Every finding on record at Cypress Glen Retirement Community

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of antidepressant medication (Resident #2), discharge status (Resident #4), antiplatelet medication (Resident #106), and insulin injections (Resident #1). This was for 4 of 6 resident Minimum Data Set assessments reviewed. Findings included: 1. Resident #2 was admitted to the facility on [DATE]. Her active diagnoses included non-traumatic intracerebral hemorrhage, and history of cerebral infarction. Review of Resident #2's physician orders revealed on 8/22/24 she was ordered Duloxetine (an antidepressant medication) 20 milligram delayed release capsule by mouth every day for pain. Review of Resident #2's Minimum Data Set assessment dated [DATE] did not indicate she had received antidepressant medication. During an interview on 9/18/24 at 9:14 AM the Director of Nursing stated she was responsible for the Minimum Data Set assessments for skilled nursing. She concluded Resident #2 did receive an antidepressant during the lookback period of the 8/22/24 Minimum Data Set assessment and she must have coded it according to the medication's usage and not the medication classification as it was used for nerve pain for Resident #2. During an interview on 9/18/24 at 9:29 AM the Administrator stated Minimum Data Set assessments should accurately reflect the medications of residents. 2. Resident #4 was admitted to the facility on [DATE]. His active diagnoses included urinary tract infection, weakness, and polymyalgia with rheumatica. Review of Resident #4's progress note dated 8/15/24 and noted as a late entry for 8/13/24 revealed Resident #4 requested to discharge on 8/14/24. The resident felt he was ready to discharge and was comfortable going home. Review of Resident #4's discharge nursing summary dated 8/13/24 revealed Resident #4 was admitted to skilled nursing on 8/6/24. Resident #4's own ability to perform his own activities of daily living had improved to the point that he was able to perform them independently. He was walking without a walker and had good strength and balance in the hallways. Resident #4 was discharged from skilled nursing services to home. He was being discharged per his own wishes. Review of Resident #4's Minimum Data Set assessment dated [DATE] revealed he was coded as discharged to a short-term general hospital. During an interview on 9/18/24 at 9:14 AM the Director of Nursing stated she was responsible for the Minimum Data Set assessments for skilled nursing. She concluded Resident #4 was discharged home and the discharge assessment dated [DATE] was incorrect. During an interview on 9/18/24 at 9:29 AM the Administrator stated Minimum Data Set assessments should accurately reflect the discharge status of residents. 41009 3. Resident #106 was admitted to the facility on [DATE]. A review of a physician's order for Resident #106 dated 8/29/24 revealed 81 milligrams of aspirin delayed release 1 tablet by mouth every day. A review of Resident #106's August 2024 Medication Administration Record revealed documentation of 81 milligrams of aspirin delayed release 1 tablet by mouth was administered to Resident #106 on 8/29/24, 8/30/24 and 8/31/24. A review of Resident #106's admission Minimum Data Set (MDS) assessment dated [DATE] did not indicate she received anti-platelet medication during the 7 look-back period days of this assessment. On 9/18/24 at 10:45 AM an interview with the Director of Nursing (DON) indicated she completed the section of Resident #106's MDS assessment dated [DATE] indicating Resident #106 did not receive anti-platelet medication during the 7 look-back period days of the assessment. She stated this was an error. She went onto say resident MDS assessments should accurately reflect the medication they were receiving. During an interview on 9/18/24 at 9:29 AM the Administrator stated Minimum Data Set assessments should accurately reflect the medications of residents. 4. Resident #1 was admitted to the facility on [DATE]. A review of a physician's order for Resident #1 dated 9/9/24 revealed insulin lispro (a fast acting insulin) 6 units subcutaneously (under the skin) 3 times daily for diabetes. A review of Resident #1's September 2024 Medication Administration Record (MAR) revealed documentation insulin lispro 6 units was administered to Resident #1 subcutaneously on 9/9/24, 9/10/24, 9/11/24, and 9/12/24. A review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he received insulin injections on 7 of 7 look-back period days of this assessment. On 9/18/24 at 9:04 AM an interview with the Director of Nursing (DON) indicated she completed the section of Resident #1's MDS assessment dated [DATE] indicating he received insulin injections on 7 of the 7 look-back period days of the assessment. She stated she used the hospital record of insulin injections he received prior to his admission to the facility in addition to his facility MAR to complete the section. During an interview on 9/18/24 at 9:29 AM the Administrator stated Minimum Data Set assessments should accurately reflect the medications of residents.

Based on observations and staff interview the facility failed to cover refuse and food debris in 2 of 2 open trash cans and close the lids of 1 of 1 dumpster present in the facility's dumpster area. Findings included: On 06/03/19 at 3:55 pm an observation was made of the facility's dumpster area with the Food and Beverage Manager. Observations revealed two opened trash cans were present in the dumpster area. The first opened trash can contained a clear plastic liner ¾ full of refuse closed at the top but not covered. The second opened trash can contained a clear plastic liner open at the top, not covered and full of refuse and food debris. Closer observations of the second trash can revealed numerous live ¼ inch black flying insects were visible on the food debris in the trash can. Additionally, a large brown dumpster was present in the area. Observations of this dumpster revealed it contained 4 clear plastic bags of refuse and the dumpster's lids were not closed. During an interview on 06/03/19 at 3:55 pm the Food and Beverage Manager stated the food service staff who brought the two trash cans to the dumpster area should have emptied the trash that was in the cans into the dumpster. She further indicated that the trash cans should not have been left uncovered without lids in the dumpster area by staff. She went on to specify the dumpster lids should have been closed. On 06/04/19 at 11:41 am, in an interview, dietary aid #1 stated he left the two uncovered trash cans in the dumpster area on 06/03/19 at 3:30 pm. He stated the dumpster was not present at the time he left the trash cans. He also said he should have tied the trash bags to close them and covered the trash cans with lids before leaving them in the dumpster area. He further specified trash can lids were available for him to cover the cans to prevent the trash from attracting insects, but he did not use them. In an interview on 06/04/19 at 11:42 am the facility's Executive Director indicated it was her expectation that trash in the dumpster area be secured and covered. She further indicated this was to prevent insects and odors and just general good sanitation practice.

Based on record review and staff interviews, the facility failed to transmit a discharge Minimum Data Set (MDS) assessment to the Centers for Medicare and Medicaid Services (CMS) system within the required timeframe for 1 of 1 resident assessments reviewed (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1' s MDS assessments revealed a completed discharge assessment dated [DATE] that had not been transmitted to CMS as of 6/1/19. An interview was conducted with the MDS Nurse on 6/1/19 at 3:36 PM who stated Resident #1 was admitted to the facility on [DATE]. She stated she was unsure why the resident ' s discharge assessment dated [DATE] was not transmitted as of 06/01/19. An interview was conducted with the Administrator on 6/1/19 at 5:15 PM who indicated assessments should be submitted in compliance with MDS manual.

Based on record review and staff interviews the facility failed to accurately code an entry tracker Minimum Data Set (MDS) for 1 of 1 resident assessments reviewed for accuracy (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s MDS entry tracker with an Assessment Reference Date (ARD, the date used to base MDS coding responses) of 12/6/18 was coded with an entry date of 11/30/18. An interview was conducted with the MDS Nurse on 6/1/19 at 3:36 PM who stated Resident #1 was admitted to the facility on [DATE] and confirmed Resident #1 ' s entry tracker MDS contained an inaccurate entry date of 11/30/18. She reported Resident #1 had a bed hold in the facility from 11/30/18 until 12/6/18. The MDS Nurse stated the system must have taken the bed hold date of 11/30/18 and populated it as the admitted . An interview was conducted with the Administrator on 6/1/19 at 5:15 PM who indicated assessments should be completed accurately.

Based on observation and staff interview the facility failed to prevent cross contamination during the preparation of raw fruit, failed to sustain hot foods at 135 degrees Fahrenheit or higher during the entire operation of the trayline in the auxiliary kitchen, and failed to monitor food storage areas. Findings included: 1. At 10:10 AM on 03/12/13 a dietary employee removed a cantaloupe from the walk-in refrigerator. She did not wash it beforehand, and sliced it in half, laying the halves rind-side down on the cutting board. The employee then peeled the halves, washed them under running water, and placed the peeled fruit back on the cutting board which was contaminated by the unwashed rind. She used gloved hands to chop the melon by knife, and place it in fluted dessert dishes. At 3:15 PM on 03/12/13 the dietary management team stated melons should be washed before the peeling process began, and when the knife was used to make the first slice into the melons, the knife was to be washed under running water before completing the peeling of the fruit. At 3:45 PM on 03/12/13 a dietary employee stated fresh fruit should be washed after it was peeled, discarding the peeling in the sink, and washed again before it was sliced completely up. 2. At 4:48 PM on 03/11/13 beginning temperatures of hot food on the auxiliary steam table were documented as 145 degrees Fahrenheit for baked ham and 175 degrees for soup. At 5:15 PM on 03/11/13 trayline temperatures were taken again before the last resident tray was prepared. Using a calibrated thermometer the baked ham now registered 114 degrees Fahrenheit, and the the soup registered 124 degrees. At 3:15 PM on 03/12/13 the dietary management team stated prior to the morning of 03/12/13 only one set of food temperatures was recorded in the temperature log as the trayline began operation. They reported per the regulations hot foods had to be held at at least 135 degrees Fahrenheit during the entire operation of the trayline, but the facility really aimed for hot foods to remain at least 140 degrees during the entire process. At 3:45 PM on 03/12/13 a dietary employee stated hot foods should be kept at at least 160 - 165 degrees Fahrenheit during operation of the trayline. He reported two sets of temperatures were to be taken on the food at the trayline, the first set taken as the trayline began operation, and the other as the trayline began to cease operation. 3. During initial tour of the facility on 03/11/13, beginning at 10:23 AM, there was water in a portable mixer bowl, 2 of 6 bowls stacked atop one another were wet, 2 of 4 bowls stacked atop one another had dried food particles inside them, 2 rows of chocolate pie were not covered by a cover pulled over the cart in a full-length reach-in refrigerator, and 10 half-pints of milk in a reach-in refrigerator under the food preparation counters had a use-by date of 03/10/13. In the walk-in refrigerators there was no labels/dates on some partially used asparagus, a tray pan of cod/two tray pans of cheese sauce, and tray pans of taco meat and turkey were dated 03/06/13, a tray pan of haddock was dated 03/07/13, and a plastic storage bag of thawing chicken was not in a pan, and was leaking blood on boxes below. In the walk-in freezer a bag of French fries, carrots, a chicken patty, a five gallon container of ice cream, and a bag of tater tots were open to the freezer air. In another walk-in refrigerator a plastic storage bag of yellow peppers was without a label and date, and a one-gallon jug of picante sauce was dated, but the date was unreadable. In dry storage two crates of gelatin dessert mix was contaminated by loose sugary gelatin granules, and a spatula in a wall utensil holder was flush against the wall. 2 of 5 saute/omelette pans under food preparation counters were scratched, and 1 of 5 had dry food particles in it. During a follow-up tour of the food storage areas, beginning at 9:58 AM on 03/12/13, a gallon of teriyaki marinade and soy sauce were being stored in a dry storage cabinet, even though labeling documented the food items were to be refrigerated after opening. There were still sugary granules in the carts of gelatin dessert mix. In a walk-in refrigerator a tray pan of rice was dated 03/08/12, and an onion wrapped in plastic wrap was ot labeled or dated. In the walk-in freezer two bags of opened buns were without labels and dates. 4 of 5 five-gallon containers of ice cream had ill-fitting lids which exposed the food product to freezer burn. 5 of 6 muffin pans were stacked wet on top of one another. At 3:15 PM on 03/12/13 the dietary management team stated at the end of each shift the chef and dietary manager walked through storage areas to make sure leftovers were not outdated, foods past their use-by dates were disposed of, and all opened food items were labeled and dated. They reported leftovers and thawing meats should be used within three days of being placed in refrigerated storage, kitchenware placed in storage should be dry and clean, thawing meats should be stored in containers with sides to prevent the spillage of blood, opened foods should not be open to the freezer air, and stored food items should be neat and without residue which might attract insects. At 3:45 PM on 03/12/13 a dietary employee stated cooks monitored storage areas daily to make sure opened items were labeled and dated and wrapped. He also stated the cooks were supposed to dispose of food items past their use-by dates, which included leftovers in storage more than three days.