SNF

bunny9095

Form2567-Staff.pdf

Home >English homework help >SNF

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page 1 of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0657

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to ensure the timeliness of each resident's person-centered care plan is reviewed and revised by an interdisciplinary team member who has knowledge of the resident and his/her needs for two (Residents #11 and #56) of six residents reviewed for person-centered care plan revision.

1. The facility failed to ensure Resident #56's care plan had been revised to reflect current fall interventions.

2. The facility failed to ensure Resident #56's care plan had been revised to reflect foley catheter care after it had been pulled out by the resident.

3. The facility failed to ensure Resident #11's care plan had been revised to reflect the resident's positioning during mealtimes.

This failure placed residents at risk of having inaccurate comprehensive care plans and not receiving appropriate care.

Findings included:

1. Review of Resident #56's electronic face sheet on 04/07/2021 revealed the resident was an [AGE] year old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Review of Resident #56's MDS Assessment, dated 03/29/2021, revealed the resident had a BIMS score of 00, which indicated severe cognitive impact. The resident required extensive assistance of two persons in bed mobility and toilet use; and total dependence with the assistance of two persons in transferring. The MDS did not indicate any falls since reentry to the facility on [DATE].

Observation on 04/06/2021 at 10:49 a.m. of Resident #56 revealed the resident was in bed, right side of bed flushed against the wall. A half side rail was in the up position on the left side of the bed. A foley catheter tubing leading from under the covers, with clear residual fluid draining by gravity to a non-transparent drainage bag, was resting directly on a fall mat was observed next to the bed and a call button at the outer left head of bed which was outside of the resident's reach.

(continued on next page)

675754 16

11/02/2021

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0657

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

Review of Resident #56's electronic care plans on 04/07/2021 at 1:07 p.m . indicated the following:

Focus - Resident has a history of falling (Initiated 12/18/2020, Revision on: 04/02/2021)

1/31/21: Fall; slid out of bed. C/O pain. Xrays ordered

4/1/21 Fall with no injuries

Goal - I will not experience any injuries from falls x 90 days (Initiated 12/18/2020, Revision on 12/29/2020, Target date 04/18/2021)

Interventions (Initiated 12/18/2020 unless otherwise noted) reflected:

Anticipate and meet the residents needs

Keep call light in reach and encourage her to use call light for assistance as needed.

Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician (position responsible - NURSE)

Monitor her positioning while in bed. (Date initiated: 04/02/2021)

There was no mention of the use of a fall mat.

Review of Resident #56's active orders, revealed the following:

-01/20/21, SAFETY DEVICES - SIDE RAILS = May have half side rails up while in bed to enable resident to turn and reposition him/herself as desired;

These orders are good for 60 days;

These are current orders and supersede all previous orders.

-02/12/2021, HOYER LIFT FOR ALL TRANSFERS.

-02/24/21,PRESSURE RELIEF - AIR MATTRESS = air mattress on bed at all times Check every shift for placement and working properly. every shift.

There was no mention of active orders for the use of a fall mat.

Review of the facility's Incident Report, involving Resident #56, dated 04/06/2021 at 12:01 p.m. revealed two unwitnessed falls for Resident #56 on 01/31/2021 at 10:54 p.m. and 04/01/2021 at 5:05 p.m Review of the Fall Investigation Worksheet(s) indicated no interventions were put into place to prevent reoccurrence of falls or reflect any injuries. However, the progress note entered by LVN K on 04/01/2021 at 5:00 p.m. indicated the patient sustained a skin tear to right shoulder.

(continued on next page)

162675754

11/02/2021

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0657

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

The incident report completed by LVN L on 01/31/21, revealed part C - Analysis of Facts, # 1 - root cause of fall: Resident did not call for help; # 2 - interventions put into place to prevent reoccurrence of fall was blank; and # 3 described always call for help as teaching provided.

The incident report completed by LVN K on 04/01/21 revealed Part C, #1: Resident moves a lot in bed, roll overs and change positions.; Numbers 2 & 3 had na for interventions and teaching.

No interventions were put into place to prevent reoccurrence of falls.

LVN's K and L were not available at time of interviews.

During an interview on 04/08/2021 at 10:52 a.m., RN G stated the facility protocol for fall prevention and person-centered care planning following a fall is to assess the resident for injuries, assist back to bed, educate patient on fall precautions, start 72 hour neuro checks for unwitnessed falls, notify doctor and family, document the fall, and complete a Fall Investigation Worksheet. RN G further stated that the nurse would implement safety measures. When asked to give an example of safety measures, RN G gave examples of placing the bed in the lowest position, frequent nurse checks, and placing the call light within reach encouraging the patient to call for help. When asked if there were other safety measures and if orders are needed, RN G replied a fall mat, followed by stating an order is not needed. Regarding person-centered care, RN G stated a comprehensive care plan is developed within 72 hours of admission, reviewed quarterly, and updated as needed. When asked what types of person-centered interventions are placed for fall prevention and patient safety, RN G stated the care plan focus is per patient needs. Interventions include making sure the call light is in reach, monitoring change of condition, monitoring bed position, and patient education. When questioned regarding Resident #56's person-centered care plan that was revised 12/29/2020, RN G stated the care plan interventions for falls had been reassessed for effectiveness, reviewed, and changed as needed to meet the resident's needs. When asked for clarification, RN G stated that it is protocol for the nurse caring for the patient to reassess and update the care plan accordingly after a fall or an incident. During the continued interview on 04/08/2021 at 10:52 a.m., RN G stated that he was not on shift at the time of the fall on 04/01/2021. However, was on shift the next day. Review of electronic notes created by RN G dated 04/02/21 at 3:02 p.m., revealed RN G performed neuro checks on day 2 after the fall occurred. When RN G was asked did he review or update care plan related to the fall RN G stated yes, to do frequent patient rounds to address patient needs. The intervention entered 04/02/2021 in the electronic care plan to Monitor her positioning while in bed confirmed statement. When asked for clarification about a fall mat, RN G replied, it's in place. When asked if an order is needed, RN G stated an order is not needed. There is no intervention for a fall mat on the electronic version of the care plan when reviewed prior to interview. The printed care plan provided following the interview with RN G indicated a revision initiated on 04/08/2021 to ensure that floor mat is in place when resident is in bed. When questioned regarding appropriate interventions for fall preventions, RN G stated having a fall mat in place, call light, low bed, and frequent rounding by staff were appropriate interventions.

2. Review of Resident #56's MDS Assessment, dated 03/29/2021, revealed the resident had an indwelling catheter and was always incontinent of bowel.

Review of Resident #56's electronic care plans on 04/07/2021 at 1:07 p.m . revealed the following:

Focus -- Resident utilizing indwelling F/C placing resident at risk for UTI (Initiated 01/28/21)

(continued on next page)

163675754

11/02/2021

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0657

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

Goal -- Resident will be free of s/s UTI next 90 days (Initiated 01/28/21, target date 04/18/21)

Interventions (Initiated 12/18/20) (position responsible - NURSE, CNA) stated:

Monitor F/C for proper placement, patency q shift and prn

Monitor for s/s UTI i.e. elevated temp, dysuria, hematuria, altered mental status, c/o lower abdominal pain/discomfort, etc.

Offer, encourage fluids, with meals, meds, prn with assist as needed.

Provide F/C care per facility protocol q shift, prn

Review of Resident #56's nursing progress notes indicated at least two incidents of the resident pulling out catheter.

Review of Resident #56's nursing progress note, created by RN G on 04/02/2021 15:15:26, revealed . Foley catheter was replaced because old was pulled out by resident .

Review of Resident #56's nursing progress note, created by Charge Nurse M dated 04/06/2021 at 11:28 p.m. , revealed, Resident accidentally pulled out foleys catheter 14FR . [doctor] notified and ordered to re-insert the catheter in the morning.

Review of Resident #56's nursing progress note, created by Charge Nurse M dated 04/07/2021 at 6:16 a.m., revealed, Attempt to re-insert Foleys catheter but was unsuccessful as resident did not cooperate. Will report the upcoming nurse about the refusal and need to re-insert the catheter.

There was no mention of interventions regarding the resident's behavior of pulling out catheter in the electronic care plans.

Charge Nurse M was not available for interview to provide detail about resident's behavior of pulling catheter out or why care plan was not updated.

During an interview on 04/08/2021 at 10:52 a.m., when asked about the nursing role in providing care and patient-centered care planning for indwelling catheters, RN G stated the protocol for foley catheter care is to change every 30 days and as needed and interventions are to monitor for UTI.

During an interview on 04/08/2021 at 12:29 p.m., when asked about the protocol and purpose of patient-centered care planning and revision, ADON F stated the protocol for person-centered care planning and revision is to identify interventions needed to provide quality care specific to each resident. When asked what could happen if care plan interventions are not updated or appropriate for the resident, ADON F stated the resident would not receive the best quality care. ADON F was asked to provide an example of when interventions are revised or added to the care plan, stated after a fall. When asked to explain why Resident #56's care plan for falls and indwelling catheter did not reflect person-centered interventions related to psychosocial needs and behaviors, ADON F stated, wasn't sure why it wasn't updated. When asked to give specific interventions for a resident pulling out catheter, stated to replace the catheter, notify doctor, monitor for behaviors that cause pulling out catheter.

(continued on next page)

164675754

11/02/2021

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0657

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

Review of the facility's Physician Services Policy on 04/08/2021, indicated that a copy of a recent hospital discharge summary containing required information needed for the care of the resident may be utilized . the physician must give orders for clinic visit.

3. Review of Resident #11's face sheet, dated 04/07/2021, revealed she was [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Review of Resident #11's MDS Assessment, dated 01/31/2021, revealed the her cognitive status was not indicated. The resident required extensive two-person assistance in bed mobility, transfers, eating, and toilet use. Resident #11 required extensive assistance of one person in dressing and personal hygiene.

An observation on 04/06/2021 at 12:15 p.m. of Resident #11 in her room during the lunch meal revealed the resident was heavily contracted on her left arm and was slouched and leaning far left with her head hanging down to her left shoulder. The resident's bed was inclined at a 45-degree angle with her bedside table in front of her along with her lunch meal. Resident #11's head and body were not positioned towards the bedside table. The resident was observed eating with her bare right hand instead of a utensil, picking up the food and bringing it to her mouth. Food was observed all over her hands, her mouth, and her neck, despite there being a towel placed over her chest to prevent food spills onto her clothes. There were no staff in the room to assist the resident in positioning .

An interview on 04/06/2021 at 12:15 p.m. with Resident #11 revealed the resident was uncomfortable with her position which prevented her from eating comfortably and stated she was unable to adjust the bed on her own. She stated staff would have to adjust the bed for her. The resident stated no one had come into the room to position her and she would like them to attempt to position her. She stated staff usually left her at that angle, which made it difficult for her to eat. Resident #11 stated she would like to sit upright and could sit up with the use of pillows . She stated she would always tell staff about her concern but felt no one cared to help.

Review of Resident #11's care plan, dated 02/10/2021, did not address of the positioning of Resident #11 during mealtimes.

Review of Resident #11's record revealed no documentation relating to the positioning the resident or the resident's refusal during mealtimes.

(continued on next page)

165675754

11/02/2021

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0657

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

An observation and interview on 04/06/2021 at 12:32 PM. with CNA A revealed during lunch time, she would pass out trays and then assist residents who needed assistance in feeding. She stated Resident #11 ate well and did not need assistance in eating. She stated it was important for residents to be positioned correctly to avoid aspiration and choking. CNA A stated Resident #11 was not able to adjust her bed or position herself and needed staff assistance in doing so. CNA A stated Resident #11 did not like to be positioned because it hurt for her to sit up. She stated the resident wanted to lay all the way down to eat but that could not be done because of choking and aspiration concerns. At this time CNA A entered Resident #11's room to demonstrate to the surveyor the positioning issue by attempting to incline the bed further up. Resident #11 was still leaning far to the left with her head at her left shoulder. The resident expressed pain at about 75-degrees angle and the CNA put the bed back to 45-degrees. CNA A reiterated the resident did not like to sit up. In response, Resident #11 stated that was not true and stated if the CNA would take the pillow away from her head, the resident would feel more comfortable. The CNA took the pillow from the back of the resident's head and inclined the bed again. The resident expressed pain again at about 75-degrees before the CNA declined the bed again. The resident was still leaning far left with her head at her left shoulder. CNA A stated the resident would be uncomfortable at any position no matter how much they tried to position her . The aide did not attempt to get help from other staff.

An interview on 04/06/2021 at 12:38 p.m. with LVN B revealed it was difficult to position the Resident #11 because she could not tolerate any position higher than a 45-degree angle and would lean far to the left despite positioning attempts. LVN B stated every time staff attempted to position her, even when she was medicated for pain, the resident would express she was uncomfortable. LVN B stated the resident had been that way since the LVN had worked at the facility, which was since the summer of 2020. LVN B stated she was not sure if the concern was in Resident #11's care plan . LVN B stated the DON was aware of the concern.

An interview on 04/06/2021 at 12:41 PM with ADON C revealed Resident #11 was difficult to position because she would want to lay down during mealtimes. ADON C stated every time staff attempted to position Resident #11, she would get upset. ADON C stated she had gone into the room to drape a towel over the resident's chest so she would not get food on her clothes. ADON C stated dietary had talked to Resident #11 before and therapy had worked with her in the past but because she plateaued, the resident was discharged from therapy. ADON C stated because the resident was non-compliant with any direction, the only intervention they could attempt was to position her to what she would most tolerate . The ADON stated she was not sure if the issue was in the care plan.

An observation on 04/07/2021 at 12:02 PM revealed two aides entering Resident #11's room to attempt to sit the resident up for the lunch meal. More aides were called in to assist in positioning and sitting up the resident.

An observation on 04/07/2021 at 12:10 PM revealed the aide had set up the resident's tray and provided Resident #11 with a spoon to eat. While the resident's bed was still at about a 45-degree angle, the resident's head and body were facing the resident's lunch meal and was observed to not be leaning far to the left. Pillows were observed propping the resident up evenly under the resident's head, back, and arms. Resident #11 appeared more comfortable and was eating with a spoon. The resident appeared clean and tolerated the position she was in . The resident stated she still felt uncomfortable despite being positioned but was not as vocal about her concern compared to the day before

(continued on next page)

166675754

11/02/2021

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0657

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

Review of the facility's Speech Therapy SLP Evaluation and Plan of Treatment, dated from 10/05/2020 to 11/3/2020, revealed the following:

-Reason for Referral: Patient referred to ST due to new onset of risk for aspiration, risk for weight loss, risk of dehydration, dysphagia .indicating the need for ST to maximize nutrition/hydration [with] oral motor facilitation

-Behaviors Impacting Safety: Poor self-monitoring skills, decreased activity tolerance as intake continues and reduced attention to task

-Position During [Evaluation] = inadequate, decreases safety/communication

-Supervision for Oral Intake = Close supervision .

-Swallow Strategies/Positions: To facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: general swallow techniques/precautions, bolus size modifications, alternation of liquid/solids and rate modification upright posture for [more than] 30 minutes after meals and upright posture during meals

An interview on 04/07/2021 at 12:15 PM with ADON C revealed Resident #11 did not require any supervision during meals and was able to eat on her own. She stated she was not aware ST notes indicated Resident #11 required close supervision. ADON C stated the DON and ADON C had not worked in the building long and was unaware of any prior assessments.

An interview on 04/07/2021 at 12:58 PM with the DON revealed when she first started working in the building, she had noticed Resident #11's position during eating and had attempted to assist in feeding the resident. She stated the resident would refuse to let the DON feed her. The DON stated when she spoke to the therapy department, she was told the only recommendation was set-up only during mealtimes. The DON stated she was not aware the resident's positioning concern during mealtimes was not care planned . The DON stated when she started working in the building, she assumed the information was already accurate and up to date.

Review of the facility's Comprehensive Person-Centered Resident Care Planning Operational/Resident Care Policy, dated 04/08/21, indicated all or in part, but not limited to: . must meet professional standards of quality; culturally competent and trauma-informed. The plan of care will have goals that focus on maintaining a safe, comfortable and supportive environment .

167675754

11/02/2021

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0675

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

Honor each resident's preferences, choices, values and beliefs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for one (Resident #11) of four residents reviewed for quality of life.

The facility failed to position Resident #11 appropriately during her lunch meal in her room.

This placed residents who are dependent on staff for ADL care at risk of increased anxiety, breathing difficulty, eating difficulty, and poor quality of life.

Findings included:

Review of Resident #11's face sheet, dated 04/07/2021, revealed she was [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Review of Resident #11's MDS Assessment, dated 01/31/2021, revealed the resident's cognitive status was not indicated. The resident required extensive two-person assistance in bed mobility, transfers, eating, and toilet use. Resident #11 required extensive assistance of one person in dressing and personal hygiene.

Review of Resident #11's care plan, dated 02/10/2021, did not address of the positioning of Resident #11 during mealtimes.

Review of Resident #11's progress notes from 01/20/21 to 04/05/21 revealed no documentation relating to Resident #11's positioning during mealtimes.

(continued on next page)

168675754

11/02/2021

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0675

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

Review of Resident #11's record revealed no documentation relating to positioning the resident or the resident's refusal during mealtimes.

An observation and interview on 04/06/2021 at 12:32 PM. with CNA A revealed during lunch time, she would pass out trays and then assist residents who needed assistance in feeding. She stated Resident #11 ate well and did not need assistance in eating. She stated it was important for residents to be positioned correctly to avoid aspiration and choking. CNA A stated Resident #11 was not able to adjust her bed or position herself and needed staff assistance in doing so. CNA A stated Resident #11 did not like to be positioned because it hurt for her to sit up. She stated the resident wanted to lay all the way down to eat but that could not be done because of choking and aspiration concerns. At this time CNA A entered Resident #11's room to demonstrate to the surveyor the positioning issue by attempting to incline the bed further up. Resident #11 was still leaning far to the left with her head at her left shoulder. The resident expressed pain at about 75-degrees angle and the CNA put the bed back to 45-degrees. CNA A reiterated the resident did not like to sit up. In response, Resident #11 stated that was not true and stated if the CNA would take the pillow away from her head, the resident would feel more comfortable. The CNA took the pillow from the back of the resident's head and inclined the bed again. The resident expressed pain again at about 75-degrees before the CNA declined the bed again. The resident was still leaning far left with her head at her left shoulder. The aide did not attempt to get help from other staff.

An observation on 04/07/2021 at 12:10 PM revealed the aide had set up the resident's tray and provided Resident #11 with a spoon to eat. The resident's bed was at about a 45-degree angle with the resident's head and body facing the resident's lunch meal and was not observed leaning far to the left with her head hanging by her left shoulder. Pillows were observed propping the resident up evenly under the resident's head, back, and arms. Resident #11 appeared more comfortable and was eating with a spoon. No food was observed on her hands, face, and neck. The resident appeared clean and tolerated the position she was in.

Review of the facility's Speech Therapy SLP Evaluation and Plan of Treatment, dated from 10/05/2020 to 11/03/2020, revealed the following:

-Behaviors Impacting Safety: Poor self-monitoring skills, decreased activity tolerance as intake continues and reduced attention to task

-Position During [Evaluation] = inadequate, decreases safety/communication

-Supervision for Oral Intake = Close supervision

(continued on next page)

169675754

11/02/2021

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0675

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

An interview on 04/07/2021 at 12:15 PM with ADON C revealed she was not aware ST notes indicated Resident #11 required close supervision. ADON C stated the DON and she had not worked in the building long and were unaware of any prior assessments.

An interview on 04/07/2021 at 12:58 PM with the DON stated she was unaware ST noted the resident required close supervision and stated close supervision meant that as long as the resident was close to the nurse's station and staff were walking back and forth to ensure the resident was safe, it would be adequate. The DON stated when she spoke to the therapy department, she was told the only recommendation was set-up only during mealtimes. The DON revealed she was not aware the resident's positioning concern during mealtimes was not care planned. The DON stated when she started working in the building, she assumed the information was already accurate and up to date.

Review of the facility's Positioning and Moving Residents in Bed policy, undated, revealed, .Position resident who is [CONDITION(S)] in supported Fowler's position .Elevate head of bed 45 to 60 degrees .Sit resident as straight as possible .Position head with chin slightly forward .Provide support for involved arm and hand on over bed table in front of resident; place arm away from resident's side and support elbow with pillow . Position flaccid hand in normal resting position with wrist slightly extended arches of hand maintained

1610675754

11/02/2021

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0677

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal grooming for 1 of 61 residents (Resident #48) reviewed for ADLs.

The facility failed to ensure Resident #48 was provided with nail care.

This failure could affect residents who were dependent on staff for grooming at risk for poor personal hygiene, odors, and a decline in their quality of life.

Findings include:

Record review of the face sheet dated 02/21/2021 for Resident #48 revealed he was a [AGE] year old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Record review of Resident #48's MDS dated [DATE] revealed his BIMS was 14 indicating cognition was intact. Resident #48 could understand when asked questions and give appropriate responses. Further review of his MDS revealed he required extensive assistance with one-to-two-person physical assist for personal hygiene, dressing, therapy and transfers.

An observation on 04/07/2021 at 1:46 p.m. revealed Resident #48's toenails on his left and right feet were noticeably long, specifically the big toenail on one foot and the toe next to the big toenail on the right foot were extremely long and appeared to be about 1 to 2 inches in length. The toenails were also brown in color, and looked hard and callused.

Interview on 04/07/2021 at 1:47 p.m. Resident #48 stated he had told the aides multiple times when entering his room and during baths that he wanted his toenails clipped. Resident #48 stated he told the nurse aide on 04/05/2021 that he wanted his toenails clipped and was told they would inform the podiatrist . The resident stated he told the aide to make sure he was first in line to get his toenails cut and that he wanted them done as soon as possible and wish they would get cut ASAP. The resident could not remember the aide and/or aides that he had told to cut his nails, but he told the Rehabilitation Director on 04/06/2021, who then informed the Social Service Director.

In an interview on 04/07/2021 at 1:50 PM LVN B stated the process for nail care was that the nurse's aides, therapy aides and those who were responsible for showers/baths should notify the Charge Nurse, who once notified would contact the Social Service Director to schedule the podiatrist . LVN B had not seen the resident's toenails and was not aware that his nails needed cutting. Resident #48 is not a diabetic, so the aides and/or staff should have been able to trim his nails had the nails been attended to at his admitted in February or in March when the podiatrist visited the facility. Because Resident #48's toenails were not attended to, the toenails had grown extremely long, hardened and brown in color, where a normal nail clipper could not cut through or access the nail because of the width.

(continued on next page)

1611675754

11/02/2021

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0677

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

Interview on 04/08/2021 at 9:40 a.m. the Social Service Director stated she was responsible for coordinating nail services. The Social Service Director stated the podiatrist was scheduled and visited the facility in March 21 [2021]. She stated she received a list from the DON with the names of residents to give to the podiatrist, who visited the facility on 03/25/2021 and Resident #48 was not included on the list. She stated she emailed the family on 04/05/2021 to request permission to get Resident #48's toenails clipped . She stated that due to the length of the nails, she asked for the caregiver's permission, but also to inform them that they were going to schedule an appointment to get his toenails trimmed. No one asked the resident directly, even though he was able to request his toenails to be clipped and had already done so multiple times. She stated she was informed that his nails needed clipping by LVN B on 04/05/2021 and on 04/06/2021 by the Rehabilitation Director. The Social Service Director stated the process was for the CNA's or therapists to notify the nurse and then the nurse would inform her, so she could coordinate it with the family and get the podiatrist scheduled. The Social Service Director stated the podiatrist last visited the facility on 03/25/2021 and the next visit was not scheduled until May 2021. The Podiatrist cuts the toenails of the resident's that are diabetics and those that have nails that require additional assessment and special trimming.

Record Review of Resident #48's shower sheets on 04/08/21 at 9:45 AM revealed Resident #48 received his baths on Monday's, Wednesday's and Friday's between 6AM-6PM. The shower sheets for 02/08/2021, 02/22/2021, 03/22/2021 and 03/29/2021 for Resident #48 reflected there were no notations on the shower sheet indicating any issues with toenails.

Record Review of the electronic charting for notes or updates on Resident #48's nail care revealed the first notation/mention of a nail care concern was documented in on 04/04/2021.

Interview on 04/08/2021 at 9:55 a.m. with LVN I revealed the process for nail care was the CNAs were responsible for notifying the nurse (so they could assess the resident. LVN I stated if nail care was needed, then he would attempt to cut/trim the nails himself. He stated he visited Resident #48 earlier in the morning of 04/08/2021, but did not conduct a nail care assessment or was aware the resident's nails needed trimming as no documentation was in his chart or he was not made aware. The Surveyor requested someone to measure of Resident #48's toenails and LVN I stated he would take a measurement. At this time LVN I measured Resident #48's toenails and stated he had one toenail on each foot that were extremely long. LVN I stated the two toenails he measured were both 2 inches long.

Interview on 04/08/21 at 9:57 a.m. ADON C stated CNAs were to notate in the resident's chart under Tasks if they trimmed the nails, but also to make the charge nurse aware if nails need to be trimmed. ADON C stated she had not had any comments or concerns regarding nail length for Resident #48. ADON C stated CNA J was one of the aides that gave Resident #48 his bath, but ADON C was unable to identify the signatures of the other aides on the shower sheets . The ADON stated that the LVNs or Charge Nurse are responsible for trimming the nails of the resident's on a regular basis, when they are notified by the aides that a resident's nails need trimming, whether fingernails or toenails.

(continued on next page)

1612675754

11/02/2021

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0677

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

Interview on 04/08/2021 at 10:05 AM the DON stated the process for nail care was for the aides to notate in the resident's chart under Tasks if they trimmed the nails. She stated the podiatrist would not come out to the facility until March 2021 due to COVID-19, but she stated the staff should have been checking the resident's nails on a regular basis. She stated because of COVID-19 some of the staff had been doing their own thing and not following the processes and procedures. However, nail care is proper hygiene and grooming that she be monitored regularly, along with areas that require shaving. The DON stated the Wound Treatment Nurse attempted to cut Resident #48's toenails on 03/25/21, but was unable to do so because his toenails were so long. She stated he did not document in Resident #48's records that his nails needed clipping or that he attempted on 03/25/2021.

Record Review of Progress Notes dated 04/08/2021 at 11:18 a.m. revealed the DON attempted to cut Resident #48's toenails on 04/08/2021, but his nails were too wide for her to cut with nail clippers. She was able to cut one toenail without the resident having any discomfort, but did not try the two nails that were 2 inches long due to the nail thickness. Resident #48 was referred to podiatry on 04/05/2021. She observed Resident #48 was alert and sipping on a drink during the nail trimming attempt.

Interview on 04/08/2021 at 12:37 p.m. the DON stated that going forward the process would be for the Wound Treatment Nurse to make weekly rounds on all residents to assess whether the residents needed nail care. The DON stated they had also added an addendum to the facility policy regarding fingernail and toenail care that reflected the new process.

Record review on 04/08/2021 of the facility's undated Nail Care - Fingernails and Toenails policy and the Addendum regarding Fingernail and Toenail Care revealed the new policy addendum regarding prioritizing the podiatry nail care list and the weekly assessment to be done by the Wound Treatment Nurse . The Nail Care Policy stated the policy was to promote cleanliness, to prevent injury and to prevent infection, but did not mention quality of life.

1613675754

11/02/2021

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0812

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Many

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen.

1. The facility failed to ensure food items in the dry storage were dated and sealed.

2. The facility failed to ensure food items in the walk-in freezer were dated, labeled, and sealed.

3. The facility failed to ensure clean pans were free from food debris.

These failures affected residents by placing them at risk for food-borne illness.

Findings included:

1. An observation and interview on 04/06/2021 at 9:16 AM, with the Dietary Manager, of the dry storage revealed the following as identified by the Dietary Manager:

- One carton of mashed potatoes opened with no date opened.

- One bag of panko breadcrumbs unsealed with a large rip in the bag, exposing the breadcrumbs to air.

- One bag of dry milk unsealed with a rip in the bag, exposing the dry milk to air.

An interview on 04/06/2021 at 9:16 AM with the Dietary Manager revealed it was important to date/label food items to ensure food items were not served out of date. She stated it was also important to seal food items to ensure pests and contaminants did not get into the food. The Dietary Manager stated the dry milk was used for emergencies and it had never been used. She stated she would throw it out as it had been in the dry storage for a long time already

2. An observation and interview on 04/06/2021 at 9:20 AM, with the Dietary Manager, of the walk-in freezer revealed the following as identified by the Dietary Manager:

- One bag of frozen corn nuggets, undated and unlabeled.

- One bag of frozen sweet potato fries, undated and unlabeled.

- One bag of frozen tator tots, undated and unlabeled.

- One bag of frozen chicken nuggets, undated and unlabeled.

- One slab of frozen roast beef, undated.

- One bag of frozen pepperoni, undated, unlabeled, and unsealed.

(continued on next page)

1614675754

11/02/2021

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0812

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Many

- One bag of opened frozen corn wrapped in plastic wrap, undated.

- One bag of frozen peas, undated.

- Three bags of frozen Brussel sprouts, undated.

- Three bags of frozen corn, undated.

- Two bags of frozen Italian blend vegetables, undated.

- Four bags of frozen spinach, undated.

- Two bags of frozen carrots, undated.

An interview on 04/06/2021 at 9:20 AM with the Dietary Manager revealed kitchen staff took the frozen food items out of the boxes and did label them with a marker, but the marker would not stick. She stated she would use something different to label the food items. The Dietary Manager stated it was also important to date and seal freezer food items to ensure they did not become freezer burnt.

3. An observation on 04/07/2021 at 12:34 PM of the clean dishes rack revealed the following:

- One small steam table pan was observed with a creamy pink residue at the bottom of the pan.

- One large steam table pan was observed with food crumb residue at the bottom of the pan.

An interview on 04/07/2021 at 12:34 PM with the Dietary Manager revealed kitchen staff normally washed off the food residue in the 3-compartment sink before running it through the low-temp dishwasher to ensure cleanliness. The Dietary Manager took the two steam table pans to have them rewashed .

Review of the facility's Cleaning the Refrigerators and Freezers policy, dated 01/01/2010, revealed, .Freezer (daily) .Check that all foods are properly covered, labeled, and dated .Dry storage .All items are dated with a received date .Open items are also dated with an open date .

Review of the U.S. Public Health Service Food Code, dated 2017, revealed:

3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition.

(A) A food specified in 3-501.17(A) or (B) shall be discarded if it:

(2) Is in a container or package that does not bear a date or day;

(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or

3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.

(continued on next page)

1615675754

11/02/2021

Department of Health & Human Services Centers for Medicare & Medicaid Services

Printed: Form Approved OMB No. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

STREET ADDRESS, CITY, STATE, ZIP CODE

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

A. Building

B. Wing

(Each deficiency must be preceded by full regulatory or LSC identifying information)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID: Facility ID: If continuation sheet Page of

675754 04/08/2021

Traymore Nursing Center 4315 Hopkins Ave Dallas, TX 75209

F 0812

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Many

(A) Except when packaging food using a reduced oxygen packaging method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Review of the U.S. Public Health Service Food Code, dated 2017, reflected: .4-603.14 Wet Cleaning. (A) Equipment food-contact surfaces and utensils shall be effectively washed to remove or completely loosen soils by using the manual or mechanical means necessary such as the application of detergents containing wetting agents and emulsifiers; acid, alkaline, or abrasive cleaners; hot water; brushes; scouring pads; high-pressure sprays; or ultrasonic devices. (B) The washing procedures selected shall be based on the type and purpose of the equipment or utensil, and on the type of soil to be removed

1616675754

11/02/2021