South Bay Post Acute Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to update or revise care plans for two of three residents reviewed for care planning (8, 78). This failure had the potential to result in delayed care, miscommunication among caregivers, and decreased physical well-being of the residents. Findings: 1. Resident 8 was admitted to the facility on [DATE] with diagnoses to include dementia (a disorder causing memory problems and impaired reasoning) and muscle weakness, per the facility admission Record. On 11/14/22 at 11:19 A.M., a concurrent observation and record review of Resident 8 was conducted. Resident 8 was in bed, with a fall mat (a protective pad) on the floor next to the bed. The Resident Matrix (a document used to identify care needs) indicated Resident 8 had fallen within the past 90 days. According to a review of Resident 8s IDT (Interdisciplinary Team, a group of healthcare professionals), Resident 8 had fallen twice within the last year. On 5/1/22 Resident 8 was found on the floor,…

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 a plan for discharge for one of four residents reviewed for care planning (Resident 49). This failure had the potential to result in an unsafe discharge, and placed Resident 40 at risk for prolonged admission to the facility. Findings: Resident 49 was admitted to the facility on [DATE] with diagnoses to include muscle weakness, per the facility admission Record. On 11/14/22 at 11:51 A.M., an interview was conducted with Resident 49. Resident 49 stated she had been at the facility almost a year, but still had no plans for discharging. Resident 49 stated she would like to be discharged back to her previous neighborhood but nobody had discussed finding her a place to live. According to Resident 49's Brief Interview for Mental Status (BIMS, an assessment tool, dated 9/1/22), Resident 49's score was 15, indicating intact cognition. On 11/30/21, an IDT met for Resident 49's initial care conference. Per the IDT, Resident 49's plan for discharge 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed provide treatment and care according to professional standards of practice when: 1. The need for a PRN (provided as needed) medication was not assessed for one of one residents reviewed for constipation (Resident 36), and 2. A physician's order to assist a resident up in a chair daily was not followed for one of three residents reviewed for care planning (Resident 49). 3. Blood sugar level checks were not performed before meal intakes for one of 3 residents reviewed for diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired) care. These failures had the potential to place the residents at risk for further medical complications. Findings: 1. Resident 36 was admitted to the facility on [DATE], per the facility admission Record. On 11/14/22 at 1:13 P.M., a concurrent observation and interview with Resident 36 was conducted. Resident 36 was sitting in a wheelchair in her room, rubbing her abdomen…

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 did not ensure a toilet seat was securely attached to the toilet bowl in a communal bathroom used by multiple residents. As a result, multiple residents were at risk for falls due to the instability of the loose toilet seat. Findings: Per the facility's admission Record, Resident 83 was admitted to the facility on [DATE] with difficulty walking. Resident 83's records were reviewed. Per the physician's history and physical, dated 10/17/22, Resident 83 had the capacity to make her own decisions. On 11/13/22 at 11:50 A.M., an observation and interview with Resident 83 was conducted. Resident 83 was sitting up on the side of her bed. Resident 83 stated she did not have a bathroom in her bedroom, so she used the bathroom down the hall, Resident 83 stated the bathroom was used by several residents on the hall. Resident 83 stated the toilet seat moved from side to side and when she tried to sit on it, she was afraid of falling because it threw her off…

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 that one of one residents (31) on intravenous (IV) antibiotic therapy had their PICC line monitored per professional standards and facility policy. A PICC line is a peripherally inserted central catheter that provides access to the large vein carrying blood to the heart to administer medication for long-term use. This failure could potentially increase the risk of infection and delay the identification of catheter-related complications for Resident 31. Findings: Resident 31 was admitted to the facility on [DATE] with diagnoses that included infective endocarditis (a bacterial infection that settles in the heart) and bacteremia (bacteria in the blood), per the facility's admission Record. During an interview with Resident 31 on 11/14/22 at 10:30 A.M., the resident stated he was receiving antibiotics through the IV in his arm because he had an infection in his blood. An IV site was observed in the resident's right upper arm, with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a physician's order for oxygen therapy was followed for one of one resident (Resident 33) reviewed for respiratory care. As a result, Resident 33 was provided with more oxygen than what the physician ordered, which had the potential to cause respiratory problems for the resident. Findings: Resident 33 was admitted to the facility on [DATE] with diagnoses to include Congestive Heart Failure (CHF - a serious condition in which the heart doesn't pump blood as efficiently as it should), Chronic Obstructive Pulmonary Disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and Asthma (a condition in which a person's airways become inflamed, narrow, swollen, and produce extra mucus, which makes it difficult to breathe), according to the History & Physical, dated 2/10/22, and the Order Summary Report. On 11/16/22, at 4:31 p.m., a concurrent observation of Resident 33's oxygen concentrator (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of four residents reviewed for dialysis (a process to remove waste products from the blood) had a dressing removed as ordered by the physician (Resident 36). This failure had the potential to cause damage or injury to the dialysis site. Findings: Resident 36 was admitted to the facility on [DATE] with diagnoses to include dependence on renal dialysis (a need for dialysis due to kidney failure), per a facility admission Record. On 11/14/22 at 3:03 P.M., an interview was conducted with Resident 36. Per Resident 36, dialysis was scheduled on Tuesdays, Thursdays and Saturdays. Resident 36 stated the nurses usually removed the dressing from her dialysis access site when she returned at night. On 11/16/22 at 9:37 A.M., a concurrent observation and interview was conducted with Resident 36. Resident 36 stated she had returned from dialysis the previous night. Resident 36 stated the night nurse did not remove the dressing from her access…

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 behaviors related to the use of an antipsychotic was accurately monitored for one of 5 residents (Resident 33) reviewed for unnecessary use of psychotropic medications. As a result, Resident 33's documented behavior showed an increase in behavioral episodes which could potentially result in inappropriate dosing of the antipsychotic medication. Findings: Resident 33 was admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder (a mental illness that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), according to Resident 33's face sheet. An interview was conducted with CNA 1 on 11/14/22, at 12:15 p.m. CNA 1 stated Resident 33 preferred to sleep in and not eat breakfast until she wakes up. CNA…

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 care conference documentation was accurate for one of 20 resident (Resident 33) reviewed for accurate medical record. This failure did not provide an accurate representation of the care provided to Resident 33 and had the potential to cause confusion amongst care providers. Findings: Resident 33 was admitted to the facility on [DATE] with diagnoses to include Congestive Heart Failure (CHF - a serious condition in which the heart doesn't pump blood as efficiently as it should), according to the History & Physical, dated 2/10/22, and the Order Summary Report. An interview and joint record review was conducted with the SSD on 11/17/22 at 11:22 a.m. The SSD stated that a care conference was scheduled for Resident 33 on 11/7/22. The SSD stated the care conference was canceled by Resident 33's daughter and was scheduled for a later date. The SSD reviewed the IDT (Interdisciplinary team - a coordinated group of professionals from several different…

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 2. During observation and interview on 11/14/22, at 2:52 p.m., CNA 3 was observed coming out of room [ROOM NUMBER] and carried a urinal filled with urine, while both hands were gloved. CNA 3 held the urinal with his right hand and closed the door to room [ROOM NUMBER] with his left hand. CNA 3 proceeded to enter the hall restroom and came out holding the urinal with his left hand. CNA 3 turned the doorknob with his right hand to enter room [ROOM NUMBER]. An interview was conducted with the Infection Preventionist (IP) on 11/21/22, at 3:34 p.m. The IP stated staff used the restroom across the hall for room [ROOM NUMBER]. The IP stated he trained staff not to use gloves in the hallway. The IP stated he trained staff to use a barrier on holding a urinal. During a review of the facility's undated P&P, titled, Infection Prevention-Control of Transmission of Infection, the P&P indicated, It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and…

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

Based on interview and record review the facility did not clarify one of two residents' (287) wishes for life sustaining treatment. This failure created the potential for Resident 287 to receive life sustaining treatment not according to his wishes. Findings: On 11/11/18, Resident 287 was admitted to the facility with chronic kidney disease (Kidney Failure) per the facility admission Record. On 11/26/18, Resident 287's record was reviewed. Per hospital History and Physical, dated 11/6/18, Resident 287 declined dialysis (the process of cleaning the blood through a machine). Per admission physician's orders, dated 11/11/18, Resident 287 was DNR (Do Not Resuscitate). Documentation of Resident 287's wishes regarding life sustaining treatment was absent from the record. The facility did not complete a POLST (Physician Orders for Life Sustaining Treatment) until 11/21/18. On 11/26/18 at 3:34 P.M., an interview was conducted with Resident 287. Resident 287 stated he did not want any hospitalization, just comfort measures. On 11/26/18 at 4:40 P.M., the MRD stated the facility did not…

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

Based on observation, interview, and record review, one of four residents (28) received treatment for a pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) without a physician's order. This created the potential for Resident 28 to receive unsafe care. Findings: On 1/21/16, Resident 28 was admitted to the facility with a diagnoses which included hemiparesis (paralysis of one side of the body) following a stroke affecting the right dominant side per the facility admission Record. On 11/27/18 at 2:17 P.M., a concurrent observation of Resident 28's skin and interview with CNA 8 was conducted. CNA 8 stated Resident 28 did not have any skin issues. Resident 28's buttocks and tailbone (base of spine) area was observed with CNA 8. A Duoderm patch (used to treat pressure ulcers) was placed over the resident's tailbone area. On 11/27/18 at 2:25 P.M., a record review and interview was conducted with LN 10. LN 10 reviewed Resident 28's treatments and stated there were no orders for treatment to the buttocks and tailbone area. On 11/27/18 at 2:37…

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 provide showers and hair washing for one of two sampled residents (187). This failure had the potential for the resident to experience psychological stress and compromised hygiene. Findings: Resident 187 was admitted to the facility of 11/21/18 with diagnoses to include muscle weakness, per the admission Record. On 11/26/18 at 12:19 P.M., an interview was conducted with Resident 187 and his wife. Per Resident 187, his wife came in each morning to change his sheets and wash him in the bathroom. Resident 187 stated he had not washed his hair since admission, and he felt bad his wife had to help him. He also stated when his wife asked about washing his hair, the CNA responded to go ahead, but made no accommodations to assist her, and did not provide supplies. Per Resident 187's wife, the CNA never informed them of a shower room where hair could be washed while accommodating the resident in a wheelchair. On 11/29/18 at 9:09 A.M., a concurrent interview and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and manage pain for two of four residents investigated for pain management (24, 20). As a result, the deficient practice had the potential for unmanaged pain. Findings: 1) Resident 24 was admitted on [DATE], with diagnoses which included hemiplegia (total or partial paralysis of one side of the body) affecting the right side, per the facility admission Record. An observation on Resident 24 was conducted on the following dates. - On 11/26/18 at 8:27 A.M., and at 9:24 A.M., Resident 24 was sleeping in bed lying on his back. At 9:47 A.M., Resident 24 was awake, lying on his back. At 1:16 P.M., and at 4:54 P.M., Resident 24 was noted lying at a 45 degree angle. - On 11/27/18 at 7:24 A.M., and at 3 P.M., Resident 24 was observed sleeping lying on his back. - On 11/28/18 at 9:01 A.M., Resident 24 was awake lying on his back. On 11/27/18 at 3:56 P.M., an interview with CNA 11 was conducted. CNA 11 stated Resident 24 was totally dependent…

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 did not ensure dialysis (the process of cleaning the blood through a machine) care was given according to professional standards of practice for two of five residents (287, 186). This practice created the potential for: 1. Resident 287's temporary access site (central line located in the right upper chest) and AV fistula (artery and a vein surgical connection created for dialysis treatment) to become infected and for the AV fistula to clot. 2. Resident 186's access site to clot. Findings: 1. On 11/11/18, Resident 287 was admitted to the facility with Chronic Kidney disease (Kidney Failure) per the facility admission Record. On 11/26/18 at 10:57 A.M., an observation of Resident 287 was conducted. Resident 287 had a slightly reddened surgical site with sutures located in the left upper arm. Per Resident 287, the surgical site was an AV fistula, and until the AV fistula was healed, the temporary access site on his chest was to be used for dialysis.…

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 individualize behavioral interventions for one of three residents (43). This failure had the potential to result in Resident 43's safety being compromised. Findings: Resident 43 was readmitted to the facility on [DATE], with a diagnosis of dementia (impaired memory) with behavioral disturbances, per the facility admission Record. On 11/29/18 a record review was conducted. Resident 43's MDS, dated [DATE], section C, indicated he had a BIMs of 9 meaning the resident had moderately impaired cognition. The MDS, section G, indicated Resident 43 ambulated with limited assistance. Resident 43's Fall Committee IDT note, dated 11/17/18, the resident had a fall on 11/15/18. The note indicated the resident had periods of severe confusion, was getting up unassisted, and did not use his call light to request assistance. Per the note, nursing interventions implemented to prevent falls included, .continue to remind to use his call light for staff…

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 of five residents (20) reviewed, received anti-anxiety medications for an approved indication and behaviors. As a result, Resident 20's distress was not accurately assessed or treated. Findings: Resident 20 was admitted to the facility on [DATE], per the facility admission Record with diagnoses to include dementia (impaired memory) and contracture (shortening or stiffening of muscles which causes deformity) of multiple sites. On 11/26/18 a record review was conducted. Per the history and physical note, Resident 20 did not have the capacity to understand and make decisions. Per a physician's order, dated 11/6/18, Resident 20 was to receive Xanax (an anti-anxiety medication) and be monitored for episodes of anxiety as evidence by calling out during care. On 11/26/18 at 9 A.M., Resident 20 was observed lying quietly in her bed. On 11/26/18 at 9:27 A.M., an interview was conducted with CNA 13. CNA 13 stated Resident 20 had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to honor dietary preferences for one of four residents (78), which resulted in Resident 78 receiving foods she disliked. Findings: Resident 78 was readmitted to the facility on [DATE] per the facility admission Record. On 11/26/18, a record review was conducted of Resident 78's EMR. Resident 78 had a physician's order, dated 5/10/18, for mirtazapine (a medication for depression) at bedtime daily for depression. Resident 78 had a physician's order, dated 5/11/18, to monitor for episodes of depression as evidenced by poor appetite. On 11/26/18, at 1:11 P.M., an observation and concurrent interview was conducted in Resident 78's room. Resident 78 was sitting in bed with a meal tray in front of her. Resident 78 stated she was given zucchini and meatballs for lunch. Resident 78 further stated she did not like zucchini, meatballs or meatloaf and that she told facility staff numerous times but continued to receive them. The dietary slip on 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, interview, and record review, one of one resident (28) was not provided adaptive equipment for meals. This failure created the potential for Resident 28 to limit her intake at mealtimes. Findings: On 1/21/16, Resident 28 was admitted to the facility with a diagnosis of hemiparesis (paralysis of one side of the body) following a stroke affecting the right dominant side per the facility admission Record. On 11/26/18 at 8:43 A.M., Resident 28 was observed lying in bed with the head of the bed elevated 60 degrees. Resident 28's breakfast tray was on the bedside table positioned over the resident's lower torso. Resident 28 was observed using a regular spoon, pushing food across the plate attempting to scoop up food. The food fell off the plate and landed on the tray. On 11/26/18 at 1:02 P.M., an observation and interview was conducted with Resident 28. Resident 28 stated, My right hand is paralyzed so I can only eat with my left hand. My right side is my dominant side. Resident 28 was observed, for the second time, pushing food with her spoon across the plate and…

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

Based on observation, interview, and record review, the facility did not implement infection control related to hand hygiene. This practice created the potential for transmission of HAI (healthcare associated infections) to residents, staff, and visitors. Findings: On 11/26/18 at 12:33 P.M., an observation of CNA 13 was conducted. CNA 13 was holding two clear plastic bags with her bare hands. Inside the clear bags were incontinent briefs and wash cloths with brown material on them. CNA 13 went to the utility room and placed the clear bags in a plastic bin. CNA 13 then left the utility room, without performing hand hygiene, and went to the linen closet and took a clean wash cloth. CNA 13 then proceeded to a resident's room, took a pair of gloves from the wall, and went to the resident's bedside, without performing hand hygiene. On 11/26/18 at 12:37 P.M., CNA 13 came out of a resident's room with a clear plastic bag. Inside the bag was a wash cloth with brown stains. CNA 13 took the clear bag to the utility room and placed the bag in a plastic bin, inside the utility room. CNA 13 then…

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.