Brookdale Santa Catalina

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to develop a complete baseline care plan that included the instructions needed to provide effective and person-centered care for one resident (#3). The deficient practice could result in resident care needs not being met. Findings include: Resident #3 was admitted on [DATE] with diagnosis including a displaced fracture of the left femur, pain in the left hip, hypertension, Alzheimer's disease, major depressive disorder, fibromyalgia, dementia, and heart disease. A review of the MDS (minimum data set) revealed a BIMS (brief interview of mental status) score of 11, indicating the resident had moderate cognitive impairment. A review of the baseline care plan initiated on June 17, 2024 revealed that resident #3 was noted to be a high fall risk and that the call light should be in reach, and that resident needs prompt responses to all requests for assistance, resident encouraged to wear appropriate footwear,…

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 documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a resident was appropriately monitored post fall. The deficient practice could result in residents being injured. Findings include: Resident #3 was admitted on [DATE] with diagnosis including a displaced fracture of the left femur, pain in the left hip, hypertension, Alzheimer's disease, major depressive disorder, fibromyalgia, dementia, and heart disease. A review of the MDS (minimum data set) revealed a BIMS (brief interview of mental status) score of 11, suggesting moderate cognitive impairment. A review of the baseline care plan initiated on June 17, 2024 revealed that resident #3 was noted to be a high fall risk and that the call light should be in reach, and that resident needs prompt responses to all requests for assistance, resident encouraged to wear appropriate footwear, occupational and physical therapy evaluations and treatment, cuing and supervision, bed lowered, mats on the floor by…

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 and interviews, the facility failed to ensure two residents (#26 and #79) and their representatives were notified, in writing, of the reason for a transfer to the hospital. The deficient practice could result in residents being inappropriately transferred or discharged and not having a continuity of care once leaving the facility. Findings included: Regarding Resident #26 Resident #26 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, acute respiratory failure, and unsteadiness on their feet. A review of the admission Minimum Data Set (MDS), assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. A progress note by social services dated February 14, 2024 at 11:01 A.M. revealed the resident's wife was contacted regarding the resident's behavior from the previous night. Review of physician order with a revision date of February 16, 2024 revealed 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.

Based on observations, staff interviews, and record review, the facility failed to ensure infection control protocols were followed during medication administration for two residents (#179 and #6). The deficient practice could result in the development and transmission of infections. Findings included: An observation of a medication administration was conducted on April 30, 2024 at 7:30 A.M. with licensed practical nurse (LPN)/staff #35). Staff #35 dispensed resident #179's medications that included an aspirin 81 milligrams (mg) tablet, calcium with vitamin D tablet, colace 100 mg capsule, folic acid tablet, multivitamin with minerals tablet, omega-3 capsule (fish oil) 500 mg capsules, vitamin C 500 mg give tablets, bupropion tablet, duloxetine hydrochloride 60 mg capsule, hydrochloroquine sulfate tablet, isosorbide extended release half a tablet (15 mg), meclizine hydrochloride 25 mg tablet, and pregabalin 100 mg capsule into a medication cup. After dispensing the medications, staff #35 locked the medications cart and signed out of the computer. At approximately 7:50 A.M. staff #35…

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 observations, interviews, and record review, the facility failed to ensure kitchen equipment was in proper working order. Findings include: A review of the facility's Food Safety Inspection Report, dated January 13, 2024, indicated that the electric meat slicer plastic food contact plate was cracked. An observation was conducted on April 29, 2024 at 10:45 A.M. of the facility's kitchen and observed that the same plastic food contact plate was still cracked, the meat slicer was not covered, and did not have an out of order sign posted. A second observation was conducted on April 30, 2024 and the meat slicer was in the same condition as observed yesterday on April 29, 2024. On May 1, 2024 at 9:00 A.M. a copy of the work order was requested from the facility to determine what was being done to fix the machine. On May 1, 2024, the facility Administrator (staff #33) provided a copy of the work order dated May 1, 2024 at 9:15 A.M. An interview was conducted with the Administrator (staff #33) on May 1, 2024 at 10:10 A.M. The Administrator provided a purchase order, dated May 1,…

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 interviews, the facility failed to ensure one resident (#79) was given a bed-hold policy before a transfer to the hospital. The deficient practice may result in the resident and resident representative not being aware of the bed-hold policy and their right to return to the facility immediately after hospital discharge. Findings included: Resident #79 was admitted to the facility on [DATE] with diagnoses that included dementia, fracture of the right femur, and heart disease. Review of a bed hold agreement signed by the resident on admission dated April 4, 2024 revealed the resident agreed with bed hold in the event the resident was admitted to the hospital. A review of the 5-day admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment. A progress note dated April 14, 2024 revealed resident #79 was sent to the hospital due to a surgical site assessed as red and hot.…

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 interviews and record review, the facility failed to ensure one resident (#20) and their representative were provided with a summary of the baseline care plan. The deficient practice could result in residents and their representative not receiving a summary of their baseline care plan. Findings included: Resident #20 was admitted to the facility on [DATE] with diagnoses that included noninfective gastroenteritis and colitis, neurocognitive disorder with lewy bodies, and type 2 diabetes mellitus. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment. The MDS also noted that the resident participated in goal setting. Review of records revealed a comprehensive care plan was developed on April 4, 2024 and a collaborative care review was conducted with the Interdisciplinary Team (IDT) on April 8, 2024. During an interview on 4/30/24 at 3:40p, with the social services director, she stated the interim…

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 personnel file review, staff interviews, and facility policy, the facility failed to ensure that two of two sampled Certified Nursing Assistants (CNA/staffs #35 and #8) were able to demonstrate competencies and skills necessary to provide care for residents. The census was 31. The deficient practice could result in inadequate care for residents. Findings include: Review of a personnel file for a Certified Nursing Assistant (CNA/staff #35) revealed a hire date of 04/17/19, for hourly employment. The personnel record contained no evidence of a comprehensive evaluation for nursing skills and competencies for 2020, 2021 or 2022. The personnel file for a CNA (staff #8) revealed a hire date of 06/17/20, for hourly employment. Review of the personnel file revealed no evidence of a comprehensive evaluation for nursing skills and competencies for 2022. An interview with the Human Resources Director (staff #84) was conducted on 01/05/23 at 10:33 a.m. She stated that the CNA skills sheets she had were dated 2021 and that she would ask the administrator if they had anything more…

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 clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to implement a surveillance plan for identifying, tracking, monitoring of infection and failed to ensure an ongoing analysis of surveillance data and documentation of follow-up activity response. The deficient practice could result in the spread of infections in the facility. Findings include: During the entrance conference on January 3, 2023 at 8:09 a.m., the Administrator (staff #61) stated the facility currently had no COVID-19, and that the last COVID-19 outbreak was on November 7, 2022. Staff #61 stated that the facility does have a staff member assigned to be the infection preventionist (IP)and that this person is Licensed Practical Nurse (LPN/staff #6). Staff # 61 stated the IP is responsible for the facility's vaccination efforts, infection surveillance, and antibiotic stewardship. Record review of the facility's infection surveillance was conducted on January 4, 2022 at 1:57 p.m. with an infection preventionist/licensed practical nurse (LPN/ staff #6). During…

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 clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to conduct an ongoing review for antibiotic stewardship as required by Center for Medicare and Medicaid Services (CMS) guidelines, and failed to review clinical signs and symptoms and laboratory reports to determine if antibiotics are indicated. The deficient practice could have the potential for residents to have adverse effects due to the lack of protocols and monitoring. Findings include: On January 3, 2023 at 8:00 a.m. the survey team entered the facility. At 8:09 a.m., an entrance conference was conducted with the facility administrator (staff #61). During the conference, staff #61 stated he has a full-time infection preventionist (IP), a licensed practical nurse (LPN/staff #6). Staff #61 stated the IP is responsible for the facility's vaccination efforts, infection control surveillance, and antibiotic stewardship. Record review of the facility's antibiotic stewardship program was conducted on January 4, 2022 at 1:57 p.m. with the IP (LPN/ staff #6). During 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 the facility's policy, the facility failed to ensure one resident's (#140) advance directives were completed upon admission. The deficient practice could result in resident's advanced directives not being known or honored. Findings include: Resident #140 was admitted to the facility on [DATE], with diagnoses that included multiple fractures of pelvis, atherosclerotic heart disease of native coronary artery without angina pectoris, and essential hypertension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 99 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognitive skills and cognitive impairment. Review of the resident's physician orders conducted on January 3, 2023 revealed no order for a code status. Review of the advance directive paperwork revealed that it had been completed upon admission. Additional review of the clinical record revealed the advance directive was not…

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 policy, the facility failed to ensure one resident's (#18) care plan was updated/revised to meet her changing needs. The sample size was 15. The deficient practice could result in inadequate care and/or not meeting the needs of the resident. Findings include: Resident #18 admitted to the facility 01/21/22 with diagnoses that included a pressure ulcer of the sacral region, stage 4, polyneuropathy and age-related osteoporosis without current pathological fracture. The risk for falls care plan initiated 01/21/22 related to impaired mobility and cognition had a goal to not sustain serious injury. Interventions included lab monitoring. Review of the clinical record revealed the resident fell without sustaining injury on dates including: 02/23/22 and 03/04/22. However, the risk for falls care plan was not updated to indicate additional fall interventions had been put in place. According to the resident's record, she sustained additional falls on dates…

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 the facility's policies and procedures, the facility failed to convey the discharge summary information to the resident and/or authorized person, and failed to include reconciliation of all pre and post discharge medications for one resident (#33). The deficient practice could result in resident's not receiving the correct discharge information and medications. Findings include: Resident #33 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, generalized muscle weakness, type 2 diabetes, stage 4 chronic kidney disease, and malignant neoplasm of the bladder. A physician progress note dated November 6, 2022 at 3:01 p.m., stated the visit type was skilled nursing facility discharge visit. The note included an assessment plan that stated discharge today, and resident does not need new prescriptions. Further, the note stated home health nursing coming in the morning that was arranged by the family. Review of nursing…

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 upon personnel file review, interviews, and policy review, the facility failed to complete yearly performance reviews and provide regular in-service education based upon the outcome of the reviews for 1 of 2 sampled Certified Nursing Assistants (CNA/staff #35). The inadequate practice could result in insufficient and inadequate care for residents. The facility census was 31. Findings include: Review of a personnel file for a CNA (staff #35) revealed a hire date of 04/17/19, for hourly employment. Review of the file did not reveal a yearly performance review had been completed or any evidence of training reflective of the review. On 01/05/23 at 10:33 a.m. an interview was conducted with the Director of Human Resources (staff #84). She stated that training is monitored in the system and that managers are responsible to enforce that with their employees. She stated that it is her responsibility to get employee reports and to give them to the department heads. She stated that the department heads are responsible for ensuring the training is completed. She stated that she did not…

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, the facility failed to ensure a pharmacist recommendation was reviewed and acted upon for one resident (#5). The sample size was 5 residents. The deficient practice could result in medication irregularities that go unnoticed or are not acted upon. Findings include: Resident #5 admitted to the facility on [DATE] with diagnoses that included anemia, major depressive disorder, recurrent and benign prostatic hyperplasia without lower urinary tract symptoms. A Bupropion (antidepressant) care plan dated 09/28/22 related to a diagnosis of depression as evidenced by verbalizing anger over new placement in the skilled nursing facility had a goal to show adjustment to the placement. Interventions included to give medications as ordered by the physician and to monitor/document side effects and effectiveness. A Lorazepam (anxiolytic) care plan initiated 09/28/22 related to a diagnosis of anxiety as evidenced by worrying over his current health…

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 policy, the facility failed to ensure one resident (#5) receiving psychotropic medications received consistent monitoring for behaviors and side effects and failed to ensure a PRN (as needed) anti-anxiety medication had a duration of treatment. Five residents were reviewed for medication use. The deficient practice could result in unnecessary medication use and adverse side effects. Findings include: Resident #5 admitted to the facility on [DATE] with diagnoses that included anemia, major depressive disorder, recurrent and benign prostatic hyperplasia without lower urinary tract symptoms. A Bupropion (antidepressant) care plan dated 09/28/22 related to a diagnosis of depression as evidenced by verbalizing anger over new placement in the skilled nursing facility had a goal to show adjustment to the placement. Interventions included to give medications as ordered by the physician and to monitor/document side effects and effectiveness. A Lorazepam…

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 facility documentation, interviews, policy, and Centers for Medicare and Medicaid Services (CMS) guidance, the facility failed to ensure the Infection Preventionist (IP) had completed infection control training. The deficient practice could lead to unqualified staff acting as the IP and improper infection prevention practices within the facility. Findings include: During the entrance conference on January 3, 2023 at 8:09 a.m., the Administrator (staff #61) stated the facility currently had no COVID-19, and that the last COVID-19 outbreak was on November 7, 2022. Staff #61 stated that the facility does have a staff member assigned to be the infection preventionist (IP)and that this person is Licensed Practical Nurse (LPN/staff #6). Staff # 61 stated the IP is responsible for the facility's vaccination efforts, surveillance, and antibiotic stewardship. An interview was conducted on January 4, 2023 at 1:57 a.m. with IP (staff #6). Staff #6 stated the facility was utilizing her as the IP and had done so since November 15. 2022. She stated the she does not have formal infection…

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 interview and policy and procedures, the facility failed to ensure one of five sampled residents (#140) received information regarding the benefits and potential side effects of influenza and/or pneumococcal immunizations, and failed to offer the vaccinations according to their policy. The deficient practice could increase the risk of residents acquiring, transmitting or experiencing complications from influenza and/or pneumococcal disease. Findings include: Resident #140 was admitted to the facility on [DATE], with diagnoses that included multiple fractures of pelvis, atherosclerotic heart disease of native coronary artery without angina pectoris, and essential hypertension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 99 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognitive skills. Review of the clinical record revealed no documentation that the resident and/or the responsible party…

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 clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to maintain documentation related to COVID-19 vaccine exemption requirement for one staff (#33). Findings include: On January 3, 2023 at 8:00 a.m. the survey team entered the facility. At 8:09 a.m., an entrance conference was conducted with the facility administrator (staff #61). During the conference, a COVID-19 staff vaccination matrix for staff was requested from the administrator (staff #61). Review of the facility employee list provided on January 3, 2023 indicated staff #33 was an active employee. On January 4, 2023 the facility provided the facility staff COVID-19 vaccine log. Review of the facility document provided by staff #61, revealed one certified nursing assistant (CNA/ staff #33) was coded GN, indicating the CNA was granted non-medical exemption. On January 4, 2022 at 8:53 a.m., a document request was given to staff #61 related to staff #33's COVID-19 exemption documents including screening for eligibility, education, and declination form. On January 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 personnel file reviews, staff interviews, and review of policy, the facility failed to provide evidence that 1 out 10 sampled staff (#36) was provided training for abuse, neglect, exploitation and misappropriation of resident property. The facility census was 31. The deficient practice could result in inadequate recognition, prevention and reporting of abuse. Findings include: Review of a personnel file for a Dietary Assistant (staff #36) revealed a hire date of 08/06/13, for hourly employment. The personnel record contained no evidence of training for abuse, neglect, exploitation and misappropriation of resident property. On 01/05/23 at 10:33 a.m. an interview was conducted with the Director of Human Resources (staff #84). She stated that training is monitored in the system and that managers are responsible to enforce that with their employees. She stated that it is her responsibility to get employee reports and to give them to the department heads. She stated that the department heads are responsible for ensuring the training is completed. She stated she was not sure what…

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 personnel file review, interviews, and Federal guidelines, the facility failed to ensure one of two sampled Certified Nursing Assistants (CNA/staff #35) had no less than 12 hours per year of required in-service training to ensure continuing competencies. The facility census was 31. The deficient practice could result in inadequate care for residents. Findings include: Review of a personnel file for a CNA (staff #35) revealed a hire date of 04/17/19, for hourly employment. Per the 2022 User Learning records, staff #35 had completed 3 out of 25 required in-service courses. On 01/05/23 at 10:33 a.m. an interview was conducted with the Director of Human Resources (staff #84). She stated that training is monitored in the system and that managers are responsible to enforce that with their employees. She stated that it is her responsibility to get employee reports and to give them to the department heads. She stated that the department heads are responsible for ensuring the training is completed. She stated that she did not know what happened in regard to the CNA #35. An interview…

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.