Baywood Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the consultant pharmacist's recommendations were acted upon for two of 12 residents (14 and 20) when: 1. Resident 14's chewable Aspirin (a drug that reduces pain, fever, inflammation, and blood clotting) was not changed to plain film coated form of baby aspirin; and 2. Resident 20's consultant pharmacist's Note to the Attending Physician/Prescriber regarding duplicate therapy of Protonix (used to treat heartburn and certain other conditions caused by too much acid in the stomach) and Pepcid (used to treat heartburn and certain other conditions caused by too much acid in the stomach) was not presented to the physician. This failure had the potential for Residents 14 and 20 to receive ineffective and unnecessary medications that could negatively impact their health and well-being. Findings: 1. Review of Resident 14's admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 14's physician order, dated 1/28/25,…

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 employ sufficient staff with the appropriate competencies and skills sets to carry out the food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards for food service managers as a full-time, qualified dietetic supervisor when the dietitian was not full time. This failure had the potential to unsafe food practices and food-borne illness for 38 residents eating facility-prepared foods. Findings: Reviewing the Food and Nutrition Services schedule for February, March, and April 2025 indicated no dietary manager (dietetic supervisor) was working in the facility. A review of the actual working schedules for all staff received on 4/1/2025 indicated that the Registered Dietician (RD) worked only two days a week. During an interview with the registered dietitian (RD) on 4/3/25 at 9:41 a.m., the RD stated that she was a part-time employee working approximately 20 hours per week and that the facility did not have a full-time dietary manager. She…

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

Based on observation, interview, and record review, the facility failed to maintain the kitchen freezer and the meal cart in a good and safe operating condition, when 1. Excessive ice buildup was observed in the reach-in freezer. 2. Kitchen Meal Cart 3 was missing a proper handle, and the meal cart door was no closing. These deficiencies could compromise the freezer's ability to keep food adequately frozen and the meal cart door may not prevent proper food temperature maintenance that could cause food-borne illness for 38 out of 39 residents who received meals prepared in the kitchen. Findings: 1. During a kitchen tour on April 3, 2024, at 11:51 a.m., significant ice buildup was observed inside the reach-in freezer, on the exterior of the freezer doors, and along both sides of the freezer gaskets. 2. During a meal pass observation on April 2, 2025, at 12:22 p.m., Meal Cart 3 was found to be missing a proper handle, the door was detached, and unable to close the door properly. During an interview with the Registered Dietitian (RD) on April 3, 2025, at 4:52 p.m., she confirmed 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 maintain the reach-in freezer in good and safe operating condition when the reach-in freezer had ice-build up and freezer temperature was negative forty degrees Fahrenheit. This failure had the potential to cause the freezer to be ineffective for keeping food frozen and may lead to food spoilage and food-borne illness (illness resulting from contaminated food) for 23 residents who received food from the kitchen out of 24 residents. Findings: During the kitchen initial tour with the cook on 1/8/24, at 8:30 a.m., she confirmed the temperature logs for refrigerator 1, 2 and freezer were blank. She stated that checking of the temperature for refrigerator 1, 2 and freezer was done at 6:00 a.m., and p.m. every day but she forgot to log this morning. During the kitchen initial tour with the cook on 1/8/24, at 8:33 a.m., the reach-in freezer had significant ice build-up inside, outside the freezer doors and both sides of the freezer gaskets. The outside thermostat and the two thermometers inside the freezer 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 maintain safe and comfortable temperature of 71 to 81 degrees Fahrenheit (F) when: 1. One of 12 sampled residents (Resident 9) complained that the room was cold; and 2. 12 resident rooms, dining/activity room, living room, and one of the two hallways were found to be below the comfortable temperature range. This failure had the potential to result in residents' decreased sense of well-being and exposed to an uncomfortable environment. Findings: During a concurrent observation and interview on 1/10/24 at 10:05 a.m., Resident 9 was in the dining/activity room with blankets over her. Resident 9 stated she informed the staff that the room was cold, and the staff provided blankets. During a concurrent environmental tour and interview on 1/10/24 at 10:40 a.m., and at 3:12 p.m. with the maintenance staff (MS), the MS measured the temperature of the following rooms using the infrared thermometer (a handheld device used to measure the temperature from a distance): Dining/Activity Room = 63.3 F Hallway MM = 70.2 F…

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 the manufacturer's recommendations for maintaining the bed side rails for 15 residents (3, 4, 5, 6, 7, 8, 10, 12, 13, 14, 17, 18, 22, 23, and 24). This failure had the potential to place the residents at risk of entrapment and injury. Findings: During an observation on 1/12/24 at 2:02 PM, Resident 13 was in bed sleeping, and had both upper 1/4 side rails in the up position. During an observation on 1/12/24 at 2:02 PM, Resident 23 was observed having 1/4 upper side rails up whenever she was in bed. During an observation on 1/12/24 at 2:44 p.m., the bed of Resident 5 had partial side rail on one side. During an observation on 1/12/24 at 2:47 p.m., the bed of Resident 24 had partial side rails on both sides. During an observation on 1/12/24 at 2:50 p.m., the bed of Resident 10 had partial side rail on one side During an observation on 1/8/24 at 8:58 a.m., Resident 12 was in bed sleeping with half side rails in the up position. During an interview on 1/9/24 at 9:02 a.m., Resident 12 stated he used the side…

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 emergency kits (E-kits, containers with specialty medications which may be needed in an emergency) did not contain expired medications, when two of four E-kits had expired medications. This failure had the potential of a resident being administered an emergency medication which was expired, and not effective. Findings: During an observation of the facility's medication room, on 1/09/24 at 1:43 PM, with licensed vocational nurse E (LVN E), the injectable E-kit (E-kit with liquid medications which are administered by needle, either directly or through an IV (catheter inserted into a blood vessel for direct access)) had a. 3 ampules of Chlorpromazine (used to treat mental illness) that had expiration dates of 12/2023, b. 3 ampules of Gentamycin (used to treat infections) 80 milligrams (mg, a metric unit of mass) per 2 milliliters (ml, a metric unit of volume) that had expiration dates of 12/2023, c. 2 ampules of Epinephrine (a hormone involved in the body's fight-or-flight response) 1 mg/1 ml that 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 1. The medication cart was locked when unattended; and 2. The opened multi-dose containers of house medications/supplements had no open date. These failures had the potential of medication (or other items) being taken without the nurse's knowledge and medications being held past the usage period after being opened. Findings: 1. During an observation, on 1/8/24 at 8:29 a.m., the medication cart was in the nurses station, unattended and unlocked. After approximately one minute, a nurse came into the nurses station. During an interview, on 1/8/24, at 08:30 a.m., with licensed vocational nurse A (LVN A), she stated when she got report, at about 8:00 a.m., the medication cart was unlocked. She stated she did not notice until she was asked, by surveyor, about cart being unlocked, which was at 8:30 a.m. During an interview, on 1/12/24 at 9:54 AM, with the director of nursing, (DON), he stated the unlocked cart was unacceptable. It should have been locked at any time. A review of the facility's policy 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 observation, interview, and facility document review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when: 1. Food preparation equipment were not maintained clean and/or in good condition including: a. Commercial can opener b. Cutting boards; 2. Five dented can goods were stored on the rack with ready to use cans; 3. Nine bananas with multiple blackish dots on top of the tray cart inside the dry storage area has no date; 4. One orange fruit soft and rotten with grayish particles, three pieces of green peppers has multiple blackish spots with grayish particles without date and one white onion inside the plastic has no date; and 5. One [NAME] bottled with approximately 300 milliliters (ml, a metric unit of volume) yellow liquid has no label and two bottles of opened Ajax powder cleanser was stored between the sink and the stove with food on top of the stove or cooking equipment. These failures had the potential to cause food…

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 implement infection control practices for 5 of 12 residents (6, 8, 10, 18, and 24) when: 1. For Resident 6, oxygen tubing was not changed for 3 weeks; storage bag for oxygen tubing was not changed for about one and a half year; the humidifier bottle was undated; and the filter of oxygen concentrator was so dusty; 2. Certified nursing assistant F (CNA F) did not sanitize her hands before serving lunch tray to Resident 10; and 3. CNA G, CNA H, and CNA I did not sanitize their hands after carrying the chair and before feeding Resident 24, Resident 8, and Resident 18. These failures had the potential to spread infection in the facility. Findings: 1. Review of Resident 6's admission Record indicated she was admitted to the facility on [DATE] with chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) diagnosis. Review of Resident 6's physician order, dated 8/30/22,…

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 need was accommodated and to ensure dignity was maintained for two of twelve sampled residents (10 and 24) when: 1. Facility staff failed to ensure a communication device was provided for Resident 10; and 2. Certified Nursing Assistant G (CNA G) were standing while feeding Resident 24. These failures had the potential to negatively affect the resident's physical and psychosocial well- being. Findings: 1. During observations on 1/8/24, at 10:05 a.m., and on 1/9/24, at 9:02 a.m., Resident 10 was lying in bed in her room. Resident 10 was using gestures and communicating with her own language other than English and no communication device at the bedside or drawers. During a concurrent observation and interview with CNA D on 1/9/24, at 9:05 a.m., Resident 10 was communicating with CNA D through gestures, pointing her fingers in native language other than English. CNA D stated that Resident 10 needed a communication device during activities of daily living (ADL's) care and CNA D could not find any…

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 documentation of whether the advance directive was discussed with one of 12 residents (Resident 13) was discussed with the resident or family upon admission/re-admission, when the Physicians Order for Life-Sustaining Treatment (POLST) section D was not filled in completely. This failure had the potential of the incorrect treatment being administered in a life-threatening emergency. Findings: During a chart review for Resident 13, a POLST, dated 2/14/17, was located. Section D had three check boxes: 1. Advance directive dated___ available and reviewed. 2. Advance directive unavailable. 3. No advance directive. None of these boxes were checked. So, no indication if advance directive was discussed with Resident 13 or her family. During an interview with the infection preventionist (IP), on 1/10/24 at 11:46 a.m., she confirmed the latest POLST in chart, dated 2/14/17, did not indicate about advance directive (Section D is blank). During an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their abuse policy for one of 12 residents (7) when activities assistant J (AA J) reported that she heard certified nursing assistant K (CNA K) slapped Resident 7 twice, but the incident was not reported to the state agency department. Findings: Review of Resident 7's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 7's Daily Nurses Notes by the infection preventionist (IP), dated 11/30/23 at 6 p.m., indicated one staff reported that while passing by Resident 7's room, she heard another staff slapped Resident 7 twice. During an interview with the IP on 1/11/24 at 3:15 p.m., she stated AA J reported to her about Resident 7's room when she heard CNA K slapped Resident 7 twice. The IP stated the facility did the investigation and did not substantiate the allegation, so the facility did not report the incident to the state agency department. During an interview with the director of nursing (DON) on 1/11/24…

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 develop and accurately assess the preadmission screening and resident review report (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI) requires specialized services such as referral to a mental health authority), received mental illness diagnoses and did not receive a level two screening to ensure they received the services needed for two of twelve sampled residents (5 and 6). This failure had the potential to put the residents at risk for not receiving appropriate care and services. Findings: Review of Resident 5's clinical record indicated she was admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses including bipolar disorder (mental illness which a person can experience mood swings (period of overly happy or periods of feeling sad), anxiety disorder (feelings of worry and fears), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday…

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 develop and implement comprehensive person-centered care plans for two of 12 sampled residents (Residents 5 and 10) when: 1. Resident 5's antipsychotic medication (medications work by altering brain chemistry to help reduce psychotic symptoms like having false, fixed beliefs, hearing voices or seeing things that aren't there, and disordered thinking) care plan was incomplete and not person-centered; and 2. For Resident 10, there was no care plan developed specifically for communication deficit related to language barrier. These failures had the potential for inaccurate development and implementation of personalized and resident-centered care plans that would address the residents' identified concerns and needs. Findings: 1. Review of Resident 5's clinical records indicated she was re admitted to the facility on [DATE] with diagnoses of bipolar disorder (mental disorder characterized by periods of elevated mood) and depression (mood disorder that causes…

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 the residents received the necessary care and services for one of 12 residents (6) when Resident 6's electrocardiogram (EKG, records the electrical signal from the heart to check for different heart conditions) was not done every year as ordered by the physician. This failure had the potential to affect the resident's care and could jeopardize her health and well-being. Findings: Review of Resident 6's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 6's physician order indicated she had an order for her EKG to be checked every year to rule out QT (the space between the start of the Q wave and the end of the T wave on EKG which indicates the time it takes for the heart to contract and refill with blood before it beats again) prolongation (occurs when the heart muscle takes longer to contract and relax than usual; it can affect heart rhythms and lead to sudden cardiac arrest), started on 2/25/20. Review of…

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

Based on observation, interview, and record review, the facility failed to follow their oxygen administration policy for one of two sampled residents (Resident 8) when staff did not place an Oxygen in Use sign outside the entrance to the resident's room. This failure had the potential to compromise the resident's safety. Findings: Review of Resident 8's clinical record indicated she was admitted on hospice care (to assist in the care and comfort of individuals with terminal illness) with a diagnosis of hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time). Resident 8 had a physician order, dated 12/15/23, for oxygen at 2 liters per minute (LPM, oxygen flow rate) via nasal cannula (NC, flexible tubing inserted into the nostrils and attached to an oxygen source) as needed for shortness of breath. During an observation on 1/8/24 at 9:43 a.m., Resident 8 was lying in bed receiving oxygen via NC. There was no Oxygen in Use sign posted outside the entrance to Resident 8's room. During a concurrent…

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 store, prepare, and serve food under sanitary conditions when: 1. The kitchen microwave was not clean; 2. Employee's food was inside the kitchen refrigerator; and 3. The test strip to check the red bucket (sanitizer bucket) was expired. These failures had the potential to cause food borne illnesses to the residents in the facility. 1. During the initial kitchen observation on 4/5/2022, at 8:28 a.m., there were brown, black, and white substances at the top of the inside of the microwave and food buildup. During a follow up observation and concurrent interview with the dietary aide (DA) on 4/5/2022, at 1:40 p.m., DA confirmed the above observation. DA stated the microwave was used to warm residents' food. DA tried to clean them but DA could not remove the debris. DA further stated it should have been replaced. During an interview with the Registered Dietitian (RD) 4/8/2022 at 3:30 p.m., RD stated all kitchen equipment should have been kept clean. RD further stated microwave ovens should have been cleaned weekly…

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 one opened multi-dose eye medication was dated with an open and discard date, to make sure it was not used beyond the discard date. The deficient practice had the potential for unsafe and ineffective use of medication being used past the expiration date. Finding: During an inspection of the medication cart on [DATE], at 9:54 a.m., with Licensed Vocational Nurse (LVN) C, one opened lubricant eye drop bottle for Resident 19 was identified without an open date, LVN C stated, the bottle was newly opened, and confirmed it should have been labeled with an open date upon opening. During an interview with the Director of Nursing (DON) on [DATE], at 1:28 p.m., he stated for multi-dose medications, the licensed nurses should have verify expiration date before opening and administering the medication, and they should have label the bottle with an open date upon opening. The DON further stated lubricant eye drops were good for 60 days after…

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

Based on interview and record review, the facility failed to electronically submit staffing information based on payroll data on a quarterly schedule to the Centers for Medicare & Medicaid Services (CMS) in 2022. The deficient practice prevented the provision of complete and accurate direct care staffing information to the public. Findings: A review of facility's Payroll - Based Journal (PBJ - nurse staffing and non-nurse staffing datasets) submission, facility did not submit the third fiscal quarter of 2022 (April 1 - June 30) staffing information to CMS. During an interview with the business office manager (BOM) on 12/8/22 at 10:59 a.m., he stated the previous BOM failed to submit the staffing information from April 1 to June 30, 2022. During an interview with the director of nursing (DON) on 12/8/22 at 11:15 a.m., the DON acknowledged the previous BOM failed to report direct care staffing and census information electronically. A review of the facility's policy titled, Reporting Direct - Care Staffing Information (Payroll - Based Journal) dated October 2017, it indicated Census…

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 effective infection process when: 1. Foley catheter (FC, a tube inserted in the bladder to drain urine) and drainage bag were in direct contact with Resident's wheelchair wheel. 2. Staff did not perform hand hygiene in between tasks. 3. One licensed nurse did not perform hand hygiene between tasks during tube feeding. These failures had the potential to result in transmission of infection in the facility. Findings: 1. During an observation on 12/5/22 at 8:43 a.m., inside Resident 24's room, Resident 24's FC tubing and drainage bag were in direct contact with Resident 24's wheelchair wheel. During an interview with licensed vocational nurse (LVN) B on 12/5/22 at 8:43 a.m. inside Resident 24's room, LVN B acknowledged the above observation and stated the FC tubing and drainage bag should have not touched the dirty surfaces such as wheelchair wheel. During an interview with infection preventionist (IP) on 12/7/22 at 10:07 a.m., the IP stated urinary tubing and drainage bags should have not direct contact…

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.