Hillcrest Post Acute

Based on observation, interview and record review, the facility failed to ensure the posted daily staffing schedule had an additional required information such as census (number of residents in the facility), the total numbers of Licensed and Unlicensed staff and the actual hours worked individually, reflect staff absences on that shift due to call-outs and illness, and clearly identify the staff's name in a clear and readable format. This failure had the potential to result in poor and inadequate care that compromised the health and safety of residents. Findings: During a concurrent observation and interview on 4/18/24 at 4 p.m. with the Administrator (ADM), during a tour to the nurses' station where the daily staffing was located, the daily staffing for Licensed and Unlicensed nurse was located inside a binder. ADM stated that the daily staffing was readily available to read to all visitors, staff, and residents. During a concurrent interview and record review on 4/18/24 at 4 p.m. at the nurses' station, when Administrator (ADM) was asked do you have the census written on 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 provide a fully credentialed Infection Preventionist (nurse who surveys and monitors infection prevention and control). This failure had the potential for Residents to obtain infections and be placed on unnecessary medications due to lack of infection control surveillance. During an interview with the DON on 4/16/24 at 10:30 a.m., DON queried as to who the Infection Preventionist is for the facility. DON stated, the nurse who has been working as the Infection Preventionist (Licensed Staff H) resigned 12/29/23. DON stated, Licensed Staff H and Licensed Staff I have been filling in. DON queried for the facility's staffing sign in sheets for Licensed Staff H and Licensed Staff I from 1/3/24 to 4/15/24. DON also queried for the timecard accounting for License Staff H and Licensed Staff I from 1/3/24 to 4/15/24. During a record review of Licensed Staff H's timecard for the time frame 1/3/24 to 4/15/24. License Staff H's worked day shift on 1/19/24, 1/25/24, 2/1/24, 2/5/24, 2/8/24, 2/18/24, 2/19/24, 2/23/24, 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 interviews and records review, the facility failed to assess and monitor for signs of after surgery complications for one of 15 sampled residents (Resident 20) when Resident 20 had left eye surgery. This failure had the potential for Resident 20 to develop an unidentified bacterial eye infection which could result in Resident 20's discomfort. Findings: A review of the document titled admission Record indicated Resident 20 was admitted on [DATE] with diagnosis including but not limited to Parkinson's Disease (disorder of the central nervous system that affects movement) and Diabetes Mellitus (disease that result in too much sugar in the blood). A review of the document titled Physician's Progress Notes dated 4/09/24 indicated Resident 20 had a left eye surgery for silicone oil (often used as a retinal [a layer at the back of the eyeball] tamponade [function by keeping the hole in the retina dry] after complex retinal detachment [a painless but serious eye condition] repair) removal and retention. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to ensure Ophthalmic (pertaining to the eye) medications were administered according to the doctor's order for two of 15 sampled residents (Resident 20 and Resident 41) when: 1. a. Resident 20 who had left eye surgery did not receive the ordered Ofloxacin Ophthalmic Solution 0.3%, (an antibiotic used to treat bacterial infections of the eye) three days after the medication was ordered, and (b) Resident 20 did not receive the medication according to the ordered administration time. These failures had the potential risk for Resident 20 to develop bacterial eye infection and eye discomfort. (Cross reference F684) 2. Resident 41 who had a diagnosis of Glaucoma (an eye diseases that can cause vision loss and blindness) did not receive his eye medications according to the ordered administration time. These failure had the potential risk for Resident 41 to experience eye pain and deterioration of visual function. Findings: Resident 20 During 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, interview and record review, the facility failed to ensure two of two residents, Resident 9 and Resident 19, received action, obtain feedback, and conduct systematic investigations to improve quality of care, quality of life and resident's safety during Quality Assurance and Performance Improvement (QAPI) meetings when: 1) The Director of Staff Development (DSD) did not report an incident reported by an Ombudsman of verbal abuse and mocking (imitating behavior) towards Resident 9 by Unlicensed Staff L. DSD did not inform the Administrator of the abuse allegation. ADM was the abuse coordinator. 2) Resident 19 attempted to complain to DSD regarding an alleged verbal abuse by Unlicensed Staff M & Unlicensed Staff N . DSD did not follow up with Resident 19 about the allegation and did not inform ADM nor the Inter Department team (IDT) during their daily IDT meeting & monthly meetings of QAPI. Findings: (1) During a concurrent interview and record review on 4/19/24 at 9:39 a.m. the Director of Staff Development (DSD) stated that she was the supervisors for 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 interviews and records review, the facility failed to develop and implement person-centered care plans for one of 15 sampled residents (Resident 20) when Resident 20 had left eye surgery. This failure resulted in a lack of communication between disciplines and care givers that could potentially cause negative outcomes for Resident 20. (Cross reference F684) Findings: A review of the document titled admission Record indicated Resident 20 was admitted on [DATE] with diagnosis including but not limited to Parkinson's Disease (disorder of the central nervous system that affects movement) and Diabetes Mellitus (disease that result in too much sugar in the blood). A review of the document titled Physician's Progress Notes dated 4/09/24 indicated Resident 20 had a left eye surgery for silicone oil (often used as a retinal [a layer at the back of the eyeball] tamponade [function by keeping the hole in the retina dry] after complex retinal detachment [a painless but serious eye condition] repair) removal 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 their Medication Storage Policy, when 3 expired COVID 19 Vaccines and 1 box of Arginaid (wound healing nutrition) were found in the facility's Medication Storage room and another expired box of Arginaid was found in Medication Cart 1. This failure had the potential to result in Residents being injected with an expired ineffective COVID 19 vaccine resulting in an unvaccinated status as well as expired deteriorated Arginaid being ineffective for wound healing. Findings: During an observation on [DATE] at 12:55 p.m., in Medication Cart 1, observed 1 box of Arginaid to be expired with an expiration date of [DATE]. During an observation on [DATE] at 12:59 p.m., in the Medication Storage room, observed 1 box of Arginaid to be expired with an expiration date of [DATE]. During an observation on [DATE] at 1 p.m., in the Medication Storage room, 3 expired Covid 19 vaccines were observed with an expiration date of [DATE] in the medication…

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, residents were made to feel uncomfortable when staff spoke Spanish in front of residents and during care for two of 15 sampled residents (Residents 35 and 28), and seven of seven residents in a group interview. This caused Resident 35 to feel disoriented and wished staff would speak English in front of her, caused Resident 28 to feel upset, and caused residents in the group interview to feel left out. Findings: During an interview on 2/28/22 at 10:33 a.m., Resident 28 stated, I wish they (the staff) would speak English around us, it's hard to understand them. They speak Spanish (to each other) until they're talking to you. When I wake up and they're speaking Spanish it makes me feel like 'where am I?' They're real nice to me, but I wish they would speak English. During an interview on 2/28/22 at 11:51 a.m., Resident 35 stated she found it upsetting when staff spoke Spanish in front of her, and stated she felt like telling them to do that at home. During an observation on 2/28/22 at 4:23 p.m., two staff members were speaking Spanish…

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 accurate MDS assessments (The Minimum Data Set is a tool for implementing standardized assessment and for facilitating care management in nursing homes) were submitted for two of two sampled residents (Residents 46 and 145) when they: 1.Failed to document the correct discharge disposition for one Resident, Resident 46. This failure led to an incorrect discharge disposition submitted on Resident 46 MDS which indicated Resident 46 was discharged to a hospital. 2. Failed to identify risk for pressure ulcers on one Resident, Resident 145. This failure could have potentially lead to Resident 145 not getting the pressure ulcer prevention she needs. Findings: 1. Review of the closed record/progress notes and care plan for Resident 46 on 03/03/22 at 11:00 am, indicated that Resident 46 did not get discharged to a hospital from the facility. Resident 46 was discharged to home with Home Health. During an observation and concurrent 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, one of 15 sampled residents (Resident 21's): 1. Fall Risk care plan and 2. Risk for Constipation care plan were not adequately updated with interventions to prevent falls from occurring and constipation. These failures contributed to Resident 21: 1. falling twelve times from 5/20/21 through 3/4/22, which had the potential to lead to harm, hospitalization, and in severe cases death and 2. Resident 21's abdomen feeling full, bloated, and in pain, hard stools causing hemorrhoids (swollen veins in your lower rectum), unexplained weight loss, amongst other health issues, which could lead to Resident 21 being hospitalized . Findings: 1. A review of Resident 21's admission Record, date 3/3/22, indicated Resident 21 was admitted on [DATE], with a diagnosis including a stable burst fracture (injury to the spine, which consists of the bones, muscles, tendons, and other tissues that reach from the base of the skull to the tailbone) of second lumbar vertebra (one of 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 follow the physician's Protocol for Constipation and Resident 21's Risk for Constipation care plan for one of 15 sampled residents (Resident 21) causing Resident 21 to not have a bowel movement (BM) anywhere from four to seven days in a row. This had the potential for Resident 21's abdomen feeling full, bloated, and in pain, hard stools causing hemorrhoids (swollen veins in your lower rectum), unexplained weight loss, amongst other health issues, which could lead to Resident 21 being hospitalized . Findings: A review of Resident 21's admission Record, date 3/3/22, indicated Resident 21 was admitted on [DATE], with a diagnosis including a stable burst fracture (injury to the spine, which consists of the bones, muscles, tendons, and other tissues that reach from the base of the skull to the tailbone) of second lumbar vertebra (one of the many bones that form the lower back bone)and a wedge compression fracture of the third thoracic vertebra (upper back…

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 resident safety when staff did not evaluate, develop, and implement adequate interventions for 1 of 15 sampled residents (Resident 21), who had poor safety awareness and a history of falls, to prevent multiple falls. This failure contributed to Resident 21 falling twelve times from 5/20/21 through 3/4/22, which had the potential to lead to harm, hospitalization, and in severe cases death. Findings: A review of Resident 21's admission Record, date 3/3/22, indicated Resident 21 was admitted on [DATE], with diagnoses including a stable burst fracture (injury to the spine, which consists of the bones, muscles, tendons, and other tissues that reach from the base of the skull to the tailbone) of second lumbar vertebra (one of the many bones that form the lower back bone) and a wedge compression fracture of the third thoracic vertebra (upper back bone injury), dementia (loss of memory, language, problem-solving and other thinking…

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 food storage observation, dietary staff and resident interview, and dietary record review, the facility failed to ensure meals were prepared and served in a manner to maintain palatability and nutrient content as evidence by: 1. Foods were not stored in the refrigerator per facility storage guidelines including bread, premade cheese sandwiches, and gelatin, tomatoes had brown spots and felt mushy, and Romaine lettuce was not sealed and no open date, and 2. Test tray evaluation of lunch on 3/2/2022 at 12:57 p.m., found pureed Risotto tasted bland and had a gluey texture causing pureed risotto difficult to swallow, broccoli mushy and gray/green in color, and test tray evaluation of dinner on 3/2/2022 at 5:10 p.m., found the bottom bun of the grilled hamburger bun was hard, dry, and over cooked. Failure to ensure food distribution and food production systems that ensured food palpability and nutritional content may result in decreased dietary intake, which may result in weight loss and further compromise…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to assess for self-administration of medication for 1 of 15 sampled residents (Resident 36) when Resident 36 was allowed to self-administer her oral inhaler. This failure had the potential for Resident 36 to develop medication side effects if medication was self-administered inappropriately. Findings: During a clinical record review for Resident 36, the Face Sheet (A one-page summary of important information about a resident) indicated Resident 36 was admitted on [DATE] with a diagnosis that include Chronic Obstructive Pulmonary disease (COPD - diseases that cause airflow blockage and breathing-related problems). During a clinical record review for Resident 36, the Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems) dated 1/28/22 indicated Resident 36 had a BIMS score of 11/15 (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory 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 interview and record review, the facility failed to develop and implement a person-centered care plan for 1 of 15 sampled residents (Resident 36) when: 1. The facility did not develop a care plan for weight gain to indicate how the facility would monitor and maintain Resident 36's weight. 2. The facility did not develop a Congestive Heart Failure (CHF - weakness of the heart that leads to a buildup of fluid in the lungs) care plan to indicate what symptoms to expect, how often and what to monitor. (Reference F684) This failure resulted to Resident 36's continued weight-gain due to worsening bilateral leg edema and subsequently was transferred to the acute hospital due to shortness of breath. Findings: 1. During a clinical record review for Resident 36, the Face sheet (A one-page summary of important information about a resident) indicated Resident 36 was admitted on [DATE] with a multiple diagnosis that include Congestive Heart Failure (CHF - weakness of the heart that leads to a buildup of fluid 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 observations, interviews, and record reviews the facility failed to do a respiratory assessment and identify a large fluid filled blister approximately 8 cm in diameter for 1 of 15 sampled residents (Resident 36) when Resident 36 had bilateral (both sides) leg edema (swelling caused by fluid). This failure resulted in Resident 36 to experience discomfort and was subsequently sent to the acute hospital for shortness of breath and worsening of leg edema. Findings: During a clinical record review for Resident 36, the Face Sheet (A one-page summary of important information about a resident) indicated Resident 36 was admitted on [DATE] with multiple diagnoses that included Congestive Heart Failure (CHF - weakness of the heart that leads to a buildup of fluid in the lungs), Cardiomyopathy (heart loses its ability to pump blood effectively), and Chronic Obstructive Pulmonary Disease (COPD - lung diseases that make it hard to breathe and gets worse over time). During a clinical record review Resident 36's Care…

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 re-order one Resident's (Resident 95) blood thinner medication in a timely manner to ensure there were no missed doses. This failure caused Resident 95 to miss two doses of his blood thinner and had the potential to cause Resident 95 to develop a blood clot. Findings: During a review of the clinical record for Resident 95, Physician L ordered Enoxaparin (blood thinner) on 2/23/2022. The physician's order read: Inject 100mg/ml (milligrams per milliliter) subcutaneously (under the skin) two times a day for deep vein thrombosis (blood clot) prophylaxis (prevention of). During a medication administration observation on 3/2/2022 at 8:18 a.m., the day shift Licensed nurse A asked the night shift Licensed nurse B if the Enoxaparin for Resident 95 had come from the Pharmacy. The night shift Licensed nurse B stated No. During a medication administration observation on 3/2/22 at 8:29 a.m., Licensed nurse A stated he did not have the Enoxaparin for Resident 95. He stated the Enoxaparin was re-ordered from the Pharmacy 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 interview and record review, the facility failed to provide proper monitoring of drug adverse effects when one of five residents sampled for unnecessary medication review (Resident 27) did not have ordered monitoring for signs and symptoms of bleeding while taking a blood thinner. This failure could potentially lead to Resident 27 having undetected bleeding. Findings: During a record review on 3/1/22 at 4:45 p.m., Resident 27's electronic medical record revealed Resident 27 was admitted on [DATE] and her medical diagnoses included chronic embolism and thrombosis of unspecified deep veins of right lower extremity (blood clot in the right leg). Resident 27's physician orders indicated she was taking Eliquis (a blood thinner) 2.5 milligrams (a unit of measure) twice a day for deep vein thrombosis (a blood clot). Further review of Resident 27's physician orders and medication administration record (MAR) revealed there was no order or documentation for nurses monitoring Resident 27 for signs or symptoms 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 observation, interview, and record review, the facility failed to properly secure residents' medications when two of 15 sampled residents, Residents 28 and 36, had inhalers stored on their bedside tables. This failure had the potential to result in other residents misusing the inhalers when they had unrestricted access to prescription medications. Findings: Resident 28 During an observation and concurrent interview on 2/28/22 at 11:08 a.m., Resident 28 had two inhalers on her bedside table. One was a puffer-style inhaler and one was a flat, purple, disk-shaped inhaler. Resident 28 stated she did not need help to use the inhalers. During a medical record review, Resident 28's physician orders indicated Advair Diskus 500-50 mcg (micrograms, a unit of measure)/act (activation) 1 inhalation orally two times a day for COPD (chronic obstructive pulmonary disease) and Albuterol Sulfate aerosol solution 108 mcg/act 2 puffs inhale orally every 4 hours related to COPD. Resident 28's Interdisciplinary Team (IDT) Progress note dated 3/2/22 at 5:26 p.m. indicated, Spoke to [Resident 28]…

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

Based on observation, interview, and record review, one resident's urinary catheter bag and tubing (a device that drains urine from the bladder through a tube to a collection bag) were on the floor. This could potentially lead to the resident developing a urinary tract infection (UTI). Finding: During an observation and concurrent interview on 3/3/22 at 4 p.m., Resident 27 was in bed watching TV. Resident 27's urinary catheter bag and tubing were on the floor next to the bed. Infection Preventionist Nurse (IPN) came to Resident 27's room. When asked if the catheter bag was touching the floor, IPN stated it was covered with the bag (dignity bag, covers the collection bag so the resident's urine is not visible). When asked if the catheter tubing was on the floor, IPN stated, Yes. IPN stated the tubing should not be on the floor because it can cause an infection. During an interview on 3/4/22 at 11:58 a.m., when asked what measures she took to prevent a urinary tract infection for a resident with a urinary catheter, Staff M stated she checked the collection bag every two hours 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.