Kula Hospital

Based on observation, staff interview, record review, and review of equipment service manual, the facility failed to follow routine maintenance cleaning of the cabinet filter, based on the manufacturer's recommendation. This deficient practice put one Resident (R) 8 at risk for the development and transmission of communicable diseases and infections. Findings include: During resident observation on 06/03/24 at 11:45 AM, R8 was receiving oxygen via a Perfecto2 V Oxygen Concentrator. The cabinet filter of that oxygen concentrator appeared to have lint and/or dirt on the cabinet filter. During staff query on 06/05/23 at 01:50 PM, Director of Nursing (DON) said that they clean the cabinet filter once a month. Informed DON that according to the service manual, for this equipment, the recommendation for cleaning is at least once a week. DON acknowledged and revealed that there was a previous change in oxygen concentrator equipment. Review of the Service manual for the Perfecto2 V Oxygen Concentrator, Section 6 - Preventive Maintenance read the following: Cleaning the cabinet filter. There…

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 reviews the facility failed to update their facility assessment as required annually or when there is a change that would require a substantial modification to any part of the assessment (i.e. staffing shortage, COVID-19 outbreak). The facility assessment provides a comprehensive inventory of resources that are necessary to care for its residents competently during day-to-day operations and during emergencies. This deficient practice renders the administrative and management staff the inability to assess for potential system failure(s). Findings include: Cross reference to F725 Sufficient Nursing Staff. On 05/30/23 at 10:30 AM, the state agency (SA) was informed that the facility had an ongoing COVID-19 outbreak, with 13 of 27 residents positive for the infection on a nursing unit. The entire nursing floor was placed on Enhanced Droplet Isolation, meaning all the doors were kept closed, and all staff needed to ensure they were wearing a gown, gloves, an N-95 respirator, and a face shield prior to entering any resident room. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures for COVID-19, linen is processed as to prevent the spread of communicable diseases and infections. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (TBP) by wearing the proper personal protective equipment (PPE), as well as follow standard precautions by consistently performing hand hygiene. In addition, the facility failed to track and monitor that staff's COVID-19 testing was consistently conducted to minimize the risk of continued transmission of COVID-19 during a facility outbreak. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility. Findings include: 1) On 05/10/23 an anonymous complaint (ACTS #10276) was received by the state agency (SA) alleging infection control concerns. On 05/30/23, the SA entered the facility to conduct 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 observations, interviews, and record review, the facility failed to ensure a comprehensive person-centered care plan was developed and/or implemented for three of nineteen residents (Resident (R)34, R27, and R21) sampled. An intervention to apply compression stocking to reduce swelling in R34's lower extremities was not implemented as documented in the comprehensive care plan. Behavioral and skin care interventions were not implemented for R27. R21's chronic joint pain and refusals of care were not addressed. As a result of this deficient practice residents are at risk of negative outcomes and a potential for harm. Findings include: 1) Multiple observations (05/30/23 at 12:54 PM and 01:45 PM; 05/31/23 at 09:15 AM, 11:21 AM, and 01:42 PM) were made of R34 with no compression stockings applied to the resident's lower extremities. On 05/31/23 at approximately 11:21 AM, Physician (P)1, Licensed Nurse (LN)128, and Nurse Manager (NM)19 were at R34's bedside evaluating a wound on the resident's foot. R34…

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 there was sufficient nursing staff to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, in addition to their physical, mental, and psychosocial well-being. As a result of this deficient practice, the residents were placed at risk of a decreased quality of life and were unable to attain their highest practicable well-being. Findings include: (Cross Reference to F604- Physical Restraint) 1) The Office of Health Care Assurance received an anonymous compliant, Aspen Complaints Tracking System (ACTS) #10212, which included an allegation of insufficient staffing. Observations were made throughout the survey of wedges used as restraints to prevent three high fall risk residents (Resident (R)82, R33, and R193) from exiting the bed. Interview with four facility staff occurred throughout the recertification survey. Facility staff requested to remain anonymous…

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

Based on observation and interview, the facility failed to ensure a resident's right to a dignified existence for Resident (R)79. While providing care, Staff(S)45's interaction included verbal taunting which elicited a stressed response from R79. As a result of this deficient practice, residents are at risk for the potential of psychosocial harm. Findings include: While conducting observations on the second floor, observed S45 providing care and interacting with R79. The verbal interaction with the resident included staff informing the resident he/she was going to move into another position, when resident asked why, staff's response was Why, What! R79 stated Owww, why you do that? S45 responded to R79 in a sharp/harsh, irritated tone, Why, what do you mean? I am going to cut all your hair off, lean your head forward R79 began making whining noises. S45 then stated, So I can brush the back of your hair, then I'm gonna cut your hair off! R79 sounding upset and replied, what? why?. S45 wheeled R79 into the hallway and saw this surveyor. After S45 became aware of this surveyor'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to formulate an advance directive for two of three residents sampled. The deficient practice disregards the residents right to make important decisions about end-of-life treatment when the individual may be incapacitated. Findings include: On 05/31/23 at 12:01 PM during a review of the medical record for Resident (R)86, there was no Advanced Health Care Directive (AHCD) found. On 06/01/23 at 10:29 AM the minimum data set (MDS) admission assessment dated [DATE] was reviewed. Section C reviewed. Brief interview for mental status (BIMS) score is 13 (which indicates high cognitive funtion). Active diagnosis, congestive heart failure, (CHF) and Non-traumatic brain injury. admission History and Physical (H & P) dated 12/08/2022 was reviewed. [AGE] year-old male who suffered cardiac arrest, respiratory failure with resultant brain injury. R86 was admitted for skilled physical therapy (PT) services to increase strength and balance and increase 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 observations, interviews, and record review, the facility failed to ensure the resident's right to be free from physical restraints was being followed for three of three residents (Resident (R)82, R33, and R193) sampled. Observed positioning wedges placed at the (lower end) of both bedrails, adjacent to the resident's body which restricted the resident's willful movements and confine the residents to their bed. Interviews with staff verified the wedges were used to prevent the residents from exiting the bed. The resident's medical record (MR) did not include any information in the assessment, physician orders, or care plan related to the use of wedges for positioning. As a result of this deficient practice, residents are at risk for potential or physical and psychosocial harm and/or serious injury. Findings include: (Cross Reference to F725- Sufficient Nurse Staffing) 1) On 05/30/23 at 11:58 AM, conducted an observation of R82 in the resident's room. Observed R82 lying in bed, flat on her back, both bed…

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 (RR), the facility failed to develop a baseline care plan that provided effective and person-centered care for one Resident (R)41 of 19 residents in the sample. Specifically, despite identifying the residents' immediate needs, the facility failed to develop and implement resident-specific interventions that addressed those needs. This deficient practice has the potential to affect all newly admitted residents at the facility. Findings include: R41 is a [AGE] year-old female originally admitted to the facility on [DATE]. R41 was briefly transferred to the swing unit and readmitted to the long-term care unit on 05/26/23. On 05/30/23 at 11:35 AM, observations were done in the room of R41. The entire room was on isolation related to COVID-19, with the room door closed. R41's bed alarm was loudly alarming as R41 was observed steadily walking towards the room door. Hospital Aide (HA)108 attempted to stop her, however, R41 was angry, argumentative, and insistent on…

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

Based on interviews and record reviews, the facility failed to ensure a resident who is unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good personal hygiene for one Resident (R)12 sampled. R12 is dependent on staff for showers, did not receive a shower for two weeks and reported feeling unkept and unclean. As a result of this deficient practice, dependent residents are at a potential risk of psychosocial harm and potential physical harm because of unmet needs. Findings include: On 05/30/23 at 12:35 PM, conducted an interview with R12. During the interview R12 was alert and oriented to person, place, time, and situation, and responded to questions cognitively appropriate. R12 reported he/she is scheduled to have showers twice a week (Wednesdays and Saturdays) and had not recently received a shower. R12 confirmed he/she had not refused the opportunity to shower and looks forward to the task as it makes him/her feel good. R12 reported that he/she looks forward to showering. R12 stated that he/she is dependent on staff for showers,…

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

Based on observation and interview, the facility failed to ensure its nurse staffing information posted on the third floor contained the required data elements. Specifically, the posted nurse staffing information did not contain the facility name, unit census, and actual hours worked, on any of the survey days, and did not contain the date on the first day of the survey. Findings include: On 05/31/23 at 08:42 AM, an interview was done with Charge Nurse (CN)106 at the third floor Nurses' Station. When asked about the required posting of nurse staffing information, CN106 directed the state agency to an 8 x 12 inch white board placed at the beginning of the unit near the elevators. CN106 explained that normally the night shift completes the staffing board before the end of their shift. Observed four columns and two rows on the board. The top row was left blank. The second row had D [day shift], E [evening shift], N [night shift]. The first column had position titles, and the remaining columns had whole numbers ranging from 0 to 4 written under the D, E, N for the three shifts. No 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.

Based on observations, record reviews, and interviews, the facility failed to provide a complete and accurately documented medical record of one resident (R), R21, out of a sample of 19 residents. Rehabilitation Services Supervisor (RSS)22 did not document that R21's referral for an occupational therapy (OT) evaluation for R21's complaint of pain was received and the reasons for the delay of services. This deficient practice could potentially have R21 be lost to appropriate follow up of necessary services. Findings include: On 05/31/23 at 09:07 AM, observation and interview were done with R21. R21 was sitting in her wheelchair, and she stated that she has chronic joint pain for which she takes scheduled pain medication around the clock for and tries to minimize joint movement for pain management. Record review of R21's paper chart revealed a Situation-Background-Assessment-Recommendation-Communication document from nurse to physician dated 04/26/23 at 3:00 PM. The document noted that R21 had left shoulder pain related to a torn rotator cuff (a group of muscles and tendons…

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

Based on observation and interviews, the facility failed to implement an effective pest control program so that the facility is free of pest. As a result of this deficient practice, residents are at risk for potential harm related to disease spread by pest. Findings include: The Office of Health Care Assurance received an anonymous compliant, Aspen Complaints Tracking System (ACTS) #10212, which included an allegation of a cockroach infestation throughout the hospital. On 06/01/23 at 11:32 AM, while conducting an observation of the 4th floor resident's nourishment kitchen with Licensed Nurse (LN)62. The nourishment kitchen includes resident snacks, resident refrigerator, stacked washer dryer, a sink, and trash bin. While inspecting the stacked washer/dryer, LN62 and this surveyor observed a German cockroach crawl out from behind the paper towel dispenser, go up the wall approximately on foot, then return behind the paper towel dispenser. On a wire storage rack (with clear heavy-duty hard plastic plexi shelves on top of the wire rack) and plastic storage bins with drawers on top of…

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

Based on observation, interview, and record review, the facility failed to ensure staff conducting point-of-care (POC) COVID-19 outbreak testing on themselves conducted the testing in a manner consistent with current standards of practice for conducting COVID-19 tests. As a result of this deficient practice, the facility placed the residents and staff at an increased risk of COVID transmission. This deficient practice has the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility. Findings include: On 06/27/22 at 10:07 AM, observed four staff members outside the main entrance taking turns at two testing stations, swabbing themselves for COVID-19. There were no gloves or personal protective equipment (PPE) worn by any of the four staff members while testing and/or handling the test kits. There was no cleansing or wiping down of the testing stations observed between uses, nor were there any cleaning supplies available at the testing stations. On 06/30/22 at 09:07 AM, an interview was done with the Infection Preventionist…

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 protect one resident's right to be free from abuse from other residents. As a result of this deficient practice, Resident (R)22 was observed by staff hitting R23 in the left temple, without provocation. This deficient practice has the potential to affect all residents in the facility. Findings include: On 06/29/22 at 09:50 AM, conducted a record review (RR) of a facility-reported incident (ACTS #9575) documenting a resident-to-resident abuse allegation occurring on 06/09/22. Per the completed facility report received by the State Agency (SA) on 06/13/22, At 0845 this morning, Resident [R23] . was in his wheelchair . [Resident 22] exited his bed, headed toward the bathroom . suddenly turning toward [Resident 23] . and striking him on his (L) [left] temple. During a review of the facility's Resident to Resident Abuse Allegation Checklist, completed by Charge Nurse (CN)1 on 06/09/22, the following was noted: Pt [patient] B [R22] got frustrated & hit Pt A [R23] because Pt A makes noise occasionally. A review of the facility'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview with staff members, the facility failed to assure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment for two (Residents 4 and 37) of 18 residents in the sample Findings include: 1) On 06/28/22 at 01:00 PM observed Resident (R)4 ambulating in the hall wearing long pants and a shirt with stand by assist. On the morning of 06/29/22 observed R4 ambulating in the hall dressed with long pants. Record review on 06/30/22 at 07:58 AM found a physician's order for onsie suit/clothing to help with or control behavioral urges (i.e. exposes self to others). A review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 03/18/22 notes in Section P. Restraints (physical restraints are any manual method or physical or mechanical equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body)…

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, interviews, and record review, the facility failed to ensure a comprehensive person-centered care plan that includes measurable objectives and timeframe to meet the resident's medical, nursing, and psychosocial needs identified on the comprehensive assessment was developed for one of 18 residents sampled, Resident (R)62. Findings include: On 06/27/22 at 11:11 AM, observed R62 in the 3rd floor dining room, seated in a wheelchair with a bedside table in front of the resident, and a catheter bag attached to the bottom of the wheelchair seat. The catheter tubing was observed to be coming out the bottom of R62's left pant leg on the ground. Approximately 9-12 inches of tubing was in direct contact with the ground before the tubing was threaded through metal center bars (located under the wheelchair seat) elevated the catheter tubing off the ground. The catheter tubing that was on the floor also ran under a base leg of the bedside table (between two wheels). On 06/27/22 at 12:30 PM, an interview…

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 review and interview with staff members, the facility did not provide necessary services for a resident who is unable to carry out activities of daily living to maintain good grooming. Findings include: On 06/27/22 observed Resident (R)12 in bed with Certified Nurse Aide (CNA)4 at bedside. CNA was planning to assist R12 with lunch and was raising the head of the resident's bed. Suddenly R12, tossed off her blanket and said shit and stated that she wanted to go home. R12 swore a couple more times and repeated that she wanted to go home. R12 sat up on the side of her bed and looked down at her feet and stated something is wrong with her feet. Observed, R12's toe nails were white, thick, and long. CNA4 attempted to assist R12 to put on her house slippers, she refused, and again said something is wrong with her feet. R12's feet looked swollen. Record review on 06/29/22 at 11:16 AM found a physician order for triamcinolone cream for left foot rash/intertrigo (inflammatory rash of the superficial skin that occurs within a person's body folds) for fourteen…

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 and record review, the facility failed to provide adequate supervision while a resident wandered on the unit. Resident (R)12 was observed wandering on the unit and entered another residents' room. This has the potential to be unsafe as it may lead to an altercation. Findings include: R12 was admitted to the facility on [DATE] from an acute hospital. Diagnoses includes but not limited to right intertrochanteric hip fracture, dementia, osteoporosis, hypertension, and depression. On the afternoon of 06/27/22, R12 was observed seated in her wheelchair and wheeling herself on the unit. Initially the Minimum Data Set Coordinator (MDSC)2 walked alongside R12 and engaged her in conversation. MDSC2 left R12 and she was observed wheeling alone on the unit. R12 was observed to wheel into room [ROOM NUMBER] where R33 and R47 resides. The male resident in the bed closest to the door was not in the room. The curtains were drawn closed around the bed furthest from the door. A male resident was observed…

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 resident was assessed for risk of entrapment from bed rails, review of the risk and benefits of bed rails with the resident representative, and obtain an informed consent for the use of bed rails for one resident (Resident (R)24) sampled. Findings include: On 06/27/22 at 02:24 PM and 06/28/22 at 09:35 AM, observed R24 resting in bed. During both observations, the right side of R24's bed was placed against the wall with the top left bedrail up. Certified Nurse Aide (CNA)4 was sitting near R24's bed and was asked about the resident's bed being up against the wall and the use of the bed rails. CNA4 stated that there was an order for the bed to be placed against the wall and the bedrail is up because R24 is impulsive, and it prevents the resident from falling out of the bed. During an interview with R24's resident representative (Family Member (FM)1) on 06/28/22 at 09:40 AM, FM1 stated that consent was given for the facility to use…

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

Based on observation and interviews, the facility failed to ensure infection control practices were implemented for a resident (Resident (R)62) with an indwelling catheter. Findings include: On 06/27/22 at 11:11 AM, observed R62 in the 3rd floor dining room, seated in a wheelchair with a bedside table in front of the resident, and a catheter bag attached to the bottom of the wheelchair seat. The catheter tubing was observed to be coming out the bottom of R62's left pant leg on the ground. Approximately 9-12 inches of tubing was on the ground before the tubing was threaded through metal center bars (located under the wheelchair seat) and off the ground, then connected to the catheter bag (located at the back bottom of the wheelchair seat). The portion of the catheter tubing that was on the floor, went under one of the base legs of the bedside table (that was in front of the resident). The way the leg of the bedside table was positioned, it appeared that staff had ran over the catheter tubing with the wheels of the bedside table. On 06/27/22 at 12:30 PM, an interview was conducted…

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.