Palm Village Retirement Comm.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a new Preadmission screening and Resident Review (PASARR- a federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) level 1 screening for one of five sampled residents (Resident 2) when Resident 2's PASARR level 1 dated 5/14/25 completed prior to admission to the facility did not include diagnosis of anxiety (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with daily activities) and use of psychotropic medications (drugs that affect the mind, emotions, and behavior). This failure had the potential for Resident 2 to not receive the appropriate services related to her diagnosis and medication used. Findings: During a concurrent observation and interview on 7/23/25 at 8:35 a.m. in Resident 2's room, Resident 2 was observed sitting up in wheelchair at bedside eating breakfast with staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed twice to complete a level 1 Preadmission Screening and Resident Review (PASARR), (a Federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) screening notifying the state mental health authority or state intellectual disability authority promptly after a significant change for one of three sampled residents (Resident 4). This failure had the potential for Resident 4 to not receive the appropriate services related to her mental disorder.Findings: During a record review of Resident 4's admission Record (AR) (a summary of important information regarding a resident which includes resident identification, past medical history insurance status, care providers, family contact information and other pertinent information), dated 7/25/25, the AR indicated, Resident 4, a [AGE] year-old female was admitted to the facility on [DATE] from another nursing home,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of eleven sampled residents' (Resident 12 and Resident 79) drug regimen was free from unnecessary drugs when: Resident 79 received acetaminophen-codeine (opioid and nonopioid combination prescription medication used to treat pain) tablet prescribed for severe pain, despite reporting moderate pain on 7/19/25, 7/20/25, 7/21/25, 7/22/25, 7/23/25, and 7/24/25. This failure resulted in over-medication and inadequate pain management practices of Resident 79 which had the potential to result in adverse consequences and complications which could lead to serious medical condition. 2. Licensed Nurses did not follow physician ordered acetaminophen medication when Resident 12 was administered acetaminophen for complaints of pain, the acetaminophen was ordered for temperatures above 101 degrees Fahrenheit. This failure had the potential for Resident 12 to not receive adequate pain relief . Findings: 1.During a review of Resident 79’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 one of three residents (Resident 1) had a non-slip mat on her wheelchair as a care plan intervention to reduce the risk of a fall. This failure had the potential for Resident 1 to have an increased risk of falls, potentially leading to injury including bone fracture, pain, and loss of function. Findings: During a review of Resident 1 ' s admission Record (AR), dated 5/23/25, the AR indicated she was a [AGE] year-old female with diagnoses that included dementia (a progressive disease of the brain that affects memory, judgment, and mood), psychosis (a person ' s thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not), and osteoporosis (a condition where the bones become thin and weak, and more likely to break). During a review of Resident 1 ' s Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 3/14/25, the MDS indicated at Question GG0170, E, a score…

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, record review, and facility policy review, the facility failed to provide one of one resident (Resident (R)118) reviewed for hospital transfers out of a total sample of 33 residents a written transfer notice when R118 was transferred to the hospital. This failure placed all residents and their representatives at risk of having incomplete information, misunderstand the reason of transfer/discharge, and the discharge appeal process. Findings include: Review of the facility's policy titled Transfer and Discharge Notice dated 06/2017 read in part 1. The resident and, if known, a family member or resident representative shall be notified in writing and in a language and manner they understand, of the transfer or discharge and the reason for the move before a transfer or discharge takes place. Review of R118's undated Facesheet located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R118's Notice of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to provide one of one residents (Resident (R) 118) reviewed for hospital transfers out of a total sample of 33 residents a written bed hold when R118 was transferred to the hospital. This failure This failure placed all residents of the facility at risk for the resident and/or responsible parties to not have the information needed to safeguard their return to the facility. Findings include: Review of the facility's policy titled Bed-Hold Notification dated 01/2017 read in part .Inform the resident or resident's representative, in writing, of their right to exercise the bed hold provision and the state bed-hold policy of seven (7) days, which will permit the resident to return and resume .provide written information at the time of admission and transfer to general acute care hospital or for a therapeutic leave. Review of R118's undated Facesheet located in the resident's electronic medical record (EMR) under the Profile tab…

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

Based on interview, record review, and review of the facility's policy, the facility failed to ensure a Registered Nurse (RN) was on duty eight consecutive hours in a 24 hour period, seven days a week. This placed all residents of the facility at risk for unmet clinical needs either directly by the lack of RN coverage or indirectly by the Licensed Practical Nurses (LPNs) or the Certified Nurse Aides (CNAs) for whom the RN was responsible for overseeing resident care. Findings include: Review of a facility's policy titled Departmental Supervision, Nursing, revised 08/2022 revealed .2. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight hours depending on the acuity needs of the resident . Review of the facility's Nursing Schedules, dated 12/24/23 through 08/02/24, provided by the Administrator indicated no documented evidence a RN worked eight consecutive hours in a 24 hour period on 01/01/24, 01/06/24, 01/07/24, 01/01/24, 01/19/24, 01/20/24, 01/28/24, 02/03/24, 02/04/24, 02/10/24,…

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

Based on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity for meals served in the East Wing dining room for 7 of 16 sampled residents (Resident's 17, 31, 46, 53, 65, 99 and 108) when: 1. Certified Nursing Assistant (CNA) 4 stopped assisting Resident 17 and Resident 53 during lunch and Resident 17 and Resident 53 were kept waiting to be fed while CNA 4 assisted other residents (Residents 5 and 63) on different occasions. 2. CNA 5 stopped assisting Resident 65 and Resident 108 during lunch and Resident 65 and Resident 108 were kept waiting to be fed while CNA 5 assisted other residents (Residents 46 and 63) on different occasions. 3. Resident 31's, Resident 86's, Resident 53's and Resident 66's right to be served meals in an area designated for dining was not done. Instead the meals were served in the hallway by CNA 6. 4. CNA 11 was in the standing position and stood over Resident 17 and Resident 53 to assist during breakfast. These failures violated the rights of Residents 17, 31, 46, 53, 65, 99 to be treated 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 the residents right to privacy during care for two of two sampled residents (Resident 23 and 89) when Licensed Vocational Nurses (LVN 3 and LVN 4) provided care to Resident 23 and 89 without closing privacy curtains during medication administration observation. This deficient practice resulted in Resident 23's and 89's right to privacy during the delivery of care. Findings: During a medication administration observation, on 7/16/19, at 7:45 a.m., LVN 4 entered Resident 89's room and took the resident's apical pulse (heart rate) in view of other staff providing care to other residents, and a visiting family member. LVN 4 did not close the privacy curtain to offer Resident 89 privacy. During an interview with LVN 4, on 7/16/19, at 7:50 a.m., she stated she should have closed the privacy curtain around Resident 89's bed to ensure her privacy was protected from others not involved in her care. During a medication administration observation, on 7/16/19, at 8:35 a.m., LVN 3 entered Resident 23's room 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 ensure the Minimum Data Set (MDS- assessment of healthcare and functional needs) assessment accurately reflected the resident's status for three of three sampled residents (Resident 2, Resident 15, and Resident 61) when: 1. Rejection of care was incorrectly coded in Section E (behavior) in four of five of Resident 2's MDS assessments. 2. Pressure ulcer was incorrectly coded in Section M (skin condition) of Resident 15's annual assessment. 3. Pain was incorrectly coded in Section J (health condition) of Resident 61's 5-day assessment. These failures resulted in an inaccurate assessments of Resident 2, 15 and 61's MDS assessment, resulted in care plans for refusal of weights to not be addressed and updated in IDT meetings for Resident 2, and had the potential to result in Resident 15 and 61's care needs going unmet. Findings: 1. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2, on 7/17/19, at 3:29 a.m., he reviewed…

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 care and services in accordance with professional standards of quality for three of five sampled residents (Residents 23, 47, and 89) when: 1. Licensed Vocational Nurse (LVN) 3 and LVN 4 signed the medication administration record (MAR) prior to the administration of medications to Resident 23, 47, and 89. These failures had the potential to place Resident 23, 47, and 89 at risk for medication errors. 2. LVN 3 did not follow the directions of use for Resident 23's medication order for stool softener. This failure had the potential to place Resident 23 at risk for developing bowel complications. Findings: 1. During a medication administration observation with LVN 4, on 7/16/19, at 7:45 a.m., in [NAME] Wing, LVN 4 prepared the scheduled morning medications for Resident 89. LVN 4 was observed clicking the box next to the medication on the Electronic Medication Administration Record (EMAR) (a software designed for medication administration) as she dispensed the medication into the medication cup prior to…

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 sufficient staffing to provide care and services to ensure residents received the needed care to attain and maintain their highest practicable physical, mental and psychosocial well-being for the eight of 16 sampled residents (Resident's 17, 31, 46, 53, 65, 86, 99, and 108) when three Certified Nursing Assistants (CNA) were unable to provide residents with full attention, continuous and uninterrupted feeding assistance during meal service. These failures had the potential to result in Resident's 17, 31, 46, 53, 65, 86, 99, and 108 not meeting their daily nutritional needs and could lead to unplanned weight loss. Findings: During a lunch meal dining observation, on 7/15/19, at 11:42 p.m., in the East wing dining room, 14 residents were seated to eat their meal inside the dining area and two residents out in the hallway. Three CNAs working in the morning shift (7am to 3:30 pm) attempted to provide meal assistance to eight residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of four medication carts were locked and medications were securely stored when: 1. Licensed Vocational Nurse (LVN) 3 left the medication cart unlocked and unattended. 2. LVN 11 left the medication unlocked and left Resident 91's medications on top of the medication cart, unattended and accessible to residents, staff and visitors passing by in the East Wing hallway. These failures placed residents at risk of actual or potential for harm. Findings: 1. During a medication pass observation and interview with LVN 3, on 7/16/19, at 8:35 a.m., LVN 3 left the medication cart unlocked and out of sight in front of room [ROOM NUMBER] while she was inside the restroom of room [ROOM NUMBER] washing her hand with door closed. LN 3 stated she was unable to see the unlocked medication cart behind the closed restroom door. LVN 3 stated the medication cart should have been locked. During interview with LVN 8, on 7/17/19, at 3:41 p.m., LVN 8…

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 13 of 13 sampled residents (Resident 29, 33, 37, 43, 47, 63, 66, 69, 71, 89, 94, 112, and 118) received the menu as planned during a dining observation when: 1. One of one Dietary Aides (DA 1) did not adjust the pureed recipe menu for pasta to account for the number of servings she was pureeing (a paste or thick liquid suspension usually made from cooked food ground finely). 2. The therapeutic diet menu portion sizes for small portion, mechanical (ground) diets was not followed for 13 of 13 sampled residents (Resident 29, 33, 37, 43, 47, 63, 66, 69, 71, 89, 94, 112, and 118) These failures had the potential to result in residents on pureed diets to choke on their food and for residents on small portion diets to be overwhelmed by the amount of food they were served and placed resident at risk of unplanned weight loss. Findings: 1. During a concurrent observation in the kitchen and interview with DA 1, on 7/15/19, at 10:19 a.m., DA 1…

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

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety in the kitchen when: 1. One dented can of puree pumpkin was stored with the undented canned food and was available for use in residents food. 2. One can of tomato base bullion with an expiration date of 2/20/19 (five months prior) was stored on a kitchen shelf and available for use in residents food. 3. Six open bags of bread were stored in the kitchen and available for use in residents food were not labeled with opened dates. 4. One unlabeled and undated, plastic container of a white powdered substance (food and liquid thickener) was stored in the kitchen and available for use in residents' pureed food. These findings had the potential to result in contaminated, expired, and non-palatable foods being served to the residents of the facility which could further result in food borne illnesses, decreased food consumption, and potential weight loss. Findings: 1. During a concurrent observation in the kitchen pantry and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible for two of six sampled residents (Resident 61 and Resident 83) when a copy of Physician Orders for Life-Sustaining Treatment (POLST) form (a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) was not readily available as part of Resident 61 and Resident 83's current medical records. This failure had the potential risk for Resident 61 and Resident 83's decisions regarding their healthcare and treatment options not being honored. Findings: 1. During a concurrent interview with medical records (MR) 1 and record review, on 7/15/19, at 11:23 a.m., MR 1 reviewed Resident 61's clinical record and was unable to find the POLST form. MR 1 stated Resident 61's clinical record should had had a POLST form. MR 1 stated the POLST form should have been completed 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.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program when: 1. Five Certified Nursing assistant (CNA's 4, 5, 6, 10, and 11) and one Licensed Vocational Nurse (LVN) 6 did not perform hand hygiene before, between and after physical contact with 11 of 22 sampled residents (Resident 5, 17, 31, 46, 53, 63, 65, 72, 86, 99, and 108) during lunch meal service in the dining room. 2. License Vocational nurse (LVN) 4 did not disinfect her stethoscope (medical instrument for listening to heart or breathing sounds) after each resident use. These deficient practices had the potential to result in cross contamination and placed residents at risk for infection. Findings: 1. During a Lunch meal dining observation on 7/15/19, at 12:30 p.m., in the East wing, CNA 4 was providing feeding assistance to Resident 17 and Resident 53. CNA 4 stopped feeding Resident 17, and 53 when she saw Resident 5 who was sitting at a corner of the dining room, stand up from her chair and tried to pick up the utensil that fell on the floor. CNA 4 took…

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 space in the East Wing dining room (the smaller of two facility dining rooms) to safely and comfortably accommodate 16 of 16 (Residents 5, 17, 26, 30, 31, 46, 53, 63, 65, 66, 72, 78, 81, 86, 99, and 108) sampled residents who ambulate (walk), use walkers and wheelchairs (mobility devices). During meal times (breakfast, lunch and dinner); tables, chairs and mobility devices blocked the entrances and exits of the dining room and did not provide comfortable spacing between residents. Facility staff did not develop and implement a plan to maintain safe passage in and out of the dining room. These failures placed residents in the Alzheimer's (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities safely) unit who used the East Wing dining room at risk for potential harm and injury due to crowded or blocked entrances and/or exits. Findings: During a lunch meal observation, on 7/15/19, at 11:35 a.m., in the East Wing dining room,…

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 use the least restrictive alternative for the least amount of time and to assess and document ongoing re-evaluation of the need for restraints in accordance with the facility's policy and procedure for one of three sampled residents when Resident 520 was prescribed a tab alarm on admission without using a less restrictive alternative and was not assessed or re-evaluated for 14 days. This deficient practice unnecessarily restrained Resident 520 and kept her from freely moving and reaching for items for fear of setting off the alarm. Findings: During a concurrent observation and interview with Resident 520, on 7/15/19, at 11:31 a.m., in the resident's room, she was sitting up in her wheelchair watching television. Resident 520 had a tab alarm device attached to her wheelchair and the alarm cord clipped to the back of her shirt. Resident 520 stated the facility had alarms attached to her while she was in her wheelchair and when she was 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 ensure a baseline resident centered care plans (a plan that provides direction for individualized care of the resident) were developed and implemented to meet the identified needs of two of four sampled residents (Resident 60 and 520) when: 1. Resident 60 did not have a fall risk care plan with interventions to address Resident 60's safety risks to prevent fall. 2. Resident 520's tab alarm care plan did not include interventions and goals. 2b. Resident 520 did not have a tab alarm restraint care plan. These failures affected Resident 60 and 520's quality of care and needs not being addressed and resulted in Resident 60's fall and contributed to Resident 520's unnecessary restraints. Findings: 1. During an interview with Resident 60, on 7/17/19, at 10:19 a.m., Resident 60 stated she had another fall on 7/8/19 when she got up from her wheelchair and tried to transfer herself to her bed and fell down on the floor. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely revise and implement a person-centered comprehensive care plans for one of three sampled residents (Resident 2) when Resident 2's refusals of physician ordered weights was not reviewed and revised by the interdisciplinary team (IDT - A coordinated group of experts from several different healthcare fields who work together toward an identified resident goal). These failures directly contributed to a severe weight gain of 92 pounds within 11 months and placed Resident 2 at an increased risk for health related complications. Findings: During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2, on 7/17/19, at 3:29 a.m., he reviewed Resident 2's weight log and stated Resident 2 had been refusing her physician ordered weekly weights and had gained a lot of weight in the last year. LVN 2 stated Resident 2's weekly weight log indicated Resident 2 began refusing weekly weights on 1/14/18 and refused all weekly weights from…

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 activities of daily living (ADL) were provided to maintain good grooming for one of 57 sampled residents (Resident 42) when Resident 42's finger nails were long and contained a black substance under the nail beds. This failure resulted in Resident 42's nails not being well groomed and the potential for harboring microorganisms (bacteria, virus, or fungus) or infection. Findings: During a concurrent observation and interview with Resident 42, on 7/15/19, at 10:20 a.m., outside of his room, Resident 42 sat in his wheelchair alone putting a puzzle together. Resident 42 had long fingernails approximately 0.5 cm (centimeter - a unit of measurement) with a black substances underneath the nail beds. Resident 42 stated I want my nails to be cut and I was just waiting for the staff to cut and trim my nails. During a concurrent observation and interview with the Certified Nursing Assistant (CNA) 13, on 7/15/19, at 10:25 a.m., she stated…

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