Kyakameena Care Center

Based on interview and record review, the facility failed to implement its Legionella Water Management Program policy and procedures when facilitydid not have a water management program. This failure had the potential risk for Legionnaires' disease, and unsafe water usage. During an interview on 11/21/25 at 8:55 a.m. with Administrator (Admin), Admin stated facility did not have a program for managing water systems to prevent Legionnaires' disease and had not tested water for legionella. During a review of the facility's policy and procedure (P&P) titled, Legionella Water Management Program, revised September 2022, the P&P indicated, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella.

Based on interview and record review the facility failed to ensure one (Resident 4) of seven sampled residents' rights was free from misappropriation of property and exploitation when Resident 4's missing pants and tops were not replaced or reimbursed. This failure had the potential to cause Resident 4 emotional distress. During a review of Resident 4's admission Minimum Data Set (MDS- a federally mandated resident assessment and care guide tool), dated 7/13/25, the MDS indicated Resident 4's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident 4's score was 13 meaning intact cognition. Resident 4 had clear speech, able to make self-understood and understood others. MDS indicated Resident 4's diagnoses included Depression (a serious mood disorder characterized by persistent feelings of sadness or loss of interest which negatively impact daily life).During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 3 and Resident 4) Preadmission Screening and Resident Review (PASRR) were screened accurately and referred to the appropriate state mental authority for Level II PASRR evaluation and determination when Resident 3 and 4 with diagnosis of schizophrenia, bipolar and major depression were screened and documented as not having serious mental illness.(PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are appropriately placed in nursing homes for long term care).This failure had the potential to prevent residents from receiving appropriate required mental health services. During a review of Resident 3's Annual Minimum Data Set (MDS-an assessment screening tool used to guide care), dated 8/18/25 the MDS indicated Resident 3 was admitted to the facility on [DATE] with diagnosis that included schizophrenia (a severe mental health condition 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 interview, and record review the facility failed to ensure one of three sampled residents (Resident 49) was provided appropriate treatment and services to maintain or improve functional mobility to carry out the activities of daily living, when: For Resident 49 facility did not provide Restorative Nursing Services (RNA) treatment for decline in functional mobility as ordered by the physician. RNA is restorative nursing care consisting of nursing interventions to help promote optimal safety and independence. During a review of Resident 49's Minimum Data Set (MDS- a federally mandated resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 8/21/25, the MDS indicated Resident 49's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status). Resident 49's score was 13 meaning intact cognition. 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 one of one sampled resident (Resident 49) was assisted to receive proper vision treatment to maintain vision when Resident 49 was not assisted with referral for cataract surgery as ordered by the doctor.This failure had the potential to cause Resident 49 decline in vision, blindness and emotional distress. During a review of Resident 49's Minimum Data Set (MDS- a federally mandated resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 8/21/25, the MDS indicated Resident 49's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status). Resident 49's score was 13 meaning intact cognition. Resident 49 had clear speech, able to make self-understood and understood others. MDS indicated Resident 49's diagnoses included anxiety disorder (a group…

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, record review, document review, and facility policy review, the facility failed to act upon the Consultant Pharmacist's recommendation for 2 (Resident #2 and Resident #32) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Consultant Pharmacist Reports, effective date 06/2021, revealed, The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. 1. An admission Record revealed the facility admitted Resident #2 on 11/15/2023. According to the admission Record, the resident had a medical history that included a diagnosis of heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview, document review, and facility policy review, the facility failed to ensure a medication error rate of less than 5%. The facility had 4 medication errors out of 26 opportunities, which yielded a medication error rate of 15.38% for 1 (Resident #40) of 4 residents observed for medication administration. Findings included: A facility policy titled, Medication Administration Oral Inhalations, dated 05/2016, indicated, 14. If another puff of the same or different medication is required, follow the manufacturer's product information for administration instructions including the acceptable wait time between inhalations. The undated Dulera Patient Information, revealed, 10. Wait at least 30 seconds to take your second puff of Dulera. A facility policy titled, Medication Administration General Guidelines, dated 09/2018, indicated, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer…

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, record review, and facility policy review, the facility failed to transcribe a physician's order for wound care for 1 (Resident #2) of 14 sampled residents. Findings included: A facility policy titled, Wound Care, revised in10/2010, revealed, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for this procedure. An admission Record revealed the facility admitted Resident #2 on 11/15/2023. According to the admission Record, the resident had a medical history that included a diagnosis of heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #2's care plan, initiated on 11/16/2023, revealed the resident had potential/actual skin impairment to skin integrity related to suspected deep tissue injury. Resident #2's Surgical Consult dated 06/12/2024, revealed the physician was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview, and document review, the facility failed to ensure enhanced barrier precautions were implemented for 1 (Resident #26) of 14 sampled residents. Findings included: The Enhanced Standard Precautions for Skilled Nursing Facilities (SNF), 2019 published by the California Department of Public Health (CDPH), revealed, CDPH recommends the use of Enhanced Standard precautions, primarily the use of gowns and gloves for specific care activities, based on the resident's characteristics that are associated with a high risk of MDRO [multidrug-resistant organism] colonization and transmission: Table 1. Characteristics of Residents at High Risk for MDRO Colonization and Transmission Functional Disability: Totally dependent on others for assistance with activities of daily living Incontinence: Habitual soiling with stool or wetting with urine Presence of indwelling devices: urinary catheter, feeding tube, tracheostomy tube, vascular catheters Ventilator-dependence Wounds or presence of pressure ulcer (unhealed) Implement Enhanced Standard Precautions…

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 administer the medication Tramadol 50 mg (medication used to help relieve moderate to moderately severe pain) as per physician ' s order for one (Resident 1) of three sampled residents. This failure resulted in Resident 1 receiving a double dose of medication within 12 hours and placed Resident 1 ' s health and safety at risk. Findings: During a review of Resident 1 ' s admission record, printed on 11/1/23, the admission record indicated Resident 1 was originally admitted to the facility on [DATE]. During a review of Resident 1 ' s physicians orders dated 8/15/23, the physician orders indicated to administer Tramadol HCL oral tablet 50 mg, 1 tablet every 12 hours as needed for pain. During a review of Resident 1 ' s Antibiotic and Controlled Drug Record, dated 8/30/23, the controlled drug record indicated on 9/20/23, Tramadol was taken out of the medication cart at 10:15 p.m. and signed by licensed nurse. The controlled drug record also 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to meet professional standards for care for one of three residents (Resident 1) when Certified Nurse Assistant (CNA) 1 provided Resident 1 two instant hot packs (a chemically activated disposable pack squeezed to pop an inner fluid bag and shaken to produce heat) without a physician order or protective barrier. Resident 1 placed the hot packs directly on her abdomen and was not supervised or reassessed during the application. This failure caused a second-degree burn (a burn that damages the outer layer [dermis] and second layer [epidermis] of skin) on Resident 1's lower abdomen. Findings: During a review of Resident 1's admission Record dated [DATE], the admission Records showed Resident 1 was admitted in [DATE]. During a review of Resident 1's Minimum Data Set (MDS - an assessment used to guide care) assessment dated [DATE], Section C showed a Brief Interview for Mental Status (BIMS - an assessment tool used to evaluate mental status) score…

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 implement written policies and procedures (P&P) that prevent abuse, neglect, and exploitation of residents when registry Certified Nursing Assistants (CNAs) were not given abuse training/orientation prior to working with residents. This failure had the potential to result in abuse of residents. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses that included muscle weakness, end stage kidney disease, and high blood pressure. During a review of Resident 1's Progress Notes, dated 9/4/23, the Progress Notes indicated Resident 1 complained of eight of 10 (0 for no pain and 10 as the most painful) pain on the back of her head after being transferred from the chair to the bed by CNA 1 and she hit her head on the headboard. The Progress Notes indicated Resident 1 had a round contusion at the back of the head that measured half an inch, Resident 1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility document review, the facility failed to serve two residents (Resident 51 and 49) of 57 sampled residents diets prescribed by a physician. This failure had the potential for two residents, Resident 51 and 49, to receive inadequate calories and/or nutrients contraindicated for a prescribed diet leading to nutritional related health issues. Findings: 1. An observation of trayline food service on 6/8/21, at 12 p.m., showed resident [NAME] 1 placed a scoop of mashed potatoes on a plate for resident 51's lunch. An observation of the tray ticket for Resident 51 located on his tray showed he was on a Regular, Controlled Carbohydrate (a diet typically prescribed to diabetics), Renal (a diet typically prescribed to a person with kidney disease), Thin Liquids. During a review of the Cook's Spreadsheet titled Summer Menus Week 1 Tuesday and used for lunch on 6/8/21, showed residents on a renal diet received wheat pasta with margarine instead of mashed potatoes which was served to regular diets. In a concurrent interview with [NAME] 1, the Registered…

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 facility record review, the facility failed to store food, brought into the facility by visitors, safely for residents. The facility also failed to have a policy to show food would be stored safely for residents upon request. This failure had the potential for decreased food intake by residents who preferred to eat food brought in from outside sources for 56 residents who were able to eat food by mouth out of a facility census of 57. Findings: Review of the undated facility policy and procedure titled Food For Residents From Outside Sources showed food brought in from outside sources for the resident would first be shown to the charge nurse for approval to ensure the food was within the diet order parameters. The nurse would consult with the Food and Nutrition Supervisor (FNS) or the consultant dietitian as needed. Prepared or perishable food must be consumed within one hour of receiving . Unused food would be disposed of immediately thereafter. An observation on 6/8/21 at…

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 provide necessary treatment and services to promote healing and prevent infection for one (Resident 51) of six sample residents when the facility staff did not provide the wound treatment on multiple shifts for Resident 51's multiple wounds. This deficient practice could result in worsening of Resident 51's existing pressure ulcers. Findings: Review of the facility admission Record, dated 5/17/21, indicated Resident 51 was admitted to the facility with multiple diagnosis including sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body ' s response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). During a review of the Treatment Administration Record from 5/1/21 through 5/31/21 the following treatment were not provided: a. The treatment to the wound on the coccyx area to apply collagen powder and cover with foam dressing was not provided on 5/22/21 during the day shift b. The treatment to the wound on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

2. During a concurrent observation and interview on 6/8/21, at 12:20 p.m., with the Director of Nursing (DON), in the Medication Storage Room, an uncapped and undated multi-dose vial (MDV) of Aplisol (used in skin tests to help diagnose tuberculosis) was found in the refrigerator. During an observation, on 6/8/21, at 12:30 p.m., with the DON, the uncapped and undated MDV of Aplisol was compared side-by-side to the capped MDV of Aplisol. The fluid level was lower in the uncapped and unlabeled MDV compared to the capped MDV, which indicated the vial had been opened. During an interview on 6/9/21, at 4 p.m., the DON stated she cannot find a facility policy and procedure for dating opening MDV. During a review of the Centers for Disease Control (CDC) Injection safety, dated 6/2019, it indicated If a multi-dose (vial) has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Based on observations, interviews and record review the facility failed to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and facility document review, the facility failed to: 1. Ensure the Registered Dietitian (RD) supported the Dietary Supervisor (DS) in maintaining a clean and safe kitchen environment; 2. Ensure the Dietary Supervisor (DS) maintained a clean kitchen and clean equipment on a day-to-day basis; and 3. Involve the RD in the quality assurance and performance improvement (QAPI; a data driven and proactive approach to quality improvement), when food and nutrition services was involved. This failure had the potential for contamination of food leading to foodborne illness for a highly susceptible population of 56 residents who received food from the kitchen out of a facility census of 57. Findings: 1. During the Federal Recertification Survey from 6/7/21-6/10/21, multiple issues were identified inside the kitchen including cleanliness of the environment such as a significant amount of residue, dirt, and/or dust on windows, window screens, window shade, walls, vents, window air-conditioner unit, on the inside surface of cabinets holding clean cooking utensils,…

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 facility document review, the facility failed to ensure competency of staff in the functions of the food and nutrition service when: 1. [NAME] 2 did not follow and properly document cooldown procedures for a time temperature control for safety (TCS) food (food that is more likely to grow harmful bacteria if not stored appropriately leading to foodborne illness); 2. [NAME] 1 did not appropriately demonstrate how to check the quaternary ammonia strength to clean food contact and nonfood-contact surfaces; 3. [NAME] 1 did not follow the menu for residents on a renal diet; and 4. Dietary Assistant 2 (DA2) did not appropriately demonstrate how to check the chlorine strength for the dish machine. This lack of competency by kitchen staff had the potential to result in contamination of food leading to foodborne illness as well as residents receiving different nutrients as indicated on the planned menu. Findings: 1. An observation during the initial kitchen tour on 6/7/21, at 10:30 a.m., showed a plastic bag filled with cooked white rice. The plastic bag…

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 a safe and sanitary environment for four (Residents 21, 26, 36, and 255) of 57 sampled residents, as evidenced by: 1) Nurse did not disinfect and clean BP cuff between using the BP cuff on residents 26, 36, 255 2) Nurses did not follow manufacturer's directions for SaniWipe use on medication baskets 3) Certified Nursing Assistant did not perform hand hygiene after doffing gloves and assisting a resident 4) The facility did not screen staff members for COVID-19 symptoms on 6/6/21 prior to providing care for the residents. . These failures had the potential to result in cross contamination and infection. Findings: 1. During an observation on 6/8/21, at 8:35 am., Registered Nurse (RN)2 removed wrist blood pressure (BP) cuff from his own wrist and placed it directly on the left wrist of Resident 255. After measuring Resident 255 BP. RN 2 removed the BP cuff from Resident 255's wrist and placed it back on his wrist. The BP cuff was not cleaned or disinfected prior to or after use with Resident 255. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure one (Resident 6) of two sampled residents needs were accommodated when administrator (Adm) told him he was not allowed to smoke. This failure caused Resident 6 psychological distress. Findings: During a concurrent observation and interviews on 6/8/21, at 11:36 a.m., with Resident 44 and Resident 6 were on the back patio, Resident 44 was seen smoking and Resident 6 was not. Resident 44 stated he often assists Resident 6 to smoke, but the Adm told Resident 6 he was not allowed to smoke. Resident 6 stated the Adm told him recently he was not allowed to smoke even though he has been smoking at the facility with assistance. Resident 6 further stated he had not smoked all day and felt stressed out that he was not allowed to smoke any longer. During an interview on 6/8/21, at 11:59 a.m., with Adm, Adm stated Resident 6 does not qualify to smoke. Adm further stated Minimum Data Set (MDS - a screening and assessment tool of health status) coordinator completed a safe smoking assessment on Resident 6 and added to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the observation, interview and record review the facility failed to provide a homelike environment when three (Resident 36, 51 and Resident 255) of five sample residents were complaining about the noise level at night. This failure had the potential to result in Resident 36 and 255 inability to sleep and feeling tired. Findings: During an observation on 06/07/21, at 9:40 a.m.,. a beeping noise was heard from the call light of Resident 51's room number and was ongoing until 3:30 p.m. same day. During an interview with the Director of Nursing ( DON) on 06/07/21, at 3:20 p.m., DON stated the call light had been broken since 6/6/21 on the night shift. DON stated they had called the company to fix the call light on 6/7/21. During an interview with Resident 35 on 06/07/21, at 10:32 a.m., Resident 35 stated There was so much noise at night. Resident 35 stated she was not able to sleep because of a beeping noise and residents yelling. During an interview with Resident 255 on 06/07/21, at 11:28 a.m., Resident 255 stated She was not able to sleep at nighttime because the place was so…

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, interviews and record review, the facility failed to follow its Grievances/Complaint policy and procedure to make prompt efforts to resolve a complaint for one (Resident 40) of 15 sampled residents when the facility did not follow up and resolve Resident 40's concerns regarding cold food. This deficient practice had the potential to cause emotional distress. Findings: During an observation on 6/08/21, at 8:08 a.m., breakfast tray for Resident 40 was on the bedside table containing eggs, waffles and harsh browns. During an interview on 6/8/21, at 8:08 a.m., Resident 40 stated that breakfast was always cold. Resident 40 stated the harsh browns was very hard, dry and cold. Resident 40 stated he had complained to the staff about the cold food ,but it continued to be served cold. During an interview with Dietary Supervisor (DS) on 6/09/21, at 2:38 p.m., DS stated Resident 40 had concerns about cold food. DS stated Resident 40 complained to her about cold food and she warmed his food as needed. DS stated she had no documentation regarding resident concerns and could…

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 interviews and record review the facility failed to ensure one (Resident 3) of six sampled residents received treatement to prevent further decline of range of motion when restorative nursing exercise was not provided as ordered by the physician. This deficient practice had the potential for Resident 3's range of motion to further decline. Findings: During a review of the Minimal Data Set (MDS-an assessment screening tool used to guide care), dated 5/28/21, indicated: Resident 3 had functional limited range of motion on one side of the upper and lower extremities. Resident 3 required 2-person physical assistance with movement to and from lying positron, turns side-to-side, movement to or from bed, chair and wheelchair. Resident 3's diagnosis included hemiplegia (paralysis of one side of the body). During a review of Resident 3's physician orders dated 11/27/20, it indicated Resident 3 was prescribed restorative nursing exercise three times a week for twelve weeks for upper/lower extremities, range of motion for contractor management. During a review of Resident 3's care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility had seven resident's rooms (Rooms A, B, C, D, E, F, G and H) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied these rooms. This deficient practice had the potential to result inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an observation on 6/7/21, at 10:00 a.m.,. the following rooms and corresponding square footage per bed were identified: Room number A and B has three beds, total SQF is 235.30 and SQF per bed is 78.42. Room number C has five beds and total SQF is 463.33 and SQF per bed is 97.41. Room number D, E, F and G has six beds, total SQF is 465.60 and SQF per bed is 77.59. Room number H has five beds and total SQF is 406.28 and SQF per bed is 86.43. During random observation of care and services from 6/7/21 to 6/10/21 there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident's care…

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.