Ceres Postacute Care

Based on interview and record review, the facility failed to ensure a staff member was aware of their job duties when Restorative Nurse Aide (RNA) 1 did not have a signed job description prior to her working as an RNA. This failure had the potential to cause RNA 1 to be unaware of her job duties. Findings: During an interview on 5/14/25 at 1:35 p.m. with RNA 1, RNA 1 stated she had transitioned from being a Certified Nursing Assistant (CNA) to an RNA three months ago. RNA 1 stated she did not recall signing a job description for her new role. During a concurrent interview and record review with the Director of Staff Development RNA 1's Employee Files, undated, were reviewed. The DSD stated she could not find a signed job description for RNA 1. The DSD stated whenever a staff member gets a new role, like going from a CNA to and RNA, they should have signed a job description going over their new duties otherwise they may not be fully aware of their responsibilities. During an interview on 5/15/25 at 4:11 p.m. with the Director of Nursing (DON), the DON stated RNA 1 should have signed…

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 a resident's drug regimen was free from unnecessary drugs for one of six sampled residents (Resident 19) when Resident 19 was administered oxycodone hydrochloride (medication used to treat intense pain) without adequate monitoring. This failure had the potential to cause Resident 19 to experience side effects such as constipation, decreased respirations, dizziness, and increased fall risk. Findings: During a review of Resident 19's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/15/25, the AR indicated, Resident 19 was admitted to the facility on [DATE] with a diagnosis of chronic pain syndrome (condition that causes pain which does not easily go away). During an interview on 5/12/24 at 10:30 a.m. with Resident 19, Resident 19 stated he had had a diagnosis of chronic pain which he needed to take oxycodone hydrochloride…

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 the medication error rate was less than five percent when the facility's medication error rate was 5.88 % percent. There were 34 opportunities for errors and two medication errors occurred for two of nine sampled residents (Resident 1 and Resident 2) when: 1. Resident 2 did not receive the inhaler medication Salbutamol (medication used to treat asthma (a condition in which person's airways become inflame, narrow , and swell, and produce extra mucus, which makes it difficult to breathe) and exercise-induced bronchospasm (a life-threatening emergency that occurs when the muscles surrounding the lungs' small airways tighten, narrowing the airways) at the prescribed time of administration of 8:00 a.m. on 5/14/25. 2. Resident 1 did not receive the eye drops medication (Lubricant eye drops Ophthalmic [relating to or representing the eye] Solution 0.5% at the prescribed time of administration of 7:00 a.m. on 5/14/25. These failures…

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 post the results of the most recent abbreviated survey document titled, Statement of Deficiencies in a place readily accessible to residents and their representatives. This failure had the potential to violate the rights of the residents and their representatives to be informed of abbreviated survey deficiencies and the facility's plan of correction. Findings: During an observation on 5/21/24 at 9:20 a.m., a binder labeled Survey Inspection was located in a holder on the wall in the main entrance. The binder contained the 2019 health recertification survey deficiencies and plan of corrections and previous years abbreviated surveys. There were no abbreviated survey documents available from 2020 to 2024. During a concurrent interview and record review on 5/21/24 at 11:05 a.m., with the Administrator (ADM), a document titled, Survey Inspections, undated was reviewed. The ADM stated, the binder contained the 2019 health recertification survey deficiencies and plan of corrections and previous years abbreviated…

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 have an air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture), under the food preparation sink. This failure had the potential to result in 36 of 36 residents being exposed to contaminated water (when substances pollute the water and make it unusable for cooking and drinking) which could ultimately result in food born illness from eating contaminated food. Findings: During a concurrent observation and interview with Certified Dietary Manager (CDM), on 5/20/24 at 8:52 p.m., at the food prep sink in the facilities kitchen, the CDM validated that there was not an air gap under the food prep sink. The CDM stated she does not know why there is not an air gap under the food prep sink. The CDM stated there should be an air gap under the sink so that the water does not back up into the sink. The CDM stated that maintenance would be the person responsible for making sure there is an air gap. During an interview on 5/20/24 at 9:43 p.m., with Maintenance Staff (MAINS), MAINS…

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 cover one of one outside trash bin with a lid. This failure had the potential to harbor and feed pests. This failure had the potential for an infestation of pests which could lead to unsanitary conditions and the spread of disease. Findings: During an observation on 5/22/24 at 2:01 p.m. in the parking lot of the facility, the trash bin was uncovered, the lid was open and hanging on the back of the bin. During a concurrent observation and interview on 5/22/24 at 3:47 p.m. with Maintenance Staff (MAINS), MAINS validated the lid of trash bin was open MAINS stated, . the lid on the trash should always be closed to prevent rodents and insects . During a review of the facility's policy and procedure titled, Waste Disposal dated 1/2018, indicated, .1. All .waste destined for disposal shall be placed in closeable leak proof containers .b. Disposal of all . waste shall be in accordance with applicable federal, state, and local regulations .

Based on observation, interview, and record review the facility failed to ensure a safe clean comfortable homelike environment was provided for four of 21 residents when: 1.One third of the floor in Resident 10, 18, 19, and 26's rooms had yellow and brown stains. This failure resulted in Residents 10, 18, 19 and 26 not being provided a clean comfortable homelike environment. 2. In Resident 6 and Resident 23 room red tape was used to attach the call light cord to the call light socket. This failure resulted in a potenial fire hazard and Resident 6 and 20 not being provided a safe, comfortable homelike environment. Findings: 1. During a review of Resident 10's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive abilities), dated 4/1/24, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of nine (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 10 had moderate cognitive impairment. During a review of Resident 18's MDS, dated…

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 and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for four of 13 sampled residents (Residents 4, 18, 30, and 138) when Residents 4 and 138 did not have an individualized care plan developed and implemented for the use of side rails. This failure had the potential for Residents 4 and 138 to be injured while using the side rails. Findings: During a review of Resident 138's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/21/24, the AR indicated, Resident 138 was admitted from home on 5/13/24 to the facility, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD- is a chronic inflammatory lung disease that causes obstructed airflow of the lungs), Heart Failure (weakness in the heart where fluid accumulates in the lungs), Anxiety (a mental health disorder characterized by feelings of worry, anxiety,…

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 an effective infection control program when one of four sampled residents' (Resident 1) oxygen concentrator (a device that concentrates the oxygen from the ambient air) filters were found covered with lint and dust. This failure placed Resident 1 at an increased risk to develop respiratory and healthcare-associated infections. Findings: During a review of Resident 1's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/21/24, the AR indicated, Resident 1 was admitted from an acute care hospital on 3/21/24 to the facility, with diagnoses which included Myocardial Infarction (heart attack), Hypertension (high blood pressure), Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), and Morbid Obesity (overweight). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive…

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 treat residents with respect and dignity when staff spoke with each other in a foreign language not understood or spoken by three of four sampled residents (Residents 1, 2, and 3). This failure made Residents 1, 2 and 3 feel uncomfortable and believed staff spoke about them in a language they did not understand and Resident 3 felt disrespected when staff spoke in a language she did not understand. Findings: During a concurrent observation and interview on 1/29/24 at 10:29 a.m. with Resident 1, in Resident 1 ' s room, Resident 1 was lying in bed. Resident 1 stated he heard staff speak a foreign language to each other in the facility. Resident 1 stated it made him feel like they were talking about him when they spoke in a foreign language. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment dated 10/5/23, indicated Resident 1's Brief…

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 chemical sanitizing solution used for dishes, utensils and kitchen working surfaces met the recommended sanitation concentration when expired chemical test strips were used. This practice failed to ensure the required level of sanitation was followed and placed the residents and staff of the facility at risk for food borne illness. Findings: During a concurrent observation and interview with [NAME] 1, on 6/3/19, at 8:15 a.m., [NAME] 1 took a test strip to test the sanitizing solution in a red bucket. [NAME] 1 stated the solution in the red bucket was used to sanitize the countertops of the kitchen. The Quaternary Sanitizer (a form of disinfectant) (QT) test strip used by [NAME] 1 indicated an expiration date of 2/2019. During a concurrent observation and interview with [NAME] 1, on 6/3/19, at 8:20 a.m., [NAME] 1 took the chlorine test paper to verify the sanitation solution for the dishwasher. The container for the chlorine test paper indicated an expiration date of 5/19. [NAME] 1 stated the test…

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 conduct a facility wide assessment specific to the facility needs when the facility assessment did not include a water management plan. This practice failed to establish an individualized facility assessment to meet the requirement for a water management plan which had the potential for waterborne bacteria exposure to the residents including Legionella (disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by bacterium known as legionella, most people get legionnaires' disease from inhaling the bacteria in showers, water faucets, water fountain) in an event of an outbreak. Findings: During an interview with the Administrator (ADM), on 6/5/19, at 9:30 a.m., he stated he was aware of the facility's requirement to establish a water management plan issued by the Centers of Medicare and Medical Services (CMS) in September 17, 2018. The ADM stated the requirement indicated all healthcare facilities were required to develop a plan for water management in an effort to reduce the risk 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 interview and record review, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program that had a data driven approach to maintain safety and quality when the facility's QAPI program did not develop and implement a water management program as part of the infection Control Program. These failure resulted in the facility not having a program in place to reduce the risk of waterborne illnesses including Legionella (a severe form of pneumonia) (lung inflammation usually caused by infection, caused by a bacterrium known as legionella, most people get legionnaires'disease from inhaling the bacteria in showers, water faucets, water fountain). Findings: During an interview with the Maintenance Supervisor (MS), on 6/5/19, at 9:15 a.m., the MS stated he was not aware of the water management plan for Legionella and did not know what Legionella was. During a concurrent interview and facility document review with the Administrator (ADM), on 6/6/19, at 11 a.m., he stated he was aware of the facility's requirement to establish a water management…

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 an effective infection prevention and control program when: 1. The facility water management plan was not created or implemented to reduce the risk of Legionella (waterborne bacteria which can cause life threatening pneumonia) (a lung infection) and other waterborne pathogens (germs that cause disease) in accordance with Centers for Medicare and Medicaid Services (CMS). These failures placed the residents at risk for cross contamination, infection and had the potential for not identifying the risk of waterborne illnesses such as Legionella. 2. The Infection Surveillance Logs (to track residents with infections) was not completed in accordance with the facility policy and procedure titled, Infection Control Plan. These failures had the potential to result in an ineffective infection surveillance program which could potentially lead to undetected infection outbreaks, unnecessary antibiotic use and place residents at risk to develop antibiotic resistance. Findings: 1. During an interview 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 observation, interview and record review, the facility failed to ensure residents were provided with comfortable sound levels for three of three sampled residents (Resident 15, 13 and 20) when: Resident 17's television (TV) sound was so loud, it was heard in the hallways and adjacent rooms and disrupted Resident 15,13 and 20. This failure violated the residents' rights to a comfortable and homelike environment that would respect the residents' dignity, privacy and well-being. Findings: During an observation in the facility hallway on 6/3/19, at 9:30 a.m., a very high volume of sound came from a TV inside Resident 17's room. Resident 15 who tried to form words to speak was unable to (non-verbal) do so. She immediately signaled and pointed to her ears and Resident 17's TV. Resident 17 held her TV remote control while she watched the TV show in a loud volume. During an interview with Resident 17, on 6/3/19, at 11 a.m., in her room. Resident 17 stated she could not hear well, which caused her to increase the TV volume. Resident 17 stated the staff knew she could not hear well…

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 The facility failed to ensure residents' Minimum Data Set (MDS) (an assessment of memory, recall and functional abilities) assessment accurately reflected the residents functional status for three of three sampled residents (Resident 17, 30 and 33) when: 1. Resident 17's hard of hearing status was not coded in the MDS assessment. 2. Resident 30's dialysis (filters a patient's blood to remove excess water and waste products when the kidneys are damaged, dysfunctional, or missing) treatment was not coded in the MDS assessment. 3. Resident 33 ate by mouth and the MDS assessment coding indicated nasogastric feeding or percutaneous endoscopic Gastrostomy (PEG-tube) (tube inserted by was of the nose or stomach for administration of nutrition, fluids and/or medications) instead. These failures had the potential for the residents' needs to be unmet. Findings: During an observation on 6/3/19, at 9:30 a.m., the TV volume inside Resident 17's room was heard from the hallway outside of her room. During an interview with…

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 operationalize their policy and procedure to investigate abuse when the Director of Nursing (DON) and the Administrator (ADM) did not conduct an investigation after one of three sampled residents (Resident 23) engaged in disruptive yelling and abusive verbal behavior toward Resident's 13 and 26. This failure resulted in the missed opportunity to provide Resident 13 and Resident 26 emotional support and counseling during and after the investigation, as needed. This failure had the potential for all allegations of abuse to continue. Findings: During a telephone interview with Certified Nursing Assistant (CNA) 3, on 6/4/19, at 8:08 a.m., she stated she was on duty on 5/23/19, at 10 p.m. and assigned to a 1:1 (a caregiver assigned to one resident only) with Resident 23. CNA 3 stated Resident 23 had been restless and agitated and therefore required the 1:1 to keep him safe. CNA 3 stated Resident 23 woke up got out of bed on the night shift of 5/23/19. CNA 3…

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 the abuse prohibition policy and procedure for two of two residents (Resident 26 and 13) when Certified Nursing Assistant (CNA) 3, CNA 4, CNA 5, Licensed Vocational Nurse (LVN 1), Director of Staff Development (DSD), Director of Nursing (DON) and Administrator (ADM) failed to report an incident of verbal abuse from Resident 23 toward Resident 26 and 13 in accordance with the State law. These failures subjected the staff and the residents' safety at risk and had the potential for these incidents to continue endangering the well-being of the residents. Findings: During a telephone interview with Certified Nursing Assistant (CNA) 3, on 6/4/19, at 8:08 a.m., she stated she was on duty on 5/23/19, at 10 p.m. and assigned to a 1:1 (a caregiver assigned to one resident only) with Resident 23. CNA 3 stated Resident 23 had been restless and agitated and therefore required the 1:1 to keep him safe. CNA 3 stated Resident 23 woke up got out of bed 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.

Based on observation, staff interview and record review, the facility failed to ensure residents were assisted in gaining access to hearing services for one of three sampled residents (Resident 17). This failure resulted in not meeting Resident 17's functional hearing needs necessary to improve her quality of life. Findings: During an observation on 6/3/19, at 9:30 a.m., the TV volume inside Resident 17's room was heard from the hallway outside of her room. During an interview with Resident 17, on 6/3/19, at 11 a.m., in her room. Resident 17 stated she could not hear well, which caused her to increase the TV volume. Resident 17 stated the staff knew she could not hear well and needed the TV volume to be loud enough for her to hear. During a concurrent interview and record review with the Social Service Director (SSD), on 6/6/19, at 3 p.m., she was unable to find documented evidence of a hearing consult scheduled for Resident 17. The SSD stated Resident 17's hearing needs were not met and should have been followed up by scheduling a consultation with an audiologist. The facility'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, staff interview and record review, the facility failed to ensure one of three sample residents (Resident 27) received routine dental care when a follow-up with dental recommendations for Resident 27 to have an upper partial denture fitting was not done. This failure resulted in Resident 27 feeling embarrassed and inability to eat regular textured food. Findings: During a concurrent observation and interview with Resident 27, on 6/3/19, at 9:45 a.m., Resident 27 had no front upper teeth and interfered with her speech. Resident 27 stated she had a partial upper denture before and had lost it. During an observation and interview of Resident 27, on 6/6/19, at 4:45 p.m., Resident 27 stated she would be able to eat regular food and would be able to smile if she had a new denture plate. Resident 27 stated she was known for her smile and felt embarrassed to smile. During a review of the clinical record for Resident 27's, the dental notes dated 5/13/19, indicated Resident 27 had under gone a dental evaluation with X-ray. The recommendation indicated a referral to 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 observation, interview and record review, the facility failed to provide one of three sampled residents (Resident 21) with eating equipment necessary to facilitate drinking and reduce fluid spillage when two nosey cups (designed with a cut out on the non-drinking side enabling tilting without interference by the nose) were not included in Resident 21's lunch tray. This failure had the potential for Resident 21's fluids to spill and difficulty to drink fluids. Findings: During a lunch observation of Resident 21, on 6/3/19, at 11:50 a.m., Resident 21 lunch tray consisted of a pureed diet served in separate bowls, one four ounce (oz) glass of juice and one four oz glass of water. Resident 21 ate her pureed food from the separate bowls while a Certified Nursing Assistant (CNA) 1 supervised. Resident 21's meal ticket indicated, Serve food in bowls and 2 nosey cups. During an interview with CNA 1 and CNA 2, on 6/3/19, at 12 p.m., both CNA's stated Resident 21's lunch tray should have included 2 nosey cups for Resident 21's use. CNA 2 stated anyone of them could have transferred…

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 failed to assure full visual privacy for one of 23 sampled residents (Resident 7) when Resident's 7's cubicle curtain (material suspended from the ceiling to circle around the bed to provide privacy during resident personal care) was removed and not replaced. This failure had the potential for Resident 7 to receive personal care with out being afforded privacy. Findings: During a medication pass observation and interview with Licensed Vocational Nurse (LVN ) 2 on 6/4/19, at 8:30 a.m., LVN 2 tried to pull the curtain from the middle of the room. The curtain did not provide full circle privacy around Resident 7's bed. LVN 2 stated Resident 7 could not speak. LVN 2 stated the privacy curtain was missing for Resident 7. LVN 2 stated the hooks for the curtains were hanging in the curtain rail and the housekeepers were responsible for the replacement of the privacy curtain after their removal. During an interview with the Housekeeper/Laundry staff, on 6/5/19, at 4:17 p.m., stated she was responsible to check privacy curtains were in place…

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.