacts…

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 provide an environment free from accident hazards over which it has control. Medication was unsecured and unattended allowing access to the medication by residents, unauthorized staff, or visitors. Resident identifier: #57. Facility census: 66. Findings Included: a) Resident #57 An observation on 10/11/21 at 12:14 PM found, Anoro Eleptan 62.5 Aerosol Powder Breath Activated at Resident #57's bed side, unsecured and unattended and allowing access to the medication by residents, unauthorized staff, or visitors. During an interview with Resident #57 on 10/11/21 at 12:14 PM she stated the nurses usually don't let her keep it her room, but sometimes they do let her keep it until they deliver her lunch tray. During an interview on 10/11/21 at 12:19 PM, Licensed Practical Nurse (LPN) #16 verified, the Anoro Eleptan 62.5 inhaler should not be left out in the room. LPN #16 removed the 30ml (milliliter) cups at this time. LPN #16 stated that Resident #57 did not have a medication self-administration order.…

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 resident interview, observation, staff interview and medical record review the facility failed to provide a therapeutic diet that takes into account the resident's clinical condition and preferences, when there is a nutritional indication. This is true for one (1) of one (1) resident reviewed for the care area of dialysis during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #45 Facility Census: 66. Findings Included: a) Resident #45 During an interview on 10/11/21 at 1:08 PM, Resident #45 stated the food is horrible, I order doordash a lot. I get too many potatoes, I go to dialysis two times a week and can't have potatoes especially before going to dialysis. Look at this menu, there is potatoes on here everyday. Review of Resident # 45's medical record on 10/12/21 at 12:00 PM, found the physician order, dated 07/09/21 for. Regular, regular texture, no oranges, no prune juice, no salt packet on tray, sugar substitute, no stewed or fresh tomatoes, no tomato juice, no potatoes. On 10/12/21 at 12:13 PM, Nursing Aide (NA) #22 served Resident # 45's lunch tray.…

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 date and label a multi-use insulin pen when first accessed with the initial date. This was true for one (1) of three (3) insulin pens observed. This was a random opportunity for discovery during a medication cart check. Resident Identifier: Resident #5. Facility census 66. Findings included: a) Medication Cart On 10/13/21 at 8:41 AM, a review of the medications in the medication cart revealed there was one (1) out of three (3) insulin pens that did not have the date it was first accessed on the pen. This was witnessed and verified by Licensed Practical Nurse #87. The Humulin 70/30 Kwikpen (used to treat and control blood sugar levels in the blood stream) belonged to Resident #5. .

Based on observation, and staff interview the facility failed to store and handle food in a safe and sanitary manner in the kitchen. This failed practice had the potential to affect a limited number of residents that currently reside in the facility. Facility census 66. Findings included: During a tour of the kitchen on 10/11/21 at 11:31 PM, the following practices were observed: -16 white Styrofoam cups, containing food, were in the refrigerator without any dates on the cups or lids to indicate when the food was prepared. -11 green plastic bowls, containing food items, were in the refrigerator without any dates. -On a shelf containing square containers and plastic baskets was a metal dish with a blue gift bag laying on the dish. The gift bag had the name of a staff member. -Large amount of ice buildup in the back of a stand up freezer. Observation on 10/11/2021 at 11:35 AM, found Dietary Aide # 82 trying to get a pair of tongs hanging on a half-circle ring containing multiple serving ladles, spoons, and tongs. The ring was very high above DA #82's head. Dietary Aide # 82 could only…

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.