Prescott Valley Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, manufacturer directions and policy review, the facility failed to ensure that food was stored in accordance with professional standards for food safety, and counters and equipment were properly sanitized to prevent cross contamination. The deficient practice could result in loss of freshness and nutritive value and the risk of foodborne illness. Findings include: During an initial tour of the kitchen conducted on September 6, 2022 at 9:40 a.m. with a cook (staff #35), a large brown box containing 5 heads of lettuce were observed to have brown and yellow areas with some yellow liquid on them. Staff #35 stated that one head of lettuce looked rotten, all five heads had very brown and wilted leaves. Then, she removed the box of lettuce heads from the large refrigerator. A second cook (staff #71) had joined the tour when a one-quart sized plastic bag of loose lettuce was observed in the large refrigerator. Staff #71 agreed the loose lettuce was brown and wilted. One open…

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 clinical record review, review of facility documentation, staff interviews and review of facility policy, the facility failed to ensure one sampled resident's (#48) right to be free from misappropriation of medication by a staff member. The deficient practice could result in resident's not receiving ordered medications. Findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus, chronic skin ulcer, and pain. Review of the Medication Administration Record (MAR) for October 2021 included Methocarbamol (muscle relaxant) tablet 750 milligrams (mg) every 6 hours as needed for muscle spasm. Review of the progress notes dated October 22, 2021 included: -Entry from the Administrator that the resident was notified that one of his medications was taken by a nurse for personal use. The resident indicated that he was never denied or missed any medications. -Entry from Social Services that the Nurse Practitioner was notified of the incident that…

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 staff interviews, clinical record review, facility record review, review of the State Agency database and review of facility policy and procedure, the facility failed to ensure that an allegation of misappropriation/drug diversion involving one resident (#48) was reported to Law Enforcement within the required time frame. The deficient practice could result in delayed law enforcement intervention. Findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus, chronic skin ulcer, and pain. Review of the facility investigation included that in the late afternoon of October 18, 2021, according to the floor nurse (Registered Nurse (RN) staff #25), the interim Director of Nursing (DON/staff #97) asked her to unlock her medication cart. The floor nurse indicated that she then stepped back and witnessed the DON pop a pill out of a medication card and put it in her pocket. She stated that she told the infection control nurse (Licensed Practical…

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 staff interviews, clinical record review, facility record review, review of the State Agency database and review of facility policies and procedures, the facility failed to ensure that an allegation of misappropriation/drug diversion involving one resident's (#48) property was reported to the state agency within the required time frame. The deficient practice could result in further abuse allegations not being reported timely to the State Agency. Findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus, chronic skin ulcer, and pain. Review of the facility investigation included that in the late afternoon of October 18, 2021, according to the floor nurse (Registered Nurse (RN)/staff #25), the interim Director of Nursing (DON/staff #97) asked her to unlock her medication cart. The floor nurse indicated that she then stepped back and witnessed the DON pop a pill out of a medication card and put it in her pocket. She stated that she told…

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 -Resident #47 was admitted to the facility on [DATE] with diagnoses that included myocardial infarction, atherosclerotic heart disease of the native coronary artery with unspecified angina pectoris, chronic obstructive pulmonary disease, chronic kidney disease, depression, anxiety disorder, and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. Review of the nursing notes revealed the resident was sent to the hospital on June 9, 2022 following complaints of 10/10 pain for abdominal distention. The discharge MDS assessment dated [DATE] revealed the resident's discharge was unplanned and that return was anticipated. A subsequent health status note dated June 10, 2022 indicated the resident was admitted to the hospital for pancreatitis. Further review of the clinical record revealed no evidence that the resident was notified in writing of the reason for…

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 clinical record review, facility documentation, staff interview, and review of policy, the facility failed to notify one sampled resident (#100)/representative of the facility bed hold policy including reserve bed payment, at the time of transfer/discharge. The deficient practice could result in residents not being informed of their bed hold rights. Findings include: Resident #100 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, cirrhosis of the liver, and ulcerative pancolitis. The resident was discharged on July 27, 2022 to an Acute Care Hospital. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of a nurse progress note dated July 26, 2022 at 11:45 p.m. revealed the resident was transferred to the hospital after a fall, the note contained vital signs from July 27, 2022 at midnight. The note included that the resident's…

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 clinical record review, staff interview, and facility policy and procedure, the facility failed to ensure that a care plan was developed for one sampled resident (#23) regarding wound care/skin integrity. The deficient practice could result in care issues not being addressed in residents' plan of care. Findings include: Resident #23 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, open wound located on the left foot, open wound located on the right lower leg, non-pressure chronic ulcer of the left foot. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had intact cognition. The assessment also revealed the resident was at risk of developing pressure ulcers, and had diabetic foot ulcer(s). A review of the Wound RN (Registered Nurse) assessment dated [DATE] revealed the resident had a non-pressure left plantar foot wound and that wound care was…

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 clinical record review, staff interviews, and policy and procedures, the facility failed to ensure one resident (#44) was free from accident hazards and received adequate supervision to prevent accidents. The sample size was 4. The deficient practice could result in residents being injured. Findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses that included heart failure, unspecified dementia without behaviors, and unsteadiness on feet. Review of the care plan dated July 30, 2019 for activities of daily living (ADLs) self-care performance deficit related to decreased mobility and range of motion as evidenced by assistance with ADLs included interventions for one-person limited to extensive assistance with transfers and one-person assistance with bathing. The annual Minimum Data Set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 8 indicating the resident had a moderate cognitive impairment. The assessment stated the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure Medication Regimen Reviews (MRRs) were completed on a monthly basis by the pharmacist for one resident (#9). The sample size was 5. The deficient practice could result in gradual dose reductions not being done or unnecessary medications being administered. Findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, unspecified dementia without behaviors, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 4 indicating the resident had severe cognitive impairment. Review of the MRRs from March 2022 through August 2022 revealed one MRR dated May 2022 which stated that the resident receives Seroquel 50 milligrams but does not have behavior monitoring to support the resident's displaying behaviors associated with Parkinson's induced psychosis. There were no…

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 clinical record reviews, staff interviews, and review of facility policy, the facility failed to ensure there was monitoring for target behaviors and adverse side effects, and failed to provide non-pharmacological interventions prior to medication use for one resident (#14) on psychotropic medications. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary. Findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses that included acute systolic congestive heart failure, asthma, and anxiety disorder. Review of the current care plan revealed a focus initiated on July 1, 2022 that the resident was on anti-anxiety medication therapy related to anxiety, with a goal that the resident would be free of any discomfort or adverse side effects from anti-anxiety medication use. The interventions included monitoring the resident's condition based on clinical practice guidelines or clinical standards of practice. Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure an advanced directive was accurately documented for one resident (#197). The sample size was 2. The deficient practice could result in residents receiving services which are not in accordance with their wishes. Findings include: Resident #197 was admitted to the facility on [DATE] with diagnoses that included nonrheumatic aortic valve, atherosclerotic heart disease, and benign prostatic hyperplasia. Review of the resident's electronic clinical record revealed that the dashboard reflected Resuscitate CPR (Cardiopulmonary Resuscitation). A physician's order dated [DATE] included the resident's Advance Directive as Resuscitate (CPR). Further review of the resident's clinical record revealed a Social Services admission note dated [DATE], that the resident signed the admission paperwork and the code status was DNR (Do Not Resuscitate). The progress note stated that the physician's order was inconsistent with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documents, the Center for Disease Control and Prevention (CDC) information, staff interview, and the Centers for Medicare & Medicaid Services (CMS), the facility failed to ensure one staff (#91) was tested for COVID-19 at the required frequency. The deficient practice could result in possible spread of the COVID-19 virus. Findings include: Review of the CDC COVID Data tracker revealed the county's level of community transmission for the facility was substantial and high from April 27, 2022 through September 10, 2022 and required COVID-19 testing 2 times per week. Review of the facility's COVID-19 Staff Vaccination Matrix for September 8, 2022 indicated that a registered nurse (staff #91) had a non-medical exemption granted from the COVID-19 vaccine. Staff #91's CDC POC (Point of Care) COVID-19 test report revealed that she was tested on [DATE], 18, 25, 2022 and September 1, 2022, and the results were negative. However, on September 2, 2022, the test came back positive. The printout of staff…

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 clinical record review, resident and staff interviews, and policy review, the facility failed to ensure a wheelchair met one resident's needs (#18). The deficient practice could place residents at increased risk for injuries. Findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses that included contracture of left hand, contracture of left shoulder, abnormal posture, and hemiplegia, left side. Review of the current Order Summary revealed an active physician order dated 11/2/2018 to assess and obtain a power/motorized wheelchair. Review of the Physician Note dated 1/22/21 revealed the patient was in a manual wheelchair. The note included the physician had requested a power wheelchair but the therapist reports that the resident does not qualify for a power chair and it is desirable that the resident continue use of the manual wheelchair to ensure daily exercise of the right side. Review of quarterly minimum data set (MDS) assessment dated [DATE] revealed a Brief Interview for…

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, staff interviews, and review of policy and procedures, the facility failed to ensure one of 13 sampled residents (#3) was treated with dignity and respect by failing to ensure the resident's urinary catheter bag was covered. The deficient practice could result residents not being treated in a dignified manner. Findings include: Resident #3 was admitted to the facility on [DATE], with diagnoses that included hypertensive chronic kidney disease; obstructive and reflux uropathy, retention of urine and benign prostatic hyperplasia. A review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had indwelling urinary catheter. During a random observation conducted at 2:38 p.m. on 3/30/2021, the resident was observed propelling his wheelchair in the main dining room. The resident's urinary catheter bag was not observed covered. Urine was observed in the catheter bag. During an interview conducted at 9:50 a.m. on 4/1/20201 with a certified nursing assistant…

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 clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#35) was informed of the risks and benefits of an antidepressant medication prior to administration. The deficient practice could result in resident/representatives not being fully informed of the risks and benefits of psychoactive medications. Findings include: Resident #35 was admitted on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, mood (affective) disorder, insomnia, unspecified, major depressive disorder single episode (mild), and anxiety disorder, unspecified. A quarterly Minimum Data Set (MDS) assessment dated [DATE] included a score of 13 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Review of the physician orders revealed the following: -An order dated December 24, 2020 for Trazodone (antidepressant) 50 milligrams (mg) one tablet by mouth at bedtime for sleeplessness related to…

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 clinical record review, staff interviews, review of facility policy and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that a significant change in status Minimum Data Set (MDS) assessment was completed for one resident (#18) who experienced a significant change in activities of daily living (ADL) status. The deficient practice could affect residents' continuity of care. The facility census was 44. Findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses that included hemiplegia, contracture left hand and left shoulder, abnormal posture, history of Transient ischemic attack, and cerebral infarction. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident received supervisory assist with bed mobility, transfers and toileting, and limited assist with dressing. Review of the following quarterly MDS assessment dated [DATE] revealed the resident received extensive assist with bed mobility, transfers, dressing and…

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 review of clinical records, staff interviews, and facility policy review, the facility failed to ensure a comprehensive person-centered care plan was developed for one resident (#39) regarding hospice services. The deficient practice could result in residents' needs not being met and a lack of services being provided. The resident census was 44. Findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, severe protein calorie malnutrition, and adult failure to thrive. A physician's order dated February 10, 2021 stated to refer to hospice services related to protein calorie malnutrition. Review of a progress note dated February 12, 2021 revealed the resident was started on hospice yesterday for protein calorie malnutrition. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had adult failure to thrive, malnutrition, a condition or chronic disease that may result in a life expectancy of less than 6…

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 clinical record review, staff interviews, and review of facility policies, the facility failed to ensure that one resident (#18) was given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living related to a significant decline in Activity of Daily Living (ADL) status. The facility census was 44. Findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses that included hemiplegia, contracture left hand and left shoulder, abnormal posture, history of Transient ischemic attack, and cerebral infarction. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident received supervisory assist with bed mobility, transfers and toileting, and limited assist with dressing. Review of the following quarterly MDS assessment dated [DATE] revealed the resident received extensive assist with bed mobility, transfers, dressing and toileting. Therefore, per the MDS assessments, between the dates of…

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 clinical record review, staff interviews, and policy review, the facility failed to ensure the provider order included a stop date for an as-needed (PRN) psychotropic medication order for one resident (#35). The deficient practice could result in residents receiving medications that may not be necessary. Findings include: Resident #35 was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, unspecified diastolic (congestive) heart failure, trigeminal neuralgia, mood (affective) disorder, insomnia, unspecified, and anxiety disorder, unspecified. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] included a score of 13 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. The MDS assessment also included the resident was receiving antianxiety medication. Review of the physician's orders for resident #35 revealed an order dated March 12, 2021 for…

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 observation, staff interviews, and review of policy and procedure, the facility failed to ensure there were no expired food items readily available for resident use. The deficient practice could result in residents receiving expired food items, resulting in possible foodborne illnesses. Findings include: On 4/1/2021 at 7:34 a.m., an observation was conducted of the nutrition refrigerator on the 300-400 units. The refrigerator contained an iced tea pitcher 1/4 full with a use by date of 3/31/2021. A refrigerator/freezer temperature log was posted on the door dated 4/1/2021 by staff #78. An interview was conducted on 4/1/2021 at 7:34 a.m. with a certified nursing assistant (CNA/staff #5). The CNA stated that the kitchen staff is responsible for checking the refrigerators and freezers. An observation was conducted on 4/1/2021 at 7:48 a.m. of the nutrition refrigerator located on the 100-200 units. The refrigerator contained an orange juice pitcher with a use by date of 3/31/2021. In the freezer of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of policy and procedures, the facility failed to ensure infection control standards were maintained by failing to ensure one resident's (#3) urine collection bag and tubing was not touching the floor. The deficient practice could result in the spread of infection. Findings include: Resident #3 was admitted to the facility on [DATE], with diagnoses that included hypertensive chronic kidney disease; obstructive and reflux uropathy, retention of urine and benign prostatic hyperplasia. A review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had indwelling urinary catheter. During a random observation conducted at 2:38 p.m. on 3/30/2021, the resident was observed propelling his wheelchair in the main dining room. The resident's urine collection bag and tubing were observed dragging on the floor. The Activity Supervisor (staff #95) was observed to pick up the urine collection bag and attach it to the wheel chair. During an…

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.