Bayshire Rancho Mirage

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a care plan for one of one resident reviewed for oxygen use (Resident 16) and for one of three residents reviewed for edema [swelling] (Resident 165). This failure had the potential to negatively impact the residents' quality of care and had the potential for staff to not be aware of the residents' care needs and provide appropriate treatment. Findings: 1. On January 8, 2024, at 11:53 a.m., Resident 16 was observed in bed, with oxygen (O2) via nasal cannula (NC - a tube used to deliver oxygen through the nose). Resident 16's oxygen administration was observed at three liters per minute (LPM). In a concurrent interview, Resident 16 stated she uses O2 continuously due to shortness of breath and she takes it off at times during the day. Resident 16's record was reviewed. Resident 16 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD - a disease that causes obstructed…

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 the care plan in using the dignity bag for resident's indwelling urinary catheter (catheter used to drain urine from the bladder into a bag outside the body) drainage bag for one of one resident reviewed (Resident 164). This failure resulted in Resident 164's indwelling urinary catheter drainage bag's urine being visibly exposed to visitors entering the room and the drainage bag did not have protection from contact with the bed and other equipment at the resident's bedside. Findings: On January 8, 2024, at 12:25 p.m., Resident 164 was in a room designated with contact isolation precautions (steps healthcare facility visitors and staff need to follow before going into a patient's room to stop germs from spreading by touching the patient or surfaces in the room). The personal protective equipment (PPE - used to minimize exposure to hazards that cause serious illnesses) cart was observed outside the room. During a concurrent…

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 notify the physician of resident's left upper extremity edema and the compression sleeve, for one of one resident reviewed (Resident 165). This failure had potential to affect Resident 165's blood circulation on her left upper extremity and can lead to skin breakdown and other complications. Findings: During concurrent observation and interview, on January 8, 2024, at 12:55 p.m., with Resident 165 in her room, Resident 165 was observed lying in bed awake, alert, and able to verbalize her needs. Resident 165 was observed wearing a left arm compression sleeve (a type of medical garment used to increase blood flow, reduce pain and swelling). Resident 165 was observed with edema (swelling) of her left hand. Resident 165 stated she had a history of lymphedema (a condition caused by a blockage in the lympahatic system, part of immune and circulatory system) for five years. She stated she had a history of breast cancer. She stated sometimes 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 ensure pharmacy services were provided to meet the needs of the residents when: 1. Two medications for Resident 18 were not administered as ordered by the physician; and 2. One discontinued controlled substance (CS) medication was stored in the medication cart stored with other active medications available for use. This failure had the potential for inadequate medication treatment that could cause the resident to experience pain and constipation, in addition to the potential for ineffective medications to be administered to the resident. Findings: 1. On January 9, 2024, at 8:20 a.m., during a medication pass observation with the Licensed Vocational Nurse (LVN) 2, it was observed, LVN 2 prepared and administered, for Resident 18, her morning medications that included one potassium chloride (potassium supplement) ER (extended release) 8 MEq (milliequivalent - unit of measurement) tablet after crushing a total of eight medications. The eight medications that were administered to the resident by LVN 2 were as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for one resident (Resident 214), when two medications in the same therapeutic class were ordered by the physician and administered to the resident. This failure had the potential for the resident to receive excessive dose of medications and unwanted adverse effects. Findings: On January 10, 2024, medical record of Resident 214 was reviewed, and the following was noted: The resident was admitted to the facility on [DATE], with the diagnoses that included glaucoma (increased pressure in the eyeball that causes gradual loss of sight); There was a physician order on December 28, 2023, for Travatan Z (a medication applied directly to eye to treat glaucoma) 0.004 % eye drop with the direction to instill one drop in both eyes once at bedtime for glaucoma; There was a physician order on December 28, 2023, for latanoprost (brand name: Xalatan - a medication applied directly to eye to treat…

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 ensure residents were free from medication error rate greater than 5 % during medication pass observation when: - Two medications for Resident 18 were not administered; - One long-acting extended-release formulation medication was crushed and administered; and - One long-acting extended-release formulation medication was administered without a full glass of water being offered. This failure had the potential for inadequate medication treatment that could cause the resident to experience pain, constipation, and stomach upset. The medication error rate was 12.9 percent. Findings: On January 9, 2024, at 8:20 a.m., during a medication pass observation with the Licensed Vocational Nurse (LVN) 2, it was observed, LVN 2 prepared and administered, for Resident 18, her morning medications that included one potassium chloride (potassium supplement) ER (extended release) 8 MEq (milliequivalent - unit of measurement) tablet after crushing a total of eight medications. The eight medications that were administered to 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 ensure: 1. One medication stored at bedside for self-administration was properly labeled for Resident 49; and 2. Opened insulin lispro KwikPen (an injectable pen containing insulin, a hormone that regulates blood sugar) dated with 28-day expiration date was not available for use past the expiration date. This had the potential for wrong, and ineffective medications to be administered to residents. Findings: 1. On January 10, 2024, at 2:10 p.m., during inspection of the medication cart located in Red Hall, there was a manufacturer box for albuterol (medication to treat difficulty breathing) aerosol inhaler, which had a pharmacy label to indicate it belonged to Resident 49, without the inhaler inside, stored in the bottom drawer of the cart. In a concurrent interview, the Licensed Vocational Nurse (LVN) 1 stated the albuterol inhaler was kept at the resident's bedside inside the resident's room for resident to self-administer the medication. On January 10, 2024, at 2:35 p.m., it was noted the inhaler was stored…

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 maintain and implement infection prevention and control practices when the resident's indwelling urinary catheter (catheter used to drain urine from the bladder into a bag outside the body) drainage bag was touching the floor for one of one resident reviewed (Resident 164). This failure increased the potential to expose Resident 164 for further development of infection and transmission of communicable diseases. Findings: On January 8, 2024, at 12:25 p.m., Resident 164 was observed in a room designated with contact isolation precautions (steps healthcare facility visitors and staff need to follow before going into a patient's room to stop germs from spreading by touching the patient or surfaces in the room). The personal protective equipment (PPE - used to minimize exposure to hazards that cause serious illnesses) cart was observed outside the room. During a concurrent observation and interview on January 8, 2024, at 12:28 a.m., 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 maintain the kitchen grill in sanitary and safe operating condition, when the equipment was covered with blackish materials. This failure had the potential to cause cross contamination and unsanitary condition in the kitchen. Findings: During the initial tour of the kitchen, conducted on January 8, 2024, beggining at 9:30 a.m., with the Culinary Director (CD), the kitchen equipment was observed. During a concurrent observation and inteview on January 8, 2024, at 10:49 a.m., with the CD, the kitchen grill was observed with blackish materials on the surface and at the sides of the grill. The kitchen grill was situated next to the kitchen griddle being used by the cook for food preparation. The CD stated the kitchen grill had not been used for a long time. He further stated the grill should have been cleaned even if not in use. During a review of the facility's policy and procedure titled, GRILL - GAS, dated August 31, 2018, indicated, .SANITATION OF EQUIPMENT .frequency: After each use .Scrape grill to loosen…

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 protect other residents from potential abuse while the investigation was in progress, for two of seven residents reviewed (Resident 1 and Resident 2), when: 1. The Certified Occupational Therapy Assistant (COTA); and 2. Certified Nurse Assistant (CNA) were allowed to continue to work pending the results of the alleged abuse. These failures had the potential to place the other residents in the facility at risk for abuse. Findings: 1. During a review of Resident 1's Progress Notes (PN), dated October 4, 2023 (late entry for October 3, 2023), the PN indicated Resident 1 stated the COTA was rough with him during a shower on September 27, 2023. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure) and generalized muscle weakness. During an interview on October 16, 2023, at 10:25 a.m., with the COTA, she stated the Physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their policy and procedure for receipt of controlled substances for one of three sampled residents (Resident 1). This failure had the potential to result in Resident 1 not receiving his medication and medication diversion. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included sjorgren syndrome (a condition that reduces moisture produced by the body) , cognitive communication deficit, and narcolepsy (a disorder affecting sleep cycle). The record further indicated the resident is his own representative. A review of Resident 1's physician orders indicated an order for methylphenidate oral tablet extended release 20 mg (a unit of measure) , give 1 tablet by mouth one time a day for narcolepsy dated June 22, 2023. A review of Resident 1's prescription label by [retail pharmacy] for methylphenidate ER 20 mg tablets indicated 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 develop a personalized comprehensive care plans for one of three sample residents (Resident 1) when the facility failed to develop care plans with interventions for Resident 1 ' s urinary catheter and infection. This failure had to potential to result in Resident 1 not receiving interventions to promote the resident ' s optimal level of function. Findings: A review of Resident 1 ' s admission record indicated the resident was admitted to the facility on [DATE] with diagnoses which included sepsis, pneumonia, urinary tract infection and benign prostatic hyperplasia with lower urinary tract symptoms. A review of Resident 1 ' s Brief Interview for Mental Status (BIMS) dated May 22, 2023, indicated the resident had a score of 15 (no cognitive impairment). A review of Resident 1 ' s MDS (Minimum Data Set- an assessment) section I dated June 12, 2023, indicated Resident 1's medical condition included septicemia, urinary tract infection, and pneumonia. 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 interview and record review the facility failed to follow their policy and procedure for one of three sampled residents (Resident 1) when the facility did not implement interventions to control Resident 1 ' s pain. This failure resulted in Resident 1 experiencing pain for 4 hours. Findings: A review of Resident 1 ' s admission record indicated the resident was admitted to the facility on [DATE] with diagnoses which included sepsis, pneumonia, urinary tract infection and benign prostatic hyperplasia with lower urinary tract symptoms. A review of Resident 1 ' s Brief Interview for Mental Status (BIMS) dated May 22, 2023 indicated the resident had a score of 15 (no cognitive impairment). A review of Resident 1 ' s physician orders indicated orders for the following: oxycodone-acetaminophen (oxycodone w/ acetaminophen- a medication for pain) oral tablet 5-325 mg (milligrams- a unit of measure) 1 tablet by mouth every 6 hours for moderate to severe pain 4-10 dated May 19, 2023. acetaminophen (pain…

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 failed to notify the physician of abnormal laboratory results for one of three sampled residents (Resident 1). This failure had the potential to result in Resident 1 not receiving treatment to address abnormal laboratory values. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included fracture of right humerus (arm bone), difficulty walking, hypertension (high blood pressure), & protein-calorie malnutrition. The record indicated the resident was discharged on March 13, 2023. The record further indicated Resident 1 ' s family member as the responsible party and durable power of attorney. A review of Resident 1's Brief Interview for Mental Status (BIMS) dated March 14, 2023, indicated the resident had a score of 14 (little to no cognitive impairment). A review of Resident 1 ' s physician orders indicated an order for suprapubic catheter size Fr# 18/10 ml balloon for urinary obstruction,…

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 sufficient nursing staff for four out of four residents reviewed for sufficient staffing, when staff did not respond timely to the call lights of Residents 9, 186, 286, and 334. This failure increased the potential for the residents to not receive timely and necessary care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings: On December 5, 2022, at 11:31 a.m., Resident 286 was interviewed. Resident 286 was alert and oriented. Resident 286 stated the facility was shorthanded, it did not have enough staff. Resident 286 stated it took a long time for her call lights to get answered. On December 5, 2022, at 11:34 a.m., Resident 186 was interviewed. Resident 186 was alert and oriented. Resident 186 stated one night around midnight he had to wait about an hour to get help after he pressed the call light. He also stated one morning he had to wait 30-45 minutes after he pressed the call light for the nurse to come in. On December 5, 2022, at 12:47 p.m.,…

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 the observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and preparation were followed when the inside and outside, including the racks, of the double oven were observed to have dry, sticky, brown residue. This failure had the potential to result in foodborne illnesses to the vulnerable resident population. Findings: On December 5, 2022, at 9:38 a.m., during the initial tour of the kitchen with the Dietary Manager (DM), the inside and the outside area of the double oven and the oven racks were observed to have dry, sticky, brown residue. On December 5, 2022, at 9:40 a.m., the Culinary Director (CD) was interviewed. He stated, the double oven should have been cleaned once a week. A review of the maintenance log for oven cleaning was conducted. There was no documented evidence a weekly cleaning of the double oven was performed. On December 6, 2022, at 2:20 p.m., the Registered Dietician (RD) was interviewed. The RD stated the double oven should have been cleaned every week. She stated the CD was responsible in…

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 respiratory care and treatment for one resident reviewed for oxygen administration (Resident 184), when the resident received oxygen therapy without a physician's order. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and a decline in the resident's health condition. Findings: On December 5, 2022, at 10:52 a.m., Resident 184 was observed in bed with oxygen (O2) via nasal cannula (N/C - a tube used to deliver oxygen through the nose). Resident 184's oxygen administration was observed at 4.5 liters per minute (LPM). On December 7, 2022, at 12 p.m., Resident 184 was observed in his wheelchair with O2 via N/C at 4 LPM. In a concurrent interview, Resident 184 stated he was on O2 all the time since his admission to the facility, but he did not know why. Resident 184 stated he was not short of breath. Resident 184's record was reviewed. Resident 184 was admitted to the facility on [DATE],…

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 complete a medication administration log for emergency medication kits. This failure prevented the emergency medication kits from being tracked to prevent potential theft and diversion of medications. Findings: A concurrent observation and interview was conducted on December 6, 2022, at 3:17 p.m., with the Director of Nursing (DON), in the medication storage room. Medications had been taken from the facility emergency medication kits (E-kit) with no medication administration log available to show the documentation needed after dispensing emergency medications. The DON stated, The new pharmacy has not brought us a log for the E-kits yet. A review of the facility's policy and procedure titled, Emergency Medications, revised April 2007, indicated .The facility shall maintain a supply of medications typically used in emergencies .Any medication that is removed from the emergency kit must be documented on the emergency medication administration log .Medications and supplies used from the emergency medication kit…

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 assess for the need of an antipsychotic medication, have medication evaluated by the physician, and failed to provide adequate indications for an antipsychotic medication for one of six residents reviewed for antipsychotic medication use. (Resident 335). This failure had the potential to jeopardize the health and safety of Resident 335. Findings: A review of Resident 335's face sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included, Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, urinary tract infection (UTI) with sepsis (inflammation throughout the body). A review of Resident 335's physician's order dated November 29, 2022, indicated, SEROquel tablet (an antipsychotic medication used to treat schizophrenia, bipolar disorder, and major depressive disorder) .12.5 mg (milligram - a unit measurement) by mouth at bedtime for antipsychotic m/b (manifested…

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: 1) properly label a prescribed medication needed for safe administration, when one insulin injectable pen and one glucagon injectable pen were found in medication cart 2 without a pharmacy label; and 2) ensure proper organization and storage of Cefazolin (antibiotic) IV (intravenous) bags, risking administration of an antibiotic beyond its use-by-date. In addition, the facility was unable to differentiate between the IV solution that were different in color. These failures had the potential for residents to receive the improper amount of insulin and for residents to receive expired IV medication. Findings: 1. On December 6, 2022, at 11:10 a.m., one Toujeo SoloStar Solution Pen Injector kit (insulin used to control blood sugar) was observed in medication cart 2, readily available for use, with a resident's name written on a sticky note. There was no pharmacy label on the kit. One glucagon emergency kit was also observed being stored in medication cart 2 readily available for use, with no label. On December 6,…

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 PICC (Peripherally Inserted Central Catheter - an IV [intravenous], longer than a regular IV) line dressing was changed according to the standard of practice for one of one resident reviewed (Resident 287). This failure had the potential to place Resident 287 at risk for infection and other complications. Findings: On December 6, 2022, at 9:25 a.m., Resident 287 was observed sitting in bed. Resident 287 was observed to have a PICC line in her upper right arm. The transparent dressing was labeled 11/19/22. A concurrent interview with Resident 287 was conducted. Resident 287 stated she was admitted to the facility with the PICC line in place. She stated the dressing had not been changed since admission. Resident 287's record was reviewed. Resident 287 was admitted to the facility on [DATE], with diagnoses which included sepsis (a life-threatening complication of infection) and diabetes (increased sugar in the blood). The physician…

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.