Visalia Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that allegations of abuse and injuries of unknown origin were reported to the State Agency for three of 33 sampled residents (Resident 49, 22, and 153).This failure resulted in delay in initiation of an external investigation and ensure residents' safety and resident-to-resident abuse to go uninvestigated and leave vulnerable residents unprotected from further abuse. Findings: 1. During an observation on 3/2/26 at 4:20 PM in the Memory Care Unit, Resident 49 was observed with red and purple bruising on her right upper and lower eyelids and bridge of nose. When resident was asked how she obtained the injury to her face, the resident appeared confused and unable to respond to the question. During an interview on 3/2/26 at 4:25 PM with Licensed Vocational Nurse (LVN) 6. LVN 6 stated that she did not know how Resident 49's injury happened. She stated the injury was first noted on 2/27/26. During an interview on 3/3/26 at 10:50 AM 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 observation, interview, and record review, the facility failed to maintain an effective infection control program for 6 of 33 residents when:1.Certified Nursing Assistant (CNA) 2 obtained vital signs (pulse rate, temperature, respiration rate, and blood pressure) without disinfecting the equipment between use for Resident 100 and 93.2. CNA 1 did not wear a gown while providing toileting assistance to Resident 11 who was on Enhanced Barrier Precautions (EBP-gown and glove use to reduce spread of infection).3. Oxygen concentrator filters for Residents 6, 69 and 83 were observed covered with lint.These failures had the potential to increase the risk of cross-contamination and the spread of infection within the facility.1.During an observation on 3/2/26 at 2:33 PM in Resident 100's room, CNA 2 was observed obtaining Resident 100's vital signs. After completion, CNA 2 did not disinfect the blood pressure cuff or pulse oximeter and proceeded to obtain vital sign for Resident 93 using the same equipment.…

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 an interview, and record review, the facility failed to coordinate discharge planning with the receiving facility and communicate with the resident and resident's responsible party (RP) for one of 33 sampled residents (Resident 122). In addition, the facility failed to ensure the discharge care plan reflected the residents' goals and resident specific interventions. This failure resulted in facility staff, Resident 122, and the resident's responsible party not being aware of the resident's discharge plan. Findings: Resident 122 was admitted on [DATE], with diagnoses which included weakness and unsteadiness on feet. During an interview with Resident 122, on 3/5/26 at 8:37 AM, Resident 122 stated she was doing much better and wanted to move to an assisted living facility (ALF- residential housing for seniors or individuals with disabilities who need help with daily care). Resident 122 stated she has been waiting for a very long time and has no idea what was going on with her move. 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 observation, interview, and record review, the facility failed to administer insulin (medication used to lower blood sugar) within professional standards, when Lispro Insulin (fast acting insulin) was administered to one of 33 sampled residents (Resident 111) one hour prior to a meal. This failure had the potential to cause adverse outcome from hypoglycemia (a condition in which blood glucose concentration is below 70 mg/dl (unit of measurement) or harm to the residentFindings: Review of the admission Record indicated Resident 111 was admitted to the facility on [DATE], with diagnoses which includes Type 2 Diabetes Mellitus with Ketoacidosis (a serious health condition when the body can't make enough insulin). During an interview with Licensed Vocational Nurse (LVN) 1 on 3/4/2026 at 12 PM, LVN 1 was asked if she would be checking Resident 111's blood sugar prior to lunch. LVN 1 stated that she had already checked Resident 111's blood sugar at 11:00AM and administered Lispro Insulin to the 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 observation, interview and record review, the facility failed to ensure effective pain management was implemented for Resident 151 when:1.The as needed pain medication (Tylenol) for Resident 151 was not administered according to the physician's order.2. Resident 151's pain level was not assessed timely post-administration of the as needed pain medication.These failures had the potential to result in Resident 151's suffering and decreased mobility due to unresolved pain.Findings: 1.During a review of Resident 151's admission Record, from 1/15/26 showed that Resident 151 was first admitted to the facility on [DATE] and then re-admitted on [DATE] with diagnoses including right knee pain. During a review of Resident 151's Quarterly MDS/CAA (Minimum Data Set/Care Area Assessment: a comprehensive and mandatory nursing home assessment process utilized to evaluate a resident's functional, medical, and psychosocial status) dated 12/4/24, indicated that the Brief Interview for Mental Status (BIMS: a standardized…

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 safely store, and label drugs and supplies in accordance with acceptable standards of practice when: One of two treatment carts was left unlocked and unattended on station 3.Personal food items were stored in one vaccine refrigerator. This failure had the potential to allow unauthorized access to treatment supplies by residents, staff, or visitors and maintain a controlled and sanitary environment for the storage of vaccines. 1.During an observation on 3/3/26 at 8:35 AM, Station 3's treatment cart was observed across the nurses' station. The treatment cart was unlocked and unattended. During a concurrent observation and interview on 3/3/26 at 8:46 AM, with Licensed Vocational Nurse (LVN) 2, the treatment cart remained located across from the nurses' station against the wall and was still unlocked and unattended. LVN 2 acknowledged the treatment cart had been left unlocked and stated the cart should be locked when unattended to prevent unauthorized access. During a concurrent interview and record review 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 ensure food safety standards were met when: 1.A linear black substance was found inside the ice machine in the kitchen.2. Two open bags of pasta and one open cornstarch were found in the kitchen unlabeled and undated and were not stored in an airtight container.3. One unlabeled and undated partially consumed bottled drink was found inside the resident's nutrition refrigerator at Station 2.4. One unlabeled and undated partially consumed frozen yogurt was not found inside the resident's nutrition freezer at Station 2.5. [NAME] 1 covered his mustache while preparing food in the kitchen.These failures had the potential to result in foodborne illnesses to all residents.Findings: During a review of the facility's policy and procedure (P&P) titled, Preventing Foodborne Illness - Food Handling, dated July 2014, the P&P indicated, Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized . 1. This facility recognizes that the critical factors implicated in foodborne illness…

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 resident call system was operational and accessible when;1. The call light system in Resident room [ROOM NUMBER] bathroom was observed with missing required pull cord, preventing the residents from summoning staff assistance when needed.2. The call light system in Resident room [ROOM NUMBER] bathroom had missing call button preventing the residents from summoning staff assistance when needed.This failure had the potential to prevent residents from summoning staff assistance in a timely manner, placing residents at risk for unmet needs, accidents, or injuries.Findings:1. During an observation on 3/2/26 at 2:45 PM in room [ROOM NUMBER] bathroom, the call light system was observed with missing pull cord.During an interview on 3/3/26 at 2:50 PM with Certified Nursing Assistant (CNA) 3, CNA 3 confirmed the call light pull cord was missing.2. During an observation on 3/2/26 at 3 PM in room [ROOM NUMBER] bathroom, the call light system…

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 physical environment was maintained in safe, clean and well maintained when;1. room [ROOM NUMBER] walls had large scuff marks present on the room walls and bathroom walls.2. room [ROOM NUMBER] bathroom vinyl flooring was lifted at the bathroom entrance.The facility's failure to maintain resident living areas in good repair had the potential to create an unsafe environment and increase the risk of trips, falls, or other injuries for residents, staff and visitors.Findings:1. During an observation on 3/2/26 at 2:20 PM in room [ROOM NUMBER], multiple large scuff marks and visible damage on the walls were observed. The wall surfaces appeared worn and need of repair.2. During observation on 3/2/26 at 2:45 PM in room [ROOM NUMBER], the vinyl flooring in the resident bathroom was lifted and separating from the floor surface near the bathroom entryway. The raised vinyl flooring created an uneven surface.During a concurrent observation…

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 follow up on physician orders for one of three sampled residents (Resident 1) when a left leg arterial duplex (ultrasound used to visualize blood flow in arteries) and venous duplex (ultrasound used to visualize blood flow in the veins) was not done. These failures resulted in a delay of treatment.Findings:During a review of Resident 1's Progress Notes (PN-completed by the vascular physician [physician that specialized in diagnosis, treatment, and management of conditions affecting the arteries, veins, and lymphatic vessels]) dated 11/6/25, the PN indicated, Treatment.Suspect both CVI (chronic venous insufficiency-leg veins struggle to pump blood back to the heart due to damaged or weak valves) and PAD (peripheral arterial disease-narrowed arteries reduce blood flow to your limbs).Will get arterial and venous duplex studies at facility.During a review of Resident 1's PN dated 11/6/25 at 3:38 p.m., the PN indicated, Resident returned from appt. (appointment) at (vascular physician name) .Resident has new orders 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.

Based on observation, interview, and record review, the facility failed to assess, notify the physician and treat a change of condition for one of three sampled residents (Resident 1) when Resident 1's left foot 2nd toe was swollen, had drainage coming from it and dry crusty debris covering the top of the toe and the nail bed. These failures resulted in a delay of care and the potential for Resident 1's foot to worsen. Findings:During a concurrent observation and interview on 8/14/25 at 10:49 a.m. with Resident 1 in Resident 1's room, Resident 1 was lying on bed with her feet exposed. Resident 1's left foot appeared swollen, there were debris between the toes, a circular dried scab/skin on the inside of the foot, and the second toenail bed and top of the toe was covered with a lumpy and bumpy debris (cauliflower in appearance) that was dry, yellow, and crusty in appearance.During a review of Resident 1's Shower/Bed Bath Sheet (SBBS) dated 8/7/25 (7 days prior to the observation), the SBBS indicated, CNA: identify any skin issues.healing scab on left foot (top).Licensed Nurse: Review…

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 reevaluate wounds when the treatment orders were ending for one of three sampled residents (Resident 1). This failure had the potential to result in worsening of Resident 1's wounds and going untreated.Findings:During a review of Resident 1's Progress Notes (PN) dated 6/25/25 at 4 p.m. the PN indicated, Resident is sitting up in w/c (wheelchair) just arrived from (hospital name) appointment.skin assessment done, noted to have dry blood on the left foot sock, removed sock to left foot 2nd toe left toe noted nail is not intact and 2nd toe is bleeding, left 2nd toe nail was smashed, and nail is off from nail bed, notify MD (doctor of medicine).cleanse with NS (normal saline), pat dry apply bacitracin (antibiotic ointment) very (sic) shift, leave open to air. Cleanse skin tr=ear (sic) to left lateral (side of the body part) foot, pat dry, apply bacitracin every shift, monitor for infection and worsening shift x14 days, follow up with wound Dr.During a review of Resident 1's Treatment Administration Record (TAR) dated 7/2025,…

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 follow physician orders when there was no referral to the wound care doctor and treatment was not provided to one of three sampled residents (Resident 1) when it was ordered by the podiatrist. This failure resulted in Resident 1's wound going untreated and had the potential for Resident 1's wound to worsen. Findings:During a review of Resident 1's Podiatry Evaluation (PE) dated 6/2/25, the PE indicated, Wound of foot.The patient presently has a wound of the lower extremities. A dressing was applied today. Nursing was notified of the presence of the wound. Will defer wound management to the wound care MD (Doctor of Medicine). If recommendations for wound care are requested from a podiatry standpoint please reconsult specifically for that reason.wound x1 noted to left dorsal (back part of the body part) forefoot measuring 3x3 cm (centimeters-a unit of measurement).During a concurrent interview and record review, on 9/3/25 at 11:11 a.m. with Treatment Nurse (TN) 1, Resident 1's clinical record was reviewed. TN 1 was unable 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.

Based on observation, interview, and record review, the facility failed to ensure the physician was notified of a change of condition for one of three sampled residents (Resident 1) when Resident 1's wound worsened. This failure had the potential for Resident 1 to experience a delay in care. Findings: During a review of Resident 1's Care Plan (CP) dated 2/19/25, the CP indicated, (Resident 1) is at risk for skin breakdown related.skin tears.Interventions.Check skin during daily care provisions. Notify physician of abnormal findings. During an observation on 5/29/25 at 11:25 AM in the hallway, Resident 1 had steri-strips (small adhesive strips used to close small wounds) to her right arm near the elbow. There was green drainage (often indicating infection) noted to the wound that could be seen on the steri-strips. During a concurrent interview and record review, on 5/29/25 at 1:10 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when she was checking Resident 1's right arm on 5/28/25 (one day prior) she noticed there was a green drainage coming from Resident 1's wound. LVN 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 interview and record review, the facility failed to ensure one of eight sampled residents (Resident 1) physician's orders were followed. This failure resulted in Resident 1 not receiving a dose of intravenous (IV - used to administer medications directly into the vein) antibiotics (used to treat infection) and the potential for Resident 1's urinary tract infection to worsen. Findings: During a review of Resident 1's Physician's Orders (PO), the PO indicated, Ceftriaxone (antibiotic).use 1 gram (unit of measurement) intravenously one time a day for urinary tract infection for 7 days.start date 5/8/25. During a review of Resident 1's Care Plan (CP) dated 5/7/25, the CP indicated, Infection: Resident is at risk for complications related to Urinary Tract Infection and dehydration ceftriaxone.Interventions.Medication per physician's order. During a concurrent interview and record review on 5/15/25 at 3:13 p.m. with Assistant Director of Nursing (ADON), Resident 1's Medication Administration Record (MAR) dated 5/25 was reviewed. The MAR indicated Ceftriaxone was not administered…

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 an interview and record review, the facility failed to permit one of three sampled residents (Resident 1) to return to the facility after hospitalization. This resulted in Resident 1 having unnecessary stay in the hospital and violated Resident 1's rights. Findings: During an interview on 3/19/25 at 3:12 p.m. with acute hospital Social Worker (SW), SW stated on 3/19/25 she notified facility to inquire whether they would be permitting Resident 1 to return to the facility. SW stated she was made aware facility was not permitting Resident 1 to return to the facility. During an interview on 3/19/25 at 4:22 p.m. with Resident 1, Resident 1 stated on 3/13/25 she was not able to hold any food down and had severe abdominal pain and requested to be sent to the acute hospital. Resident 1 stated she feels better and would like to return to the facility. Resident 1 stated, I'm comfortable there [facility]. I want to go back, I've made friends there. During a review of Resident 1's admission Record (AR), dated 3/20/25,…

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 adult protective services (APS) was notified for one of three sampled residents (Resident 1) when Resident 1 was discharged from the facility home alone, when staff had concerns for her safety due to Resident 1's cognitive status. This failure had the potential to result in Resident 1 having unmet care needs and being put at risk for harm. Findings: During a review of Resident 1's Discharge Summary (DS), dated 1/17/25 at 12:05 p.m., the DS indicated, discharge date .1/23/25.Discharge location.home.Activity status.moderate assist (assistance) (50% of the effort being performed by staff) .Bed mobility.moderate assist.Transfer.substantial/maximum assist (75% of the effort being performed by staff).Dressing.moderate assist.Bathing.moderate assist.grooming and hygiene.moderate assist.toilet use.moderate assist.Incontinent-Bladder.yes.Incontinent-Bowel.yes. During a review of Resident 1's Care Plan (CP), dated 12/2/24, the CP indicated, Cognitive impairment: Resident exhibits cognitive loss.Interventions/Task.Anticipate…

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 advance directives (AD- A legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) were offered and completed for 20 of 36 sampled residents (Resident 113, Resident 73, Resident 411, Resident 128, Resident 104, Resident 135, Resident 2, Resident 111, Resident 77, Resident 312, Resident 311, Resident 81, Resident 51, Resident 68, Resident 313, Resident 36, Resident 101, Resident 43, Resident 109, and Resident 84). This failure had the potential for residents' healthcare wishes to not be honored. Findings: During a concurrent interview and record review on 1/29/25 at 11:41 a.m. with Social Services Assistant (SSA), Resident 113 AD was reviewed. The AD indicated, 1. I have executed an Advanced Directive Yes blank No blank 2. I have provided the center a copy of my Advanced Directive Yes blank No blank 3. I will bring in a copy of the Advanced Directive for the medical…

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 sanitary conditions were maintained and equipment was in good repair in accordance with professional standards for food service safety when: 1. The dishmachine and ice machine manufacturer's guidelines were not followed related to lack of a floor drain and lack of proper air gap to prevent the backflow of potentially contaminated water into the clean water supply. 2. Floor sink drains related to a steamer and hand washing sink were not maintained in a sanitary manner and in good repair in which pooled water could attract pests such as insects and rodents. 3. Clean foodservice equipment was stored on shelves with scattered dried food debris. 4. The foodservice operation lacked cleaning with detergent prior to sanitizing of food contact surfaces. These failures had the potential to result in cross contamination and foodborne illness for 159 highly susceptible residents receiving food from the kitchen. Findings: 1. During a concurrent observation and interview on 1/27/25 at 10:43 a.m. with Maintenance…

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 follow infection control policies and procedures (P&P) as evidenced by: 1. Licensed Vocational Nurse (LVN) did not follow the facility P&P) titled Administering Medications to administer medications in a clean and sanitary manner for two of two residents (Resident 66 and Resident 143). This failure had the potential to result in infection and illness for Resident 55 and Resident 143. 2. Infection Preventionist (IPN), did not follow the facility P&P titled Surveillance for Infection and Monitoring Compliance with Infection Control for surveillance (monitoring) activities, collecting, analyzing, track and trending of data. This failure had the potential for facility to be unaware of outbreaks and the transmission of infectious diseases. 3. Nursing Staff did not follow the facility P&P titled Department (Respiratory Therapy) - Prevention of Infection.) for dating, storage and discarding of tubing for one of one sampled residents' (Resident 1) respiratory tubing. 4. Housekeeping (HK) staff did not follow the facility P&P…

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 follow its policy and procedure (P&P) titled, Abuse [inappropriate treatment of an individual], Neglect [refusal to provide the needs of the resident], Exploitation [taking improper advantage of an individual], and Misappropriation [misuse, stealing from a resident] Prevention Program, annual training for the following: 1. 17 of 73 sampled Certified Nursing Assistants (CNA), CNA 1, CNA 2, CNA 33, CNA 4, CNA 5, CNA 6, CNA 7, CNA 8, CNA 9, CNA 10, CNA 11, CNA 12, CNA 13, CNA 14, CNA 15, CNA 16, and CNA 17), 2. Seven of thirty one sampled Licensed Vocational Nurses (LVN), LVN 4, LVN 15, LVN 6, LVN 10, LVN 8, LVN 19, LVN 100, 3. Four of twelve sampled Dietary Aids (DA), DA 1, DA 2, DA 3, DA 4, 4. Two of four sampled cooks, [NAME] 1, [NAME] 2, 5. Two of twenty Feeding Assistants (FA) FA 1, FA 2, 6. One of three sampled Speech Language Pathologist (SLP) SLP, 7. One of two sampled Respiratory Therapist (RT) 1, 8. One of six sampled Restorative Nursing Assistants (RNA) 1, 9. Two of three sampled Occupational Therapist (OT) 1 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 provide the Office of the State Long-Term Care Ombudsman (OSLTCO-independent advocate who helps protect the rights of residents) a Notice of Transfer when: 1. Facility transferred three of three sampled residents (Resident 51, Resident 68, Resident 127) to a local hospital and 2. Facility discharged (transfer without expectation of return to facility) one of one sampled resident (Resident 159) to a local hospital. These failures denied Resident 51, Resident 68, Resident 127, and Resident 159 immediate access to an advocate who could inform of transfer or discharge options and resident rights. Findings: 1a. During an interview on 1/27/25 at 11:48 a.m. with Resident 51, Resident 51 stated she was hospitalized in June 2024 for abdominal (stomach) abscess (a collection of pus or infected fluid surrounded by inflamed tissue) that spread to her hips and legs. During a concurrent interview and record review on 1/30/25 at 10:23 a.m. with Assistant Director of…

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

Based on interview and record review, the facility failed to follow its policy & procedure (P&P) Binding Arbitration Agreement (BAA - a way to resolve disputes between healthcare providers and residents) for four of four sampled residents (Resident 62, Resident 134, Resident 101, and Resident 135) when: 1. admission Director (AD) did not explain the BAA to two of four sampled residents (Resident 62 and Resident 134) in a manner that he or she understood, before signing the agreement. 2. AD did not document a verbal acknowledgement of the BAA from four of four sampled residents (Resident 62, Resident 134, Resident 101, and Resident 135). This failure resulted in Resident 62, Resident 134, Resident 101, and Resident 135 not being fully aware and informed of their rights if there was a dispute with the facility. Findings: 1. During a concurrent interview and record review on 1/28/25 at 4:36 p.m. with Resident 62, Resident 62's, BAA form, dated 10/14/24 was reviewed. The BAA indicated, Resident 62 had signed the BAA form. Resident 62 stated he remembers signing the form but, he did not…

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 a functioning wall light was provided in a resident's room for one of six sampled residents (Resident 139). This failure had the potential to compromise the safety of the resident. Findings: During an observation on 1/27/25 at 11:07 a.m. in Resident 139's room, there was a light on the wall above Resident 139's bed that did not turn on and the string to turn on the light was detached. During an interview on 1/27/25 at 11:09 a.m. with Director of Staff Development (DSD), DSD stated she just found out right now that the string to pull to turn on the light was detached and the light was broken. DSD stated she does not know how long it had been out of service. During an interview on 1/27/25 at 11:13 a.m. with Maintenance Supervisor (MS), MS stated he was not aware Resident 139's light was broken. MS stated the light should be working for Resident 139's use. During a record review of the facility's DEPARTMENTAL MAINTENANCE WORKSHEET (DMW),'' dated 1/25/25, the DMW indicated, LOCATION OF DEFICIENCY BE…

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 provide written information on bed-hold (holding a resident's bed during hospitalization) for two of two sampled residents (Resident 51 and Resident 68). This failure had the potential to create uncertainty for Resident 51 and Resident 68 to return to the facility and return to their previous rooms. Findings: During a concurrent interview and record review on 1/30/25 at 10:53 a.m. with Admissions Director (AD), AD stated in the facility's admission packet there was a form that discussed bed-hold upon admission. AD stated before the resident was sent out, the nurse should inform the resident and/or resident representative about a bed-hold. AD stated if the resident and/or resident representative decided to take the bed-hold, the doctor would order a seven-day bed-hold for the resident to be able to return to the facility. During a concurrent interview and record review on 1/30/25 at 10:59 a.m. with Assistant Director of Nursing (ADON), Resident 51's medical record (MR) was reviewed. The MR indicated Resident 51 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.

Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) Resident Matrix (MDSRM), was accurate and up to date for two of six sampled residents (Resident 135, and Resident 152). This failure had the potential for Resident 135 to have unmet care needs and inaccurate medical records for both Resident 135, and Resident 152. Findings: 1. During a review of Resident 135's, MDSRM, dated 1/27/25, the MDSRM indicated, Resident 135 was on Transmission based precaution (TBP-set of infection control measures). During an interview on 1/27/25 at 11:32 a.m. with Licensed Vocational Nurse, (LVN) 5, LVN 5 stated Resident 135 does not use oxygen or have a breathing type of device. During an interview on 1/28/25 at 5:05 p.m. with Minimum Data Set Coordinator (MDSC), MDSC stated that is a coding error because Resident 135 is not on TBP. During a concurrent interview and record review on 1/29/25 at 9:53 a.m. with Director of Nursing (DON), Resident 135's, MDS Sections J and O, dated 11/18/24 was reviewed. The Section J…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide Baseline Care Plan (BCP - an initial person-centered care plan within the first 48 hours of admission that provide instructions for care of the resident) Summary for three of three newly admitted sampled residents (Resident 311, Resident 312, and Resident 313). This failure had the potential for Resident 311, Resident 312, and Resident 313 to not receive the care and the safeguards necessary within the first 48-hours of admission. Findings: During a concurrent interview and record review on 1/29/25 at 10:28 a.m. with Assistant Director of Nursing (ADON), Resident 311's admission Record (AR) was reviewed. The AR indicated Resident 311 was admitted on [DATE]. During a concurrent interview and record review on 1/29/25 at 10:30 a.m. with ADON, Resident 311's BCP summary, dated 1/13/25, was reviewed. The BCP summary indicated, The resident and/or the resident representative participated in the baseline care plan review with a printed/written summary…

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 the Medical Doctor (MD) reviewed and countersigned a verbal order (VO) for two of two sampled residents (Resident 101 and Resident 127). This failure had the potential for the nurse to not properly follow the VO for Resident 101 and Resident 127. Findings: 1. During a concurrent interview and record review on 1/29/25 at 4:15 p.m. with Licensed Vocational Nurse (LVN) 9, Resident 127's Nurse's Note (NN), dated 12/19/24 was reviewed. Resident 127's NN indicated, upon assessment Resident 127 had crackles (indicates fluid in small airways) in the right lung, diminished (no sound or dull sound) breath sounds heard in the left lung with difficulty breathing. Resident 127 was on oxygen at 3 Liters. MD ordered Resident 127 sent out to the hospital. LVN 9 stated she notified the MD of Resident 127's condition. LVN 9 stated MD gave a verbal phone order to send resident out to hospital. During a concurrent interview and record review on 1/29/25 at 4:20 p.m. with LVN 9, Resident 127's Medical Record (MR) was reviewed. LVN 9…

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 follow their policy and procedure (P&P) titled Activities of Daily Living (ADL) for one of seven sampled residents (Resident 81) when nursing staff did not provide personal grooming and hygiene. This failure had the potential to result in Resident 81's lowered self-esteem and the potential make Resident 81 susceptible to disease and/or infection. Findings: During an observation on 1/28/25 at 9:46 a.m. in Resident 81's room, Resident 81 sat on his bed, still wearing a hospital gown. Resident 81's hair was long and had not been combed. Resident 81's facial hair, moustache and beard were long. Resident 81's fingernails were long and had blackish substance inside the tips of all the fingernails. Resident 81 stated, I needed to be shaved. My fingernails also needed to be trimmed. I am waiting for the Certified Nursing Assistant (CNA) to trim my nails. During an interview on 1/28/25 at 10 a.m. with Registered Nurse (RN) 1 in Resident 81's room, RN 1 stated [Resident 81] had not been showered. RN 1 stated Resident…

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

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 84) in Hospice Care (end of life care) received care and treatment for the edema (swelling) on both the legs when: 1. Weekly Nursing Assessments did not indicate Resident 84 had edema. 2. After Hospice Nurse (HPN) notified Medical Doctor (MD), MD did not provide treatment orders for Resident 84's edema. These failures resulted in Resident 84's not receiving the necessary services, treatment and quality of care needed for the swelling in both her legs. Findings: During a concurrent observation and interview on 1/28/25 at 8:44 a.m. with Hospice Nurse (HPN) and Registered Nurse (RN) 1, in Resident 84's room, Resident 84 was sitting up in bed. Both of Resident 84's legs had pitting (when pressure is applied to the swollen area, an indentation [pit] remains) edema. HPN stated Resident 84 was dependent, and unable to do things for herself. HPN stated Resident 84's legs were edematous. RN 1 stated Resident 84 was not receiving any medications for her edema. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure sufficient communication between the facility's Registered Dietitian (RD) 1 and RD 2 employed by the dialysis center related to provision of lunch meal in a safe manner for one of one sample resident (Resident 139) who received dialysis three times a week. This failure had the potential to result in Resident 139's lunch to contain Time Temperature Control for Safety (TCS - food that requires time-temperature control to prevent the growth of bacteria) foods to include a turkey or tuna sandwich had inadequate monitoring of time/temperature control for food safety which placed Resident 139 at an increased risk for a foodborne illness. Findings: During a review of Resident 139's Resident Information, dated 2/3/25, Resident 139 was admitted to the facility on [DATE] with a diagnosis Dependent on Renal Dialysis. During an interview on 1/27/25 at 12:09 p.m. with Licensed Vocational Nurse (LVN) 10, LVN 10 stated Resident 139 left 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 follow its policy and procedure (P&P) on Resident Rights, for one of six sampled residents (Resident 106) did not receive routine dental services. This failure had the potential for poor eating and broken or lose teeth to go unnoticed. Findings: During an observation on 1/27/25 at 1:11 p.m. in Resident 106's room, Resident 106 did not have teeth. During a concurrent interview and record review on 1/30/25 at 3:35 p.m. with Social Services Assistant (SSA), Resident 106's Order Summary (OS), dated 6/1/24 was reviewed. The OS indicated, consult dental for oral hygiene with follow-up and treatment. SSA stated Resident 106's dental referral was missed. During a review of the facility's P&P titled, Resident Rights, dated 9/2009, the P&P indicated, e. choose[sic] a physician and treatment and participate in decisions and care planning.

Based on observation, interview, and record review, the facility failed to: 1. Provide the therapeutic diet as ordered for one of seven sampled residents (Resident 311) when: a. Resident 311 was served his nectar-thick (thickness of milkshake) drink and house nourishment after sitting out at room temperature for approximately five (5) hours on 1/27/25. b. Resident 311's meal tray did not have 8 fluid ounces (fl. oz) nectar-thick punch drink for lunch on 1/27/25. These failures had the potential for Resident 311 to not meet the nutritional requirements due to decreased palatability (tastiness). Findings: 1a. During an observation on 1/27/25 at 12:30 p.m. in Resident 311's room, Resident 311 was laying in bed. Two sippy cups, full of liquid, were on the nightstand, on the left side of Resident 311's bed. Neither sippy cup was within Resident 311's reach. Resident 311 was non-verbal (did not speak). Resident 311 had no teeth and constantly smacked his lips. Resident 311's left hand was contracted (unable to straighten due to shortening of tendons and muscles). 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.

Based on observation, interview, and record review, the facility failed to: 1. Honor resident's food preferences for two of 13 sampled residents (Resident 28, and Resident 51). This failure resulted in an unpleasant dining experience due to the facility serving both Resident 28 and Resident 51 food listed as disliked and Resident 28 not receiving soup under her standing orders. 2. Ensure one of seven sampled residents (Resident 51) was aware of the menu in time to request an alternative menu item. This failure had the potential for Resident 51's nutritional needs to not be met. 3. Provide alternative milk product for one of one sampled residents (Resident 311) who had lactose (milk sugar) intolerance (unable to digest). This failure had the potential for Resident 311 to not meet his nutritional requirements. Findings: 1a.During a concurrent observation and interview on 1/27/25 at 12:42 p.m. with Resident 28 in the dining room, there were uneaten chili beans on Resident 28's meal tray. Resident 28 stated she disliked beans. Resident 28 stated, she had a standing order for chicken…

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 the minimum square footage as required by the regulation for 11 of 50 of the facility rooms. Findings: During an observation on 1/29/25 at 12:04 p.m. in room [ROOM NUMBER], there were three residents in the room. Bed A had a wheelchair parked at the right side of the bed and Bed C had a wheelchair parked in form of the closet. During an observation on 1/29/25 at 3:14 p.m. in room [ROOM NUMBER], there were three residents in the room. Bed B had a walker and side table at the right side of the bed and Bed C had a side table to the right side of the bed. During a concurrent interview and record review on 1/30/25 at 8:42 a.m. with Administrator and Maintenance Supervisor (MS), the facility's Rooms Not Meeting Required Square Footage (RNMRSF), undated was reviewed. The RNMRSF indicated the following rooms did not provide the minimum square footage (Sq ft.) as require by regulation (80 Sq ft. per resident) for multiple resident rooms:…

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 five sampled residents (Resident 1) call light was within Resident 1's easy reach. This failure had the potential for Resident 1 to not received assistance when needed. Findings: During a concurrent observation and interview on 10/2/24, at 12:10 p.m. in Resident 1's room, Resident 1's call light (a communication device used to alert staff for assistance) was noted on the floor not within Resident 1's reach. Resident 1 stated he uses the call light to call for staff assistance. Resident 1 started looking for his call light, using his hands to feel under his back, bottom area, above head, and on the bed side rails. Resident 1 was unable to locate his call light. Resident 1 stated, Oh well, it's not here. During a concurrent observation and interview on 10/2/24, at 12:17 p.m. with Certified Nursing Assistant (CNA 1), in Resident 1's room, CNA 1 confirmed Resident 1's call light was on the floor not within Resident 1's reach. CNA 1 stated Resident 1's call light should always be within reach. 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.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) when an outbreak of scabies (a contagious, intensely itchy skin condition caused by a tiny, burrowing mite) was not reported to the state health department for three of fourteen sampled residents (Resident 1, Resident 2, and Resident 3). This failure resulted in the state health department being unaware of the outbreak. Findings: During a review of Resident 1 ' s Integumentary Assessment Sheet (IAS), dated 8/8/24, the IAS indicated, Pt (patient) seen exam bedside with generalized pruritic (having or causing itching) maculopapular (flat, discolored area of skin and raised bumps) rash with some tracking without burrowing and ddx (differential diagnosis) scabies. During a review of Resident 2 ' s IAS, dated 8/8/24, the IAS indicated, Pt seen exam bedside with generalized pruritic rash tracking to trunk and upper extremities and ddx of scabies. During a review of Resident 3 ' s IAS, dated 8/8/24, the IAS indicated, Pt seen exam bedside with generalized pruritic maculopapular rash…

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 a psychiatrist (medical practitioner specializing in the diagnosis and treatment of mental illness) referral was made for one of two sampled residents (Resident 1). This failure resulted in a delay of the psychiatrist evaluation for Resident 1. Findings: During a review of Resident 1's Psychologist Consultation/Follow-Up (PCF), dated 4/9/24, the PCF indicated, Resident alert with confusion, has tendency to wander take others property believing it is hers, behaviors increase at night. Consider re-starting Seroquel (medication used to treat several kinds of mental health conditions) . During a review of Resident 1's IDT (interdisciplinary team-knowledge from different health care disciplines to help people receive the care they need) Psychotherapeutic Review (IPR), dated 4/12/24, the IPR indicated, IDT does not agree with considering to re start medication used prior to admission. IDT recommends that (Resident 1) be referred to a psychiatrist for further evaluation. IDT reviewed recommendations with (Primary MD) who…

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

Based on observation, interview, and record review, the facility failed to provide a homelike environment for one of three sampled residents (Resident 1) when the bed linen was not in good repair. This failure resulted in Resident 1's bed sheet having a hole and two areas where the sheet was discolored due to the thinning of the sheet. Findings: During a concurrent observation and interview on 5/16/24 at 12:15 p.m. with Certified Nursing Assistant (CNA) 1, in Resident 1's room, Resident 1 had a hole at the bottom of her bed sheet and an area of discoloration caused by thin and tattered threads on the side of the bed sheet. CNA 1 stated the sheet was thinning and identified the hole at the bottom of the sheet. During a concurrent observation and interview on 5/16/24 at 1 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, Resident 1 had two areas on her bottom bed sheet that were thinning and discolored. LVN 1 stated the sheets were thin, and it was causing the discolored areas. During an interview on 5/29/24 at 12:29 p.m. with Director of Nursing (DON), DON 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 report an allegation of abuse for one of three sampled residents (Resident 1) when a Family Member (FM) 1 made Licensed Vocational Nurse (LVN) 1 aware of the allegation of abuse. This failure had the potential for delayed investigation and place other residents at risk for abuse. Findings: During an interview on 5/16/24 at 8:40 a.m. with FM 1, FM 1 stated over the weekend (approximately 4-5 days earlier), she reported to Licensed Vocational Nurse (LVN) 1 every time a male staff (unidentified) walked by Resident 1 would say he hits me. During an interview on 5/16/24 at 11:56 a.m. with LVN 1, LVN 1 stated When there is an allegation of abuse the allegation was to be reported (to the management) right away. During an interview on 5/16/24 at 1 p.m. with LVN 1, LVN 1 stated approximately two weeks ago, Resident 1's FM had reported to her Resident 1 seemed upset when a male staff would work with her. Resident 1 would say the male staff would hit her. LVN 1 stated she did not report the allegation. During an interview on 5/16/24…

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 provide podiatry services for two of three sampled residents (Resident 1 and Resident 2). This failure resulted in Resident 1 and Resident 2 having long, jagged, discolored toenails. Findings: a. During an observation on 5/16/24 at 12:03 p.m. in the hallway, Resident 2 was walking in the hallway with opened toe sandals. Resident 2's toenails were long and discolored. During a review of Resident 2's Order Summary Report (OSR) dated 5/20/24, the OSR indicated, Consult – Podiatry as needed for Mycotic (disease caused by a fungus)/Hypertrophic (alteration of shape, partial loss, or absence of the nail) nails and/or keratotic (patches or lesions on the outer layer of the skin) lesions.order date 2/13/23. During a concurrent interview and record review on 5/16/24 at 2:21 p.m. with Director of Nursing (DON), DON reviewed Resident 2's clinical record and was unable to provide evidence Resident 2 had received podiatry care. DON stated the facility staff does not provide toenail care and relies on the podiatrist. b.…

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 notify the physician in a timely manner when one of three sampled resident's (Resident 1) continued to experience a change in condition. This failure resulted in a delay of care. Findings: During a review of Resident 1's ED [Emergency Department] Note Physician (EDNP), dated 2/2/24 at 4:02 p.m. the EDNP indicated, Chief Complaint.Abdominal pain.Final Diagnosis.Abdominal Pain.Nausea.Hx (history) of gastric bypass (weight loss surgery).small bowel obstruction (digested material is prevented from passing normally through the bowel). During a review of Resident 1's Progress Notes (PN), dated 1/31/24 at 3 p.m. the PN indicated, Resident had 2 episodes of emesis (vomiting) and meal refusal for breakfast and lunch. Resident complained of abd (abdominal) pain to left upper quadrant and mid abdomen. Placed call to [Physician 1] and gave new orders: Stat (immediately) CBC (complete blood count-measures many different parts and features of the blood) & CMP (comprehensive metabolic panel-provides important information about balance 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 interview and record review, the facility failed to ensure wound treatments were provided for one of three sampled residents (Resident 1). This failure had the potential for Resident 1's wounds to worsen. Findings: During a review of Resident 1's Treatment Administration Record (TAR), dated January 2024, the TAR indicated, Monitor right heel diabetic ulcer (serious complication caused by a combination of poor circulation, susceptibility to infection and nerve damage from high blood sugar levels) daily for 1. Pain/discomfort, 2. s/s (signs and symptoms) of infection. Every day shift.start date 1/12/24.Monitor right lower back stage 3 (full thickness tissue loss wound caused by pressure) daily for 1. Pain/discomfort, 2. s/s of infection. Every day shift.start date 1/12/24.Monitor sacrococcygeal (base of the spine near the tailbone) DTI (deep tissue injury) daily for 1. Pain/discomfort, 2. s/s of infection. Every day shift.start date 1/12/24.Right heel diabetic ulcer treatment: wipe with betadine swab. Every day.start date 1/11/24.Right lower back stage 3 treatment: Cleanse…

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 bowel movement (BM) documentations were completed for one of three sampled residents (Resident 1). This failure resulted in incomplete documentation. Findings: During a concurrent interview and record review with Director of Nursing (DON), on 5/30/24 at 12 p.m. Resident 1's BM Report (BMR), undated, was reviewed. The BMR indicated, Resident 1 had no BM documentation on 1/15 and was incontinent of BM on 1/10, 1/11, 1/13, and 1/16. There was no consistency or size of BM documented on 1/10, 1/11, 1/13 and 1/16. DON stated the BM documentations were incomplete. DON stated the size and consistency of the BM should have been documented. During an interview on 5/7/24 at 12:30 p.m. with Director of Staff Development (DSD), DSD stated she was responsible for training the staff on how to document BM's. DSD stated the staff should have documented whether the resident was continent or incontinent, the consistency of the BM and the size. During a review of the facility's policy and procedure (P&P) titled, Bowel Management…

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 three sampled residents (Resident 1) was provided supervision when staff failed to respond to a security door alarm going off in the dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking) unit. This resulted in Resident 1 exiting the open security gate that provided access off of the facility grounds and being found approximately a quarter of a mile away from the facility. Findings: During a review of Resident 1's Plan of Care (POC), dated 8/22/22, the POC indicated, Elopement Care Plan. [Resident 1] is at risk for elopement/exiting seeking due to: altered cognitive status (dementia).date initiated: 8/22/22.interventions.monitor resident's whereabouts frequently.provide redirection to resident as needed. During a review of Resident 1's admission Record (AR), dated 2/14/24, the AR indicated, admission Date 3/13/2018.Diagnosis Information.Unspecified dementia,…

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 three sampled residents (Resident 1) was provided a safe environment when there was exposed staples from a missing drawer face on Resident 1 ' s night stand. This failure had the potential for Resident 1 to be injured by the exposed staples. Findings: During a concurrent observation and interview, on 1/12/24 at 11:22 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 1 ' s room, there was a nightstand at the head of Resident 1 ' s bed. The face of the top drawer was missing and there was exposed staple legs on the right side, where the face was supposed to be attached. CNA 1 stated, she noticed the face of the drawer was missing a few weeks ago, when she returned from her days off. CNA 1 stated, when items need to be repaired, they are supposed to write them in the maintenance log at the nurses station. CNA 1 stated, when she returned everyone was aware, so she did not put it in the maintenance log. During a concurrent interview and record review, on 1/12/24 at 11:41 a.m., with Licensed…

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 responsible party (RP) was notified when medication was discontinued for one of three residents (Resident 1). This failure resulted in the RP being unaware of a change in Resident 1 ' s medical care. Findings: During a review of Resident 1 ' s Medication Administration Record (MAR), dated 11/23, the MAR indicated, Quetiapine Fumarate (used to treat mental health condition) Tablet 50mg (milligrams-unit of measure) take 1 tablet by mouth at bedtime. The MAR indicated the medication was last administered 11/15/23. During a review of Resident 1 ' s Progress Notes (PN), dated 11/14/23 at 11:27 a.m., the PN indicated, IDT (Interdisciplinary Team-a group of health care professionals with various areas of expertise who work together toward the goals of their clients) Note.Resident was admitted to the facility on [DATE] at which time he was receiving Quetiapine.Since his admission, resident has displayed no episodes of delusional thinking, therefore,…

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 9 of 66 sampled residents' (Resident 147, Resident 126, Resident 11, Resident 136, Resident 79, Resident 78, Resident 144, Resident 35, and Resident 61) information regarding Advanced Directives (AD - a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury) was provided. This failure had the potential to result in Resident's being unable to make decisions about their medical care. Findings: During a concurrent interview and record review on 12/6/23 at 3:15 p.m. with Social Service Director (SSD), Resident 147's Facility Supplemental Documentation (Advanced Directive - [FSD-AD]), form dated 11/15/23 was reviewed. The FSD-AD form was blank with only the residents signature. SSD stated the form is blank and it should have been completed with the residents wishes. During a concurrent interview and record review on 12/6/23 at 3:33 p.m. with SSD, Resident 126's Consent to Treat(CTT), form dated 10/17/23…

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 six of six sampled Licensed Vocational Nurses (LVN 1, LVN 2, LVN 3, LVN 4, LVN 5 and LVN 6) had annual competency (measurable pattern of knowledge, skills and abilities an individual needs to perform occupational functions successfully) evaluations. This failure had the potential to result in nursing staff to not have specific skills and training needed to care for resident needs. Findings: During an interview on 12/6/23 at 8:54 a.m. with LVN 2, LVN 2 stated she is not sure how often competencies are checked. LVN 2 stated competency check are done randomly. During an interview on 12/6/23 at 9:17 a.m. with LVN 3, LVN 3 stated she does not remember when her last competency evaluation was performed. During an interview on 12/6/23 at 9:27 a.m. with LVN 4, LVN 4 stated she does not remember when her last competency evaluation was performed. During a concurrent interview and record review on 12/7/23 at 10:51 a.m. with Director of Staff Development (DSD), LVN 1's employee file (EF) was reviewed. DSD stated there were no…

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 develop for 3 of 66 sampled residents' (Resident 136, Resident 73, and Resident 24) an individualized care plans when: 1. Resident 136 did not have an activities Care Plan (CP). 2. Resident 73 did not have a refusal CP. 3. Resident 24 did not have a CP indicating the use of bedrails. These failures had the potential for Resident's to not receive care specific to their preference or choice. Findings: 1. During a review of Resident 136's Progress Notes (PN), dated 11/17/23 at 5:00 p.m. the PN indicated, [Family Member (FM)] provided with room number and informed [Resident 136] currently has no roommates. [FM] expressed concern regarding resident [Resident 136] being in room without doing any activities to keep him busy. During concurrent interview and record review on 12/7/23 at 9:46 a.m. with Director of Activities (DOA), Resident 136's Care Plans (CP), were reviewed. DOA stated there was no activities CP for Resident 136. During a review of Resident 136's Activities Assessment (AA), dated 6/12/23, the AA indicated it 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: 1. Follow physician's orders (PO) for one of 66 sampled resident's (Resident 129) when Resident 129's blood sugars (BS) were not monitored and documented. This failure had the potential to result in unmet care needs and adversely affect resident's health. 2. Obtain a physician's order for one of 66 sampled resident's (Resident 120) when Resident 120 was administering oxygen (O2 A chemical element needed to breath) to himself. This failure had the potential for Resident 120 to receive the incorrect dose of oxygenation, which can adversely affect her health condition. 3. Obtain a physician's order for bedside rails for one of 66 sampled resident's (Resident 24). This failure had the potential to result in injuries and unmet care needs. Findings: 1. During a review of Resident 129's admission Record (AR), dated 12/7/23, the AR indicated, Resident 129 was admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus (DM high…

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 66 sampled residents (Resident 73) was assisted with oral care. This failure resulted in Resident 73 having dental issues and tooth decay. Findings: During an interview on 12/5/23 at 1:00 p.m. with Responsible Party (RP) 1, RP1 stated, Prior to admission he [Resident 73] had a full set of his own teeth, and now the front teeth are chipping. During an observation on 12/5/23 at 3:16 p.m. in Resident 73's room, Resident 73's teeth had plaque (A sticky film that coats teeth and contains bacteria. Dental plaque can damage a tooth and lead to tooth decay or tooth loss. Regular brushing can help prevent plaque) build up, a yellowish discoloration, and chipped upper front teeth. During a concurrent observation and interview on 12/5/23 at 3:19 p.m. with Certified Nursing (CNA) 2, in Resident 73's room, Resident 73's teeth had plaque buildup, a yellow discoloration and chipped upper front teeth. CNA 2 stated, No his [Resident 73] teeth do not look clean, I have attempted [to brush], but he refuses. 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.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and in the facility for at least eight consecutive hours a day, seven day per week. This failure had the potential to adversely affect resident care. Findings: During an interview on 12/6/23 at 8:45 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she is not sure if there is an RN who works on the floor eight hours per day. During an interview on 12/6/23 at 9:03 a.m. with LVN 2, LVN 2 stated, We only have [DON-Director of Nursing], we don't have any other RN who works in this facility. During an interview on 12/6/23 at 9:17 a.m. with LVN 3, LVN 3 stated, [DON] is the only RN that I am aware of that works in this facility. During an interview on 12/6/23 at 9:27 a.m. with LVN 4, LVN 4 stated Monday through Friday they have the DON. LVN 4 stated there is a part time RN who works occasionally, but there is no RN coverage on weekends. During an interview on 12/6/23 at 9:35 a.m. with LVN 7, LVN 7 stated there are no RN's working in the facility except for the DON. During an…

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 66 sampled residents' (Resident 136) was placed on contact precautions after receiving a contagious infection diagnosis. This failure had the potential to result in the spread of infection to residents, staff and visitors. Findings: During an observation on 12/5/23 at 8:43 a.m. in Resident 136's room, Resident 136 was laying in bed on his right side, with blankets pulled up to his chin and both feet sticking out. Resident 136's feet were covered with multiple raised red bumps. During a review of Resident 136's Minimum Data Set (MDS-assessment tool), Section C Cognitive Patterns, dated 9/8/23, the MDS indicated Resident 136 had a Brief Interview of Mental Status (BIMS) score of 0, indicating Resident 136 was severely cognitively (mentally) impaired (score of 0-7 suggests severe cognitive impairment). During a review of Resident 136's Care Plan (CP), dated 11/9/23, the CP indicated Resident 136 had been diagnosed with Scabies (skin infection with severe itching caused by burrowing mites).…

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, this facility failed to provide the minimum square footage as required by the regulation in 50 of the facility bedrooms. Findings: During a concurrent observation and interview on 12/5/23 at 9 a.m. with Administrator and Maintenance Supervisor (MS) in the facility, the following rooms did not provide the minimum square footage (sq. ft) as required by regulation (80 sq. ft. per resident) for multiple resident rooms: 1,2,3,5,6,7,8,9,10,11,18,19,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63. Administrator stated the residents have not complained about in the room size. Although the facility did not provide the minimum square footage as required by regulation, variations in the rooms. the rooms were in accordance with the particular needs of the residents. Closet and storage space was adequate. Bed stands were available. There was sufficient room for nursing care and for the residents to ambulate. The health and safety of the residents would not be affected by the waiver.

Based on observation, interview, and record review, the facility failed to ensure one of 66 sampled residents (Resident 42) call light system was properly working. This failure had the potential for Resident 42's care needs to be unmet. Findings: During a concurrent observation and interview on 12/5/23 at 8:17 a.m. with Resident 42, in Resident 42's room, Resident 42 stated the call light had not been working for three days. Resident 42 pressed her call light and the light outside of Resident 42's room did not come on. During a concurrent observation and interview on 12/5/23 at 8:19 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 42's room, CNA 1 pushed Resident 42's call light button and the light outside of Resident 42's room did not come on. CNA 1 unplugged and plugged the call light cord back into the wall connection. CNA 1 stated the call lights plug was not pushed in. CNA 1 stated Resident 42 and her roommate both have their own call light cord, but they share the wall outlet that the cords plug into. CNA 1 stated sometimes when they give patient care to Resident…

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

Based on observation, interview, and record review, the facility failed to monitor, assess, document, and notify a change in condition for one of three sampled residents (Resident 1) when Resident 1 was left outside of the facility for a prolonged period of time. This failure resulted in Resident 1 feeling hot and had the potential for Resident 1 to experience heat stroke (body overheating). Findings: During an observation on 9/8/23 at 11:20 a.m. in Resident 1's room, Resident 1 was sitting in his wheelchair. Resident 1 was unable to be interviewed. During an interview on 9/8/23 at 11:20 a.m. with Family Member (FM) 1, FM 1 stated Resident 1 made his family aware staff left him outside and got too hot. FM 1 stated, My dad [Resident 1] told me the staff were checking him over and asking him how he was feeling [after being left outside for unknown period of time]. During a review of Resident 1's Minimum Data Set (MDS - assessment tool), dated July 17, 2023, the MDS indicated Resident 1 had a Brief Interview for Mental Status Score of 10 (score of 8-12 means moderately cognitively…

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 three sampled residents (Resident 1) wheelchair was free of debris. This resulted in Resident 1 using a dirty wheelchair and the potential for spread of bacteria. Findings: During an observation on 8/21/23 at 11:09 a.m., in the outside patio, Resident 1 was observed sitting in [Resident 1's] wheelchair. The wheelchair had brown debris on the wheelchair seat, frame, and the wheels. During an interview on 8/21/23 at 11:17 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated the residents wheelchairs should be cleaned weekly. During a concurrent observation and interview on 8/21/23 at 11:28 a.m. with Licensed Vocational Nurse (LVN 1), in the outside patio, Resident 1's wheelchair was observed. LVN 1 stated, Resident 1's wheelchair was gross [it] looks like cornflakes stuck to it where the footrest go. During a concurrent observation and interview on 8/21/23 at 11:48 a.m. with Housekeeping Director (HD), in the outside patio, Resident 1's wheelchair was observed. HD stated Resident 1's…

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

Based on observation, interview, and record review, the facility failed to ensure a care plan was developed for one of three residents (Resident 1) refusal of care. This failure had the potential for staff to not know how to provide care to Resident 1 when refusing. Findings: During a review of Resident 1's Dental Notes (DN) dated, 8/11/23, the DN indicated, Tx [treatment] notes.Refused. During a review of Resident 1's Shower Day Skin Inspection (SDSI) sheets, dated 7/7/23, 7/11/23, 7/18/23, 8/15/23 and one undated indicated, Resident 1 had refused to shower. During an observation on 8/21/23 at 10:46 a.m. with Resident 1, in the outside patio, Resident 1 was observed sitting in [Resident 1's] wheelchair at a picnic table. Resident 1's fingernails were long and had brown debris under them. During an observation on 8/21/23 at 11:28 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 asked Resident 1 if she could clip [Resident 1]'s fingernails. Resident 1 refused to allow LVN 1 to clip [Resident 1]'s fingernails. During an interview on 8/21/23 at 11:35 a.m. with Certified Nursing…

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 Podiatrist (doctor that treats the feet) recommendation for a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was followed upon for one of three sampled residents (Resident 1). This failure resulted in a delay in care for Resident 1 and the potential for Resident 1 to experience worsening of the pressure ulcer. Findings: During a review of the Podiatry Evaluation (PE), dated 8/19/23, the PE indicated, Treatment.Pressure ulcer, ankle, left, unstageable (pressure ulcer when a stage is not clear).Notes: The wound appears stable and should heal with local care. Plan of care should be daily betadine application and offloading with pillows. During a concurrent interview and record review on 9/8/23 at 10:31 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 reviewed Resident 1's clinical record and was unable to find any treatment or monitoring to Resident 1's pressure ulcer. During an observation on 9/8/23 at 11:10 a.m. with LVN 2, in Resident 1's 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.