Arvin Post Acute

Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 43) receiving tube feedings was kept with his head elevated at least 30 degrees while receiving tube feedings. This failure placed Resident 43 at risk of aspiration (food or liquid going into the lungs causing disease and respiratory problems). Findings: During a concurrent observation and interview on 3/23/26 at 12:37 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 43's room, Resident 43 was receiving tube feedings while lying flat in his bed. LVN 1 stated Resident 43's head of bed should be elevated 45 degrees when receiving tube feedings. During a concurrent observation and interview on 3/25/26 at 3:35 p.m. with the Director of Nursing (DON) in Resident 43's room, Resident 43 was receiving tube feedings while lying flat in his bed. DON stated Resident 43's head of bed should be elevated 30 degrees when receiving tube feedings. During a review of Resident 43's care plan (CP) titled Resident requires tube feeding ., dated 3/20/26 with the objective, 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 interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted.Findings:During a concurrent interview and record review on 3/24/26 at 3:18 p.m. with Director of Staff Development (DSD), the Detail Time and Job (clock in log) dated 1/10/26, 2/22/26, 3/14/26, and 3/15/26 was reviewed. DSD stated there was no RN present in the building for 8 hours a day during those days.During a review of facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent nursing, dated 8/2022, the P&P indicated, 3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident.

Based on interview and record review, the facility failed to ensure Performance Evaluation (PE - a process to give employees feedback on their job performance) for five of five sampled employees (Certified Nursing Assistant [CNA] 1, CNA 2, CNA 3, CNA 4, CNA 5) were completed. This failure had the potential for the staff not to be aware of their need for improvement in certain areas, which could affect resident care.Findings:During a concurrent interview and record review on 3/25/26 at 8:13 a.m. with Director of Staff Development (DSD), CNA 1's Personnel File (PF) was reviewed. The PF indicated CNA 1 was hired on 2/1/18 and last PE was done on 7/5/24 and there was no PE found after 7/5/24. DSD stated PE should be completed annually.During a concurrent interview and record review on 3/25/26 at 8:27 a.m. with DSD, CNA 2's PF was reviewed. The PF indicated CNA 2 was hired on 5/7/24 and there was no PE found in their PF. DSD stated PE should be completed annually.During a concurrent interview and record review on 3/25/26 at 8:29 a.m. with DSD, CNA 3's PF was reviewed. The PF indicated…

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 the safe administration of medications when medications were found at Resident 33's bedside table without a medication self- administration assessment or a physician order for one of 24 sampled resident (Resident 33). This failure had the potential for medications to be administered incorrectly and unsafely.Findings:During a concurrent observation and interview on 3/23/26 at 9:20 a.m. with Licensed Vocational Nurse (LVN) 2, in Resident 33's room, Resident 33 had a medication cup on the bedside table with five pills and three capsules in the medication cup and no nurse was present in the room. LVN 2 stated in the medication cup there were pantoprazole (medication used for stomach acid), aspirin (to prevent blood clots), cresemba (medication to treat fungal infections), metformin (medication used to treat high blood sugar), multi-vitamin, vitamin C, Vitamin B12 (used for vitamin deficiency) and senna (stool softener). LVN 2 stated nurses should wait and watch until residents swallow all 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, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 56 and Resident 43) were provided care using Enhanced Barrier Precautions (EBP - use of gowns and gloves to reduce transmission of multi-drug resistant organisms). This failure had the potential to result in Resident 56 and Resident 43 developing an infection. Findings: During an observation on 3/23/26 at 8:57 a.m. in the doorway of Resident 56's room, Certified Nursing Assistant (CNA) 6 was at Resident 56's bedside wearing gloves (no gown) while giving care to Resident 56. A sign on the name plate outside of Resident 56's room indicated Resident 56 was on EBP. During a concurrent observation and interview on 3/23/26 at 9:03 a.m. in the doorway of Resident 56's room, CNA 6 was at Resident 56's bedside wearing gloves (no gown) tying a trash bag then exited the room. CNA 6 stated Resident 56 had a wound on his groin but was not sure what EBP means. CNA 6 stated she was only wearing gloves while providing care to Resident 56. During a review of Resident 56's Order…

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 follow their policy and procedure (P&P) on abuse, neglect, exploitation or misappropriation reporting and investigating when: 1. The facility did not complete a follow-up investigation report (FIR) after a resident-to-resident altercation (RRA) within five days for two of seven sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 to have another altercation, and to develop distress and injuries. 2. The facility did not report an allegation of financial abuse to California Department of Public Health (CDPH) within 24 hours of an allegation for one of seven sampled residents (Resident 3). This failure had the potential for emotional distress for Resident 3. Findings: 1. During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation), dated 5/20/25, the SBAR indicated, Resident (1) states he woke up and saw (Resident 2) sitting on the end of the bed, (Resident 2) grabbed (Resident 1's) pillow from behind his head and starting to hit him 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.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) responsible party (RP) was notified of a change of condition (COC). This failure had the potential for Resident 2's RP not to be aware of Resident 2's COC. Findings: During a concurrent interview and record review, on 4/23/25 at 2:10 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's Change in Condition, (COC) dated 4/9/25 was reviewed. The COC indicated Resident 2 had a witnessed fall. Resident 2's admission Record, (AR) indicated Resident 2 had RP. Resident 2's Minimum Data Set, (MDS - an assessment tool) dated 1/31/25 was reviewed. The MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) score was 6 (a score of 0-7 points severely impaired cognition). LVN 1 reviewed Resident 2's progress notes and confirmed no RP notification was documented. LVN 1 stated Resident 2's RP should have been notified regarding Resident 2's fall on 4/9/25. During a review of the facility's policy and procedure (P&P) titled, Change of Resident's Condition or Status,…

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.

During a concurrent interview and record review on 12/17/24 at 10:39 a.m. with Nurse Consultant (NC) 1, Resident 30's medical record, was reviewed. NC 1 was unable to find documentation of an AD for Resident 30. During a concurrent interview and record review on 12/17/24 at 10:40 a.m. with NC 1, Resident 59's medical record, was reviewed. NC 1 was unable to find documentation of an AD for Resident 59. During a concurrent interview and record review on 12/17/24 at 10:42 a.m. with NC 1, Resident 64's medical record, was reviewed. NC 1 was unable to find documentation of an AD for Resident 64. During a review of the facility's P&P titled, Advance Directives, dated 9/2022, the P&P indicated,1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. A. The resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision. B. Nursing staff will document in the medical record the offer to assist and 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 observation, interview, and record review, the facility failed to follow and implement nationally recognized infection prevention and control practices for seven of seven sampled residents (Resident 12, Resident 30, Resident 33, Resident 43, Resident 49, Resident 183, and Resident 379) as evidenced by: 1. Linens stored for two of two sampled residents (Resident 33 and Resident 183) on the bedside table inside Resident 33 and Resident 183's room. 2. Resident 12 and Resident 43's hands were not cleansed prior to eating lunch. 3. The treatment nurse (TN) did not wear proper Personal Protective Equipment (PPE- refers to gowns, gloves, masks, goggles, face shields to protect the wearer from injury or infection) during wound treatment and dressing change for one of one resident (Resident 49) on Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO-bacteria that have become resistant to multiple antibiotics] that employs…

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, interview, and record review, the facility failed to maintain an effective Pest Control Program when live cockroaches were repeatedly found in the kitchen. This failure placed 70 of 72 highly susceptible sampled residents, at risk for foodborne illnesses when receiving food from the kitchen infested with cockroaches. Findings: During a concurrent observation and interview on 12/16/24 at 8:15 a.m. with Dietary Manager (DM) in the kitchen, there were nine dead cockroaches in a floor drain above the sink where food was prepared. DM stated, those are bugs [dead cockroaches in the drain]. During an interview on 12/16/24 at 8:16 a.m. with DM, DM stated she had seen ants, pincher bugs, and cockroaches in the kitchen. DM stated she noticed them (ants, pincher bugs, and cockroaches) during the renovation of the kitchen approximately March 2024. During an observation on 12/17/24 at 11:25 a.m. in the kitchen, there was a live cockroach crawling on the wall above the dishwasher. During an interview on…

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: 1. Ensure the physician provided the informed consent (the process in which a health care professional educates a patient about the risks, benefits, and alternatives of a given procedure or medication) on the use of antipsychotic (drugs that treat psychosis [mental distress, mental disorder] and related conditions and symptoms) medication for one of one sampled resident (Resident 43) prior to the verbal consent obtained from Resident 43's representative. This failure had the potential for the resident and/or the resident representative to not receive the appropriate information regarding the drug, its indication, side-effects, and make the right decision. 2. Ensure licensed personnel witness and validate the verbal consent received from the resident representative for one of one resident (Resident 43) and sign the informed consent form to validate the consent and the material information provided. This failure had the potential for the informed consent to be dismissed. Findings: 1. During a concurrent interview and record…

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 ensure confidentiality of Private Health Information (PHI) was maintained for two of two sampled residents (Resident 25 and Resident 58). This failure resulted in Resident 25 and Resident 58's PHI being compromised and seen by unauthorized personnel. Findings: During a review of Resident 25's Clinical Record (CR), The CR contained Resident 58's clinical note titled, Skilled Nursing Progress Note (SNPN), dated 10/18/24. During a concurrent interview and record review on 12/17/24 at 9:53 a.m. with Medical Records Clerk (DMR), Resident 25's CR was reviewed. DMR stated, Resident 58's SNPN was in Resident 25's CR. DMR stated that was the incorrect clinical record. During a review of Resident 58's admission Agreement (AA), dated 6/21/24, the AA indicated, Resident 58 agreed that she read and understood Resident [NAME] of Rights Section (e) Privacy and confidentiality indicating the resident has the right to personal privacy and confidentiality of his or her personal and clinical records and Section X. Confidentiality of Your…

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, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Personal Property, for two of two sampled residents (Resident 30 and Resident 21) when: 1. Resident 30's belongings were not inventoried and documented on admission. 2. Resident 21's clothing went missing in the facility. These failures had the potential to negatively affect the resident's psychosocial well-being and had the potential to result in lack of reimbursement for lost belongings. Findings: During an interview on 12/16/24 at 3 p.m. with Resident 30, Resident 30 stated he had four pairs of underwear when he was admitted to the facility, and he had two left. Resident 30 stated he reported it to a Certified Nursing Assistant (CNA) few days ago and the CNA looked for them in the laundry and did not find them. During a review of Resident 30's admission Record (AR), dated 11/27/24, the AR indicated Resident 30 was readmitted to the facility on [DATE]. During a concurrent interview 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 interview and record review, the facility failed to ensure a Baseline Care Plan (BCP- outlines a process for development of an initial person-centered care plan within the first 48 hours of admission, that will provide instructions for care of the resident) was completed for one of one sampled resident (Resident 12) within 48-hours of admission and a summary provided to the resident and/or resident representative. This failure had the potential for Resident 12 to not receive the care and the safeguards necessary within the 48-hour of admission. Findings: During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was admitted on [DATE] with diagnosis including, Diabetes Mellitus (blood sugar is too high) with diabetic neuropathy (nerve damage that is caused by diabetes), End-Stage Renal Disease (ESRD- final, permanent stage of chronic kidney disease). During a concurrent interview and record review on 12/18/24 at 1:58 p.m. with Minimum Data Set (resident assessment tool)…

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 develop a comprehensive person-centered care plan for personal grooming, including care of the fingernails for one of one sampled resident (Resident 12). This failure had the potential for unmet care needs. Findings: During a concurrent observation and interview on 12/16/24 at 2:50 p.m. with Licensed Vocational Nurse (LVN) 2 in Resident 12's room, Resident 12 was seated in his wheelchair. Noticed Resident 12's hands were dry. The left-hand fingernails were long and inside the nailbeds were blackish substance. The 5th and 4th fingernails were long, and the nailbeds were black in color. LVN 2 stated Resident 12's fingernails were long and needed trimming. During a concurrent observation and interview on 12/17/24 at 8:50 a.m. with Treatment Nurse (TN) and Resident 12 in Resident 12's room, Resident 12's fingernails remained long and nailbeds black in color. TN stated Resident 12's fingernails have dirt inside the fingernails. TN stated Resident 12's fingernails were long on the left hand; the right hand had some…

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 revise a care plan after a change of status for Hospice (end of life care) services for one of two sampled residents (Resident 25). This failure had the potential for Resident 25 to receive Hospice services when no longer needed. Findings: During a record review of Resident 25's Order Summary Report (OSR), dated November 2024, the OSR indicated, Resident is discharged from [Name of Hospice Company] as of 11/15/24 due to extended prognosis. During a record review of Resident 25's Nursing-Weekly Summary (NWS), dated 12/15/24, the NWS indicated, Currently under hospice care. During a review of Resident 25's End of Life: Care Plans (ELCP), dated 11/15/24, the ELCP indicated, Resident requires Hospice care and is at risk for rapid decline in activities of daily living, sudden onset or worsening skin integrity, weight loss, nausea/vomiting, pain, abnormal breathing, impaired psychosocial wellbeing related to terminal illness. During a concurrent observation and interview on 12/17/24 at 8:19 a.m. with Administrator in 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 observation, interview, and record review, the facility failed to ensure oral care was rendered for one of one sampled resident (Resident 33) to maintain oral hygiene. This failure had the potential for Resident 33 to acquire oral infections, tooth decay, or gum disease. Findings: During a review of Resident 33's admission Record (AR), the AR indicated Resident 33 was admitted on [DATE] with diagnosis including Hemiplegia (complete paralysis) and Hemiparesis (weakness on one side) following cerebral infarction (stroke-[bleeding in the brain]). During a concurrent observation and interview on 12/16/24 at 9:46 a.m. with Licensed Vocational Nurse (LVN) 2 in Resident 33's room, Resident 33 was awake sitting in his bed. Resident 33 had weakness on the right side of the body. LVN 2 stated Resident 33 is paralyzed on the right side. Resident 33 was slow in communicating but able to respond to questions. Resident 33's mouth was dry and teeth yellowish in color. Resident 33 stated no one brushes his teeth before…

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 implement person center quality care for one of one sampled resident (Resident 10) when Resident 10's fingernails were not trimmed, hand splint was not applied and, physician's order for surgical consultant was not procesed. This failure resulted in delayed care for Resident 10 and had the potential for adverse outcomes. Findings: During an observation on 12/16/24 at 10 a.m. in Resident 10's room, Resident 10's left hand was contracted (abnormal bend of the joint) where her middle three fingers were folded in toward her palm. Resident 10's fingernails on her left hand were long, thick, and curled over going into the skin of her left palm. Resident 10 did not have any type of splint on her left arm/hand. During a concurrent observation and interview on 12/18/24 at 10:21 a.m. with Licensed Vocational Nurse (LVN) 3 in Resident 10's room, Resident 10's left hand was observed. LVN 3 stated, I do not know if Resident 10 is supposed to have a hand splint on her left hand or not. I have worked the last three days 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.

Based on observation, interview, and record review, the facility failed to provide foot care and podiatry (foot specialist) referral for one of one sampled resident (Resident 33). This failure resulted in Resident 33's feet and toenails to be left untreated. Findings: During a concurrent observation and interview on 12/17/24 at 8:11 a.m. with Treatment Nurse (TN) in Resident 33's room, Resident's right big toenail appeared deformed, with abnormal growth, yellowish, and had fungus-like appearance. The right 2nd, 3rd, 4th, and 5th toes had long, thick, yellowish toenails. The right 5th toenail had blackish discoloration. The skin on the top of the right foot was dry and flaky. The left big toenail was yellowish in color and thick. The left 2nd, 3rd, 4th, and 5th toenails were long and the nails were curled inwards. TN stated Resident 33's nails needed trimming. TN stated she just checked around the monitoring bracelet to see if there were any abrasions around the lower extremity. TN stated, I check the feet whenever the resident has no socks on; otherwise, no. TN obtained a measuring…

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 interview and record review, the facility failed to manage and document pain accurately for one of one sampled resident (Resident 12). This failure had the potential for Resident 12 to not be able to function and perform daily activities and improve quality of life. Findings: During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was admitted on [DATE] with diagnosis including, Diabetes Mellitus (blood sugar is too high with diabetic neuropathy (nerve damage that is caused by diabetes), End-Stage Renal Disease (ESRD- final, permanent stage of chronic kidney disease). During a review of Resident 12's Wound Evaluation, dated 11/28/24, the Wound Evaluation indicated, 1. Pressure-Deep Tissue Injury (DTI- purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear), right heel: area 10.19 centimeter (cm), length 5.83 cm, and width 4.4 cm. Present on admission 2. Pressure-DTI, left heel: area…

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 Dietary Manager (DM) failed to demonstrate competency to carry out the functions of the food and nutrition service for all the residents residing in the facility when there was a multi-generational cockroach infestation in the kitchen. This failure resulted in no action plan put in place to address and meet the health and safety needs for the residents. Findings: During an observation on 12/16/24 at 8:15 a.m. in the kitchen, there were nine dead cockroaches in a drain above a sink where food is prepared. During an interview on 12/16/24 at 8:16 a.m. with Dietary Manager (DM), DM stated, Those are bugs [dead cockroaches in the drain]. DM stated she has seen ants, pincher bugs, and cockroaches in the kitchen. DM stated she started noticing them (ants, pincher bugs, and cockroaches) when the facility started renovation this year approximately March 2024. During an interview on 12/18/24 at 10:28 a.m. with Registered Dietitian (RD), RD stated she was not made aware by anyone in the facility that there were live cockroaches. During a…

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 ensure the Admissions Coordinator (AC) had the full understanding of the Binding Arbitration Agreement (BAA-the parties waive their right to a trial and agree to accept the arbitrator's decision as final) to be able to explain the content of the BAA for three of 47 sampled residents (Resident 7, Resident 8, and Resident 64) in the manner, form, and language understood by the resident and/or resident representative. This failure had the potential for Resident 7, Resident 8, and Resident 64 and/or their representatives to be misinformed and not fully understand the terms and conditions stipulated in the arbitration agreement. Findings: During an interview on 12/19/24 at 8:21 a.m. with AC, AC stated there were 47 residents who had participated and signed the BAA. AC stated the BAA is part of the admissions packet. AC stated the expectation of the Administrator and Leadership was to ensure the arbitration agreement was signed. AC stated, I inform the resident and/or the resident representative they will go to a mediator…

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 a safe and sanitary shower area was provided for the residents. This failure had the potential for injury and spread of infectious disease to facility residents. Findings: During a concurrent observation and interview on 10/1/24 at 2:10 p.m. with Certified Nursing Assistant (CNA) 1, in the south shower room stall one. CNA 1 stated, There was a plastic piece (vinyl cover) that fell off over the weekend on Saturday (9/28/24). CNA 1 stated she put the vinyl cover to the side (space just outside of shower room stall one). During a concurrent observation and interview on 10/1/24 at 2:15 p.m. with Housekeeping Manager (HM), in the south shower room stall one. There was a broken and missing tiles and a tan substance noted on the pony wall (half wall) of shower stall one. HM stated the housekeeping staff could not properly clean the area with the missing tiles. There was a black substance noted on the bottom of the shower grout line. HM stated, I do not know what that is but it looks like it will come back if…

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 one of two sampled residents (Resident 1 and Resident 2) were free from verbal abuse. This failure resulted in Activity Assistant (AA) verbally abused Resident 1 and Resident 2 during activities and had the potential to cause emotional harm. Findings: During a concurrent observation and interview on 4/9/24 at 4:03 p.m. with Resident 1 in the dining room, Resident 1 had his eyebrows folded and moved his head side to side (right to left) and stated, I was in shock. He [AA] yelled and cursed at him and Resident 2 during activities on 4/7/24. Resident 1 stated AA lead activities at the facility and activities were supposed to be fun and it wasn't that day [4/7/24]. During a review of Resident 1's History and Physical (H&P), dated 10/24/23, the H&P indicated, Resident 1 had the mental capacity to make medical decisions. During a review of Resident 1's Weekly Summary Note (WSN), dated 4/25/24, the WSN indicated, Resident is alert and oriented, able to verbalize needs. During a concurrent observation 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.

Based on interview and record review, the facility failed to complete an investigation of a verbal abuse allegation within five working days for one of four sample residents (Resident 1). This failure had the potential to place Resident 1 at risk for suffering continuous verbal abuse. Findings: During an interview on 2/28/24 at 10:29 am with Resident 1, Resident 1 stated Certified Nursing Assistant (CNA) 1 was being rude to her. Resident 1 stated she woke up and called CNA 1 for help, and CNA 1 was already in Resident 1 ' s room attending to Resident 2. Resident 1 stated she was in her wheelchair and wheeled herself towards CNA 1. Resident 1 stated CNA 1 told her, Again? You? I hardly want to talk to you. Resident 1 stated she asked CNA 1, What have I done to you? and she stated CNA 1 told her, I don ' t want to have you. If I know you ' re here, I wouldn ' t have come. Resident 1 stated she is worried that it (verbal abuse) will happen again. During a review of Resident 1 ' s Progress Notes (PN), dated February 26, 2024, the PN indicated, Resident [1] was very upset stating 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.

Based on observation, interview and record review, the facility failed to ensure laundry was cleaned and sanitized according to the manufacturer's guidelines. This failure had the potential to result in the transmission of infection and communicable diseases to all residents. Findings: During a concurrent observation and interview on 1/5/24 at 9:26 a.m. with Laundry Staff (LS) 1 and Housekeeping and Laundry Supervisor (HLS) in the facility laundry room, LS 1 loaded towels and sheets into the washing machine and pressed 19. LS 1 left the room immediately after loading the machine. HLS stated she did not know what the number 19 meant, but stated her staff knew that information. During a concurrent observation and record review on 1/5/24 at 9:32 a.m., an ECOLAB Formula Chart [chart that describes which type of laundry is being washed so the correct chemicals for that type will be automatically dispensed into the machine] was observed on the side of another washing machine. The formula chart indicated Towels Formula 1.Sheets Formula 2. During a concurrent interview and record review on…

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 one of three sampled residents (Resident 2) care plan was implemented. This failure had the potential for Resident 2 to have unmet care needs. Findings: During a review of Resident 2 ' s care plan [Resident 2] is high risk for falls ., initiated 12/14/23, interventions included was a falling star program. During a concurrent observation and interview on 12/19/23 at 2:40 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 confirmed Resident 2 did not have a star on his name plate on the door. CNA 1 stated, I don ' t know the criteria you have to have to get the star. [Resident 2] did have a fall he rolled off the side off his bed a week ago. CNA 1 stated a star would normally be on the name plate on the door and wheelchairs of residents at risk for falls. During an interview on 12/19/23 at 4:05 p.m. with Director of Nursing (DON), DON was informed of the findings and stated care plans should be created and implemented. During a review of the facility ' s policy and procedure (P&P) titled, Falls 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 interview and record review, the facility to ensure fall risk assessments were completed for one of three sampled residents (Resident 2). This failure had the potential for staff not to be aware of Resident 2 ' s risk for falls. Findings: During a review of Resident 2 ' s Progress Notes, (PN) dated 12/13/23, the PN indicated Resident 2 was admitted on [DATE] at 6:57 p.m. During a review of Resident 2 ' s PN, dated 12/13/23 at 9:45 p.m., the PN indicated Resident 2 had an unwitnessed fall. During a concurrent interview and record review on 12/19/23 at 2:01 p.m. with Director of Nursing (DON), DON reviewed Resident 2 ' s medical record and confirmed there was no fall risk assessment completed upon admission and there was no post fall assessment completed after Resident 2's fall incident on 12/13/23. During an interview on 12/19/23 at 4:05 p.m. with DON, DON stated fall risk and post-fall assessments should be completed. During a review of the facility ' s policy and procedure (P&P) titled, Falls and Fall…

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 ensure a care plan was developed and implemented after a change of condition for one of two residents (Resident 1). This failure had the potential for Resident 1 not to receive need medical treatments. Findings: During an interview on 11/21/23 at 10:43 a.m. with Director of Nursing (DON), DON stated Resident 1 PICC (peripherally inserted central catheter - is a long, thin tube inserted through a vein in your arm and passed through to the larger veins near your heart, used to deliver medications and other treatments directly to the large central veins near your heart.) line in place and he pulled the PICC line out twice two days in a row. DON stated the facility staff sent Resident 1 to the emergency room (ER) hoping the ER would admit Resident 1 until treatment was completed. During a review of Resident 1 ' s EMAR (electronic medication administration note), dated 11/4/23 at 10 a.m. the EMAR indicated, [Resident 1] pulled out picc [sic] line. During a review of Resident 1 ' s Nurse ' s Note, (NN) dated 11/8/23 at 12:11…

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 properly maintain sanitary kitchen and food storage areas. These failures had the potential to spread food borne illness to residents. Findings: During a concurrent observation and interview on 6/21/21, at 9:59 AM, with Cook, in the facility kitchen, the handwashing sink had dried debris and food crumbs in the basin and rim of the sink. [NAME] verified the findings. A stainless-steel tray was located on the immediate left side of the handwashing sink. The tray held cylinders of eating utensils. The top portion of the tray had dried water spots and food crumbs around the cylinder utensil holders. [NAME] stated the utensils being stored in the tray were clean. [NAME] verified the tray holding the clean utensils was not clean. During a concurrent observation and interview on 6/21/21, at 10:03 AM, with Cook, in the kitchen near the dishwasher, two bowls on drying racks had food crumbs on their exposed surface. [NAME] stated the bowls on the drying racks were clean and verified the findings. A stainless-steel…

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 revise the care plan for one of 44 sampled residents (Resident 50). This failure had the potential for unmet care needs. Findings: During a concurrent observation and interview on 6/21/21, at 1 PM, with Resident 50, in the dining room, Resident 50 was observed eating a mechanical soft diet (foods made easier to chew and swallow). Resident 50 stated, I do not know why I am still eating a mechanical soft diet. I want to eat real food. During a review of Resident 50's Order Details (OD), dated 11/7/20, the OD indicated, Mechanical Soft, chopped meat texture, Nectar Thick Consistency [fluids thickened for residents with difficulty swallowing]. During a concurrent interview and record review on 6/24/21, at 9:28 AM, with Assistant Director of Nursing/Infection Preventionist (ADON/IP). ADON/IP was unable to provide a care plan addressing Resident 50's need for mechanical soft diet. During a review of the facility's policy and procedure (P&P) titled, Interdisciplinary Team (IDT), dated 11/17, the P&P indicated 1. 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, interview, and record review, the facility failed to label a multiple-dose insulin (regulates the amount of glucose in the blood) pen (an injection device with a needle that delivers insulin underneath the skin) in the medication cart. This failure had the potential for medication to be given to the wrong resident. Findings: During a concurrent observation and interview on 6/23/21, at 9:10 AM, with Licensed Vocational Nurse (LVN) 1, at medication cart 1, an unlabeled Novolog (brand of insulin) Insulin Pen was noted with a labeled date of 6/22/21. LVN 1 stated, she had removed the insulin pen from the emergency kit (E-Kit - medication that can be dispensed when pharmacy services are not available) yesterday, and dated it with the date opened and administered a dose of insulin to a resident. LVN 1 stated, she did not label the insulin pen with the resident's name. During a concurrent observation and interview on 6/23/21, at 9:40 AM, with the Director of Nursing (DON) and LVN 1, the unlabeled Novolog Insulin Pen was observed. DON verified the insulin pen 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 observation, interview, and record review, the facility failed to provide and facilitate smoking activity for one of 44 sampled residents (Resident 49). This failure resulted in Resident 49's inability to exercise his rights regarding activity preferences. Findings: During a review of Resident 49's admission Record (AR), undated, the AR indicated, Resident 49 was admitted on [DATE]. The Minimum Data Set (MDS-an assessment tool), dated 5/12/21, was reviewed. The MDS indicated, Resident 49 was able to think coherently, clearly, logically and had no altered level of consciousness. During a concurrent observation and record review, on 6/22/21, at 11:11 AM, with Resident 49, in his room, Resident 49 was observed lying in bed with a smoking schedule signage posted on the wall. Resident 49 stated, They put the schedule up so I can see the times when to go out and smoke. I used to smoke, but the facility doesn't allow me to smoke anymore. I don't mind getting up to smoke, but they won't let me. It makes me mad…

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 interview and record review, the facility failed to complete a comprehensive assessment (CA) after a significant change in the resident's condition for one of 44 sampled residents (Resident 44). This failure had the potential to result in delay of treatment, planning of care, and provision of appropriate services for Resident 44. Findings: During a review of Resident 44's admission Record (AR), undated, the AR indicated Resident 44 was admitted on [DATE] with a diagnosis of Cutaneous Abscess (Skin abscess) of the right lower limb. During a review of Resident 44's Wound Nursing Home Visit Notes (WN), dated 5/21/21, the WN indicated, Resident 44 developed a Stage 2 Pressure Ulcer (PU-partial thickness loss of skin) to sacral area (base of the spine to the tailbone). During a review of Resident 44's Weights and Vitals Summary (WVS), dated 5/21 and 6/21, the WVS indicated, the weights as follows: 5/1/21: 255.8 pounds (lbs-unit of measurement) 5/8/21: 248.4 lbs 5/16/21: 242.2 lbs 6/1/21: 241.4 lbs (weight…

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 the Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities to identify health problems) reflected the accurate status for one of 44 sampled residents (Resident 49). This failure had the potential to negatively affect Resident 49's plan of care and delivery of services. Findings: During an interview on 6/22/21, at 11:22 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 49 refuses to get out of bed, eat, and take his medications. During a concurrent observation and interview on 6/22/21, at 1:10 PM, with Resident 49, in his room, Resident 49 was observed lying in bed. Resident 49 stated he does not like to take his medications at times. No other staff members except the nurses who give him his medications have addressed this issue with him. During a concurrent interview and record review on 6/24/21, at 2:29 PM, with MDS Coordinator (MDSC), Resident 49's MDS (Section E - Behavior), dated 5/12/21 was reviewed. The MDS indicated, Resident 49's Rejection…

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 follow a physicians order for one of 44 sampled residents (Resident 39) when a positioning device was not implemented. This failure had the potential for skin breakdown. Findings: During a review of Resident 39's Order Summary Report (OSR), dated 6/22/21, the OSR indicated, Turn resident (Resident 39) every 2 hours, float heals [sic] in the morning During a concurrent observation, interview, and record review, on 6/22/21, at 9:33 AM, with LVN l, in Resident 39's room, Resident 39 was lying in his bed with no positioning device to float his left heel. Resident 39's OSR, dated 6/22/21 was reviewed. LVN 1 verified Resident had an order to float heels in the morning. LVN 1 verified there was no positioning device underneath Resident 39's left heel as ordered. During a review of the facility's policy and procedure (P&P) titled, Physician orders, accepting, transcribing and implementing (Noting), the P&P indicated, Licensed nursing personnel will ensure that telephone and verbal orders will be recorded 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.

Based on observation, interview, and record review, the facility failed to ensure assistive care was provided for two of 44 sampled residents (Resident 26 and Resident 39). This failure had potential for emotional discomfort and decline in functional abilities. Findings: During a concurrent observation and interview on 6/21/21, at 10:28 AM, with resident 26, in Resident 26's room, Resident 26 was lying in his bed wearing a facility gown. Resident 26 stated, he had not been out of his bed for a few days and a staff member was supposed to get him out of bed. During a concurrent observation and interview on 6/22/21, at 11:49 AM, with Resident 26, in Resident 26's room, Resident 26 was lying in his bed wearing a facility gown. Resident 26 stated, he would like to get up and out of his bed. Resident 26 stated, he would also like to be changed into his own personal clothes. During a review of Resident 26's Minimum Data Set (MDS-an assessment tool), dated 4/13/21, the MDS indicated, Section G - Functional Status. Activities of Daily Living (ADL) Assistance.1. Self - performance. extensive…

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 restorative nursing services (person-centered care designed to improve or maintain the functional ability of residents) were provided for one of 44 sampled residents (Resident 39). This failure had the potential for Resident 39 to not maintain his highest level of physical function. Findings: During a concurrent observation and interview on 6/21/21, at 11:12 AM, with Resident 39, in Resident 39's room, Resident 39 was lying in his bed and stated he was unable to move his left arm and left leg. Resident 39 stated, he had been admitted to the nursing facility after having a stroke (when blood supply to a part of the brain is interrupted or reduced) to receive physical therapy. Resident 39 stated, his physical therapy had stopped, and he had been told he was going to have someone come in to exercise his body, but this had not occurred. During an interview on 6/21/21, at 2:51 PM, with Resident 39, and Family Member (FM) 1, FM 1 stated, the reason we came to this facility was because we were told they had…

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 medication error rate was five percent or less when two medication errors were observed out of 26 medication administration opportunities, which yielded a medication error rate of 7.69 percent. These failures had the potential for residents to not receive the therapeutic effects of the medications. Findings: During a medication pass observation on 6/23/21, at 12:05 PM, with Licensed Vocational Nurse (LVN) 2, LVN 2 removed Resident 20's Terazosin (for high blood pressure) 2 mg (milligrams-unit of measure) capsule from the medication bubble pack (MBP) (medication capsule in individual compartments), opened capsule and placed contents in medicine cup. LVN 2 did not review Resident 20's MBP label. LVN 2 gave Terazosin 2 mg via G tube (gastric tube - tube inserted into stomach for food and medication administration). During a concurrent interview and record review on 6/23/21, at 12:05 PM, with LVN 1, the MBP label was reviewed. The MBP label indicated Terazosin 2 mg capsule, 1 capsule via G tube every…

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 implement infection control standards, when staff didn't perform hand hygiene. This failure had the potential to spread illness and disease to two of 44 residents (Resident 21 and Resident 221). Findings: During a concurrent observation and interview on 6/21/21, at 12:51 PM, with Certified Nursing Assistant (CNA) 1, in the South Hallway, CNA 1 pushed a meal tray cart into the South Hallway. CNA 1 opened the door to the meal tray cart and removed the tray for Resident 221 without performing hand hygiene. CNA 1 knocked on the door before entering the room and delivered Resident 221's tray. CNA 1 exited the room and did not perform hand hygiene. CNA 1 removed Resident 21's tray from the meal cart and entered the room. CNA 1 retrieved a bedside table from another room for Resident 21. CNA 1 arranged the bedside table for Resident 21 and placed the meal tray on the table. CNA 1 then came out of the room and removed a third tray from the cart without performing hand hygiene. CNA 1 verified she did not perform hand…

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.