Caregivers of Pleasant Grove, Inc

Inspectors wroteBased on observations, interviews and a review of the facility's documents titled, Resource: Taking Accurate Temperatures, Proper Handwashing Technique, and Receiving And Storing Foods, the facility failed to ensure on 3/8/21 and 3/9/21: 1. dietary staff did not sanitized the food thermometer in the red bucket sanitizing solution and ensure staff washed her hands after using the cloth from the red bucket solution; and 2. food in the deep freezer was labeled with an open and use by date. This had the potential to affect 41 of 41 residents who received meals from the kitchen. Findings Include: 1. A review of a policy titled, Resource: Taking Accurate Temperatures with a date of 2017 revealed .Taking Accurate Temperatures using metal stem thermometers 1. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure Resident Identifier's (RI) #17, 34, and 29's, residents with urinary catheters, had a care plan specific enough to guide urinary catheter care, and RI #6 had a care plan for oxygen use. This affected three of three sampled residents with urinary catheters, and one of one sampled residents with oxygen. Finding Include: 1) RI #17 was admitted to the facility on [DATE]. Diagnoses inlcuded abnormal posture and muscle weakness. A review of RI #17's Active Orders As Of: 3/20/2021 revealed a prescriber written order . Change suprapubic catheter . (Q) month and as needed (PRN) .dated 10/30/2020. On 3/9/21 at 9:34 AM RI #17 was observed with an indwelling catheter. 2. RI #34 was admitted to the facility on [DATE] and had diagnosis that included Neuromuscular dysfunction of the bladder. [...]

Inspectors wroteBased on observation, interview, and a review of a facility policy titled HIPPA (Health Insurance Portability and Accountability Act) PRIMARY RULES EMPLOYEE SECURITY AND CONFIDENTIALITY AGREEMENT, the facility failed to ensure a Registered Nurse (RN) Employee Identifier (EI) #9, did not leave the Electronic Medication Administration Record (EMAR) screen visible and unattended which exposed Resident Identifier (RI) #17 personal information and medications. This deficient practice affected RI #17. One of five residents observed during the medication administration pass, and EI # 9 one of four nurses observed administering medication. Findings Include: Review of the facility's undated HIPPA PRIMARY RULES EMPLOYEE SECURITY AND CONFIDENTIALITY AGREEMENT revealed, . 2. [...]

Inspectors wroteBased on interview, medical record review and a review of the CMS's (Center for Medicare Services) Long-Term Care Facility RAI (Resident Assessment Instrument) 3.0, User's Manual Version 1.17.1 October 2019, the facility failed to: 1) accurately code RI (Resident Identifier) #38 Admissions MDS's (Minimum Data Set) to reflect he/she was receiving dialysis, 2) accurately code RI #17's Quarterly MDS as having an indwelling catheter. This deficient practice affected two of 21 sampled residents whose MDS's were reviewed. 1) A review of the CMS's, RIA 3. 0 User's Manual, Chapter 3, . MDS Items (O) documented: . O0100J, Dialysis Code . renal dialyses which occurs . at another facility record treatment of hemofiltration . in this item . RI #38 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a Diagnosis of End Stage Renal Disease and Chronic Kidney disease. [...]

Inspectors wroteBased on record review, interviews, and review of a facility policy titled WEIGHT LOSS INTERVENTION, the facility failed to recognize and assess a ten pound weight loss over eight days for Resident Identifier (RI) #200. This affected one of four residents sampled for weight loss. This deficient practice was cited as the result of the investigation of complaint/ report number AL00041289. Findings Include: A review of a facility policy titled, WEIGHT LOSS INTERVENTION POLICY & PROCEDURE with an effective date of 12/1/2010 revealed: Purpose: To intervene in unplanned weight loss process and prevent further decline in weight status and/or restore weight back to usual body weight . RI #200 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Unspecified Convulsions, Epilepsy and Spina Bifida. [...]

Inspectors wroteBased on observation, interviews and review of the 2017 Food Code, the facility failed to ensure there was an air gap between the 3 compartment sink and sewage drain. This has the potential for backflow from the sewage to the sink. This was observed on 1/14/20 and had the potential to affect 51 of 51 residents receiving meals from the kitchen. Findings Include: A review of the FDA 2017 Food Code revealed: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 1/14/20 at 11:00 AM, the surveyor entered the kitchen to observe tray line. The surveyor observed a dietary staff at the 3 compartment sink washing pots and pans. There was no air gap noted under the sink. The drain extended from under the sink into the wall behind the sink. [...]

Inspectors wroteBased on observation, interviews and review a facility policy Clean and Used Linen Policy and Procedure, the facility failed to ensure laundry staff was not transporting clean linens to the main building of the facility from the outside laundry building uncovered. This was observed on 1/13/20 and had the potential to affect 57 residents residing in the facility. Findings Included: A review of a facility policy titled Clean and Used Linen Policy and Procedure with an effective date of June 2019, revealed .From Pick-up Point to the Laundry: .Each linen storage cart must be carefully directed with the clean laundry on the cart covered. On 1/13/20 at 3:39 PM, the surveyor observed a laundry aide delivering linens to the hall on a 3 shelf rolling cart. On the very top of the cart was 2 stacks of brown and white blankets that were not covered. [...]

Inspectors wroteBased on observation, interviews, and review of a facility policy titled, Laundry Policy & Procedures Handling Soiled & Clean Linen, the facility failed to ensure a Laundry Aide did not allow clean towels, sheets, wash cloths, and socks from the dryer to touch the staff's shirt on the their upper body area, and did not put one white sock and one white wash cloth in the large laundry container with other clothing after dropping them on the floor. This had the potential to affect one of three halls of residents (16 of 46 residents) in the facility. Findings Include: A review of a facility policy titled, Laundry Policy & Procedures Handling Soiled & Clean Linen with no date, revealed .a. Linen should not be allowed to touch the uniform or floor .to avoid contamination of air, surfaces, and persons . On 11/28/2018 at 12:10 p.m., the surveyor observed the laundry room in the facility. [...]

Inspectors wroteBased on observations and interview, the facility failed to ensure the facility's most recent survey results were accessible for residents and/or visitors to obtain at the facility. This had the potential to affect all residents, staff, and visitors in the facility. Findings Include: On 11/26/2018 at 1:35 p.m., the surveyor toured the building and observed a note on the bulletin board, in the hallway across from Nursing Station One, that stated, Resident and Family Members. You can find a copy of the most recent survey in the foyer of our facility. However, the Surveyor observed no recent survey results posted in the foyer of the facility. On 11/26/2018 at 4:25 p.m., the surveyor again toured the building and observed no recent survey results posted in the foyer. [...]