Parkview Care Center

Based on document review, and staff interviews the facility failed to employ a Certified Dietary Manager to carry out the functions of the food and nutrition service. The facility reported a census of 47 residents. Findings include: During an interview on 08/13/24 at 11:00 AM, the Dietary Supervisor stated she did not have education and training completed to be a Certified Dietary Manager. She stated she enrolled and began the class to be certified over a year ago but had not completeted the course work. A review of the Dietary schedule for July 21, 2024 to August 3, 2024 revealed the Dietary Supervisor scheduled to work: 7/21/24, 7/23/24, 7/24/24, 7/28/24, 7/29/24, 7/30/24, and 8/3/24. During an interview on 08/13/24 at 3:30 PM, the Administrator confirmed the facility did not employ a Certified Dietary Manager but had her enrolled in the program to become a Certified Dietary Manager.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, the facility failed to provide an effective rodent control program within the facility. The facility reported census was 44 residents. Findings include: In an interview on 4/18/24 at 10:40 a.m. Staff N, Housekeeper, stated she has worked at the facility for three months and during that time mouse infestation has been an on-going issue. Staff N stated she had observed multiple mice in resident rooms and frequently sees droppings when sweeping. Staff N stated just today she swept up mouse droppings in room [ROOM NUMBER] on B-hall. Staff N stated they are to check the glue traps daily, but noted it had been so bad the mice are chewing on the traps and don't seem to be sticking to the glue. Staff N stated the residents in room [ROOM NUMBER] and 113 on B-hall have both complained about seeing mice in their room. Staff N stated she heard an aide, Staff M, witnessed seeing a mouse on the lap of a resident in room [ROOM NUMBER] on B-hall. In an interview on 4/18/24 at 1:30 p.m.…

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 the clinical record review, staff interviews, and facility policy review, the facility failed to implement a Legion Water Management Program. The facility reported a census of 47 residents. Findings include: During an interview on 2/13/24 at 10:24 AM, Staff Q, Maintenance queried on documentation for water temperatures and he stated the water heaters only went up to 110 degrees. Staff Q stated he only visualized the temperatures and never documented them. When asked Staff Q what he did for Legion, he stated no one spoke to him about Legion. Staff Q stated he received a policy from another facility a couple of days ago. When asked Staff Q what he did when rooms vacant, he stated he checked them out before someone moved into them. The Legion Map Surveillance (no date identified) revealed the following information: a. where the water located b. the direction of the water flow c. where the water heaters located The Legion Map Surveillance lacked documentation of where showerheads, hoses, fountains, and filters located. The facility lacked documentation for locations of possible…

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, policy review, and staff interviews the facility failed to prepare foods under sanitary conditions for 1 of 2 days of kitchen observation. The facility reported a census of 47 residents. Findings include: On 2/13/24 at 11:15 AM observed Staff F, Dietary, put her hand in her left pocket and take out a pen and a marker while wearing a serving glove. She wrote on the foil covering a pan of hot food. Still wearing the glove, Staff F placed the marker back in her left pocket. She then picked up a pan of rice with her gloved hand and her bare right hand. She opened the oven with her bare right hand and placed the pan in the oven. She picked up another pan her gloved hand and opened a drawer with her her right hand. Staff F then picked up cooked chicken pieces with the same glove and put them in another pan. She covered the pan with foil and carried it to the stove. Staff F then threw the glove away and used hand sanitizer. She then put her hand back in her pocket and took out a marker which she used to label more tinfoil. She put her left hand back in her pocket…

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 clinical record review, staff interviews, and facility policy review, the facility failed to offer the influenza vaccine annually to 2 out of 5 residents reviewed; and failed to offer the pneumococcal vaccine at recommended times to 4 out of 5 residents reviewed for influenza and pneumococcal vaccinations (Resident #1, #2, #4, #24). The facility reported a census of 47 residents. Findings include: 1. The Preventative Health Care Report revealed the following information for Resident #4: a. pneumococcal vaccine administered 9/4/20 from an outside source. The Iowa Registry Immunization Record revealed resident received the Pneumococcal 23 on 9/4/20. The IRIS revealed 1 of 2 dose series. The facility lacked documentation of consent or declination forms for Resident #4 for the pneumococcal vaccine. 2. The Preventative Health Care Report revealed the following information for Resident #2: a. Influenza administered on 11/8/22 The facility consent form for influenza and pneumococcal signed on 11/8/22 by Resident #2 revealed resident consented for influenza and pneumococcal…

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, clinical record review, policy review, and staff interview, the facility failed to honor a resident's food and beverage preferences for 1 of 16 residents reviewed during dining services (Resident #1). The facility reported a census of 47 residents. Findings include: The facility policy Resident Food Preferences, revised July 2017, stated individual food preferences would be assessed upon admission and communicated to the interdisciplinary team and the Food Services Department would offer a variety of foods at each scheduled meal. The Care Plan approach dated 1/27/22 directed staff to encourage fluids throughout the day. The Minimum Data Set (MDS) assessment tool, dated 11/24/23, listed diagnoses for Resident #1 which included cerebrovascular accident(stroke), schizophrenia, and hypertension(high blood pressure). The MDS stated the resident was independent with eating and listed her Brief Interview for Mental Status(BIMS) score as 5 out of 15, indicating severely impaired cognition. On 2/13/24 at 8:30 a.m., observed the resident sitting at the breakfast table…

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, clinical record review, staff interviews, and policy review the facility failed to notify a resident's responsible party and hospice provider in a timely manner when an injury occurred for 1 of 3 residents reviewed (Resident #46) for notification. The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) for Resident #46 dated 1/5/24 indicated a significant change related to a decline in health and the start of hospice care. It included diagnoses of heart failure, post traumatic stress disorder, and chronic obstructive pulmonary disease. The Brief Interview for Mental Status documented a score of 7 which indicated severe cognitive impairment. The Care Plan with a care conference date of 12/7/23 documented impaired decision making and a history of falling related to dementia with a hospice consult on 12/28/23. On 2/12/24 at 1:07 PM observed the resident finished meeting with a hospice provider and laying in bed. Resident #46 stated his knee hurt. He pulled up the bottom of his covers and pant leg to show an open wound about 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 clinical record review, policy review, facility document review, and staff interviews, the facility failed to ensure a resident was free from physical abuse for 1 of 2 residents reviewed for abuse (Resident #38). The facility reported a census of 47 residents. Findings include: The facility policy Abuse, revised 8/31/16, stated the facility would not permit residents to be subjected to abuse by any person and defined abuse to include willful infliction of injury. The Minimum Data Set (MDS) assessment tool, dated 12/1/23, listed diagnoses for Resident #38 which included hypertension, depression, and hyperlipidemia (a high level of fat in the blood). The MDS stated the resident required partial to moderate assistance for bathing, dressing, and personal hygiene. The MDS stated the resident had physical behavioral symptoms directed toward others such as hitting and kicking 4-6 days during the 7 day review period and displayed rejection of care daily. The MDS listed the resident's cognition as severely impaired. Care Plan entries, dated 12/7/23, documented the resident often…

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 clinical record review, staff interviews, and facility policy review, the facility failed to complete Minimum Data Set (MDS) assessments on time for 3 of 14 residents reviewed for MDS assessments (Resident #2, #29, and #41). The facility reported a census of 47 residents. Findings include: 1. The MDS Quarterly assessment dated [DATE] for Resident #2 revealed an assigned Assessment Reference Date (ARD) of 8/18/23 and the Omnibus Budget Reconciliation (OBRA) ARD date of 8/12/23, with a completion due date of 9/1/23. The record review revealed the MDS assessment had not been submitted as of 2/15/24. During an interview on 2/15/24 at 9:08 AM, the MDS Coordinator queried on Resident #2 MDS assessment dated [DATE] and she stated she didn't do that assessment and someone started the assessment but didn't finish it. The MDS Coordinator stated her expectation for MDS assessments is to be completed within 14 days from the 8/18/23 date. During an interview on 2/15/24 at 12:40 PM, the Director of Nursing (DON)…

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 clinical record review, staff interviews, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) Assessment for a resident's (Preadmission Screening and Record Review) Level II PASRR for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 scored a 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The Annual MDS dated [DATE] revealed the resident wasn't currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The record review revealed Resident #4 Level II PASRR completed on 9/22/22. During an interview on 2/15/24 at 9:08 AM, the MDS Coordinator queried on Resident #4 MDS dated [DATE] and she confirmed the MDS needed coded to reflect the resident currently considered a PASRR Level II. During an…

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 clinical record review and staff interviews the facility failed to submit a Preadmission Screening and Resident Review (PASRR) related to a new diagnosis for 1 of 3 residents reviewed for PASRR level II screening (Resident #41). The facility reported a census of 47 residents. Findings include: A Minimum Data Set (MDS) assessment for Resident #41, dated 9/22/23, documented a diagnosis of non-Alzheimer's dementia and did not include any psychiatric/mood disorders. The MDS assessment dated [DATE] for the resident documented diagnoses of Parkinson's disease and unspecified dementia of unspecified severity without behavioral disturbance. It did not include any psychiatric/mood disorders. The MDS assessment dated [DATE] documented diagnoses of non-Alzheimer's dementia, Parkinson's disease, and psychotic disorder other than schizophrenia. The PASRR dated 10/11/23 indicated the outcome was Level 1 negative, no status change. It documented no mental health diagnosis was known or suspected, and no known mental…

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 clinical record review, staff interviews, and facility policy review, the facility failed to revise the care plan for a resident with a significant weight loss and an opioid pain medication and didn't address an antipsychotic with a new diagnosis for 2 of 14 residents reviewed for care plans (Residents #34 and #41). The facility reported a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 scored a 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS revealed diagnosis of fracture of unspecified part of neck of left femur, subsequent encounter. The MDS revealed the resident received an opioid. The Electronic Medical Record (EMR) revealed the following diagnosis: a. pain, unspecified b. fracture of unspecified part of left femur, subsequent encounter for closed fracture with routine healing. The Physician Orders revealed the following orders: a. Fentanyl patch 72 hour 12…

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 interviews, clinical record review, and facility policy review, the facility failed to use professional standards by not cleaning the rubber seal of an insulin pen with an alcohol pad or priming the insulin pen prior to administration for 1 of 2 residents observed for insulin administration (Resident #7). The facility reported a census of 47 residents. Finding include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 scored a 7 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS revealed the diagnosis of diabetes mellitus and the resident received insulin injections 7 out of 7 days. The Care Plan revealed a focus area revised on 10/19/23 for diabetes mellitus. The Electronic Medical Record (EMR) revealed the following diagnosis: a. diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma The Physician Orders revealed the following…

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, clinical record review, policy review, resident interview and staff interviews, the facility failed to provide incontinence care for 1 resident (Resident #1) and nail care for 1 resident (Resident #28) for 6 residents reviewed for assistance with activities of daily living (ADLs). The facility reported a census of 47 residents. Findings include: 1. The facility policy Perineal Care, revised February 2018, stated the purpose of perineal care, to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The Care Plan focus dated 1/27/22 stated Resident #1 had bladder incontinence related to decreased mobility and wore briefs. The Care Plan directed staff to provide incontinence care after each incontinent episode. The Minimum Data Set (MDS) assessment tool, dated 11/24/23, listed diagnoses for Resident #1 which included cerebrovascular accident (stoke), schizophrenia, and hypertension (high blood pressure). 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, clinical record review, policy review, and staff interviews, the facility failed to regularly assess a wound and notify the provider of changes in the wound, and failed to intervene in a timely manner after a critical lab result for 1 of 4 residents reviewed for a change in condition (Resident #21). The facility reported a census of 47 residents. Findings: The facility policy Wound Care, revised October 2010, stated the policy provided guidelines for the care of wounds to promote healing and stated the resident's record should include characteristics such as the wound color, size, and drainage. The facility policy Change in a Resident's Condition or Status, revised May 2017, stated the facility would promptly notify the physician of changes in the resident's medial condition. A 6/30/22 Care Plan entry stated staff would assess the resident's skin on shower days with quarterly assessment, and as needed. The entries directed staff to report any reddened or compromised areas to nursing. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and the facility policy review, the facility failed to supervise a resident in their room while they sat in a shower chair which resulted in a fall from the shower chair for 1 of 4 residents reviewed for falls (Resident #2). The facility reported a census of 47 residents. Finding include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 scored a 15 out of 15 on the Brief Interview for Mental Status exam, which indicated cognition intact. The MDS revealed impairment of both sides of the lower extremities and resident used a wheelchair. The MDS revealed the resident dependent with toileting hygiene and while transferred from chair/bed to chair. The MDS revealed resident needed substantial/maximal assistance with shower and bathing. The MDS revealed a diagnosis of traumatic brain dysfunction. The Care Plan revealed a focus area dated 12/4/23 for a history of falling related to weakness and needed assistance with transfers. The interventions…

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, clinical record review, staff interviews, and facility policy review the facility failed to address a resident weight loss in a timely manner and offer different options at meal times to encourage adequate nourishment for 1 of 2 residents reviewed for weight loss (Resident #34). The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 scored a 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The Care Plan revealed a focus area for a therapeutic regular mechanical soft diet dated 9/19/23. The interventions dated 9/19/23 revealed the resident provided with as much control as possible in routine and food preferences. The Record Review revealed the following information for weight loss: a. On 10/26/2023, the resident weighed 112 lbs. On 12/06/2023, the resident weighed 105 pounds which is a -6.25 % Loss. b. On 12/06/2023, the resident weighed 105…

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 clinical record review, policy review, and staff interview, the facility failed to ensure a resident was seen by a physician every 60 days for 1 of 14 residents reviewed for physician's visits (Resident #45). The facility reported a census of 47 residents. Findings include: The facility policy Attending Physician Responsibilities revised August 2014, stated the physician would see resident every 60 days. The Minimum Data Set (MDS) assessment tool, dated 12/15/23, listed diagnoses for Resident #45 which included non-Alzheimer's dementia, tachycardia (fast heart beat), and pain and listed the resident's Brief Interview for Mental Status (BIMS) score as 7 out of 15, indicating severely impaired cognition. Review of the resident's clinical record revealed a lack of documentation of a provider visit from May 2023 to 2/14/24. On 2/14/24 at 11:23 a.m., the Director of Nursing (DON) stated she called the clinic and the provider did not see the resident since May of 2023. The DON stated the frequency should be every 60 days and the provider would see the resident tonight. On 2/19/24…

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 clinical record review, staff interviews, and facility policy review, the facility failed to administer a Risperidone injection when ordered, which resulted in a behavioral change with the resident for 1 of 8 residents reviewed for medication administration (Resident #4). The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS revealed diagnoses of anxiety disorder, bipolar disorder, and schizophrenia. The MDS revealed the resident received antianxiety, antidepressant, and antipsychotic medications. The Care Plan revealed a focus area dated 3/28/22 and revised on 9/21/23 for resident took Buspar, Mirtazapine, Risperdal Consta, Zoloft, Wellbutrin related to the diagnoses of schizophrenia and bipolar disorder. The interventions dated 3/28/22 revealed to monitor for any behaviors, and monitor 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.

Based on observations, staff interviews, and facility policy review, the facility failed to keep medication carts locked when not in use and staff not around the medication cart and not keeping medication storage rooms keys kept on their persons for 1 of 2 medication carts and 1 of 2 medication storage rooms reviewed. The facility reported a census of 47 residents. Findings include: During an observation on 2/14/24 at 1:48 PM, the medication cart in Hallway A left unlocked and no nurse or residents around the cart. The cart located behind the nurse's desk. A set of keys placed in the medication storage room doorknob. During an observation on 2/14/24 at 1:49 PM, a resident came up in front of the nurse's desk and picked up the cordless phone and made a phone call and walked away. During an observation on 2/14/24 at 1:50 PM, a CNA (Certified Nurse Aide) went behind the nurse's desk and went to the bathroom and walked by the medication cart and didn't lock it. During an observation on 2/14/24 at 1:53 PM, the DON (Director of Nursing) walked behind the nurse's desk and walked by 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 the clinical record review, staff interviews, and facility policy review, the facility failed to offer the COVID (Coronavirus disease) booster vaccination to 2 out 5 residents reviewed for COVID-19 vaccinations (Resident #2 and #4). The facility reported a census of 47 residents. Findings include: 1. The Preventative Health Care Report revealed the following information for Resident #2: a. COVID vaccine administered on 11/18/22 The facility lacked documentation of the COVID booster vaccine been offered to Resident #2 in 2023. 2. The Preventative Health Care Report revealed the following information for Resident #4: a. COVID vaccine administered on 11/18/22 The facility lacked documentation of the COVID booster vaccine been offered to Resident #4 in 2023. During an interview on 2/14/24 at 2:10 PM, the Director of Nursing (DON) queried on how they track vaccines and she stated they received a report from IRIS. When asked the DON how often they offered the COVID booster/vaccine, she stated the pharmacy came down and administered them, they sent a sheet out and the facility…

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.