Fowler Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for five of six sampled residents (Residents' 1, 39, 40, 41, and 97) when: 1. LVN 1 administered medications to Residents' 39, 40, 41 and 97 without closing the privacy curtain or the door. 2. Licensed Vocational Nurse (LVN) 2 checked Resident 1's blood sugar level (BS-amount of sugar in the blood) without closing the privacy curtain or the door. These failures resulted in Residents' 1, 39, 40, 41, and 97 not provided respect and dignity during care which could potentially impact residents' well-being leading to vulnerability, decreased dignity, anxiety, stress and depression. Findings: 1. During a concurrent observation and interview on 3/6/25 at 7:55 a.m. in Station 1 East Hall with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared Resident 40's medications and entered Resident 40's room. Resident 40 was lying in bed and inside the room was another resident. LVN 1 administered…

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 develop and implement a comprehensive care plan for 10 of 15 sampled residents (Residents 10, 28, 29, 30, 37, 39, 40, 27, 24, and 14) when: 1. Resident's 10, 29, 30, 37, 39, and 40 did not have care plan for enhanced barrier precautions (EBP-infection control strategy, involving use of gowns and gloves during high-contact resident care). These failures placed Residents' 10, 29, 30, 37, 39, and 40 needs not being met. 2. Resident 28 care plan for Enhanced Barrier Precaution (EBP-a set of infection control measures that use personal protective equipment [PPE] to reduce the spread of multidrug-resistant organisms [MDROs]). This failure had the potential for Resident 28's needs being unmet. 3. Resident 27's actives care plan lacked person-centered approach for conversation and socializing. This failure had the potential for missed opportunities for emotional and cognitive stimulation. 4. Resident 24's care plan for impaired 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 observations, interviews, and record reviews, the facility failed to ensure services provided met professional standards of practice of quality for eight of nine sampled residents (Resident 12, 10, 30, 39, 40, 29, 37 and 28) when: 1. Resident 12 had a physician's order for a low air loss machine (a medical device used primarily to prevent or treat pressure ulcer (bedsores) and was not provided to Resident 12 and was unplugged. This failure resulted for Resident 12 not receiving the necessary care which could lead to development of pressure ulcer. 2. Resident 10, 30, 39, 40, 29, 37, and 38 needed Enhanced Barrier Precaution (EBP- an infection control measures to reduce the risk of transmission of infections) and the Infection Preventionist (IP) did not get a physician's order, did not perform a wound assessment and did not initiate a care plan (a personalized, structured document used to outline the care and treatment the residents needs). This failure placed Resident 10, 30, 39, 40, 29, 37, and 38 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the facility medication error rate did not exceed five percent. The facility's medication error was 6.9%. 1. Licensed Vocational Nurse (LVN) 1 did not follow medication direction when she administered lactulose solution (medication used to treat constipation) to Resident 40. This failure resulted for Resident 40 not receiving the full therapeutic benefit of the prescribed lactulose solution (medication used to treat constipation) which could lead to constipation or serious health condition. 2. LVN 1 administered metformin (medication used to treat diabetes) medication without food and did not follow the physician's order to administer with food. This failure had the potential risk for Resident 39 to experienced gastrointestinal upset (GI-gastric upset like diarrhea) and could decrease the absorption of Metformin leading to less effective blood sugar control. Findings: 1. During a concurrent medication administration pass observation…

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 and interview, the facility failed to implement and maintain an effective infection prevention and control program to prevent the transmission of infection for 11 out of 11 sampled residents (Residents' 8, 9, 23, 24, 26, 33, 35, 39, 41, 44, and 97) when nursing staff did not provide or assist residents in performing hand hygiene before they were served their lunch tray. This failure to provide hand hygiene placed Residents' 8, 9, 23, 24, 26, 33, 35, 39, 41, 44, and 97 at increased risk for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Findings: During an observation on 3/4/25 at 11:50 a.m. during meal observation in the dining room. Residents' 8, 9, 23, 24, 26, 33, 35, 39, 41, 44, and 97 were seen assisted by staff for lunch and staff placed apron on a couple residents. Staff distributed lunch trays to residents and did not provide or offered hand hygiene to residents…

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 care that promoted rights of the resident and enhancement of quality of life for one of six sampled residents (Resident 147) when resident 147 was not allowed to smoke. This failure resulted in Resident 147 not being able to smoke since admission which led to decreased sense of pleasure and increased anxiety. Findings: During a review of Resident 147's admission Record (AR- document containing resident personal information), dated 3/6/25, the AR indicated, Resident 147 was admitted to the facility on [DATE], with diagnoses which included psychosis not due to a substance or known physiological condition (a mental health condition characterized by a loss of contact with reality. It is a state of altered perception, cognition, and behavior), major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere 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 observation, interview, and record review, the facility failed to provide a safe and homelike environment for one of two sampled residents when Resident 12's low air loss machine (designed to distribute patient's body weight over a broad surface area and help skin breakdown) was turned off. This failure had the potential for Resident 12 to develop skin breakdown which could result in pressure ulcer development. Findings: During a concurrent observation and interview on 3/5/25 at 9:40 a.m. in Resident 12's room, Resident 12 was seen lying in bed, covered with blanket and yelling out. Resident 12 did not answer questions asked. Resident 12's bed was positioned in lowest position and had a low air loss mattress. Resident 12's low air loss mattress was turned off and was unplugged from the wall. During a review of Resident 12's admission Record, (AR) dated 3/6/25, the AR indicated Resident 12 was re-admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg,…

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 Infection Preventionist (IP) have the specific competencies, and skill sets necessary to ensure residents who required Enhanced Barrier Precaution (EBP) were properly managed to prevent the risk for infections for seven of seven sampled residents (Residents' 10, 30, 39, 40, 29, 37 and 28) when the IP demonstrated a breakdown in following critical infection control policies and procedures. These failures placed Residents' 10, 30, 39, 40, 29, 37 and 28 at increased risk for infection. Findings: During a review of Resident 10's admission Record, (AR) dated 3/6/25, the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses which included diabetes (high sugar level in the blood), open wound to right knee, open wound to left knee and muscle weakness. During a review of Resident 10's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical…

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 three sampled residents (Resident 27) were provided special eating equipment when Resident 27's lunch was not served on an adaptive equipment scoop plate per her meal ticket. This failure resulted in Resident 27's individualized care needs not met which led to difficulty eating, delayed in finishing her meals and the potential risk for decreased oral intake. Findings: During a review of Resident 27's admission Record (AR- document containing resident personal information), dated 3/6/25, the AR indicated, Resident 27 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (complete and partial weakness on the left side of the body following a stroke [blood flow to the brain is decreased, causing brain cells to die]) , chronic obstructive pulmonary disease (COPD-air flow obstruction and inflammation of the airways, leading…

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 received adequate supervision to prevent elopement for one of three sampled residents (Resident 1) who was a high risk for elopement (when a resident, who is incapable of adequately protecting themselves, departs the facility unsupervised and undetected) when Resident 1 eloped from the facility on 11/6/24. This failure placed Resident 1 ' s safety at risk when Resident 1 was found on the side of the road a mile and a half away from the facility by staff. Findings: During record review of Resident 1 ' s admission Record (AR- a document that provides resident contact details, a brief medical history), the AR indicated, Resident 1 had diagnoses which included .TRAUMATIC BRAIN INJURY (alteration in brain function caused by an external force such as a blow, bump or jolt to the head) .ALCOHOL DEPENDENCE .SEIZURES (a sudden uncontrolled burst of electrical activity in the brain) .HISTORY OF FALLING .ANXIETY DISORDER (mental health condition that causes excessive and persistent feelings of worry 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 provide adequate supervision for one of one sampled resident (Resident 1) who was a high risk for elopement when Resident 1 eloped from the facility on 9/2/24. This Failure placed Resident 1's safety at risk when Resident 1 was found on the side of the road half a mile away from the facility by a passing motorist. Findings: During an observation on 9/18/24, at 8:20 a.m., the facility building was surrounded with an 8-foot-tall metal fence. The fence extended entirely around the building and staff & visitors entered and exited the facility through a single locked gate which opened with a key. During a concurrent observation and interview on 9/18/24, at 8:40 a.m., with Sitter 1, in Resident 1's room, Sitter 1 was sitting at Resident 1's bedside. Sitter 1 stated she was assigned to provide one-on-one monitoring and supervision for Resident 1. Sitter 1 stated Resident 1 recently eloped. During a review Resident 1's Progress Notes (PN) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of one sampled resident (Resident 1) who was a high risk for elopement when Resident 1 eloped from the facility on 6/16/24. This Failure placed Resident 1's safety at risk when Resident 1 was found walking on the side of the road ½ a mile away from the facility. Findings: During a review of Resident 1's admission Record (AR- a document containing resident profile information) dated 6/27/24, the AR indicated Resident 1 was a [AGE] year-old male admitted to the facility with diagnoses included traumatic brain injury (TBI, serious injury to the brain that affects problems with how a person thinks, understands, moves, communicates, and acts), and mild cognitive impairment (impaired ability to remember, think, or make decisions). During a review of Resident 1's Care Plan (CP), dated 6/26/24, the CP indicated Resident 1 is an elopement risk/wanderer related to impaired safety awareness, Resident wanders…

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 adequate supervision for one of two sampled residents (Resident 1) who was a high risk for elopement when Resident 1 eloped from the facility on 5/15/24 at 7:40 PM and was found by the Sheriff's Department on 5/16/24 at 4 AM in the orchard a mile away from the facility. This failure resulted in Resident 1 leaving the facility without supervision for over eight hours which had the potential to cause injuries. Findings: During an observation on 7/7/24 at 2:35 PM Resident 1 was sitting in the lobby smiling and waving hello to visitors. Resident 1 had an approximately 1-millimeter dot size scabbed on the forehead and on the forearm. During a review of Resident 1's admission Record (AR-contains important information about a patient such as their personal details, the reason for admission and medical history), dated 6/10/24, the AR indicated Resident 1 was admitted to the facility with diagnoses that included traumatic brain injury (TBI, serious injury to the brain that affects problems with how a person…

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 in accordance with the facility's policy and procedure and professional standards for food safety when: 1. [NAME] and gray particles were found in the windowsill (ledge on bottom of window) next to the food preparation sink. 2. [NAME] build up was found on the exterior of the dish washing machine. 3. The ice machine and food preparation sink had no air gaps (a vertical space usually one inch or more between the end of a pipe or faucet and the top of a sink which creates a separation between the water supply and contaminated water). 4. The temperature of the dish washing machine was under the minimum 120° Fahrenheit (F- unit of measurement) requirement. 5. Oven mitts used to handle hot foods were soiled with orange and brown grime and debris. 6. Food stored in the resident's refrigerator was not labeled with resident's name and use-by-date (the last day for the consumption of food item while at peak quality). These failures had the potential to cause cross-contamination and 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.

Based on observation, interview, and record review, the facility failed to provide a clean and safe environment for residents, staff and the public when: 1.The kitchen dry storage floor had areas of brown stains, missing and cracked linoleum, exposing the cement underneath with accumulation of dark gray debris. 2.The facility floors in the common areas and resident rooms, had black-colored stains, uneven surfaces, cracked linoleum with accumulation of black and brown debris and missing baseboards. This failure to ensure the physical environment was maintained in a safe, clean, and sanitary manner as evidenced by multiple contact surfaces in disrepair placed residents, staff, and the public at potential risk for falls and cross contamination (the process by which bacteria are unintentionally transferred from one substance or object to another with harmful effect) which could lead to foodborne illness (caused by food contaminated with bacteria). Findings: 1. During an observation on 3/12/24 at 9:26 a.m. in the kitchen's dry food storage room, the floor had multiple areas of brown…

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 grievance policy and procedure for five of 15 sampled residents (Residents 18, 27, 28, 37, and 39) when the facility did not ensure Resident 18, 27, 28, 37 and 39 were able to submit grievances anonymously. This failure resulted in Residents 18, 27, 28, 37, and 39 not able to exercise their rights to submit grievances anonymously regarding the facility and their care and could negatively affect their pyschosocial well-being. Findings: During the resident council meeting on 3/14/24 at 9:10 a.m. with Residents 18, 27, 28, 37, and 39, Residents 18, 27, 28, 37, and 39 stated they did not know how to file anonymous grievances. Resident 39 stated he did not know how to submit grievances anonymously. During an interview on 3/14/24 at 4:23 p.m. with the Social Services Director (SSD), the SSD stated residents must ask staff members for grievance forms. The SSD stated he kept grievance forms in his office, in a drawer behind the nurses' station and in a drawer locked in the Activities Director's (AD)…

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 maintain an accurate medical record consistent with professional standards and practices for four of 10 sampled residents (Resident 1, 4, 13, and Resident 34) when Resident 1, 4, 13, and 34's Physician Orders for Life-Sustaining Treatment (POLST - a medical order signed by both the patient and medical provider that specifies the types of medical treatment a patient wishes to receive toward the end of life) were incomplete. These failures resulted in a medical record that did not reflect Resident 1, 4, 13, and 34's treatments for end-of-life care and services. Findings: During a concurrent interview and record review on 3/14/24 at 5:11 p.m. with Medical Records Director (MRD), Resident 1's POLST, dated 8/2/23 was reviewed. MRD stated Resident 1's POLST was not completed. MRD stated Resident 1's POLST was missing all the physician's information, which included the physician's name, physician's address, physician's phone number, physician's license number…

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 services provided met professional standards of quality for one of 27 residents (Resident 28), when Resident 28 was not offered water to rinse her mouth after aerosol oral inhaler (a medication used to prevent difficulty breathing administered by way of inhalation both oral and nasal) administration as ordered by the physician. This failure had the potential for the inhaler medication to accumulate in Resident 28's mouth and placed Resident 28 at risk to developed oral thrush (fungal infection). Findings: During an observation on 3/13/24 at 8:37 a.m., in Resident 28's room, the Director of Staff Development (DSD) administered aerosol oral inhaler to Resident 28. The DSD did not offer Resident 28 water to rinse her mouth after medication administration. During a review of Resident 28's Order Summary Report, dated 3/13/24 indicated, . 2 puffs inhale orally . rinse mouth with water and spit back into cup after use . During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool used to…

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

Based on observation, interview, and record review, the facility failed to ensure drugs were labeled with resident identifier and expiration date in accordance with the facility's policy and procedure Labeling Medications and Biological's (a substance such as vaccines or drugs derived from a living organism used for treatment) when one Fluticasone propionate salmeterol inhaler (medications used to treat respiratory disease, a mist or spray that the patient breathes in the nose or mouth) and one nasal spray ( liquid medicine spray into the nose) medication was stored in medication cart 1 without a resident identifier label (resident's name and date of birth ) and expiration date. This failure placed residents at potential risk for receiving the wrong medication and expired medications, which could lead to medication ineffectiveness and medication adverse reaction. Findings: During a concurrent observation and interview on 3/14/24 at 11:13 a.m. with the Infection Preventionist (IP), in front of the nurse's station, medication cart 1 stored one inhaler medication and one nasal spray…

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 policy and procedure to monitor and maintain essential equipment in a safe operating condition for one of six residents, (Resident 4), when Resident 4's oxygen concentrator (a medical device to deliver oxygen) was not routinely monitored and maintained in accordance with facility policy and procedure. This failure had the potential for Resident 4's oxygen concentrator to break down and fail which could result in Resident 4 going without oxygen. Findings: During a concurrent observation and interview on 3/13/24 at 8:54 a.m. with Certified Nurse Assistant (CNA) 1, in Resident 4's room, Resident 4's oxygen concentrator had gray particles on the surface. CNA 1 stated the oxygen concentrator had a lot of dust and should be cleaned. CNA 1 stated maintenance was responsible to ensure the oxygen concentrator was clean. During a concurrent observation and interview on 3/14/24 at 12:15 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 4's room, LVN 1 opened the oxygen concentrator filter cover and LVN 1…

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

During an observation, interview, and record review, the facility failed to maintain a functioning communication system (call light system-an alerting device used by residents to request assistance from nursing staff) for 17 residents bed (3 C,4 B, 7 D, 9 A,B,D 10 C,D 11 A,B,C 12 A,B,C 14 A,B,C) out of 46 residents bed when the patient call light system warning lights above residents doorway and monitoring panel located in the nurses station to indicate when patients have perceived needs requiring attention were not functioning properly. This failure resulted for residents in the facility not able to call for help and receive immediate assistance from nursing staff which placed residents ' health and safety at risk. Findings: During an interview on 1/16/24 at 10:10 a.m., with Maintenance Supervisor (MS), the MS stated he conducted daily inspections for all the call lights in residents ' room for proper functioning. The MS stated when residents pressed the call light button, the warning lights above resident ' s doorway and the monitoring panel located in the nurse ' s station must…

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 one of six sampled Certified Nursing Assistant (CNA) 1 met the specific certification requirements when CNA 1 was working in the facility without an active CNA certification. This failure had the potential for Residents not being provided adequate and quality care according to their needs. Findings: During a concurrent interview and record review on [DATE] at 11:15 a.m. with the Director of Nursing (DON), the facility document titled, Active Employees (AE) dated [DATE] was reviewed. The AE indicated, CNA 1 ' s Certified Nursing Certificate had an expiration date of [DATE]. The DON stated CNA 1 ' s certificate expired on [DATE] and CNA 1 was not scheduled to work until her certificate was active. During a review of the facility document titled CNA NOC Shift [DATE], the document indicated, CNA 1 was on the schedule to work on [DATE], [DATE], [DATE] [DATE], and [DATE] for the night shift. During a review of the facility document titled Daily…

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.