Hayward Gardens Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to refer one resident with a serious mental disorder for level II Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR requires that 1. all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2. be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and 3. receive the services they need in those settings. Regulations governing PASARR are found at 42 CFR §483.100-138) screening when Resident 57's Level 1 PASARR did not accurately show the resident's diagnosed psychiatric condition. This failure had the potential for the resident to receive inappropriate or ineffective care, treatment, or services. Findings: During a record 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 ensure one out of five sampled residents (Resident 38) received the necessary services to maintain good grooming, and personal hygiene when Resident 38's shower schedule was not consistently followed and reason for refusals were not documented and acted upon. This failure resulted in Resident 38 having unmet physical, physiological, and psychological needs. Findings: A review of Resident 38's face sheet indicated Resident 38 was admitted with diagnoses that included end stage kidney disease, dependence on kidney dialysis, diabetes, and generalized muscle weakness. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 10/24/24, the MDS indicated, a Brief Interview Mental Status (BIMS, a brief scanner to help detect cognitive impairment) score of 15 indicated no cognitive impairment. The MDS also indicated, Resident 1 required partial/moderate assistance from staff for shower/bathe self. During…

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 Director of Nursing (DON) was a registered nurse (RN) for seven months. This failure resulted in an unqualified nurse being designated the DON and had the potential for inadequate supervision and management of the facility residents and nursing staff. Findings: During a concurrent observation and interview on 11/25/24, at 10:04 a.m., with the DON, the DON was wearing a badge indicating they were the Director of Nursing. The DON stated they had been the DON since 3/2024 as the acting DON. The DON stated they had just finished school to be a RN and was waiting to take the National Clinical Licensure Examination (NCLEX, an examination to become a RN) to be a RN. During a concurrent phone interview and record review on 11/25/24, at 11:15 a.m., with the Administrator (Admin), the facility ' s job description for the DON was reviewed. The Admin stated the job description indicated the DON is a registered nurse who oversees and supervises the care of all residents .minimum requirements to perform this…

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 one of three sampled resident ' s (Resident 1) brief was changed with two people helping to turn Resident 1 in the bed. This failure resulted in Resident 1 falling off the bed and suffering a right femur fracture (broken right upper leg bone). Findings: During a review of Resident 1 ' s Minimum Data Set (MDS - an assessment tool used to plan care for the resident), dated, 1/4/2022, MDS indicated two people were required to move Resident 1 to and from lying position, to turn side to side, and to position body in the bed. During a concurrent observation and interview on 4/12/2023, at 10:37 a.m. in Resident 1 ' s room with Certified Nursing Assistant (CNA) 1, CNA 1 stated, CNA 1 was changing Resident 1 ' s brief on 3/21/2022, when Resident 1 fell off the bed. CNA 1 stated, Resident 1 was in her bed with side rails up at the head of the bed only. CNA 1 stated, CNA 1 was standing on one side of the bed. CNA 1 stated, she assisted Resident 1 to roll up on her side, while Resident 1 was holding the side rail…

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

Based on observation, staff interviews, and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of a qualified, competent, full-time supervisor resulted in staff not having adequate supervision, training, and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner. The lack of full-time, competent oversight of food and nutrition staff placed 61 residents who received food from the kitchen at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and/or decreased nutrient intake which had the potential to result in death and/or nutritional related medical complications. Findings: 1. There was no…

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 facility document review, the facility failed to ensure the competency of staff when: 1. a staff did not know how to read a freezer thermometer correctly; 2. staff did not know how to test the food-contact surface sanitizer correctly; 3. staff did not know how to sanitize juice machine according to posted cleaning instructions; and 4. a staff did not label a chemical containing container. These failures had the potential to result in the kitchen not being maintained in a safe and sanitary manner leading contamination of food and utensils, and/or reduced quality of food for 61 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 6/6/23, at 9:55 a.m., [NAME] 2 (C2) stated she was responsible for documenting freezer temperatures when she arrived for her shift in the morning. She stated she used the internal thermometer in the reach-in freezer to determine the temperature. Stated the freezer temperature had to be at least negative one. C2 demonstrated how she read the thermometer and showed she…

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

Based on observation, staff interview, and facility document review, the facility failed to ensure the planned menu was followed when: 1. Milk was not provided as shown on the lunch menu for 55; 2. Incorrect servings of food were served to10 residents who received a pureed, minced and moist, or a mechanical soft diet. These failures had the potential to result in not meeting the nutritional needs of the residents and compromising the nutritional status of the residents. Findings: Review of the policy and procedure titled Menus dated 2001, showed menus are developed following established national guidelines for nutritional adequacy. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. If a food group is missing from a resident's daily diet, the resident is provided an alternate means of meeting his or her nutritional needs. 1. Review of the Week 2 Therapeutic Spreadsheets dated Monday Cycle 2 2023, showed milk was listed for…

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

Based on observation, interview and record review, the facility failed to ensure residents were served palatable food when food was bland and at a low temperature. This deficient practice placed the residents at risk of decreased nutrient intake leading to weight loss and/or nutritional medical complications for 61 residents who received food from the kitchen. Findings: During observation on 6/5/23 at 1:10 p.m., a meal delivery cart holding resident trays and two test trays left the kitchen. During an observation and interview with Dietary Manager (DM) on 6/5/23 at 1:16 p.m., a regular and puree texture meal was sampled immediately following the delivery of the last resident tray. The regular tray contained chicken parmesan with marinara sauce and pasta. The puree tray contained pureed chicken parmesan and pureed zucchini. Temperatures of the food were measured with the surveyor's calibrated thermometer. The pureed chicken was 113 Fahrenheit (°F), and the pureed zucchini was 104.9 °F. The regular chicken parmesan was dry and regular pasta was very bland and dry. The pureed chicken…

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: 1. an alternate for gluten (a protein found in wheat, barley, and rye) containing food for one resident (Resident 288) who had a documented gluten allergy and a diagnosis of ulcerative colitis (a condition in which the lining of the large intestine (colon) and rectum become inflamed). 2. an alternate for garlic bread at a lunch meal for 61 residents who received food from the kitchen. This deficient practice had the potential to result in decreased nutrient intake leading to weight loss and/or nutrient related medical complications. Findings: Review of the facility's policy and procedure (P&P) titled, Menus, dated October 2017, showed if a food group is missing from a resident's daily diet, the resident is provided an alternate means of meeting his or her nutritional needs. 1. Review of the admission Record showed Resident 288 was admitted on [DATE] with a primary diagnosis of ulcerative colitis. On 6/5/23 in an interview with…

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

Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. Stored equipment in the kitchen was dirty and ready for use; 2. Kitchen storage areas, floors, and vents were dirty; 3. A fan in use in a food storage area was dirty; 4. Floor tiles were in poor condition; 5. Food was stored without identifying use-by-dates; 6. The ice machine was dirty. 7. A food preparation sink drain did not have an airgap (a gap between the sink drain and the drain that leads to sewage drain. This gap prevents a back-up of non potable water and/or bacteria into the sink). These failures had the potential for contamination of food resulting in food borne illness for 61 residents who received food from the kitchen. Findings: 1. An observation and interview with [NAME] 1 (C1) during the kitchen's initial tour, on 6/5/23, at 9:23 a.m., showed a blender stored on a preparation table. The blender lid had black, slimy residue on the removeable plastic insert. In addition, there was significant black slimy…

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 facility document review, the facility failed to maintain the reach in freezer in safe operating condition. This failure had the potential for food stored in the freezer to remain frozen at all times leading to decreased food quality and food safety for 61 residents who received food from the kitchen. Findings: An observation on 6/5/23, at 9:54 a.m., showed a two-door reach-in freezer located by the dry food storeroom. There was ice build-up on inside door surface and on upper inside surface with icicles hanging. A rubber gasket on the inside of one door had over 12-inch segments at the side and bottom of the door that were separated from the door and ripped. During an interview on 6/6/23 at 12:30 p.m., with Maintenance Supervisor (MS), MS stated he was aware of ice build-up and ripped gaskets in reach-in freezer 1 for a couple of months. During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, dated November 2022, the P&P indicated supervisors inspect refrigerators and freezers monthly for gasket condition…

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 interviews and record review, for ten (Resident 19, 20, 23, 28, 53, 59, 60, 64 and 65) of twelve sampled residents that were reviewed for resident assessments, the facility failed to complete quarterly Minimum Data Set assessments (MDS) in a timely manner. (MDS is a resident assessment tool used to guide care). These failure had the potential to result in the delay of assessment of residents' needs, goals of care and inability to monitor each residents' decline and progress over time. Findings: During a record review of the following Residents' Quarterly Minimum Data Set (MDS - a standardized assessment and screening tool), Resident 15's MDS indicated the last quarterly MDS with assessment reference date (ARD) 4/25/23 was completed 6/2/23 (37 days after ARD). {ARD is the last day of the observation period that the assessment covers for the resident, the ARD is the date of the assessment}. During a record review record review of Resident 19' Quarterly MDS, the MDS indicated, the last quarterly MDS…

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 provide resident's monthly Resident Council Meeting (RCM-a scheduled meeting where residents voice concerns and grievances to the facility, to improve residents' quality of life). This failure had the potential for residents to not be able to exercise their rights to have a monthly resident council meeting and for the facility to address the residents' concerns Findings: During a concurrent interview and record review with the Social Services Director (SS) on 6/5/23, at 10:30 AM, the SS stated, she was the previous activities director of the facility, and just recently hired to be the social services director. The SS reviewed the Resident Council Minutes (RCM) and acknowledged that RCM was not done for the month of April and May 2023. The SS confirmed the RCM should be done monthly. She stated, the facility department related to any issues or concerns were the responsible for addressing the resident's concerns. The SS acknowledged some of the issues in RCM in March 2023 were not resolved. The SS was not able to provide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a baseline and/ or comprehensive care plan for two of two sampled resident (Resident 82, and 81) to include resident-centered plan of care within 48 hours of their admission to the facility. This failure resulted in Resident 82, and 81 to not have a baseline and/or a comprehensive plan of care during her stay at the facility. Findings: 1. During a record review of Resident 82's admission Record dated 06/06/23, the record indicated, Resident 82 was admitted to the facility on [DATE]. During a review of Resident 82's Physician Discharge Summary dated 04/07/23, the record indicated, Resident 82 course of treatment was skilled nursing and rehabilitation and that she expired in the facility on 04/07/23. During a concurrent interview and record review with Director of Staff Development (DSD) on 06/09/23, at 8:16 a.m., Resident 82's Electronic Medical Record (EMR) including Care plans, Miscellaneous/Scanned documents were reviewed. DSD…

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, interviews and record review the facility failed to ensure one (Resident 63) of three sampled resident a non English speaker was provided functional system consistent to meet communication needs when; staff did not consistently used a qualified interpreter or translator to help Resident 63 communicate better. This failure had the potential to cause Resident 63 emotional distress. Findings: During a concurrent interview and observation on 6/5/23 at 11:19 a.m., Resident 63 was seating up in bed in her room awake, pleasant unable to communicate in English. Resident 63's husband was present at bedside. Resident 63's husband stated, they do not speak English. Resident 63's husband called daughter-in-law by phone to translate for surveyor. Daughter in-law stated, she is Resident 63's responsible party and will translate conversation between Resident 63 and surveyor during this interview process. Resident 63 stated, staff did not understand what she needed most of the time because staff used gestures to communicate with her. Resident 63 stated, nursing staff will say…

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, interviews and record review the facility failed to ensure one of four sampled resident ( Resident 49) received treatment services to address decline in range of motion to lower extremities. This failure had the potential to cause Resident 49 pain, injury, difficulty with transfers, turning and repositioning. Findings: During an observation on 6/6/23 at 9:14 a.m., Resident 49 laid in bed, awake non communicative. Resident 49 observed to have contractures (shortening of the muscles, tendons or other tissue often leading to deformed and stiff joints) of lower extremities. During a review of the Annual Minimum Data Set (MDS - an assessment screening tool used to guide care) dated 12/26/21,the MDS indicated, Resident 49 had limited range of motion and impairment on one side lower extremity, hip, knee, ankle and foot. Resident 49 had diagnoses that included Traumatic Brain Injury. During a review of the Minimum Data Set, dated [DATE], the MDS indicated Resident 49 had limited range of motion 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, interviews and record review the facility failed to ensure one of one sampled resident (Resident 17) received treatment and services when; - Resident 9's Tube Feeding (TF) was not administered as ordered by the physician. - Dietician recommendation to increase Resident 17's tube feeding was not acted upon. - The facility's policy and procedure titled, Food and Nutrition Services, revised October 2017 did not addressed who, when and how should nursing staff follow up with dietician recommendations. These failures had the potential to result in residents decline and weight loss. Findings: During a review of the Minimal Data Set (MDS - an assessment screening tool used to guide care), dated 3/31/23, the MDS indicated, Resident 17's diagnosis included Dysphagia Oropharyngeal phase (swallowing problems occurring in the mouth and or the throat) and Gastrostomy status (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach. During an…

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, interviews and record review, for one (Resident 9) of four sampled residents the facility failed to ensure pain assessment was completed before the administration of as needed (PRN) pain medication according to professional standard of practice when; Licensed Nurses did not assess and document Resident 9's pain characteristics that included location, severity, duration and timing of pain before the administration of PRN hydromorphone pain medications. Licensed Nurses did not document the adverse side effects of hydromorphone pain medication administered to Resident 9. According to manufacturer Hydromorphone belongs to a class of drugs called opioids, it has a rapid onset of action. Unless using for severe acute pain, opioids are not considered a drug of choice in older patients. The elderly may be particularly susceptible to respiratory and CNS depression, as well as the constipating effects of opioids {Reference: [NAME].com}. These failure had the potential to cause residents unrelieved…

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 interviews and record review, the facility failed to act upon the Consultant Pharmacist's (CP) Medication Regimen Review (MRR) report for two (Resident 23 and 63) of five sampled residents when; - Resident 23 CP recommendation for the physician to consider initiating ACE inhibitor such as Lisinopril 2.5 mg daily as first-line therapy for individuals with hypertension (high blood pressure) and Diabetes Mellitus (high blood sugar) was not acted upon. - Resident 63's CP recommendation to clarify erythromycin eye ointment (an antibiotic medication) to include a stop date was not acted upon. - The facility policy and procedure titled, Medication Regimen Review, revised May 2019 did not addressed who, when and how to follow up with CP medication regimen reviews and recommendations. These failure had the potential for residents to receive unnecessary drugs and suffer adverse medication side effects. Findings: During a review of the Minimal Data Set (MDS-an assessment screening tool used to guide care), dated 4/20/23, the MDS indicated, Resident 23's diagnosis included 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 observation, interview, and record review, the facility failed to ensure safe and secure storage and accurate labeling of drugs when multiple loose medication pills was observed inside drawers for one of three medication carts inspected. This failure had the potential for loss or misuse of medications and the potential to jeopardize the residents' health and safety and could cause delay in the delivery of treatment services. Findings: During an inspection and concurrent interview on 6/8/23, at 9:54 a.m., of back wing medication cart with Licensed Vocational Nurse (LVN) 2, multiple loose medication was observed scattered inside drawer 2 and drawer 3. LVN 2 then removed the loose pills from the drawers and placed in medication cups for destruction. LVN 2 stated, this was not acceptable practice. LVN 2 also stated, there was a potential risk if residents got a hold of the medications if it falls out of the drawer during medication pass. LVN 2 further added, residents can can also run out of medications before they are due for refills. During an interview on 6/8/23, at 10:25…

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

Based on interview and record review, the facility failed to ensure appropriate use of antibiotic (medication for infection) for one of two sampled residents (Resident 63) when facility did not monitor and reviewed antibiotic eye ointment for a stop date. This failure had the potential for Resident 63 to take unnecessary antibiotics which could lead to antibiotic resistance. Findings: During a review of the order summary report dated 5/22/23, the order summary report indicated, physician prescribed Resident 63 to receive Erythromycin Ophthalmic Ointment 5mg/gm instill 0.5 inch in right eye three times a day for eye infection. During a review of the Medication Administration Records (MRRs) for the month of May and June 2023, MRRs indicated, Resident 63 was administered Erythromycin eye ointment in right eye three times a day for eye infection from 5/22/23 through 6/7/23. During a review of the Consultant Pharmacist's (CP) Medication Regimen Review (MRR), dated 5/1/23 and 5/27/23, MRR indicated, Resident 63 had an order for erythromycin ointment that was subject to stop order policy.…

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.