The Blossoms At West Dixon Rehab & Nursing Center

Based on observation, record review, and interview, the facility failed to ensure an indwelling urinary catheter bag was covered to promote dignity for 1 (Resident #42) of 1 sampled resident who was reviewed for an indwelling catheter. The findings are: Resident #42's Order Summary dated 08/19/2024 was reviewed and indicated the resident had diagnoses of Alzheimer's disease and an obstruction in urine flow. The Order Summary indicated an order dated 07/24/2024 to change the [brand name] catheter tubing and bag as needed. An admission Minimum Data Set with an Assessment Reference Date of 07/31/2024 was reviewed and indicated Resident #42 had a Brief Interview for Mental Status score of 10, which indicated moderate confusion and for bladder and bowel appliances an indwelling catheter. A Care Plan dated 08/01/2024 was reviewed and indicated Resident #42 required a [brand name] catheter and a privacy bag. On 08/19/2024 at 8:53 AM, Resident #42 was sitting in a chair in the hallway with a catheter bag hooked on the right side of the chair. The contents of the catheter bag were visible,…

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 interview, it was determined the facility failed to ensure the Minimum Data Set (MDS) accurately reflected on section O0110, Special Treatment, Procedures, and Programs the resident received dialysis on admission or while a resident for 1 (Resident #31) of 1 sampled resident. This failed practice had the potential to inaccurately represent Resident #31's health status, impacting his care plan, reimbursement levels, and the ability to properly identify necessary interventions. Findings include: Review of the Medical Diagnoses revealed Resident #31 had diagnoses of end stage renal disease, right lower lobe cancer, and type II diabetes mellitus. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/16/2024 indicated a Brief Interview for Mental Status (BIMs) score of 06 (0-7 indicates severely cognitively impaired). Section I8000 revealed an active diagnosis of dependence on renal dialysis. a. A review of the Progress Notes, dated 07/08/2024 revealed 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, record review, interview, and facility policy review, it was determined the facility failed to ensure an uncapped razor was not left unattended in a resident's room to prevent accidents or injuries for 1 (Resident #44) of 1 sampled resident reviewed. to prevent accidents or injuries. The findings are: Review of the Medical Diagnoses revealed Resident #44 with diagnoses of schizoaffective disorder, dementia, and stroke. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 0f 02/28/2024 suggested a Brief Interview for Mental Status (BIMs) score of 4 (0-7 indicates severe cognitive impairment). Section GG 0130 indicated the resident was dependent for personal hygiene, and Section B1000 indicated the resident had impaired vision. a. Review of a facility policy titled, Shaving the Resident, (revised, October 2010) indicated after a resident is shaved the razor should be discarded in a designated sharps container labeled For Disposable Razors Only, located outside the resident rooms. b. Review of Resident 44's Care Plan, dated 03/28/2024,…

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, interview, and facility policy review, it was determined the facility failed to ensure oxygen was set at the physician ordered rate for 1 (Resident #67) of 1 sampled resident with oxygen orders to prevent the potential for respiratory complications. Findings include: Review of Medical Diagnoses revealed Resident #67 had diagnoses of chronic obstructive pulmonary disease, acute respiratory failure, and pulmonary emphysema. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/24/2024 suggested a Brief Interview for Mental Status (BIMS) score of 12 (7-12 indicates moderately impaired). Section 0110 C1 indicates Resident #67 has been on oxygen while a resident. a. A review of Physician Order, dated, 07/03/2024, indicated Resident #67 receives oxygen at 2 liters as needed for shortness of breath. b. A review of the Care Plan, dated 06/08/2023, showed Resident #67 had chronic obstructive pulmonary disease and to give aerosol, bronchodilators, and oxygen 2 liters as needed per physician orders. c. On 08/19/24 at 07:43 AM,…

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 interview, the facility failed to ensure a mechanical soft diet was provided during the lunch meal service for 1 (Resident #7) of 1 sampled resident reviewed for a therapeutic diet. The findings are: Resident #7's Order Summary dated 08/21/2024 was reviewed and indicated a diagnosis of type two diabetes and an order dated 05/21/2024 for a mechanical soft texture diet. A quarterly Minimum Data Set with an Assessment Reference Date of 06/14/2024 was reviewed and indicated Resident #3 had a Brief Interview for Mental Status score of 9, which indicated moderately confused. A Care Plan dated 06/27/2024 was reviewed and had no indication that Resident #7 required a mechanical soft texture diet, or the resident did not have upper teeth or dentures. A Dietary Progress Note dated 05/20/2024 was reviewed and indicated Resident #7 was recommended to be offered a mechanical soft diet related to difficulty chewing. On 08/19/2024 at 10:26 AM, Resident #7 was observed lying in bed awake and stated, I need my top teeth fixed. Resident #7 stated the breakfast…

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 interview, the facility failed to ensure a pneumococcal vaccine was provided for 1 (Resident #44) of 5 (Resident's #11, #44, #48, #80 and #81) sampled residents. reviewed for immunizations. The findings are: Resident #44's Order Summary dated 08/22/2024 was reviewed and indicated the resident had diagnoses of dementia and an irregular heartbeat. An order dated 02/23/2024 indicated Resident #44 could receive Pneumovax (a pneumonia vaccine) unless contraindicated. An order dated 08/20/2024 indicated, may give pneumococcal vaccine unless contraindicated or refused, and one dose of Prevnar 20 - 0.5 milliliters (ml) was ordered to be administered intramuscular (IM). On 08/22/2024, Resident #44's immunization screen was reviewed and Prevnar 20 was listed as an immunization required under consent status. On 08/22/24 at 1:21 PM, the Infection Preventionist was interviewed and provided a copy of an immunization record from a website. The document was reviewed and did not indicate if the pneumonia vaccine was administered to Resident #44. She was unable to explain…

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.

illness, failed to ensure 1 of 2 ice machines, 2 of 2 ice chests were maintained in clean and sanitary condition. These failed practices had the potential to affect 18 residents who received ice on 300 hall and 31 who received ice 600 hall and 84 residents who received meals from the kitchen, as documented on a list provided by the Assistant Dietary Supervisor on 08/29 /2023 at 12:43 p.m. The findings are: 1. On 08/28/23 at 09:09 AM, the following observations were made on the food preparation counter. a. A can opener attached at the end of the food preparation counter had dried black matter on the blade. b. An opened box of cream of wheat was on the counter. The box was not covered. 2. On 08/28/23 at 09:12 AM, the following observations were made on a shelf in the refrigerator: a. An opened box of sausage. The box was not covered or sealed. b. An opened bag of lunch meat. The bag was not sealed. c. An opened packet of cheese slices. it was not sealed. 3. On 08/28/23 at 09:16 AM. The following observations were made on a shelf in the freezer. a. An opened box of chicken breasts…

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 observations, and interviews the facility failed to ensure the resident rooms, hallways, dining room, and bathrooms were maintained for 5 of 5 rooms observed (room [ROOM NUMBER], 109, 102, 300 and 302). The findings include: On 8/28/23 at 9:41 AM observed a ceiling tile in room [ROOM NUMBER] bathroom above the toilet that was bulging and had brown water spots extending one fourth of the length of the tile extending into corner of air vent. On 8/28/23 at 10:29 AM observed the door frame in the bathroom shared by room [ROOM NUMBER] and 109 was rusted with sharp jagged edges at the bottom where the frame meets the floor. There was paint peeling off the door frame at the bottom and the paint was bubbled about one fourth of the way up the door frame. On 8/28/23 at 12:34 PM observed the bathroom light switch was not working in room [ROOM NUMBER]. On 08/28/23 at 12:41 PM observed the dresser drawers in room [ROOM NUMBER] were crooked, and the top right drawer was missing. There were no personal items 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 observation, record review and interview, the facility failed to ensure Activities of daily Living (ADL) care including was provided regularly for 5 (Resident #20, #28 #36, #65 & #72) of 17 (Residents #1,#2,#4,#8, #10, #13, #14 R#19, R#20, R#25, R#28, R#36, R#48, R#63, R#67, R#72, & R#74) sampled residents. The findings include: 1. Review of Resident #36 Quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 7/20/23 noted a Staff Assessment for Mental Status (SAMS) showed memory problems and severely impaired cognitive skills for daily decision making. The resident required extensive assistance for hygiene with 1-person physical assist. a. On 8/28/23 at 9:39 AM observed Resident #36 fingernails were uneven in length and jagged, with sharp edges on the corners of the nails on both hands. Nails varied in length from approximately 1/4 - 1/2 inches or more in length past the tips of fingers. b. On 8/29/23 at 2:38 PM observed Resident #36 fingernails remained long and uneven. The Surveyor asked Resident #36 if she would like to have the nails trimmed. 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, interview, and record review the facility failed to ensure interventions were implemented for 1 (Resident #28) of 3 (Resident #68, #4, and #28) sampled residents who had an intervention for anti- rolled backs to wheelchair after a fall, and the facility failed to ensure a gait belt was used in a 2 person transfer for 1 (Resident #21) of 6 (Resident #11, #15, #20, #21, #49, and #76) sampled residents. The findings are: 1. Review of a care plan for Resident #28 for fall risk showed an intervention of anti-roll backs to the wheelchair initiated on 7/27/23. a. A review of an incident report dated 7/26/23 indicated that Resident #28 was found lying on the floor with feet under bed and head under wheelchair. Under the immediate action taken section the document showed, Antiroll back applied to wheelchair. b. On 8/30/23 at 11:59 AM there was no anti-roll back device observed on Resident #28 wheelchair. c. During an interview on 9/01/23 at 9:41 AM LPN (Licensed Practical Nurse) #3, stated, when a resident falls, interventions are put in place immediately and stated she…

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 interview, the facility failed to maintain a medication error rate of less than 5% to prevent potential complications during the medication pass. The findings are: The facility had 36 opportunities for medication errors, with 2 errors. The team medication error rate was 5.56%. On 8/30/23 at 8:00 AM Licensed Practical Nurse (LPN) #3 did not administer Florastor 250mg to Resident #48. Review of August 2023 physician order for Resident #48 showed an order for Florastor 250 mg two times a day. On 8/31/23 at 2:35 PM LPN #3 was asked, Can you tell me why you didn't administer Florastor 250 mg when you did the medication pass on yesterday morning? She stated, I didn't know it was an over-the-counter medication. I was looking for a card. On 8/30/23 at 9:53 AM observed LPN #2 administer Resident #11's Advair 250/50 disc inhaler. LPN #2 then gave the rest of Resident #11's medications. LPN #2 did not have Resident #11 rinse her mouth after the Advair inhaler. On 8/30/23 at 9:53 AM LPN #2, said she was not aware the resident was supposed to rinse after…

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 interview, the facility failed to ensure that meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 7 residents who received pureed diets from 1 of 1 kitchen, according to a list provided by the Dietary Supervisor on 08/29/2023 The findings are: 1. The menu for lunch showed that the residents who received pureed diets were to receive a #6 scoop (2/3 cup) of noodles, a #8 scoop (1/2 cup) of pureed vegetable blend, a #8 scoop (1/2 cup) of pureed meat sauce and a #16 scoop of pureed bread. 2. On 08/29 /23 at 01:17 PM, the following observations were made during the noon meal service. a. Dietary Employee (DE) #3 used #16 scoop (1/4 cup) to serve a single portion of noodles to the residents on pureed diets, instead of a #6 scoop (2/3 cup) of pureed spaghetti. b. DE #3 used a #12 scoop (1/3 cup) to serve a single portion of pureed vegetable blend, instead of a #8 scoop (1/2 cup). c. DE #3 used #12 scoop (1/3 cup)…

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 interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 7 residents who received pureed diets and 2 residents who received pureed meat only, as documented on the list Dietary Supervisor provided by the Food Service Supervisor on 08/29/2023 The findings are: 1. 08/28/23 at 12:12 PM Dietary Employee (DE) #3 used 4 oz spoon to place 9 servings of meat sauce into a blender and pureed. At 12:15 PM DE #3 poured the pureed meat sauce into a pan and placed it on the steam table. The consistency of the pureed meat sauce was gritty and was not smooth. There were pieces of meat visible in the mixture. 2. 08/28/23 12:19 PM DE #3 used a tong to place 9 servings of noodles into a blender and pureed. At 12:24 PM DE #3 placed the pureed noodles on the steam table. The consistency of the pureed noodles was thick. 3. On 08/28/2023 at 01:17 PM 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 and interview the facility failed to prevent the potential for cross contamination in the facility laundry processing area. This failed practice had the potential to affect 84 residents who have their laundry done in the facility based on a list provided by the Nurse Consultant #1 on 9/1/23 at 07:54 AM. The findings are: During an interview on 8/31/23 at 1:47 PM with the Laundry Aide who stated after loading the contaminated laundry in the washing machine, she removes the gown and hangs it over the edge of one of the laundry containers. Observed the Laundry Aide pick up the dirty gown and moved it to the sink. The Laundry Aide confirmed the staff washed hands in the sink and stated there is not a special container to place the contaminated gown, it would go in the trash. On 8/31/23 at 1:50 PM observed the following in the laundry room: a wet blanket on the floor in the dirty area soaked with water that had been leaking from the washing machine. Observed a drink sitting on the table in the clean side of the laundry room, and an open coffee cup with lipstick marks…

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 interview and record review the facility failed to notify the State agency that 1 (Resident #2) of 1 (Resident #2) sampled residents with unknown injuries were reported to the Office of Long-term Care immediately or within 2 hours. The findings include: Review of the Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 8/08/23/23 indicated that Resident #2 Cognitive Skills for Daily Decision Making was Severely Impaired. Review of a care plan initiated on 8/29/23 showed, the Resident was noted to have an injury to the eye and was unable to give details of incident. A witness statement dated 8/30/23 indicated that on Sunday 8/27/23 a CNA (Certified Nurse Assistant) informed the nurse that Resident #2 eye was black. An incident report dated 8/28/23 indicated that the Office of Long-Term Care was notified on 8/28/23 at approximately 9:45 AM. It stated, resident noted to have dark area under left eye, cause unknown. Resident takes daily aspirin. On 9/01/23 at 9:56 AM the surveyor asked the DON (Director of Nurses), When should injuries of unknown source…

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, interview, and record review the facility failed to ensure wound care treatments and whirlpool baths were being performed according to physician orders for 1 (Resident #45) of 5 sampled residents (R#45, R#49, R#65, R#66, R# 76). The findings include: During an interview on 8/28/23 at 11:45 AM Resident #45 said, the wound dressings are not getting changed on the weekend and the wound will sometimes leak. The resident stated he does not always get the ordered whirlpool baths three times a week. Review of the physician's orders for wound care are as follows: a. whirlpool bath to be given every Monday, Wednesday, and Friday on the day shift with a start date of 7/31/23. b. Mupirocin ointment to the wound bed one time a day with a start date of 8/24/23. Review of the Treatment Administration Record (TAR) dated August 2023, showed on Saturday August 26, 2023, the Mupirocin ointment was not applied to the wound bed. Review of the TAR dated August 2023 showed an order to cleanse the wound and provided orders for the dressing to be completed one time a day with a start…

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, interview, and record review the facility failed to ensure 1 (Resident #4) of 4 (Resident #4, #15, #72, and #75) sampled residents oxygen tubing was kept in a storage bag when not in use. The findings were: A physician order for resident #4 dated 1/27/22 showed an order for oxygen at 2 liters by nasal cannula as needed for shortness of breath. A care plan for resident #4, initiated 7/13/20 showed, change oxygen tubing weekly on Sunday night shift, date and initial tubing and bag. On 8/28/23 02:45 PM observed the oxygen concentrator had oxygen tubing attached dated 8/28/23. The tubing was not on the resident, and it was not in a storage bag. On 8/29/23 at 1:34 PM observed the oxygen tubing on the oxygen concentrator. It was not in a storage bag. On 9/01/23 at 9:41 AM the surveyor asked LPN (Licensed Practical Nurse) #3 Where should oxygen tubing be stored if it's not being used? She stated, In a plastic bag on the oxygen tank. On 9/01/23 at 9:56 AM the surveyor asked the DON (Director of Nurse), Where should oxygen tubing be stored if it's not being used? She…

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 interview the facility failed to ensure that medications were not left in a resident's room for 1 resident (Resident #57) of 18 residents living in the 300 unit according to a list provided by the Social Services Manager on 08/28/2023 at 10:54 AM. The findings are: 1. On 8/28/23 at 1:03 PM observed a large, pink pill on the bedside table in resident #57 room. Resident #57 said, I couldn't swallow it, when asked where the pill came from. 2. On 8/28/23 at 1:10 PM the surveyor asked if Licensed Practical Nurse (LPN) #1 could identify the large pink pill on resident #57's bedside table and explain their process for giving medications. LPN #1 said, that is Depakote. I will go get him another one. During the interview LPN #1 said, our process is to give residents their pill and to make sure they swallow them. Anyone could walk in here and take that pill. We have a few wanderers in the 300 unit. They can all come out of their room. 3. On 08/31/2023 at 03:25 PM Nurse Consultant #3 said, We do not have a medication storage, or medication administration policy. 4.…

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 interview, the facility failed to ensure the refrigerated narcotic medications were stored in a permanently affixed compartment to prevent the potential of misappropriation of resident property for 1 of 1 medication room observed. The findings are: 1. On 8/28/23 at 8:27 AM observed Licensed Practical Nurse (LPN) #1 remove a small gray lock box from the refrigerator in the medication room. The locked narcotic box contained a lorazepam 2mg/ml (milligram per milliliter), 22ml multi- dose vial, and 3 Ativan 2 mg/ml vials. 2. On 8/28/23 at 8:29 AM during an interview LPN #1, confirmed the narcotic box was not permanently affixed in the refrigerator. 4. On 8/31/2023 at 4:01 PM during an interview the Director of Nursing (DON) confirmed the narcotic box should be permanently affixed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure they had a current Clinical laboratory Improvement Amendment (CLIA) certification. This failed practice affected 84 residents according to an alphabetical list of residents provided by the Social Manager on [DATE] at 10:40 AM. The findings are: 1. Review of the CLIA certification in Medication room [ROOM NUMBER] showed the certification expired on [DATE]. 2. On [DATE] at 10:12 AM the Nurse Consultant provided a receipt showing that she paid CLIA laboratory fees on [DATE] at 10:06 AM. During the interview the nurse consultant said, I just went online and paid the fee. We are supposed to have it for the facility. 3. On [DATE] at 4:01 PM during an interview the DON said, It is not acceptable for the CLIA certification to not be current. It is DON's responsibility to make sure that it is current.

Based on observation and interview the facility failed to ensure call lights were functioning. This failed practice affected 2 (Resident #57, and #68) of 18 residents living on the 300 unit according to a list provided by the Social Manager on 08/28/2023 at 10:54. The findings are: On 08/28/23 at 12:24 PM observed the light above the door in resident #68's room, and the wall did not come on when the call light was pushed. There was no response from the staff. On 8/28/2023 at 12:49 PM the surveyor pushed the call light button firmly, three times and observed the light outside resident #68's door, and the wall did not come on. There was no alarm, and no response from staff. On 8/29/2023 at 9:36 AM the call light clamped to resident #68's bed, and the light above the door, and at the wall did not come on when the call light buttons were firmly pressed for the A and B bed. No alarm was heard, and staff did not respond. On 8/28/2023 at 1:03 PM observed the call light outside resident #57's door, and at the wall did not come on when pressing the call light button. Staff did not respond.…

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.