Sea Breeze Rehab And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure they obtained an assessment for bed rails, physician orders, a consent and a care plan for the bed rails was completed for 6 of 6 sampled residents reviewed for bed rails, Residents #3, #39, #49, #81, #95, and #112. The findings included:1. Record review revealed Resident #3 was admitted to the facility on [DATE] with a diagnosis to include: Hemiplegia and Hemiparesis following a Cerebral Infarction, Type II Diabetes Mellitus, Chronic Respiratory Failure, Acquired Absence of Left Leg Above the Knee (AKA), Aphasia, Dysphagia, Bipolar Disorder, and Major Depressive Disorder. A review of the annual MDS (Minimum Data Set) assessment dated [DATE] revealed the BIMS (Brief Interview for Mental Status) was 12 of 15 indicating moderate cognitive impairment. A review of the Resident's care plan documented under resident has a potential for Activities of Daily Living (ADL) selfcare deficit r/t (related to) ADL needs and participation vary,…

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 drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 2 sampled residents reviewed for controlled substance reconciliation, Resident #87. The findings included:Record review revealed Resident #87 was admitted on [DATE] with diagnoses that included in part the following: Displaced Intertrochanteric Fracture of Right Femur. Review of the physician's orders for Resident #87 revealed an order dated 04/17/26 for Tramadol HCl tablet 50 MG give 1 tablet by mouth every 6 hours as needed for moderate and severe pain.Review of the Medication Monitoring Control Record for Resident #87 for Tramadol documented the medication (med) was signed out on 04/26/26.Review of the Medication Administration Record for Resident #87 revealed no documentation for Tramadol having been administered on 04/26/26.During an interview conducted on 05/06/26 at 5:00 PM, Staff CC, Licensed Practical Nurse, 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 observations, interviews, and record review, the facility failed to respond to the pharmacist's recommendations for Lidocaine patch to have a removal time and to specify the site of administration for 1 of 5 sampled residents identified for medication regimen review, Resident #4. The findings included:Review of the facility's policy titled, Medication Regimen Reviews, dated April 2007, included the following: The Consultant Pharmacist Shall review the medication regimen of each resident at least monthly.Policy Interpretation and Implementation:5. The primary purpose of this review is to help the facility maintain each resident's highest practical level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible.Record review revealed Resident #4 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included: Chronic Systolic (Congestive) Heart Failure; Type 2 Diabetes…

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 observations, interviews and record review, the facility failed to monitor for behaviors and side effects for residents receiving psychotropic medications for 2 of 59 sampled residents receiving psychotropic medications, Residents #12 and #109. The findings included: 1. Record review revealed Resident #109 was admitted to the facility on [DATE] with diagnoses that included in part the following: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Generalized Anxiety Disorder, Major Depressive, and Brief Psychotic Disorder. Review of the Brief Interview of Mental Status (BIMS) assessment dated [DATE] documented a score of 9 indicating moderate cognitive impairment. Review of the physician's orders for Resident #109 revealed in part the following: An order dated 04/30/26 for Lorazepam (a psychotropic medication) tablet 1 MG give 1 mg by mouth every 8 hours as needed with no end date. An order dated 05/01/26 for Lorazepam (a psychotropic medication) tablet 1 MG give 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was not 5% or greater. The medication error rate was 34.48% with 10 medication errors identified while observing a total of 29 opportunities, affecting Residents #95 and #78. The findings included: 1. Record review revealed Resident #95 was originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses that included in part the following: Acute On Chronic Diastolic (Congestive) Heart Failure, Dysphagia, Disease of the Pericardium, and Venous Insufficiency (Chronic) (Peripheral). Review of the Brief Interview of Mental Status (BIMS) assessment dated [DATE] documented a score of 15 indicating an intact cognitive response. Review of the physician's orders for Resident #95 revealed in part the following: An order dated 03/31/26 for Effer K (Klor-Con) EF25 meq [milliequivalent] give via G-tube every morning and at bedtime. An order dated 03/21/26 for multivitamin 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 observations, interviews and record review, the facility failed to ensure medications were secure at all times for 4 of 6 medication (med) carts, and 3 of 5 medication pass observations, Residents #95 and #29, and for 1of 98 sampled residents, Resident #38. The findings included: 1. On 05/03/26 at 8:36 AM, an observation was made of the medication (med) cart (B1) next to B-side nursing station. The med cart was left unlocked and unattended with 2 residents and 1 visitor in the hallway. During an interview conducted on 05/03/26 at 8:43 AM, Staff A, Licensed Practical Nurse (LPN), was asked about the unlocked and unattended med carts. He stated they should be locked at all times. 2. On 05/04/26 at 6:55 AM, an observation was made of the med cart (B1) next to B-side nursing station. The med cart was left unlocked and unattended with a set of keys on top of the med cart. During an interview conducted on 05/04/26 at 7:05 AM with Staff R. Registered Nurse (RN), was asked about the unlocked and unattended 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 observations, interviews, and record reviews, the facility failed to follow their policy for cleaning and disinfecting resident-care equipment after obtaining blood pressure (BP) readings, affecting Resident #78; and after use of a Glucometer to test blood sugar levels, affecting Resident #29, during 2 of 5 medication administration observations; and failed to ensure hand hygiene was perform during medication administration for 2 of 5 medication administration observations, affecting Residents #31 and #78. The findings included: Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 12/28/25, included the following: Resident care equipment can be a source of indirect transmission of pathogens. Reusable resident care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection.Definitions: Cleaning is the removal of visible soil from objects and surfaces and normally is accomplished manually…

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 the facility shower schedule, record review and interview, the facility failed to honor the shower preferences and schedules for 2 of 7 sampled residents reviewed for choices, Resident #14 and #48. The findings included: 1. Review of the shower schedule revealed Resident #14 was scheduled to receive a shower on the 7 AM to 3 PM shift on Tuesdays and Fridays. A second shower schedule by room number confirmed those days and time. Review of the record revealed Resident #14 was admitted to the facility on [DATE] and moved into his current room on 07/03/24. Review of the most currently completed Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, on a scale of 0 to 15, indicating the resident was cognitively intact. Review of the most recently completed comprehensive assessment revealed the resident had a lower BIMS of 05, indicating cognitive confusion, but still reported the choice between a bath and a shower was somewhat…

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 and interview, the facility failed to provide a safe, clean comfortable homelike environment for 1 of 2 units, Unit B. The findings included: Observations on 01/06/25, 01/07/25, and 01/08/25 revealed the following: a. On 01/08/at 9:30 AM: room [ROOM NUMBER]- the IV pole was rusted at base of pole. b. On 01/06/25 at 11:00 AM: room [ROOM NUMBER]A - During an interview with the resident's spouse on 01/06/25 at 11:00 AM, she stated that the chairs in the sitting room next to nurses station are disgusting. She showed surveyor the pictures of the chairs and stated this was from when he first came. She said she told someone but nothing has been done. She stated she was in the sitting room on 12/30/24 and 12/31/24, pulled up the cushion and observed trash and stained seats for 2 of the chairs in the room. The surveyor observed the spouse's concerns via observation on 01/06/25 at 2:20 PM and 01/07/25 at 7:15 AM. The couch had debris underneath the cushions as well as a paperback book that was folded…

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 policy review, interview and record review, the facility failed to respond to a verbal grievance regarding missing personal items for 1 of 1 voiced grievance, affecting Resident #13. The findings included: Review of the policy, titled, Grievance-resident rights, dated 7/2024, indicated the administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Any resident, family member or appointed resident representative may file a grievance or complaint concerning the care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to verbally and/or in writing upon request including 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, record review, and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 3 of 23 sampled residents, as evidenced by improperly coding Resident #14 as comatose, inaccurate dental status for Residents #82 and 87, and an inaccurate hearing status for Resident #87. The findings included: 1. Review of the record revealed Resident #14 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE], completed for a significant change in status, documented Resident #14 was comatose. Further review of the record lacked any evidence of a comatose status. Resident #14 was interviewed on 01/06/25 at 10:18 AM, who volunteered an extensive medical history, with no mention of any comatose status. During an interview on 01/09/25 at 11:50 AM, Staff B, MDS Coordinator, was made aware of the comatose coding. The MDS Coordinator explained that section of the MDS was completed by the previous Social Service Director (SSD), who 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, record review and interview, the facility failed to develop and implement care plans for 2 of 23 sampled residents reviewed, Residents #87 and #15, as evidenced by lack of care plans related to hearing for Resident #87 and lack of care plans relating to self-administration of medication for Resident #15. The findings included: 1. Review of Resident #87's record revealed she was admitted to the facility on [DATE] with a diagnosis to include Wedge Compression Fracture, Rhabdomyolysis, Muscle Weakness and Abnormalities of Gait and Mobility. Review of the [Company Name] admission Nursing Evaluation dated 10/16/24 asks the question Does the resident have impaired hearing, and the answer was marked yes, no auditory aides. Review of Resident #87 care plan revealed that this resident did not have a care plan related to her hearing concerns. During observations and attempted interview with Resident #87 on 01/06/25 at 2:08 PM, the resident stated she can't hear in left ear, she is deaf and in 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 interview and record review, the facility failed to ensure narcotic removal was recorded in the medication administration records (MARs) for 3 of 6 sampled residents reviewed, Residents # 28, # 6 and #9. The findings included: 1. On 01/07/25 at 11:24 AM, medication storage observations were started at the B-unit. Resident # 28's medication records were selected for review. It was revealed Resident #28 had a physician order of Oxycodone HCl Oral Tablet to give 15 mg via peg-tube every 4 hours as needed for moderate-severe chronic pain. Review of the January 2025 medication and treatment administration records (MARs and TARs) were compared against the medication monitoring control record. There was a discrepancy between these records. The medication monitoring control record indicated the medication was removed twice on 01/03/25 at 10:57 AM and 3:36 PM Review of the MARs had no documentation and were not signed for the removal on 01/03/25 at 10:57 AM and administration to the resident. 2. On 01/07/25 at 12:12 PM, medication storage observation commenced at the A-unit.…

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 record review, policy review and interview, the facility failed to prevent elopement; failed to thoroughly investigate the incident; failed to implement corrective measures to minimize reoccurrence and failed to report the adverse event. The failure affected 1 of 2 sampled residents, Resident #1. The findings included: Review of the Facility policy, titled, Elopement and Wandering, dated 07/2024 documented: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Guideline: To provide care guidance for staff on the current standards of professional practice for residents who are identified as an elopement risk or wanderer upon clinical assessment Definition: A situation in which a incapacitated resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement (Ex: If the resident is observed by a staff member or a staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide showers as per residents' choice and schedule for 2 of 4 sampled residents, Residents #37 and #14. The findings included: 1. During a phone interview on 10/10/23 at 3:55 PM, the daughter of Resident #37 stated the staff were not providing her mother with showers, and their current reason was that the shower room was under construction. The daughter voiced when she requested anything, including a shower for her mother, staff constantly tell her they are understaffed and don't have time. Review of the record revealed Resident #37 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #37 had a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the Significant Change MDS assessment dated [DATE] documented it was very important for Resident #37 to choose between a bath and a shower. 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 record review and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for 2 of 5 sampled residents, related to medication use, Residents #54 and #52. The findings included: 1. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/04/23, documented Resident #54 received insulin injections 7 of 7 days during the look-back period of 07/29/23 through 08/04/23. Review of the corresponding Medication Administration Records (MARs) for that same look-back period revealed Resident #54 only received the scheduled Lantus insulin on 08/03/23 and 08/04/23. These MARs lacked any other insulin administration. During an interview on 10/12/23 at 1:17 PM, the MDS Coordinator was asked about the Quarterly MDS dated [DATE] with the documented daily insulin injection. As the MDS Coordinator was looking up Resident #54 on the electronic medical record, she stated the resident was on daily scheduled long-acting insulin. Upon review of the August 2023 MAR, the MDS Coordinator…

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 observations, interviews, and record review, the facility failed to ensure care and services for a Peripherally Inserted Central Catheter (PICC) line dressing change as ordered for 1 of 2 sampled residents with intravenous access, Resident #5. The findings included: Review of the facility's policy, titled, PICC Line or Midline Catheter Dressing Change, with a revised date of August 2023, included: Frequency - Change the dressing in the first 24 hours. After the first 24 hours, the frequency is every 7 days and PRN (as needed) if dressing is loose, damp, or soiled. Record review for Resident #5 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission date of 08/17/23. The resident's diagnoses included: Type 2 Diabetes Mellitus, Bacterial Infection, and Acquired Absence of Right Leg Below Knee. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 08/18/23 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15, indicating…

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 observations, interviews and record review, the facility failed to obtain a physician order for oxygen use for 1 of 3 sampled residents reviewed for respiratory issues, Resident #38; and failed to post 'oxygen in use' signage for 2 of 3 sampled residents reviewed for respiratory issues, Residents #38 and #6. The findings included: Review of the facility's policy, titled, Oxygen Administration, with a revised date of October 2010, included: the purpose of this procedure is to provide guidelines for safe oxygen administration. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of the facility's policy, titled, Oxygen In Use Signage, with a revised date of 03/08/17, revealed it is the policy of the facility that wherever oxygen is in use a sign must be posted at the location. 1. Record review for Resident #38 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure blood sugar monitoring, failed to follow blood pressure parameters with medication administration, and failed to ensure consistent and appropriate monitoring of medication side effects, all as per physician orders, for 3 of 5 sampled residents, Residents #36, #46, and #54. The findings included: 1. Review of the record revealed Resident #36 was admitted to the facility on [DATE]. Review of the current physician orders documented to administer 25 milligrams of Metoprolol twice daily, withhold parameters if the systolic (upper number) blood pressure reading was less than 100, the diastolic (lower number) blood pressure reading was less than 60, or the heart rate was less than 60. Review of the September 2023 Medication Administration Record (MAR) revealed the following: On 09//19/23 at 5:00 PM, the nurse administered the Metoprolol with a documented blood pressure reading of 109/57. On 09/22/23 at 9:00 AM, the nurse administered the Metoprolol…

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, record review, and policy review, the facility failed to ensure accuracy of medical records related to the administration of wound care and the provision of a Central Venous Catheter dressing change, for 2 of 2 sampled residents reviewed for wound care, Residents #15 and #52, and for 1 of 2 sampled residents with intravenous access, Resident #5. The findings included: Review of the facility's policy, titled, Central Venous Catheter Dressing Changes with a revised date of April 2016, included under Section Purpose: The purpose of this procedure is to prevent catheter related infections that are associated with contaminated, loosened, soiled, or wet dressings. Included under the Section Documentation: 1. The following information should be recorded in the resident's medical record: a) Date and time dressing was changed. b) Location and objective description of insertion site. c) Any complications, interventions that were done. d) Condition of sutures (if present). e) Any questions,…

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.