Hillside Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews the facility failed to provide enteral nutrition as ordered by the physician for one resident (#34) out of two sampled. Findings included: An observation on 05/17/2026 at 1:44 p.m. of Resident #34 revealed her tube feeding was connected; the pump was off and not running. Resident #34's nutrition feed bottle was dated 5/16/2026 at 2:00 P.M.; also written on the bottle was 65 mL/hr. There was 375 mL of nourishment left in the bottle as indicated by the measurement markings on the side of the bottle. Hanging beside the bottle was a clear bag with 400 mL of water remaining. The clear bag was also connected to the pump and Resident #34. At the time of this observation, the pump was off and not running. Review of Resident #34's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to dysphagia following non traumatic intracerebral hemorrhage, encounter for surgical aftercare following surgery on the digestive 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 interviews and record reviews the facility did not ensure medications were correctly reconciled upon admission to the facility for one resident (#131) of one resident sampled, resulting in delayed medical intervention and pain.Findings included: An interview on 5/19/2026 at 3:02 P.M. with Resident #131 was conducted. Resident #131 said she did not receive any medication on 5/15/2026 after she arrived at the facility. Resident #131 said she experienced excruciating pain on 5/15/2026 and 5/16/2026. Resident #131 said she explained to the staff that she was supposed to receive 200mg of Gabapentin three times a day and not 100mg three times a day.A record review of Resident #131's admission record showed he was admitted to the facility on [DATE] with diagnoses including but not limited to open wound left ankle, polyneuropathy, and spinal stenosis. A review of Resident #131's admission assessment, dated 5/18/2026 revealed a brief interview for mental status (BIMS) score of 12 out of 15, indicating moderate…

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 observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for two residents (#6 and #68) out of five residents sampled for medication administration. This resulted in 2 errors out of 29 medication administration opportunities for a medication error rate of 6.9%.Findings included: An observation was conducted on 5/18/2026 at 8:20 A.M. of medication administration with Staff E, Licensed Practical Nurse (LPN). Staff E, LPN was observed preparing and administering the following medications for Resident #6: Lorazepam 0.5mg x 1 tabletReconciliation of Resident #6's physician orders showed the following orders:- Lorazepam Oral Tablet 0.5mg; Give 1 tablet by mouth every 6 hours for anxiety-agitation-restlessness A review of the medication audit report for Resident #6 on 5/18/2026 at 11:40 A.M. revealed the last documented dose for lorazepam was administered on 5/18/2026 at 5:16 A.M.An interview on 5/18/2026 at 1:10 P.M. with Staff E, LPN was conducted. Staff E, LPN was unable to locate any administration in the electronic…

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 did not ensure therapy or restorative service were provided for two residents (#68, and #83) of two residents sampled. Findings included: 1. An observation and interview on 05/17/2026 12:48 PM with Resident #68 was conducted. Resident #68 was observed lying in bed and had bilateral upper arm contractures. Resident #68 said he was not receiving therapy services and had not received therapy since he was admitted . Resident #68 said he would like to be receiving therapy; Resident #68 said he does not have any braces or splints. A record review of Resident #68's admission record showed he was admitted to the facility on [DATE] with diagnoses including but not limited to early-onset cerebellar ataxia, Friedreich ataxia, and major depressive disorder. A review of Resident #68's minimum data set (MDS), section C, dated 4/5/2026 revealed a brief interview for mental status (BIMS) score of 15 out of 15 indicating cognitively intact. A review of 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, record review, and interview, the facility failed to maintain an effective infection prevention program related to accurate signage posting for one resident (#18) out of one resident sampled for contact precautions. Findings included: An observation on 05/18/2026 at 10:53 AM, revealed a sign posted outside of Resident #18's room door reading, Enhanced Barrier Precautions. Record review for Resident #18 revealed an order for contact precautions as follows: encourage and assist resident to maintain contact precautions for Extended-Spectrum Beta-Lactamase (ESBL) in urine. The order start date was 05/09/2026, with an end date of 05/19/2026. An interview with Staff I, Certified Nursing Assistant (CNA), on 05/19/2026 at 12:45 PM revealed the most recent education for transmission-based precautions (TBP) was completed in the prior week. Staff I said the staff was educated to ask a nurse questions if they do not understand a particular precaution. Staff I stated staff had been educated to observe door signage of resident rooms in order to determine the proper protocol…

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 observations, interviews, and policy review, the facility failed to ensure food in the refrigerator was discarded upon the expiration date and the facility failed to ensure the facility had and followed a cleaning schedule for food service equipment for one of one kitchen.Findings included: A kitchen tour was conducted on 08/18/2025 at 9:07 AM with the Dietary Manager (DM). The walk-in refrigerator revealed two containers of cottage cheese that had an expiration date of 08/16/2025. The tour of the kitchen also revealed a covered piece of equipment identified as a meat slicer. The DM uncovered the meat slicer stating it was supposed to be clean when covered. An observation was made of food particle debris on the base and blade of the meat slicer.An interview with the Dietary Manager (DM) was conducted on 08/18/2025 at 9:17 AM. The DM confirmed the two expired cottage cheese containers and the food particle debris on the meat slicer. The DM verified expired foods should be disposed of prior or on the expiration date. The DM stated the meat slicer should not have been covered…

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 residents received respiratory services consistent with professional standards of practice related to oxygen administration and respiratory equipment storage for four residents (#99, #78, #42 and #83) out of four sampled residents. Findings included: 1. Review of Resident #99’s admission record revealed an admission date of 02/08/2025 and diagnoses of chronic obstructive pulmonary disease unspecified (lung disease that blocks air flow in the lungs and makes it hard to breath), hyperlipidemia unspecified (high cholesterol), and essential primary hypertension (high blood pressure). Review of Resident #99's physician orders dated 07/23/2025 revealed, Respiratory-Oxygen: NC [nasal cannula]/Mask. Encourage and assist resident to use O2 [oxygen] @ 2 liters via NC as needed for SOB [shortness of breath]/DOE [dyspnea on exertion] as needed for O2 less than 93%. Review of Resident #99's comprehensive care plan revealed a focus 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.

Based on interview and record review, the facility failed to administer insulin according to physician orders for one resident (#65) out of two residents reviewed for insulin administration.Findings included:Review of Resident #65's admission record revealed a diagnosis of type 2 diabetes mellitus without complications.Review of Resident #65's physician order dated 04/17/2025 revealed, Insulin Glargine-yfgn 100 UNIT/ML(milliliter) Solution pen-injector. Inject 50 unit subcutaneously at bedtime for diabetes and inject 5 unit subcutaneously in the morning for DM [diabetes mellitus].Review of Resident #65's August medication administration record revealed documentation on 08/02/2025 at 6:00 AM of a chart code of 4. Review of the Chart Codes/ Follow Up Codes revealed 4=Pulse below 60/min [minute] Ineffective.Review of Resident #65's July medication administration record revealed documentation on 07/16/2025 at 6:00 AM, on 07/25/2025 at 6:00 AM, on 07/28/2025 at 6:00 AM and on 07/30/2025 at 6:00 AM a chart code of 4.During an interview on 08/20/2025 at 6:30 AM Staff G, Licensed Practical…

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 physician ordered parameters were followed related to hypertensive medications resulting in the administration of unnecessary medications for one resident (#106) out of five residents reviewed for unnecessary medications.Review of Resident #106 admission record documented diagnosis of unspecified atrial fibrillation, heart failure unspecified, unspecified protein calorie malnutrition, chronic obstructive pulmonary disease unspecified, type 2 diabetes mellitus without complications, unspecified osteoarthritis unspecified malignant neoplasm of esophagus unspecified, and atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain).Review of Resident #106 physician order dated 3/22/2025 read, Metoprolol Succinate ER (extended release), extended release 24 hour 25 mg (milligrams) give 0.5 tablet every 12 hours for hypertension, hold for SBP (systolic blood pressure) less than 100 or DBP (diastolic blood pressure) less than 60 or HR (heart rate) less than 60.Review of Resident #106'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 and policy and procedure review, the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) and performed hand hygiene upon entering and exiting residents rooms while providing care to residents on enhanced barrier precautions to prevent the possible spread of infection and communicable diseases for three residents (#1, #14, #44 and #27) out of seven residents sampled for infection control. Findings included: 1. On 08/18/2025 at 1:17 PM Resident #1's room was observed without isolation signage or personal protective equipment (PPE) available outside or in Resident #1's room, Staff E, Certified Nursing Assistant (CNA) was observed entering Resident #1's room with incontinence care supplies, closed the door, and Staff E, CNA did not don a gown prior to entering Resident #1's room. Staff E, CNA was observed assisting Resident #1 with gloves on but no gown. Staff E, CNA removed a soiled brief and provided incontinence care. Staff E, CNA stated, Oh I'm just changing [Resident #1]. Staff E, CNA confirmed…

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 dignity to one resident (#108) out of two sampled residents related to a catheter bag covering.Findings included:During an observation and interview on 08/18/2025 at 9:05 AM Resident #108's urinary catheter collection bag was hanging on the left side of the Resident's bed, uncovered, containing 300 milliliters (ML) of yellow fluid. There was a folded up white towel placed under the collection bag on the floor. Resident #108 stated, The urine bag has not been covered. Everyone can see it when they enter the room or even walk by, and it is embarrassing.Review of Resident #108's medical record revealed Resident #108 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of, but not limited to, fracture of the right femur, subsequent encounter for closed fracture with routine healing, encounter for surgical aftercare following surgery on the digestive system, cholecystitis, and urinary retention.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 provide a safe environment and implement their policy on securing smoking materials in a secure location for one resident (#3) out of three residents reviewed for accidents.Findings included:Review of Resident #3 medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnosis of, but not limited to, trimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing, unspecified fracture of upper end of left tibia, subsequent encounter for closed fracture with routine healing, asthma, chronic obstructive pulmonary disease (COPD), unspecified, type 2 diabetes mellitus with other oral complications, non-ST- elevation myocardial Infarction (heart attack), chronic diastolic (congestive) heart failure, and essential (primary) hypertension.Review of a list, provided by the Administrator titled, Residents who smoke revealed, the first and last name of Resident#3.An observation 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 observations, interviews, and record review, the facility failed to ensure midline catheter dressing changes were completed according to professional standards of practice for one resident (#111) of one resident reviewed with a midline catheter.Findings include:During an observation on 08/18/2025 at 9:45 AM Resident #111 was observed in bed with a left upper arm single lumen midline catheter, with a dressing date of 08/11/2025 with gauze under the transparent semi-permeable dressing.During an observation on 08/18/2025 at12:15 PM Resident #111 was observed in bed with a left upper arm single lumen midline catheter with date of 08/11/2025 with gauze under the semi-permeable transparent dressing. Review of Resident #111's admission record revealed an admission date of 08/09/2025 and diagnoses of encounter for surgical aftercare following surgery on the genitourinary system, generalized anxiety disorder, adjustment disorder with depressed mood, adjustment insomnia, acute cystitis with hematuria, metabolic encephalopathy, and sarcopenia.Review of Resident #111's physician order…

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 pharmacy reviews were conducted monthly and the facility failed to ensure a physician provided a clinical rational for two residents (#11 and #51) out of five residents reviewed for medication regimen review (MRR). Findings included: 1. Review of Resident #11’s Consultant Pharmacist MRR’s for the months of August 2024 through July 2025 revealed the following: · There was no documentation a pharmacist performed an MRR for the month of September 2024 for Resident #11. · There was no documentation a pharmacist performed an MRR for the month of October 2024 for Resident #11. · There was no documentation a pharmacist performed an MRR for the month of April 2025 for Resident #11. · A pharmacy review for the month of June 2025 had a pharmacist recommendation for Resident #11 that revealed, the Resident received Eliquis 5mg (milligram) twice daily for “anticoagulation” and Phenytoin ER (extended release) 200mg every 12 hours for seizures. A recommendation was made to re-evaluate the continued use of the combination 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 Activities of Daily Living (ADLs) were performed for one (#3) three sampled residents related to incontinence care. Findings included: On 01/23/2025 at 9:55 a.m., an interview was conducted with Staff A Licensed Practical Nurse (LPN) and Staff C, Certified Nursing Assistant (CNA) with Resident #3. The resident was sitting in a wheelchair in her room. The resident was dressed and groomed for the day. She had no noted odors. The resident was sitting on a cushion in her wheelchair. Requested Staff A and Staff C contact the surveyor when the resident was due and needed incontinence care. On 01/23/2025 at 1:00 p.m., an observation of Resident #3 with Staff A and Staff C was conducted during the transfer of the resident to the bed from her wheelchair. They both applied gloves and transferred the resident to the bed using the sit to stand lift onto the bed. The resident was placed on her right side. Her legs had a straight line across 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 observation, interview, and record review, the facility failed to ensure Quality of Care was provided related to wound care and following Infection Control Practices for one (#3) of one sampled resident. Findings included: Review of the admission record showed Resident #3 was admitted on [DATE] and readmitted on [DATE]. Her diagnoses included but not limited to atrial fibrillation, morbid obesity, dementia, hypertension, osteoarthritis, and disorder of kidney and ureter. On 01/23/2025 at 1:20 p.m., wound care was observed for Resident #3. Staff B, Licensed Practical Nurse (LPN) brought dressing supplies, normal saline in syringes, and the resident's [Antifungal] powder bottle and sat them on the overbed table. Staff B did not clean the overbed table nor place a barrier down. Staff B went into the bathroom and washed her hands. Staff B removed the old dressing and stated, that looks like calcium alginate, that was not ordered for her. Staff B stated the resident was supposed to be on [Antifungal] powder…

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 observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and seven errors were identified for three (#73, #11, and #446) of four residents observed. These errors constituted a 25.93% medication error rate. Findings included: 1. On 8/13/23 at 11:11 a.m., an observation of medication administration with Staff A , Licensed Practical Nurse (LPN), was conducted with Resident #73. Staff A obtained a blood glucose level of 207 from the resident and dispensed the following medication: - Novolog FlexPen The staff member dialed the pen to 4 units, placed the pen and needle in a plastic cup, and entered the residents room. Staff A applied a needle to the pen and injected the insulin in the back of the residents' left arm. Staff A did not prime the insulin pen prior to the injection. The Director of Nursing (DON) stated, on 8/15/23 at 2:14 p.m., Novolog pens needed to be primed. The DON reported to prime insulin pens was to set it (dose selector) to 2…

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, record reviews, and interviews, the facility failed to ensure one (#4) of one resident sampled for self-administration of medications was assessed for the administration of nebulizer treatments. Findings included: The admission Record for Resident #4 showed resident was admitted on [DATE] with diagnoses not limited to chronic obstructive pulmonary disease with (acute) exacerbation, unspecified heart failure, and acute and chronic respiratory failure with hypoxia. On 8/13/23 at 12:24 p.m., Resident #4 was observed lying in bed, eyes closed, and wearing a nebulizer mask with a nasal cannula. The nebulizer mask did not have any aerosol being emitted and no liquid was observed in the medication cup of the mask. An observation was made on 8/13/23 at 12:31 p.m., of the resident removing the nebulizer mask after his lunch tray was placed on the over-bed table. The observation continued at 12:40 p.m., Staff A, Licensed Practical Nurse (LPN) was observed in a room across the hall from resident #4…

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, record review, and interviews, the facility failed to ensure residents received medications in accordance with professional standards related to monitoring of blood pressure medications parameters and to ensure the physician was notified of held doses for one (#56) of six residents sampled for unnecessary medications. Findings included: During a facility tour on 08/15/23 at 09:56 a.m., Resident #56 was observed lying on his bed. He stated he did not feel well because his blood pressure was too low. Resident #56 stated this had been going on for weeks and he had not seen the nurse practitioner or a physician. The resident said, I get dizzy, they said it's my ears, I don't think so. I am sweating all the time. The resident stated he had notified the nurses on multiple occasions, and they just held his blood pressure medication at that time. Resident #56 said, Last night my bed was soaked. I was sweating profusely. The CNA (Certified nursing Assistant) said I had spilled juice. It was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records review, the facility did not ensure a resident with contractures received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence. The facility failed to ensure restorative services were provided for one (Resident #56) of 14 residents. Findings included: On 08/13/23 at 10:01 a.m., an interview was conducted with Resident #56. The resident stated therapy was discontinued for him because of funding. The resident stated he was not receiving restorative services from the facility. Resident #56 was noted with a left arm contracture. He stated he was paralyzed on his left side and had some nerve ending damage. Resident #56 stated he used to receive exercises from nursing staff, but it had been a long time. He stated he was afraid of being contracted even more. Review of an admission record, dated 08/16/23 showed Resident #56 was admitted to the facility on [DATE] with diagnoses to include contracture, left shoulder,…

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 a pain assessment was conducted in a timely manner for one (Resident #13) of two residents reviewed for pain. Findings included: On 08/13/23 at 10:00 a.m., an interview was attempted with Resident #13. The resident did not speak English. Staff F, CNA (Certified Nurse's Assistant) stated she would interpret for the surveyor. When asked if she had any concerns, Resident #13 motioned her hand over her peri area while grimacing and spoke in Spanish. The resident displayed frowning and clenching of her jaw as she spoke to Staff F. Staff F, CNA interpreted and stated the resident said she felt some irritation and pain in her peri area. Staff F stated the resident said the pain had started two days earlier. Resident #13 was observed wrinkling her nose and squeezing her eyes shut as she described how she was feeling. Resident #13 reported it hurts when she urinates. Staff F stated she would let the nurse know immediately. Staff F 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.