Mesun Health and Rehabilitation Center

Based on staff interviews and review of the facility's policies titled, Infection Prevention and Control Program and Water Management, the facility failed to develop an effective water management plan which included routine water management activities to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens throughout the facility's water system. The facility's census was 49 residents. Review of the undated facility's policy titled, Infection Prevention and Control under Policy Explanation and Compliance Guidelines revealed the following: Number 17. Water Management, (b): Control measures and testing protocols are in place to address potential hazards associated with the facility's water system. Review of the undated facility's policy titled, Water Management Program under Policy Explanation and Compliance Guidelines revealed the following: Number 8. The water management team shall regularly verify that the water management program is being implemented as designed. Auditing assignments will reflect that individuals will not verify the program…

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, staff interviews, and review of the facility's policy titled iQIES or Other System Downtime MDS, the facility failed to ensure that required Minimum Data Set (MDS) assessments were transmitted within regulatory guidelines to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for 31 residents (R) (R89,R55, R56, R8, R62, R7, R33, R85, R3, R19, R86, R84, R16, R31, R91, R15, R25, R72, R75, R88, R81, R90, R77, R38, R45, R20, R92, R78, R50, R278, and R368) out of 44 sampled residents. Findings Include: Review of the undated facility's policy titled iQIES or Other System Downtime MDS, under the Policy section revealed, It is the policy of this facility to transmit MDS data timely so that the facility will not be negatively impacted by iQIES or other system downtimes. Under the Policy Explanation and Compliance Guidelines section revealed, 1. All required MDS assessment files will be transmitted to…

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

Based on record reviews, staff interviews, and review of the facility's policy titled, Baseline Care Plan, the facility failed to develop a baseline care plan within 48 hours of admission that addressed two medications, (an opioid and a diuretic) for one out of five sampled residents (R ) (R33) selected for unnecessary medications review. This had the potential to cause adverse medical effects for R33 with no known interventions for staff. Findings include: Review of the undated facility's policy titled; Baseline Care Plan under Policy Explanation and Compliance Guidelines revealed, 1. The baseline care plan will: (a.) Be developed within 48 hours of a resident's admission. (b.) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders; ii. Physician orders; iii. Dietary orders; iv. Therapy services; v. Social services; vi. PASARR recommendation, if applicable 2.(b.) Interventions shall be initiated that address the resident's current needs including: i. Any health and safety…

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, staff and resident interviews, and review of the facility's policy titled, Comprehensive Care Plans, the facility failed to develop a care plan that included a communication or language preference for one of three sampled residents (R) (R179) whose primary language was not English. This deficiency had the potential to adversely impact the quality of care and quality of life provided to the resident. Findings include: Review of the undated facility's policy titled, Comprehensive Care Plans, under Policy Explanation and Compliance Guidelines revealed the following, Number 3. The comprehensive care plan will describe, at a minimum, the following: (f.) Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English-speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. Number…

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 resident family interview, Staff interviews, record review, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to protect the resident's (R) R1 right to be free from sexual abuse by (R5). Specifically, the facility failed to ensure a safe environment for (R1) from (R5) with known behaviors of exposing his penis, masturbating, and inappropriately touching female residents. Findings include: Review of the policy titled Abuse Neglect and Exploitation dated 8/1/2023 indicated under Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. VI. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples…

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 staff interviews, record review, and review of the facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act of an allegation of sexual abuse was reported to the State Survey Agency (SSA) within the required time frame for two of eleven residents (R) (R5 and R8). Specifically, the facility failed to report R5 exhibited sexually aggressive behavior, saying sexual things, and exposing his penis to R8. Findings include: Review of the policy titled Compliance with Reporting Allegations of Abuse, Neglect, Exploitation dated 8/1/2023 indicated under Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, are reported immediately to appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Compliance…

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 interviews, review of facility documentation, and policy review titled Quality Assurance Performance Improvement, the facility failed to ensure policies and procedures were implemented to address the facility's Quality Assessment and Performance Improvement (QAPI) plan and program, in which data was gathered, analyzed, developed, implemented, and re-evaluated to address adverse events related to potential deficient practice. This had the potential to affect all 44 residents residing in the facility at the time of the survey. Findings include: Review of the facility policy titled Quality Assurance Performance Improvement, dated 7/10/20, indicated . It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life . The QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by the facility . At a minimum, the QAPI will . Address all systems of care and management practices . Include clinical care,…

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 record review, interviews, and review of facility policy titled Quality Assurance and Performance Improvement (QAPI), the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly. The census was 44. Findings include: Review of the facility policy titled Quality Assurance & Performance Improvement (QAPI), dated 7/20/20, indicated . Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. Review of documents titled QAPI Sign In Sheet, for the year 2021, indicated the facility held QAPI meetings on a monthly basis. The last QAPI meeting was held on 12/30/21. There was no additional information provided to show the facility held a quarterly QAPI meeting for the month of March 2022. During an interview on 5/25/22 at 4:16 p.m., the Administrator confirmed the March 2022 quarterly QAPI meeting was not held. 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 record review, interview, and review of the Centers for Medicare and Medicaid Services (CMS) policy, the facility failed to ensure that all residents and/or their representatives were informed by 5:00 p.m. the next calendar day following the occurrence of a single resident or staff confirmed COVID-19 positive infection, received cumulative updates, and informed of mitigating actions taken by the facility to prevent or reduce the risk of transmission. The census was 44. Findings include: Review of CMS QSO-20-29-NH, dated 5/6/20, indicated, Facilities must .Inform residents, their representatives, and families of those residing in facilities by 5:00 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other.Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered; and . Include any cumulative updates . During 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 record review, interviews, and review of the facility policy titled, Baseline Care Plan, the facility failed to develop a baseline care plan for five of five residents (R) (R#242, R#1, R#40, R#193, and R#141), out of 20 sample residents Findings include: Review of the facility's policy titled Baseline Care Plan dated 1/1/21 revealed The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident . A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: a. The initial goals of the resident. b. A summary 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 record review, observation, interviews, review of the Resident Assessment Instrument (RAI), and review of the facility policy titled, Comprehensive Care Plan the facility failed to develop and implement a person-centered comprehensive plan of care with measurable goals and timeframe's to meet resident needs for five of 20 residents (R) (R#29, R#12, R#40, R#1, and R#141) reviewed for care planning. Findings include: Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, dated 10/19, indicated, . Care Area Assessment (CAA) Process. This process is designed to assist the assessor to systematically interpret the information recorded on the MDS . The CAA process helps the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident . Specific components of the CAA process include: - Care Area Triggers (CATs) are specific resident responses for one or a combination of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the admission Record, revealed R#1 was admitted on [DATE]. Review of R#1's physician orders (PO) dated 5/12/22, revealed Droplet Precautions x 10 days every shift for 10 Days and review of the Medication Administration Record (MAR) revealed the droplet precautions were schedule for completion on the end of the day shift, 3:00 p.m., on 5/22/22. Observation on 5/22/22 at 10:59 a.m. revealed outside R#1's room there were signs for Contact & Droplet Precaution and CDC signs for how to properly don and doff PPE. Continued observation on 5/22/22 revealed R#1 was taken to the therapy room without a mask by Physical Therapist (PT) VV who was only wearing a surgical mask and no gown or gloves. Continued observation revealed PT VV worked with R#1 for a half-hour and transported R#1 back to his room, without a gown or gloves. Interview on 5/22/22 at 11:34 a.m. with PT VV stated that R#1 has been on quarantine for more than 10 days, so he knew that he did not need to wear PPE. During an additional observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer three of five residents (R) (R#11, R#26, and R#241) reviewed for influenza/pneumonia vaccinations. Specifically, the facility failed to offer R#11, R#26, and R#241 and/or their representative the opportunity to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) or Prevnar 20 (PCV20) in accordance with nationally recognized standards. In addition, the facility's pneumococcal vaccination data was not updated to reflect current CDC guidelines dated 1/27/22. Findings include: Review of the CDC guidance titled Use of 15-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2022 dated 1/27/22 revealed Adults aged 65 years who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive 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 record review, interview, and policy review, the facility failed to ensure that the staff COVID-19 vaccination rate was 100%, and that the facility's COVID-19 Vaccination Policy for staff was in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. The census was 44. Findings include: Review of CMS QSO- 22-07-All-Revised revised on 4/5/22 revealed, . the regulations and guidance described in this attachment apply to all states. Implementation of this guidance will occur according to the timeframe's and parameters identified in either QSO-22-07-ALL-Revised effective 12/28/21, QSO-22-09-ALL- Revised effective 1/14/22, or QSO-22-11-ALL-Revised effective 1/20/22, . Long Term Care and Skilled Nursing Facility Attachment A . The facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for…

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 interviews, the facility failed to ensure written information on advance directives was provided to two of four residents (R), (R#12 and R#1), reviewed for advance directives. Findings include: Review of a document included in the facility's admission packet titled Acknowledgement and Consents, revealed Resuscitation.The policy of this Healthcare Facility is to initiate Cardiopulmonary Resuscitation (CPR) as a resuscitation procedure to restore breathing and/or heartbeat if I am found to be in Cardiopulmonary arrest, except when my attending physician has documented a valid Do Not Resuscitate (DNR) order on my permanent record. Review of this document revealed no information on what constitutes an advance directive and/or any instructions on how to develop an advance directive. 1. Review of clinical record revealed R#12 was admitted to the facility on [DATE] with a diagnosis of end stage renal disease. Review of R#12's admission Minimum Data Set (MDS) with an Assessment Reference Date…

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, interviews, and review of the facility policy titled Restraint Free Environment the facility failed to assess one resident (R) (R#141) for the safe use of a medical hand mitten (used to hinder disrupting medical treatment such as pulling out tubes) and/or an arm/hand restraint prior to implementation, failed to ensure there were physician orders to apply and remove restraint. In addition, the facility failed to obtain consent for the use of the restraint and failed to re-evaluate the continued use of the restraint. Findings include: Review of a facility policy titled Restraint Free Environment, dated 5/22/22, indicated It is the policy of this facility that physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner unless the resident has previously made a valid refusal of the treatment in question. A physician's order alone is not sufficient to warrant the use of a physical restraint. 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, record review, and review of the facility policy titled Abuse, Neglect, and Exploitation, the facility failed to implement the facility abuse policy by failing to ensure the references for the Administrator were checked prior to employment. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation, dated 9/28/21, indicated . The components of the facility's abuse prohibition plan are discussed herein. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property.Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants . Review of the employee file for the Administrator indicated the date of hire was 6/29/20. The Administrator's employee file did not include evidence that a reference check for employment was completed prior to employment. During an interview on 5/24/22 at 2:48 p.m., Human Resources confirmed there were no employment…

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, interviews, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to ensure a thorough investigation was completed for an injury of unknown origin for one of three residents (R) R#1, reviewed for accidents. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation, revised on 9/28/21, directs Possible indicators of abuse include . Physical injury of a resident, of unknown source . An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . written procedures for the investigation include . identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Review of the clinical record revealed R#1 was admitted on [DATE] with diagnoses of fractures and other multiple traumas, coronary artery disease, dementia, and depression. 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, observation, interviews, and review of the facility policy titled, Fall Prevention Program, the facility failed to ensure one resident (R) (R#29) of three residents reviewed for accident hazards, identified potential risk factors to prevent further falls. Findings include: Review of facility policy titled Fall Prevention Program, dated 5/22/22, indicated . Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . The facility utilizes a standardized risk assessment for determining a resident's fall risk . The risk assessment categorizes residents according to low, moderate, or high risk . For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment . Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall…

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, staff interviews, and review of facility policies, the facility failed to assess nutritional status after a significant weight loss and failed to notify the physician of the weight loss for one resident (R) (R#29), of three residents reviewed for nutrition. Findings include: Review of the facility policy titled Nutritional Management, dated 11/19/21, indicated . The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition . A systematic approach is used to optimize each resident's nutritional status . Identifying and assessing each resident's nutritional status and risk factors . Evaluating/analyzing the assessment information . Developing and consistently implementing pertinent approaches . Monitoring the effectiveness of interventions and revising them as necessary . Review of the facility policy titled Weight Monitoring, dated 11/19/21, indicated . Based on 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 record review, staff interview, and review of the Facility Assessment, the facility failed to conduct and document a comprehensive facility-wide assessment to evaluate the characteristics of the resident population, community resources, and risks and failed to develop a plan to address these factors and deploy their resources in the most effective manner to maintain safety and security for all facility residents. The census was 44. Findings include: Review of the Facility Assessment revealed the purpose is to determine what resources are necessary to care for the residents competently during day-to-day operations and emergencies. Review of the Facility Assessment revealed it was not completed in its entirety and was not signed by the Administrator or approved by the Quality Assurance (QA) Committee. Further review revealed the Facility Assessment failed to address the following pertinent characteristics affecting day-to-day operations: 1. The specialized training and competencies of the staff who work in the facility, such as a certified wound care professional, infection…

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.