Caregivers of Pleasant Grove, Inc

In the surveyor’s words

From the most serious findings on record at Caregivers of Pleasant Grove, Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 17, 2021

  Based on interviews, review of Resident Identifier (RI) #1's medical record, RI #1's hospital medical record, the Witnessed Fall report, the facility's investigation file and a complaint received by the State Survey Agency, the facility failed to ensure the Hoyer lift (sling) pad, used to transfer RI #1 on 9/3/2021 was in good condition. During the morning of 9/3/2021, Employee Identifier (EI) #8 and EI #9, both Certified Nursing Assistants (CNAs) attempted to transfer the resident from the bed to a shower chair. While the resident was hoisted into the air, the sling pad on the Hoyer lift broke and RI #1 fell to the floor on his/her right side and hit his/her head on the metal portion of the Hoyer lift. […]

• Immediate jeopardy, isolatedF835Sep 17, 2021

  Based on interviews and review of the DIRECTOR OF NURSING JOB DESCRIPTION and the ADMINISTRATOR JOB DESCRIPTION, the facility's Director of Nursing (DON), who is responsible for the direction of the overall nursing department and the facility's Administrator, who directs the day-to-day functions of the facility, failed to have a system in place to check the Hoyer lift equipment to ensure it was in good working condition. During the morning of 9/3/2021, Employee Identifier (EI) #8 and EI #9, both Certified Nursing Assistants (CNAs) attempted to transfer the resident from the bed to a shower chair. While the resident was hoisted into the air, the sling pad on the Hoyer lift broke and RI #1 fell to the floor on his/her right side and hit his/her head on the metal portion of the Hoyer lift. […]

• No harm, potential for more than minimal, widespreadF812Mar 11, 2021

  Based 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. […]

• No harm, potential for more than minimal, patternF580Feb 26, 2022

  Based on interviews, record review, review of facility incident report, review of facility policy titled, ACCIDENT/INCIDENT/UNUSUAL OCCURRENCE REPORT, and the State Agency's Intake Information, the facility failed to provide evidence that: 1. RI # 5's representative/responsible party was notified when RI #5 had an unwitnessed fall on the 11-7 shift on 02/21/2022. 2. Resident Identifier (RI) #1's representative/responsible party was notified when RI #1 developed a pressure ulcer on his/her bottom (identified at the hospital on 9/24/2021), and This deficient practice affected RI #1 and RI #5; two of three residents sampled for notifications. Findings include: 1. […]

• No harm, potential for more than minimal, patternF656Mar 11, 2021

  Based 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 REDACTED]. 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. […]