Broadway Villa Post Acute

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 2 (Resident #64 and Resident #79) of 26 sampled residents. Findings included: A facility policy titled, Accuracy of Minimum Data Set (MDS) Assessments, revised 04/2024, indicated, [Facility name] is committed to completing accurate and timely MDS assessments for all residents in compliance with the Resident Assessment Instrument (RAI) User Manual, Federal Regulations under the Code of Federal Regulations (CFR), Title 42 483.20, and California Department of Public Health (CDPH) guidelines. The policy further indicated, Each assessment must accurately reflect the resident's current clinical status, functional abilities, and care needs. 1. An admission Record indicated the facility admitted Resident #64 on 03/11/2021. According to the admission Record, the resident had a medical history that included a diagnosis of nicotine dependence. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/23/2024, revealed…

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 facility policy review, the facility failed to hold insulin as ordered by the physician when the resident's blood sugar was out of parameters for 1 (Resident #57) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Medication Pass Observation, revised 09/2024, specified, D. Vital signs and blood sugar need to be monitored according to facility policy and/or the physician's order with medication given based on results. An admission Record indicated the facility readmitted Resident #57 on 11/24/2023. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/08/2025, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident received insulin seven of seven days of the assessment period. Resident #57's care plan included a focus area…

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, record review, and facility policy review, the facility failed to ensure medications were stored properly for 1 (Resident #37) of 6 sampled residents reviewed for accidents. Findings included: A facility policy titled, Self-Administration of Medications, revised 11/2023, specified, Storage and location of drug administration will comply with state and federal requirements for medication storage. An admission Record indicated the facility readmitted Resident #37 on 06/28/2023. According to the admission Record, the resident had a medical history that included a diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/27/2024, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Observation on 01/20/2025 at 9:50 AM, 01/21/2025 at 11:40 AM, and 01/22/2025 at 11:25 AM revealed a container of Citrucel (an over-the-counter fiber…

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, record review, and facility policy review, the facility failed to have a physician order for the use of a continuous positive air pressure (CPAP) and failed to properly clean and store CPAP and nebulizer equipment for 1 (Resident #57) of 3 sampled residents reviewed for respiratory care. Findings included: A facility policy titled, BiPap [bilevel positive airway pressure]/CPAP, revised 05/2024, specified, It is the policy of this facility that BiPap/CPAP be administered as ordered by the physician under the following procedures. Per the policy, Procedures: 1. Verify settings per MD [medical doctor] order and 4. BiPap/CPAP checks will be done before use. 5. BiPap/CPAP settings are preprogrammed by Pulmonologist and preset by company providing the equipment for the facility. An admission Record indicated the facility readmitted Resident #57 on 11/24/2023. According to the admission Record, the resident had a medical history that included a diagnosis of obstructive sleep apnea. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD)…

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 one of four sampled residents (Resident 3) was treated with dignity and respect when a Certified Nursing Assistant (CNA) made an inappropriate comment to Resident 3. This failure resulted in Resident 3 feeling uncomfortable and insulted. Findings: A review of Resident 3's admission record indicated she was admitted on [DATE] with the diagnoses of malignant neoplasm (a cancerous tumor [abnormal growth of tissue] that forms when cells grow and divide uncontrollably) of the left female breast. A Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/27/24, indicated Resident 1 had no memory impairment. During an interview, on 1/14/25 at 2:50 p.m., Resident 3 stated that while providing care CNA 1 had made a comment regarding her tumors something like, Why is your boob so big? Resident 3 stated the comment was inappropriate and it was none of CNA 1's business. During a phone interview, on 1/14/25 at 3:17 p.m., CNA 1 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.

Based on interview and record review, the facility failed to ensure allegations of abuse were reported within the required timeframe for three of four sampled residents (Resident 1, Resident 2 and Resident 3) when initial reports of an allegation of abuse were not received by the Department. These failures of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety. Findings: A review of a facility document, dated 12/19/24 and received by the Department on 12/19/24, indicated it was a follow-up summary of a reported allegation of abuse related to an altercation between Resident 1 and Resident 2 which had occurred on 12/15/24. A review of a facility document, dated 1/6/25 and received by the Department on 1/6/25, indicated it was a follow-up summary of a reported allegation of abuse related to an incident involving staff and Resident 3 which had occurred on 12/30/24. During an interview, on 1/14/25 at 4:28 p.m., the Assistant Director of Nursing (ADON) stated it was the facility's policy to report an allegation of abuse 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 safe food handling and sanitary practices, when: 1. Dietary Aide (DA) 2 failed to perform hand hygiene after touching a dirty utility cart, before touching a clean utility cart and clean dishes. 2. The Maintenance Supervisor (MS) failed to ensure one of one facility ice-machines was sanitized in accordance with the ice-machine's manufacturer's guidelines. These failures had the potential to result in cross contamination and foodborne illness in a highly susceptible resident population of 111 residents who were on oral diets. Findings: 1. During an observation on 10/16/23, at 10:21 a.m., in the kitchen at the dirty side of the room in front of the dirty side of the dish machine, Dietary Aide (DA) 1, was using a high- pressure water sprayer to spray food debris off a black utility cart that had just held dirty dishes from residents' breakfast. During an observation on 10/16/23, at 10:22 a.m., in the kitchen, Dietary Aide (DA) 2 was entering the dirty side of the room, located in front of the dish…

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 did not ensure its Social Service Manager (SSM) was qualified for her position, when the SSM was leading the Social Services Department since approximately June, 2023 (approximately four months), but did not hold a Bachelors Degree (four-year college degree covering standard general education requirements and a specialized area of interest) in a human services field ([NAME] including, but not limited to, sociology, special education, rehabilitation counseling, and psychology); the SSM had an Associates Degree (two to three-year college degree; academic qualifications below a bachelor's degree) in business. In addition, the SSM did not have prior Social Service work experience in a Skilled Nursing Facility (like the facility) prior to her employment, which began in April, 2023 (approximately six months earlier). This failure potentially prevented 114 residents, in a census of 114 residents, from attaining or maintaining their highest practicable mental 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.

Based on interview and record review, the facility's Quality Assurance and Performance Improvement Committee (QAPI, a data driven and proactive approach to quality improvement; process used to ensure services are meeting quality standards and assuring care reaches a certain level) failed to identify quality deficiencies and subsequently investigate and act upon the deficiencies once identified, as evidenced by: 1. Facility leadership did not identify that the Social Service's Manager (SSM) was not qualified to run the Social Services Department (Cross reference F850); 2. Clinical staff failed to recognize, evaluate, and address unplanned weight gain, and slow and progressive weight loss (Cross reference F692); and, 3. Facility leadership did not ensure residents were treated with dignity and respect when effective interventions were not implemented to address staff failure to answer call lights (dome light typically located outside a resident's room providing a visual/audio indication of calls for help originating from the bedside and bathroom) or answer call lights timely and did…

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 did not ensure residents were treated with dignity and respect when: 1) Resident call lights (dome light typically located outside a resident's room providing a visual/audio indication of calls for help originating from the bedside and bathroom) were not answered and were not answered timely; and, 2) Staff communicated with each other, in front of residents, using languages residents did not understand. These failures caused the following: Confidential Resident (CR) 2 felt awful, CR 3 felt they would get [NAME] from staff, CR 5 felt lousy, CR 7 felt angry, CR 11 felt mad, CR 9 felt insulted, CR 8 felt disrespected, and CR 4 felt very frustrated and felt like she was not a whole person. These failures caused potential for any resident (in a census of 114) seeking help from staff to feel they were being treated in a manner that did not maintain their sense of dignity, thereby potentially negatively impacting their sense of psychosocial well-being.…

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 MDS was accurately completed for three of 26 sampled residents (Residents 76, 56, and 38). This failure could potentially result in care planning for residents based on inaccurate information. Findings: Resident 76 During an observation on 10/16/23 at 9:37 a.m., Resident 76 was lying in her bed. A tube feeding pump was attached to a pole next to her bed, and an empty bag of tube feeding formula, dated 10/15/23, was hanging from the pole. Review of Resident 76's medical record revealed she was re-admitted from the hospital on 9/6/23. Resident 76's medical diagnoses included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), gastrostomy, and dysphagia (swallowing difficulties), among others. Review of Resident 76's physician's orders revealed an order, dated 9/6/23, for NPO (non per os, Latin for nothing by mouth). During an interview on 10/20/23 at 10:19 a.m., Licensed Staff B verified Resident…

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

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 3 of 4 sampled residents (Resident 44, Resident 21, and Resident 110). These failures had the potential for facility staff to provide inadequate care to vulnerable residents when their individual needs and interests were not addressed appropriately. Findings: During a review of the Progress Notes titled, Change in Condition, dated 10/02/23 at 6:20 a.m., indicated Licensed Staff A found Resident 44 gasping for air with eyes rolling back at 3:30 a.m. on 10/02/23, and was sent to the hospital at 3:47 a.m. During a review of the hospital record titled, After Visit Summary, dated 10/02/23, indicated Resident 44 had a diagnosis of COVID-19 (Corona Virus Disease of 2019 - an infectious respiratory disease) virus infection. During an interview with the IP (Infection Preventionist) on 10/09/23 at 11:33 a.m., the IP stated Resident 44 shared a room with Resident 21 and Resident 110 prior to her…

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 licensed staff failed to meet professional standards of nursing practice when: 1. Nurses did not call to clarify the insulin order for one of two residents sampled for tube feeding (Resident 76); 2. Nurses did not call to clarify the decision-making capacity order for one of 10 residents sampled for accidents (Resident 269). These failures resulted in a lack of communication between disciplines and care givers that could potentially cause negative outcomes for vulnerable residents including: 1. uncontrolled blood sugars, or confusion about when to administer the insulin; 2. making decisions and signing consents for medical care without the mental capacity to understand the risks and benefits or the potential outcome of their decision. Findings: 1. During an observation on 10/16/23 at 9:37 a.m., Resident 76 was lying in her bed. A tube feeding pump was attached to a pole next to her bed, and an empty bag of tube feeding formula, dated 10/15/23, was…

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 an effective comprehensive system for monitoring parameters of nutritional status for three of ten sampled residents (Resident 38, Resident 19 and Resident 76), when: 1. a. Resident 38's Desirable Body Weight Range (DBWR - general term for a person's optimal weight for a particular height) was not consistently established with the involvement of Resident 38 and/or Resident 38's RP (Responsible Party), to reflect Resident 38's and/or the RP's personal goals and preferences and was not coordinated with the IDT (Interdisciplinary Team) to include the physician responsible for Resident 38's care. b. The facility staff did not recognize insidious (proceeding in a gradual, subtle way, but with harmful effects) weight loss as a criteria to monitor, identify, and evaluate in order to recommend nutrition interventions, during which time Resident 38's weight loss continued to significant weight loss. c. The facility failed to ensure quantity…

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 maintain an effective infection control program, when nursing staff did not assess and monitor for signs of COVID-19 (Corona Virus Disease of 2019 - an infectious respiratory disease) for three of four sampled residents (Resident 44, 21 and 110), when Resident 44 tested positive for COVID-19 and Residents 21 and 110 were exposed to a COVID positive resident. This failure had the potential risk for exposing health care workers to undetected COVID-19 positive residents thereby exposing other residents, staff, and visitors of the infectious disease. Findings: During a review of the Face Sheet (A one-page summary of important information about a resident) indicated Resident 44 was admitted on [DATE], with diagnoses including but not limited to Alzheimer's Disease (type of dementia that causes problems with memory, thinking and behavior); and Major Depressive Disorder (a mental disorder characterized by a persistently depressed mood and long-term loss 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 ensure one of one residents (Resident 28), was able to have her provider care, from outside of the facility, incorporated into Resident 28's overall plan of care. This resulted in Resident 28's provider's recommendations being left out of the medical record and plan of care; due to lack of follow up after Resident 28 attended the appointment. Findings: During an interview on 10/16/23 at 9:42 a.m., Resident 28 stated, when she was first admitted to the facility she brought in her own medications. Resident 28 stated those medications were used and, once those medications had been used, an appointment was made with a provider to obtain prescriptions of the medication of choice. Resident 28 stated the appointment had already taken place, and Resident 28 was waiting for the medication prescription to be processed through the facility. Resident 28 stated there had been no communication regarding the medication prescription and was concerned. During the interview, Resident 28 was waving her hands and stated the hand…

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

Based on observation and interview, the facility failed to ensure one (Resident 31) of two sampled residents had belonging's which did not have a resident identification. This failure resulted in a resident's article of clothing not being labeled appropriately and being placed in another resident's closet. Finding: During an interview on 10/17/23 at 2:41 p.m , with Resident 30's family member, Resident 30's family member stated clothes were always getting lost in the laundry. Resident 30's family member stated Resident 30 would be wearing clothes which she had not purchased and did not know where the clothes came from. Resident 30's family member stated another family member dropped off a new shirt for Resident 30 at the front desk in a bag labeled with the resident, but the shirt had not been added to the inventory sheet or labeled with the resident's name and was subsequently lost. Resident 30's family member stated it was very frustrating because the staff had informed her to place new articles in a bag labeled with resident's name, and the inventory sheet would be updated 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.

Based upon observation, interview and record review, the facility failed to put systems in place to safeguard one of one (Resident 30) sampled resident from misappropriation of resident funds. This failure had the potential of Resident 30's funds being used by someone else inappropriately, since Resident 30 was not able to safeguard his personal funds. Findings: A review of Resident 30's, admission Record, dated 4/27/17, indicated Resident 30 had a diagnosis including vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain), emphysema (one of the diseases that comprises chronic obstructive pulmonary disease) and nicotine dependence. A review of Resident 30's admission MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 7/25/23, indicated Resident 30 had a BIMS (Brief Interview of Mental Status) score of 8 (moderately cognitively impaired). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a significant change MDS (Minimum Data Set, an assessment tool) within 14 days of a change in condition for one of four residents, sampled for change of condition (Resident 76), when Resident 76 was hospitalized and came back to the facility with a G-tube (gastrostomy tube, a flexible tube surgically inserted through the abdominal wall to bring nutrition directly into the stomach). This failure could potentially lead to a lack information for staff to update Resident 76's care plan. Findings: During an observation on 10/16/23 at 9:37 a.m., Resident 76 was lying in her bed. A tube feeding pump was attached to a pole next to her bed, and an empty bag of tube feeding formula, dated 10/15/23, was hanging from the pole. Review of Resident 76's medical record revealed she was re-admitted from the hospital on 9/6/23. Resident 76's medical diagnoses included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction),…

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 did not provide trauma-informed care, for behaviors, for 1 of 5 residents sampled, when Resident 92 was experiencing claustrophobia, anxiety, and panic attacks. Resident 92 lived at the facility for approximately one year and informed staff he suffered from claustrophobia (extreme or irrational fear of small, enclosed, or confined places) but the facility did not assess or attempt to treat his mental health needs as evidenced by: 1. Staff did not develop nursing care plans (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) that addressed Resident 92's claustrophobia and accompanying anxiety; 2. Staff did not notify Resident 92's Physician about his reports of claustrophobia and anxiety; 3. All care staff were not aware of Resident 92's claustrophobia and anxiety and did not attempt to minimize his triggers (a stressor; action/situation leading to an adverse emotional reaction); and, 4. Leadership team members (Administration, Nursing) did not ensure…

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 implement an order for a sippy cup for all beverages to ensure one of one sampled resident (Resident 18) could use the assistive device when drinking. Failure to provide appropriate assistive devices to residents who need them could impede their ability to drink independently and may result in decreased fluid intake. Findings: During a concurrent observation and interview on 10/16/23, at 12:32 p.m., with Unlicensed Staff R, in the presence of Registered Dietitian (RD), in the dining room, Resident 18 had a sippy cup with brown liquid, a cup of water, and a cup of milk in front of her on the table. Resident 18 was drinking her beverage from the sippy cup. Resident 18 was pointing to the cup with milk and looking at staff while pointing. Unlicensed Staff R spoke to Resident 18 in Spanish and asked Resident 18 how she preferred to drink her fluids. Unlicensed Staff R stated, Resident 18 stated she preferred to drink from a sippy cup. Unlicensed Staff R stated the brown liquid in the sippy cup was coffee. 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.