Villa Gardens Health Care Unit

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent falls (move downward, typically rapidly and freely without control, from a higher to a lower level) for one (1) of two (2) sampled residents (Resident 35) by failing to identify causative factors of the resident's fall, and revise the care plan with new resident- specific interventions (programs or activities that are designed to address the specific needs of the resident to ensure their well-being) to prevent further falls. On 7/14/2024 at 8:24 AM, Resident 35 was found sitting on the floor at 6:15 AM awake, very confused, and soaking wet with urine, there was no documented evidence of interventions provided to address resident's confusion and incontinence (involuntary loss of bowel and bladder control). This failure resulted in Reisdent 35 had six (6) falls incidents (8/5/2024, 9/9/2024, 9/10/2024, 9/23/2024 at 1:45 AM and 2:30 AM, and 9/29/2024) with the potential for injuries. On 9/23/2024, the resident sustained forehead laceration 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 follow its oxygen therapy (a treatment that provides extra oxygen) policy for two (2) of three (3) sampled residents (Residents 8 and 37) by failing to: 1. Ensure Resident 8's humidifier bottle (plastic bottle of water that adds moisture to the flow of oxygen) was dated and not empty during oxygen therapy. This failure had the potential to result in adverse effects (an undesired harmful effect resulting from a medication or other intervention) of oxygen therapy for Resident 8 including nasal membrane (moist tissue that lines the nasal cavity and produces mucus) drying. 2. The facility failed to follow Resident 37's physician order to receive two (2) liters of oxygen per minute (LPM) via nasal cannula (oxygen tubing used to deliver supplemental oxygen that is placed directly on the nostrils) continuously and failed to store empty portable oxygen cylinder tanks separately from full portable oxygen cylinder tanks as indicated in the…

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

Based on observation, interview, and record review, the facility failed to to follow proper food handling practices in accordance with its policy and procedure by failing to:: 1. Properly label food items in the kitchen refrigerator. 2. Ensure there was no expired bread in the kitchen dry storage area. 3. Properly label food items in the resident refrigerator. These deficient practices have the potential to result in food borne illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) in a population of 35 residents who consume food by mouth. Findings: 1. During a concurrent observation and interview in the kitchen on 10/1/2024 at 7:50 AM with [NAME] 1, there were multiple food items inside walk in refrigerator 1 without a label to indicate the date when the following food items were opened: a. One large clear container of cranberries b. One grocery bag (cook stated did not belong to the facility but could be from one of the staff) which contained coleslaw packed in a zip lock and in a small…

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

Based on observation and interview the facility failed to ensure two (2) of three (3) dumpsters were covered with a lid and were not overflowing with trash in accordance with the facility policy. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g., rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents. Findings: During a concurrent observation of the facility's garbage area, and interview with the Director of Dining Services (DDS) on 10/1/2024 at 11:35 AM, there were 3 dumpsters located outside the facility's main kitchen area, which was about 15 to 20 feet away from the facility's kitchen exit. DDS verified 2 of the 3 dumpsters were observed without lids and both were overflowing with trash bags. DDS stated the dumpsters should have been covered with a lid and not overflowing with trash since this could attract all live animals. During observation of the facility's garbage area on 10/01/24 at 3:45 PM, about 5 empty boxes…

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 Amended: Based on observation, interview and record review, the facility failed to implement appropriate infection control practices for 4 of 5 sampled residents (Residents 19, 24, 37 and 199) as indicated on the facility's policy and procedure (P&P) by failing to ensure: 1. Resident 199's visitor was educated and used indicated personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) inside novel respiratory isolation (an isolation that requires the use of a disposable gown, eye protection [goggles or face shield], fit-tested respirator [N-95 or higher] and gloves) room. 2. The nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) tubing was placed in a bag after use as indicated in the facility's policy and procedure (P&P) and ensure the oxygen tubing was not touching the floor for Resident 37. 3. Facility staff observed infection control measures for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to follow its manual catheter irrigation (a procedure that uses sterile fluid to flush a blocked or clogged indwelling catheter [a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage]) policy when Licensed Vocational Nurse 5 (LVN 5) failed to cap the drainage tube of the indwelling catheter with a sterile protective sheath during irrigation for one (1) of one sampled Resident (Resident 18) as indicated in the facility's policy and procedure (P&P). This deficient practice had the potential for Resident 18 to develop urinary tract infection (UTI- an infection in the bladder/urinary tract). Findings: During a review of Resident 18's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 18 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included benign…

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, for one (1) of 12 sampled resident (Resident 5), the facility staff failed to: 1. Accurately and completely document the insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) dose administered on 10/2/2024, after administering insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). 2. Have documented evidence for the monitoring of signs and symptoms of hypoglycemia (a condition in which your blood sugar level is lower than the normal range) and hyperglycemia (a condition where too much sugar is circulating in the blood) as indicated in the resident's care plan and the pharmacist recommendations. These deficient practices placed Resident 5 at risk to not receive appropriate diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) management/care including unmonitored and untreated adverse…

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 call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within the resident's reach (arm's length) for one (1) of 1 sampled resident (Resident 24) as indicated on the facility's call system policy. This deficient practice had the potential for Residents 24 to not being able to call the facility staff for assistance especially during an emergency, which could lead to an injury or harm to Resident 24. Findings: During a review of Resident 24's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included functional quadriplegia (complete immobility due to severe disability from another medical condition without injury to the brain or spinal cord) and urinary tract infection (UTI- an infection in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to document and perform a wound care treatment for one of two sampled residents (Resident 1). This failure had the potential to result in Resident 1's wounds getting worse in condition. Findings: During a review of Resident 1's admission Record, admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of cellulitis (a bacterial skin infection) of the right and left lower limbs and metabolic encephalopathy (a disorder that affects brain function that can be temporary or permanent depending on severity of the damage). During a review of Resident 1's History and Physical Examination (H&P), dated 11/10/23, H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 12/15/23, MDS indicated the resident was moderately impaired with cognition (ability…

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 residents (Resident 1) was free from accident hazards by failing to secure a keyboard that was placed on top of a music equipment cart on 12/31/23 at 3:30 PM while an entertainer (a person such as a singer, musician, [NAME], or comedian whose job is to entertain others) was setting up their equipment for a performance. This failure resulted in the keyboard slipping off the cart and falling onto Resident 1's feet and caused her to sustain blood blisters that needed surgical intervention. Findings: During a review of Resident 1's admission Record, admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of cellulitis (a bacterial skin infection) of the right and left lower limbs and metabolic encephalopathy (a disorder that affects brain function that can be temporary or permanent depending on severity of the damage). During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one of four sampled residents (Resident 23) by failing to flush in between each medication administered through the gastrostomy tube (G-tube, tube inserted through the abdomen that delivers nutrition directly to the stomach). This deficient practice had the potential for drug-to-drug interactions (a reaction between two or more drugs) and for the resident to be at risk for adverse reactions (an unwanted, uncomfortable, or dangerous effects the drugs/medications may have). Findings: A review of Resident 23's admission Face Sheet (record of admission) indicated the resident was admitted to the facility on [DATE] with a diagnosis of hydrocephalus (buildup of fluid in the hollow places inside the brain) and urinary tract infection (UTI, an infection in any part of the urinary system, the kidney, bladder, or urethra). A review of 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 clean the dryer lint trap for three (3) of 3 dryers as indicated in the policy. This deficient practice had the potential to cause fire in the facility. Findings: During a concurrent observation in the facility laundry room and interview with Environmental Service Director (ESD) on 10/8/23 at 11:03 AM, three large blue laundry carts with unfolded linen inside were noted in front of three washers. ESD placed his hand inside one of the blue laundry carts and stated the linen felt a little damp. ESD stated he did not know if the linen inside the blue laundry carts were clean or dirty. ESD stated all three washers and dryers were working. During a concurrent observation in the laundry room and interview with Laundry Staff 1 (LS 1) and ESD on 10/08/23 at 11:13 AM, three dryers were observed in the dryer room between the linen storage and the washer room. Lint found in the lint traps on all three dryers. Dryer 1 lint trap also had a used band aid and paper towel. LS 1 stated, Lint is removed from the lint traps 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 they were free of medication error rate of five (5) percent or greater, as evidenced by the identification of two medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications [not recommendations] regarding the preparation and administration of the medication or biological; or accepted professional standards and principles) out of 25 opportunities (observations during medication administration) for error and yielded a cumulative error rate of eight (8) percent for two of four sampled residents (Resident 4). Resident 4 did not receive Eliquis (a medication used to prevent blood clots) and Carvedilol (a medication used to help control blood pressure [BP]) with food in accordance with the physician's order. This failure had the potential to cause Resident 4 to experience pain and discomfort of the stomach.…

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 provision of pharmaceutical services by failing to dispose expired medications found in the medication room as indicated on the facility policy. This deficient practice had the potential for adverse reaction in the event that these expired medications were administered to the residents. Findings, On 10/7/23 at 4:27 PM, during an inspection of the medication room with Licensed Vocational Nurse 1 (LVN 1), the following were observed: a. 16 individual packets of Simply Thick Easy Mix Instant Food Thickener 96 g (Gram - a unit of measure) with an expiration date of 8/3/23. b. Two bottles of Pepto-Bismol (medication used to treat diarrhea, heartburn nausea, and upset stomach) 525 mg (milligrams - unit of measure)/30 ml (milliliter - unit of measure) with an expiration date of 5/20/23. On 10/7/23 at 4:40 PM., LVN 1 stated, There should not be any expired medications left in the medication room because if the residents took the medication, they could get sick. On 10/7/23 at 4:42 PM, the Director of…

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

Based on observations, interviews, and record reviews, the facility failed to store food under sanitary conditions in one (1) of 1 kitchen, by: a. Failed to ensure pasteurized eggs (gently heated in their shells, just enough to kill the bacteria but not enough to cook the egg) was not stored in the same shelve and/ or beside the regular eggs. b. Failed to ensure opened food items stored in dry goods area were labeled and dated. c. Failed to discard expired food and was not stored in the kitchen. The deficient practice of not separating pasteurized eggs with regular eggs has high risk of accidental usage of regular eggs that to be served to residents and had high potential for transmission of salmonella (a germ that may cause diarrhea, fever, and stomach cramps, leading to hospitalization and death). The deficient practice of failing to ensure unlabeled and expired dry goods are dispose accordingly had the potential to result in growth of bacteria and transmission of foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea,…

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 complete the facility's Infection Surveillance Log Form (ISL - a form used by the facility to indicate if the resident met the criteria for the use of antibiotic [medication used to treat infection]) which is part of the facility's Antibiotic Stewardship Program (protocols and a system in the facility to monitor antibiotic use) prior to the administration antibiotic medication for three of three sampled residents (Resident 22, 26, and 90). This deficient practice had the potential for Residents 22, 26, and 90 to develop infection that is resistant (organism that is not able to be killed and continued to grow) to antibiotics or multiple drug resistant organism (MDRO, are define as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents) that is difficult to treat due to unnecessary or inappropriate antibiotic use. Findings: A review of Resident 22 's admission Record indicated the resident was admitted…

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 an individualized baseline care plan within 48 hours of admission to reflect the assessment and meet the immediate needs that included interventions to address hearing for one of 12 sampled residents (Resident 189). This deficient practice had the potential to negatively affect the well-being and the delivery of necessary care and services for Resident 189. Findings: A review of Resident 189's Face Sheet indicated Resident 189 was admitted on [DATE] with diagnoses that included malignant neoplasm of lower lobe left lung (cancerous abnormal growth of tissue in the lungs), chronic obstructive pulmonary disease (COPD-a lung disease characterized by long term poor airflow), asthma (swelling and narrowing of the airway making it hard to breathe), and dependence of supplemental oxygen. A review of Resident 189's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/29/23, indicated Resident 189 had severely…

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 record review and interview, the facility failed to ensure a coordination of care between facility and hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) staff for one of two sampled resident (Resident 24) in accordance with the facility's hospice agreement by failing to ensure: a. A physician's order for hospice care from December 2022 to October 2023 b. A current physician's certification for hospice benefit from 3/2023 to 10/2023 c. A hospice comprehensive assessment to include a documented evidence of hospice staff progress notes visit and hospice staff visit calendar d. Hospice care plan was developed This deficient practice had the potential for Resident 24 not to receive the hospice care and services necessary to promote comfort and quality of life. Findings: A review of Resident 24's admission Record indicated Resident 24 was originally admitted to the facility on [DATE]. Resident 24's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement appropriate infection control practices for one sampled resident (Resident 26) as indicated on the facility's policy and procedure by failing to ensure availability and use of EPA (Environmental Protection Agency) approved disinfectant solution in cleaning a contact isolation ( used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) room with Clostridioides difficile (C. diff, a germ that causes diarrhea). This failure placed all the residents, staff, and the visitors at higher risk for cross contamination, and increased spread of C. diff infection in the facility and the community. Findings: During a review of Resident 26's admission Record indicated Resident 26 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 26's diagnoses included dementia (memory loss), chronic kidney disease (a gradual loss of kidney…

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 observations, resident and staff interviews, the facility failed to follow the facility's menu for thirty- one (31) of thirty-four (34) residents in accordance with the facility's policy and procedure by: 1. 31 residents who are on a regular (diet with no restrictions) and therapeutic diets (diet that controls the intake of certain foods or nutrients) received unportioned Haricot Verts (French [NAME] beans) 2. Seven (7) residents received unportioned steak fajitas. These deficient practices placed facility residents on regular and therapeutic diets at risk of potential increased or decreased nutrient intake causing unplanned weight gain or unintentional weight loss (weight loss without trying). Findings: A review of the facility's menu spread sheets dated 8/23/2023, indicated the following items will be served on Regular Diet and Therapeutic Diets based: a. For Option One (1) - Half cup of Haricot Verts b. Option two (2) - Three (3) oz Steak Fajita During tray line (area used to plate food of the residents) observation in the dining room on 8/24/2023 at 12:42 p.m., 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 always maintain the facility's roof in good repair. This deficient practice had the potential to result in accidents and negatively affect the health and safety of all residents, staff, and visitors. Findings: During a concurrent observation in the facility's satellite kitchen and interview on 8/23/2023 at 11:24 a.m., with the Administrator (ADM), Registered Dietician (RD), Maintenance Coordinator (MC), and Maintenance 1 (M1), there was a large hole on the ceiling near the hand washing sink and entrance exposing the pipes, ducts, and electricals. The ADM stated, there was water leaking from the roof due to the rain on 8/20/2023, that affected the area. The ADM also stated, the next day (8/21/2023), the facility decided to close the satellite kitchen to assess the damage and clean the area and when the staff came here to work and clean, the ceiling fell down because the rainwater had soaked into the ceiling. M1 measured 14 feet (ft) by 5 ft hole on the kitchen ceiling. During a concurrent observation at the…

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