Brighton Post Acute

Based on observation, interview and record review, the facility failed to ensure nurse staffing information was accurately posted when: 1. The actual number of hours worked per shift by Registered Nurses (RNs), Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs) was not accurately reflected.2. The actual number of Licensed Staff (RN's, LVNs, and CNAs) was not specifically reflected in the staffing sheets. This failure resulted in an inaccurate posting of daily nurse staffing information and had the potential to result in residents, visitors and the public from determining the number and type of nursing staff providing direct care in the facility. Findings:During a concurrent interview and review of daily staffing hours sheets on 4/9/26 at 1:40p.m. with the Employee Services Representative (ESR), the ESR stated she generated the staffing hour reports each morning, which included RN, LVN and CNA hours and was calculated from midnight to midnight. Upon review of the staffing hours sheet dated 4/8/26, the ESR stated the posted staffing hours reflected projected…

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 two of five sampled residents (Resident 84 and Resident 133) drug regimen was free from unnecessary drugs when:1.Resident 84 received Namenda (medication used to improve memory, attention, reason, and language abilities) for memory loss without a written informed consent and monitoring of side effects and behaviors. This failure resulted in Resident 84 receiving medication and not properly informed of the possible side effects which had the potential for Resident 84 to have experienced side effects of medication and changes of behavior without proper monitoring.2. Resident 133 received acetaminophen (medication used to treat pain) tablet as needed for pain and oxycodone HCL (hydrochloride) (opioid prescription medication used to treat pain) tablet as needed for pain daily without pain parameters. This failure had the potential for Resident 133 to not received adequate pain relief which could lead to serious medical condition.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to meet the needs of residents in accordance with established national guidelines for three of 49 sampled residents (Residents 41, 53 and 95) when Residents 41, 53 and 95 were not served cornbread with lunch on 4/8/26 and the menu indicated cornbread to be served.These failures resulted in Residents 41, 53 and 95 not receiving all the nutrition and calories for lunch and the potential for unintended weight loss.Findings: During an observation on 4/8/26 at 11:14 a.m. with [NAME] (CK) 1, in the kitchen, CK 1 was preparing to plate lunch for the residents in the facility. CK 1 put ham, beans and steamed cabbage on the first plate. CK 1 placed ham, beans and steamed cabbage on the second plate. CK 1 placed ham, beans and cabbage on the third plate. There was a pan of squared cornbread on the food counter next to the food items that were kept warm. During a concurrent observation and interview on 4/8/26 at 11:57 a.m. with Resident 53 in the dining…

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 food preferences were followed for one of eight sampled residents (Resident 33) when he was served cabbage and the resident's care plan stated resident disliked cabbage. This failure violated Resident 33's food preference and had the potential to result in weight loss.Findings: During a concurrent observation and interview on 4/8/26 at 4:11 p.m. with Resident 33 in his room. Resident 33 stated, . - I did not enjoy my lunch, the cabbage was soggy, the beans had no flavor, I only ate the ham, and I am ready to eat again but I will wait for dinner .During a review of Resident 33's admission record (AR), dated 4/9/26, the AR indicated Resident 33 was admitted to the facility on [DATE] with the following diagnosis: Hemiplegia (a form of paralysis that causes severe or complete loss of movement on one side of the body) to the right side of the body, major depressive disorder (a mental health condition characterized by persistent, intense…

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 store and prepare food in accordance with professional standard for food service safety for 49 residents who were served food from the ice machine and kitchen when there was no air gap (a safety feature that uses open air to physically separate a clean water line from a dirty drain line) at the ice machine drain and no air gap at the drain of food preparation sink.These failures had the potential to result in contamination of ice and food and could lead to illnesses.Findings: During a concurrent observation and interview on 4/7/26 at 8:25 a.m. during the initial tour in the kitchen, with the Certified Dietary Manager (CDM), the food preparation sink had black pipes that went into the wall. There was a drain sink under and to the left of the food preparation sink that was not being used. The black pipe under the sink had a white plastic piece on top of the black pipe. The CDM stated the white plastic piece was an air gap installed by the maintenance department.During a concurrent observation and interview on…

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 have an effective pest control program to ensure the facility was free of pests for 51 residents that ate food prepared in the kitchen when two flies were in the kitchen on 4/7/26 and one fly was in the kitchen on 4/8/26.These failures had the potential for cross-contamination (the transfer of harmful germs from one surface to another) from the flies to resident food which could result in illnesses.Findings:During an observation on 4/7/26 at 8:35 a.m. during the initial tour in the kitchen, two flying insects were observed flying around the dishwashing area.During an interview on 4/8/26 at 9:18 a.m. with Dietary Aid (DA) 1, DA 1 stated there had not been a problem with flies in the kitchen until today. DA 1 stated the kitchen had a negative airflow over the exit door to assist with the control of flies. DA 1 stated it was important not to have flies in the kitchen because of cross contamination. DA 1 stated if there was a problem with flies…

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

Based on observation, interview, and record review, the facility failed to provide a safe environment for the residents, staff, and visitors when the fire protection system (a combination of equipment and technologies designed to detect, alert, control, and extinguish fires automatically or manually, aiming to save lives, minimize property damage, and ensure safe evacuation) stopped functioning from 12/31/25 to 1/2/26, and the facility failed to notify the California Department of Public Health (CDPH, a government agency for the State of California in charge of protecting the public's health and helps shape positive health outcomes for individuals, families and communities) and the California Department of Healthcare Access and Information (HCAI, a government agency for the State of California in charge of safety regulations for health care facilities, provide financial assistance to health care institutions, collecting healthcare data and more). This failure placed residents, staff, and visitors at risk for injury and/or death in the event of a fire. During a concurrent 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, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan was developed and implemented to meet the identified needs for one of three sampled residents (Resident 1) when Resident 1 was assessed as being a high fall risk with poor safety awareness and a known behavior of not calling staff for assistance and the facility did not develop and implement effective care plan interventions including assistance and supervision to prevent falls. This failure resulted in Resident 1 ' s unwitnessed falls on 3/15/25 and 3/16/25 sustaining a fracture of the left greater trochanter (a type of hip fracture [broken bone] where the femur [upper thigh bone] meets the pelvis) causing pain and decreased mobility which required transportation to the emergency department (ED) for assessment and treatment of his injury. Resident 1 had a third fall on 3/17/25 which placed the resident at risk for further serious injury. (Cross reference F689) Findings: During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the physician-prescribed therapeutic diet (a diet order as part of treatment for a disease or clinical condition to decrease or increase specific nutrients in the diet) for one of four sampled residents (Resident 1) when, during lunch on 11/1/24, Resident 1, who has physician prescribed No Added Salt (NAS) diet Mechanical Soft texture, was served a piece of uncut country-fried steak. This failure had the potential to result in a choking episode and further compromise the nutritional and medical status of Resident 1. Findings: During a review of Resident 1's admission Record (AR), dated 11/1/24, the AR indicated, Resident 1 was admitted to the facility on [DATE] and had a diagnosis which included Anemia (a condition where the body does not have enough healthy red blood cells), Muscle Weakness, Heart Failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Hypertension…

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

Based on interview, record review, and facility policy review, the facility failed to ensure staff reported an allegation of abuse for 1 (Resident #55) of 1 resident reviewed for abuse. Findings included: A facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised in 2023, revealed, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy revealed, 3. 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. An admission Record revealed the facility admitted Resident #55 on 08/01/2023. According to the admission Record, the resident had a medical history that included diagnoses of palliative care, hemiplegia and hemiparesis (weakness on one side of the body) following a cerebral…

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

Based on observation, record review, interview, and facility policy review, the facility failed to ensure the medication error rate was not greater than 5 percent (%). The facility had 2 medication errors out of 27 total opportunities, resulting in a medication error rate of 7.41%, affecting 2 (Resident #78 and Resident #43) of 5 residents observed during medication administration. Findings included: A facility policy titled, Medication Administration General Guidelines, dated 01/2021, revealed the section titled Medication Preparation: included 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record [MAR]. Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule. Apply a 'direction change' sticker to label if directions have changed…

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 notify the Long Term Care Ombudsman office (LTC-Ombudsman, a resident advocacy agency) of transfer to the hospital for one of three sampled residents (Resident 1) when the facility failed to send a copy of Resident 1's transfer and discharge notification to the local LTC-Ombudsman office. This failure resulted in the LTC-Ombudsman not aware of Resident 1's discharge circumstances should appeals be filed by the resident or his representative. Findings: During a review of Resident 1's admission Record (AR, documents containing resident demographic information and medical diagnosis), undated, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy (a disorder caused by a buildup of toxins in the brain that can happen with advanced liver disease), Pneumonia (lung infection caused by bacteria), Type 2 Diabetes Mellitus (a disorder in which blood sugar or glucose levels are abnormally high),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a comprehensive, person centered care plan for one of three sampled residents (Residents 1) when Resident care plan intervention to have auto locks to wheelchair (device used to automatically lock the wheels whenever the person stands or sits) was not implemented to prevent falls. This failure placed Resident 1 at risk for falls. Findings: During an observation on 11/3/23, at 9:35 a.m., in Resident 1's room, a wheelchair with Resident 1's name on the back of the wheelchair was next to her bed. No auto lock device was attached to the wheelchair. During a review of Resident 1's admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included weakness and history of falling. During a concurrent interview and record review on 11/3/23 at 9:44 a.m., with Licensed Vocational Nurse (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.

Based on interview and record review, the facility failed to ensure support personnel were competent to effectively carry out the function for food and nutrition services when two of two sampled Maintenance Assistants (MA 1 and MA 2) did not clean and sanitize the facility ice machine in accordance to the manufacturer's recommendations. (Cross reference F908.) This failure had the potential for the ice machine to not function properly, cause contamination of the ice, and lead to resident illnesses. Findings: During a concurrent interview and record review on 12/4/19, at 8:18 a.m., with MA 1 and the Housekeeping & Maintenance Supervisor (HMS), MA 1 stated he had been cleaning and sanitizing the ice machine once a month since 9/2019. MA 1 stated he followed the manufacturer's guidelines located inside the ice machine binder. MA 1 stated he diluted a cleaner with two gallons of room temperature water, flushed the machine twice, and allowed the machine to make ice three times. MA 1 stated he would discard the ice three times and would consider the ice machine clean once these steps were…

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 nutritional needs of residents were being met in accordance with established dietary national guidelines when the Registered Dietitian Nutritionist (RDN) did not sign to demonstrate approval of the facility's food menus. This failure placed the residents at risk for not receiving adequate nutrition which could further compromise their medical status. Findings: During a review of the facility's menu titled, Week 3 [Sunday through Saturday] (01-05) Cycle 4 2019 Therapeutic Spreadsheets on 12/3/19, at 3:15 p.m., the signature line for all seven days was left blank with dates below the line for signatures to be obtained on 10/6/19, 11/3/19, 12/1/19, and 12/29/19. During an interview on 12/4/19, at 11:03 a.m., with the RDN, the RDN stated the facility used an outside contractor to provide the menus for the facility. The RDN stated it was her responsibility to make nutritional analysis of menu items and it was her responsibility to approve the menus. The RDN stated she had been working at the facility as…

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 food in accordance with professional standards for food service safety when multiple food items available for resident consumption were stored without being covered and without open dates inside Freezer 1, walk in refrigerator, kitchen dry food storage areas and inside refrigerators in nursing station 1 and 3. These findings had the potential to cause gastric upset from the consumption of improper stored food. Findings: During a concurrent observation and interview on 12/3/19, at 8:27 a.m., with the Dietary Supervisor (DS), in the Freezer 1, one large cardboard box was left open with multiple individual butter pats (squares). The DS stated the box of butter pats should have been closed or placed inside a sealed container to prevent freezer burn. During a concurrent interview and record review on 12/3/19, at 9:21 a.m., with the DS, the DS reviewed the facility policy and procedure titled, Sanitation and Infection Control Subject: Freezer Storage dated 2018, the DS stated the policy indicated all foods…

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 maintain the ice machine in accordance with manufacturer's instructions for use when the ice machine was not cleaned and sanitized per manufacturer's guideline. (Cross reference F802.) This failure had the potential for the ice machine to not function properly, cause contamination of the ice, and lead to resident illness. Findings: During a concurrent interview and record review on 12/4/19, at 8:18 a.m., with Maintenance Assistant (MA) 1 and the Housekeeping & Maintenance Supervisor (HMS), MA 1 stated he had been cleaning and sanitizing the ice machine once a month since 9/2019 and followed the manufacturer's guidelines in the ice machine binder. MA 1 stated he diluted a cleaner with two gallons of room temperature water, flushed the machine twice, let the machine make ice three times and threw the ice away, then considered the ice machine clean and sanitized. MA 1 stated MA 2 trained him to clean and sanitize the ice machine. MA 1 retrieved the binder for logging the cleaning and sanitizing of the ice machine. MA stated…

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 staff followed professional standards of practice for two of two sampled residents (Resident 22 and Resident 45) who used indwelling urinary catheters (a flexible tube inserted into the bladder to drain urine) when Resident 22's and Resident 45's urinary catheter tubing was not secured to prevent discomfort and accidental dislodgment of the catheter. This failure had the potential to cause discomfort, injury to the urethra (duct that leads from the bladder and transports urine out of the body) and accidental dislodgment of the indwelling catheter. Findings: 1. During a concurrent observation and interview on 12/3/19, at 10:09 a.m., with Resident 22, Resident 22 was in bed, her urinary catheter bag hung on the right side of her bed frame. Resident 22 pointed to the urinary catheter tubing after she removed her blanket. Resident 22's catheter tubing hung loose and was not secured to her leg. During a concurrent observation 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 establish an environment free from accidents and hazards for two of 27 sampled residents (Resident 13, 96) when: 1. Resident 13 and Resident 96 smoked in an area without smoking fire safety accommodations to ensure the residents remained safe while they smoked. This failure potentially placed Resident 13 and 96 at risk for smoking related injuries. 2. Resident 59 was not accommodated with staff assistance when ambulating to the restroom as indicated in her plan of care. This failure had the potential for Resident 59 to fall and sustain injuries from fall. Findings: 1. During an interview with Resident 96 on 12/3/19, at 8:42 a.m., Resident 96 stated he smoked every day. Resident 96 stated he smoked without supervision and he was able to access his cigarettes that he kept at his bed side. During an observation of Resident 96 on 12/3/19 at 8:47 a.m., Resident 96 announced to his nurse that he was going out to the patio area to smoke. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain medical records that were complete and accurately documented for three of 27 sampled residents (Resident 110, Resident 43, and Resident 45) when: 1. The physician's visit and assessment of Resident 110 was not documented on the progress note for [DATE]; and the Physician Orders for Life-Sustaining Treatment (POLST-a summary of medical orders to be followed during a medical emergency and end of life wishes) dated [DATE], was not revised by the physician to reflect end of life wishes. This failure had the potential for end of life wishes not to be respected in the event of an emergency. 2. Minimum Data Set assessment (MDS - a standardized assessment and care screening tool) coding requirements were not followed for two of 27 sampled residents (Resident 43 and Resident 45) when aspirin medications were coded under the classification of anticoagulant (medication used to stop the formation of blood clots) and should not have been. This failure…

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 and record review, the facility failed to ensure the minimum square footage was maintained for 25 of 47 resident rooms (100, 102, 104, 106, 108, 110, 112, 114, 116, 118, 120, 122, 200, 204, 206, 208, 210, 212, 214, 216, 304, 306, 308, 310, and 314), and three of 25 sampled resident rooms (104, 216, and 304) did not provide residents and staff with enough space to accommodate resident needs when: 1. Staff had limited space and difficulty providing resident care in room [ROOM NUMBER]. 2. Resident 96 was not able to exit or enter his room when care was being given to his roommates in room [ROOM NUMBER]. 3. Resident 59 was not able to easily and safely ambulate herself to and from the restroom or store her wheelchair in room [ROOM NUMBER]. This failure resulted in inadequate space for staff to deliver care and the potential to impact the residents' safety and quality of life. (Cross reference F588.) Findings: 1. During an observation on 12/5/19, at 2:10 p.m., in the facility,…

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 reasonable accommodations to meet the needs and preferences for one of 23 sampled residents (Resident 59) when Resident 59 did not have the bedroom set up in a manner that provided sufficient space to easily and safely navigate to and from her restroom and to keep her wheelchair within easy reach. This failure had the potential to result in injury to Resident 59. Findings: During an observation on 12/3/19, at 10:15 a.m., Resident 59's room was a three-person room, with three beds in the room. Resident 59's bed was the first bed in the room and was located across from the restroom entrance adjacent to the bedroom. Resident 59's wheelchair was parked next to her bed, approximately two feet from the wall. Resident 59's bedroom door was opened wide and blocked access to and the ability to open the restroom door. Resident 59 was inside the restroom and struggled to open the restroom door which was blocked by the bedroom door. 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, the facility failed to maintain an infection control program to prevent the transmission of infections for one of six sampled residents (Resident 11) when an oxygen humidifier (a device that introduced moisture to a gas) and a nasal cannula (NC) tubing were not replaced after five days and continued to be used for 13 days. This failure placed Resident 11 at risk for developing respiratory infections. Findings: During an observation on 12/3/19, at 10:32 a.m., in Resident 11's room, Resident 11 was resting in bed with her NC tubing attached to a humidifier next to the bed. There was no date on the NC tubing and the water bottle attached to the humidifier was dated 11/20/19. During a concurrent observation and interview on 12/3/19, at 10:44 a.m., with licensed nurse (LN) 4, LN 4 observed Resident 11's humidifier and NC tubing and stated there was no date on the NC tubing and the date on the humidifier was 11/20/19. LN 4 stated the facility's policy was to change the humidifier and NC tubing every five days to prevent respiratory…

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.