Beacon Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a Minimum Data Set (MDS, a standardized assessment and care-screening tool) was accurately completed for one of one sampled resident (Residents 99). Resident 99's MDS did not accurately reflect the resident's hearing abilities and limitations. This deficient practice had the potential for Resident 99 not to receive necessary treatment and/or services. Cross Referenced with F676 Findings: During a review of Resident 99's admission Record (AR), the AR indicated Resident 99's was admitted to the facility on [DATE] with diagnoses that included intestinal obstruction (blockage in the intestine), hydronephrosis (swelling of the kidneys), atelectasis (complete or partial collapse of the lungs) and lack of coordination. During a review of Resident 99's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/4/2024, the MDS indicated Resident 99 was cognitively intact (able to make decisions) and had adequate (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 99) received necessary treatment to prevent a decline, maintain or improve Resident 99's hearing abilities and quality of life. This deficient practice had the potential to result in Resident 99's decline in hearing, social interaction, and overall quality of life. Findings: During a review of Resident 99's admission Record (AR), the AR indicated Resident 99's was admitted to the facility on [DATE] with diagnoses that included intestinal obstruction (blockage in the intestine), hydronephrosis (swelling of the kidneys), atelectasis (complete or partial collapse of the lungs) and lack of coordination. During a review of Resident 99's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/4/2024, the MDS indicated Resident 99 was cognitively intact (able to make decisions) and had adequate (no difficulty in normal conversation, social interaction) with hearing. The MDS…

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

Based on observation, interview, and record review, the facility failed to properly apply a pressure relief boot (PRB) for one of three sampled residents (Resident 2) who had a pressure ulcer (localized injury to the skin and or underlying tissue usually over a bony prominence because of pressure or pressure in combination with shear and/or friction) on Resident 2's right heel. This failure had the potential to worsen Resident 2's pressure ulcer. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 10/1/2024 with diagnoses including pressure-induced deep tissue damage (a pressure injury, occurs when the tissue between the heel bone and the skin is compressed and deformed by pressure, shear, or strain) of right heel, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and cognitive communication deficit (reduced awareness and ability to initiate and effectively communicate needs). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 100) who received oxygen therapy, was provided safety in accordance with the facility's Policy and Procedure (P&P) on oxygen administration and professional standards of practice by ensuring a cautionary sign was posted on the resident's door indicating oxygen was in use. This deficient practice placed Resident 100's safety at risk regarding oxygen use. Findings: During a review of Resident 100's admission Record (AR), the AR indicated Resident 100 was admitted to the facility on [DATE] with diagnoses that included compression fracture of the vertebra (a break in a bone in the spine), hypertension (elevated blood pressure) and hyperlipidemia (abnormally high concentration of fats in the blood). During a review of Resident 100's Physician Orders (PO) dated 11/12/2024, the PO indicated for Resident 100 to receive oxygen at two (2) liters per minute (L/min) via nasal cannula (NC- tube which on one…

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 properly assess resident's pain for one of one sampled resident (Resident 23) during a medication pass observation. This deficient practice had the potential to negatively affect Resident 23's physical comfort and psychosocial well-being. Findings: During a review of the admission Record, the admission Record indicated Resident 23 was admitted to the facility on [DATE] with diagnosis including Dementia (a progressive state of decline in mental abilities) and anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress). During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/28/2024, indicated Resident 23's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 1 required moderate to maximal assistance from staffs for toileting/personal hygiene, upper and lower body dressing. 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.

Based on interview and record review, the facility failed to post actual worked nursing hours at the start of each shift for one of three dates (11/14/2024) according to the facility's policy and procedure (P&P) titled, Consumer Information, revised 1/18/2023. This failure had the potential to result inaccurately reflecting the actual nurses providing direct care to the residents. Findings: During a concurrent interview and record review on 11/17/2024 at 9:19 a.m. with the Director of Staff Development (DSD), the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 11/14/2024 and Projection of Nursing Hours, dated 11/14/2024 were reviewed. The DHPPD indicated the actual total Certified Nursing Assistant (CNA) direct care service hours for 11/14/2024 was 92.34 hours. The Projection of Nursing Hours indicated there was supposed to be 97.5 hours of CNA direct care service hours scheduled for 11/14/2024. The DSD stated a Daily Direct Care Staffing was posted at Nurses Station 1. The Projection of Nursing Hours indicated there were supposed to be 4 CNA's working…

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 five sampled residents (Resident 149) was reviewed for the McGeer's criteria (criteria used for retrospectively counting true infections. To meet the criteria for definitive infection, more diagnostic information [e.g., positive laboratory tests] is often necessary) when Resident 149 was receiving antibiotics (medications that fight bacterial infections). This deficient practice had the potential for Resident 149 from receiving unnecessary antibiotic. Findings: During a review of Resident 149's admission Record, the admission Record indicated Resident 149 was admitted to the facility 11/14/2024 with diagnoses including spastic quadriplegic cerebral palsy (a severe form of cerebral palsy where all four limbs [arms and legs] are affected by increased muscle stiffness, resulting in significant limitations in movement and often causing difficulties with walking, speaking, and other daily activities) and contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) of the right and…

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

Based on observation, interview, and record review the facility failed to prepare food by method that conserved flavor, texture, and appearance by servicing at a safe temperature. During a tray-line observation, soup temperature from the requested test tray measured at 120 degrees Fahrenheit (F, a scale of temperature) for one of one facility kitchen. This deficient practice had the potential to result in meal dissatisfaction, decreased intake, and placed the residents at risk for unplanned weight loss. Findings: During an initial facility tour on 11/15/2024 at 8:38 p.m., complaints about the texture and flavor and temperature of the food were identified. During a review of the facility's menu, black bean soup was to be served on 11/16/2024 with the evening's dinner. During an observation and interview in the facility's kitchen [NAME] 1 (C1) on 11/16/2024 at 4:42 p.m., black bean soup was observed in the tray line. C1 stated black bean soup will be served with dinner. During the test tray tasting and observation on 11/16/2024 at 5:45 p.m. with the Dietary Supervisor (DS), the black…

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 three sampled residents (Resident 2), who signed an Arbitration Agreement (Binding Arbitration Agreement), had the capacity to understand and make an informed decision. This failure had the potential to result in Resident 2 to not be able to make an informed decision and/or Resident 2's rights to be denied. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 10/1/2024 with diagnoses including pressure-induced deep tissue damage (occurs when the tissue between the heel bone and the skin is compressed and deformed by pressure, shear, or strain) of right heel, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and cognitive communication deficit (reduced awareness and ability to initiate and effectively communicate needs). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 10/4/2024, the MDS indicated Resident 2 was moderately impaired in cognitive skills…

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 complete documentation regarding discharge planning was done for one of three sampled residents (Resident 1). This deficient practice had the potential to not provide full information regarding the discharge plans that were discussed for Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/22/2024, with diagnoses of non-pressure chronic ulcer (non-healing open sore caused by poor circulation) of the left heel and midfoot (middle of the foot) with unspecified severity (unknown how severe), local infection of the skin and subcutaneous tissue (deepest layer of the skin), and type 2 diabetes mellitus (characterized by high levels of blood sugar in the blood). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/25/2024, the MDS indicated Resident 1 had the ability to understand others and was understood by others. The MDS indicated Resident 1 was dependent (helper does all of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Resident Access to Records, by not providing a copy of medical records within the policy ' s time frame for one of three sampled residents' (Resident 1) responsible party (RP, a person responsible for paying resident's bills or making healthcare decisions). This failure resulted in Resident 1 ' s RP ' s rights being violated when the facility did not provide access to Resident 1 ' s medical records within 48 hours. from 10/30/23 to 12/8/23 (total of 39 days). Findings: During a review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included urinary tract infection (an infection when bacteria gets into the urinary system [system that removes waste from the blood, in the form of urine]) and acute pancreatitis (a condition where the pancreas [organ that regulates digestion and blood sugar] becomes inflamed [swollen] over a short period…

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 develop and implement care plans (CP) that met the needs of two of two sampled residents (Residents 17 and 32) as indicated in the facility's policy and procedure, titled, Care Plans, Comprehensive Person-Centered. a. The facility did not follow interventions inidicated in Resident 17's Pressure Injury CP. Resident 17 was not repositioned every two hours as indicated in Resident 17's CP. b. b. Resident 32's CP for communication skills did not include appropriate interventions that addressed Resident 32's problem areas. Resident 32 did not speak English only spoke Thai and Resident 32 could not see the communication board indicated in the CP due to glaucoma (a group of eye conditions that can cause blindness). These failures had the potential to result in a psychosocial and physical decline to Residents 17 and Resident 32. Cross Reference F676 Findings: a. During a review of Resident 32's admission Record (AR), the AR indicated Resident 17…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 32), who had limited English proficiency (LEP), received translation support and services by the facility according to the facility's policy and procedure (PP) titled, Translation and/or interpretation of Facility Services, by failing to when Resident 32's primary language was Thai (language of Thailand) and the facility spoke English to Resident 32. This failure had the potential in Resident 32 not to be able to communicate basic needs and had the potential to result in Resident 32 to suffer a physcial and psychosocial decline. Cross Reference F656 Findings: a. During a review of Resident 32's AR, the AR indicated Resident 32 was admitted to the facility on [DATE], with diagnoses that included glaucoma (group of eye diseases that can vision and blindness by damaging the optic nerve) and type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates…

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 in-service training was completed for one of one Certified Nursing Assistants (CNA 2). This failure had the potential to result in the residents with diagnoses of Dementia (a decline in mental ability) to not receive proper care and services and result in a decline in physical health. Findings: During a review of the facility's 2023 Annual In-Service Calendar for C.N.A, the calendar indicated, Dementia training or definition was scheduled in January 2023. During a review of the facility's In-Service Meeting Minutes (the Minutes), dated 1/6/23, the minutes indicated the topic for the training was Dementia. The Minutes indicated CNA 2 did not attend the training. During an interview on 11/18/23, at 2:55 pm., Director of Staff Development (DSD) stated the DSD was the person that provided Dementia in-service on 1/6/23. The DSD stated all staff should attend regular scheduled in-service training including Dementia. The DSD stated the DSD did not know CNA 2 did not attend the training. DSD stated he did not have a 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 interview and record review, the facility failed to ensure a Minimum Data Set (MDS, an assessment and screening tool) was coded correctly for two of two sampled residents (Resident 36 and Resident 32). a.Resident 36 was discharged to home and the Minimum Data Set (MDS, an assessment and screening tool) dated 10/11/23 was coded as Resident 36 being discharged to the hospital. b. Resident 32's primary language was Thai and was documented as English in the MDS dated [DATE]. This failure resulted in inaccuracy of Resident 36 and 32's MDS clinical status and had the potential to result in both residents to not receive the necessary care and services. Findings: a.During a review of Resident 36's admission Record, the AR indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included hypertension (increased blood pressure) and dysphagia (difficulty swallowing). During a review of Resident 36's Transfer/Discharge Report, signed 10/11/23, the Transfer/Discharge Report indicated 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 safety measures were implemented, for one of two sampled residents (Resident 26) and as indicated in the facility's policy and procedure (P&P), when Resident 26's bed pad alarm (device that alerts staff when a resident gets out of bed) was turned off. Resident 26 was at high risk for falls and had a history of multiple falls. This failure had the potential to result in injury and a physical decline to Resident 26. Findings: During a review of Resident 26's admission Record (AR), the AR indicated Resident 26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided to one of two sampled Residents (Resident 29). Resident 29, who had experienced weight loss, did not receive his supplement of ice cream with his lunch tray as ordered by the physician. This failure had the potential to result in further weight loss to Resident 29. Findings: During a review of Resident 29's admission Record (AR), the AR indicated Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), hypertension (high blood pressure), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 29's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/19/23, the MDS indicated 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 interview and record review, the facility failed to act upon the pharmacist medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication.) recommendation to not use insulin sliding scale (a sliding scale varies the dose of insulin based on blood glucose level. The higher the blood glucose the more insulin to take) for one of five sampled residents (Resident 14). This deficient practice had the potential for the resident receiving unnecessary mediations and not maintaining the resident's highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible. Findings: During a review of Resident 14's admission Record indicated Resident 14 was readmitted on [DATE], with diagnoses that included type 2 diabetes mellitus (high levels of sugar in the blood) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to discard a Lantus insulin (long-acting medication used to regulate blood sugar levels) vial, for one of four sampled residents (Resident 18), during medication administration observation and according to the facility's policies and procedures (P&P). This failure had the potential to result in Resident 18 to experience adverse reactions (any unexpected or dangerous reaction to a medication) due to the administration of the expired medication. Findings: During a review of Resident 18's admission Record (AR), the AR indicated Resident 18 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar) and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 18's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE], the MDS indicated…

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 prepare meals that met resident preferences and allergy status for one of four sampled residents (Resident 2)as inicated in the facility's policy and procedure (P&P), titled, Nutrition Care. This failure had the potential to affect Resident 2's dietary intake and result in Resident 2 to experience an allergic response and cause a physical decline to Resident 2. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was readmitted on [DATE], with diagnoses that included fracture of superior rim of left pubis (edge of hip bones) and hypertension (increased blood pressure). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 11/3/23, indicated Resident 2 had clear speech, ability to understand others and make self-understood. Resident 2 had intact cognition (ability to think, remember and reasoning). During an interview on 11/17/23, at 2:27 pm.,…

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

Based on observation and interview, the facility failed to ensure sanitary practices were followed by one of three sampled staff (Dietary Aid, DA 1). On 11/17/23, DA 1 did not wear a hairnet (netting over the hair to keep hair from contacting exposed food, clean equipment and utensils) during the handling and preparation of food. This failure had the potential to result in foodborne illnesses (illness caused by food contaminated with bacteria) from pathogens (organism that cause disease) that could have been on the hair and land on exposed food fed to residents who ate food orally (by mouth). Findings: During an observation on 11/17/2023 at 1:13 pm., DA 1 was observed handing food in the kitchen and at the table located next to the stove. DA 1 was wrapping tortillas in plastic wrap (thin, transparent film that adheres to surfaces and itself used for the storage of food) and was not wearing a hairnet as indicated in the facility's policy and procedure (P&P) titled, Sanitation and Infection Control. During an interview on 11/17/2023 at 11:17 am, DA 1 stated DA 1 was not wearing 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 follow infection control practices for one of four sample residents (Resident 19) when Resident 19's urine drainage bag (urinary bag, attaches to a catheter [tube] that is inside your bladder to collect urine.) was observed touching the floor on 11/17/23, as indicated by the facility's policy and procedure P&P titled, Catheter Care, Urinary. This failure had the potential to result in a urinary tract infection (UTI, an infection in any part of the urinary system.) to Resident 19. Findings: During a review of Resident 19's admission Record (AR), the AR indicated Resident 19 was readmitted to the facility on [DATE], with diagnoses that included pneumonia (lung inflammation caused by bacterial or viral infection), sepsis (life-threatening complication of an infection) and immunodeficiency (failure of the immune system to protect the body adequately from infection, due to the absence or insufficiency of some component process or substance).…

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.