Orchard View Post Acute

Based on observation, interview, record review, facility menu review, and policy review, it was determined the facility failed to ensure menus were followed as planned for 3 of 3 residents (Resident #16, #25, and #36) reviewed for this concern. This failure had the potential to cause nutritional needs to go unmet for residents who consumed food prepared from the facility's kitchen. Findings include: The facility's policy titled Menus, revised 10/2008, documented, menus will be prepared in advance, meet the nutritional needs of residents, and be followed. 1. The facility's menu for Sunday 10/6/24 documented sweet and sour chicken with Asian stir-fry was planned to be served for the evening meal. Resident #25's MDS assessment on 8/20/24 documented he was cognitively intact. During an interview on 10/8/24 at 2:55 PM, Resident #25 stated on Sunday, 10/6/24, the menu was not served as planned. He stated this tends to happen on the weekends or Monday's because the kitchen did not have the ingredients required to prepare what was on the menu. On 10/9/24 at 12:52 PM, the DM stated he was…

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

Based on observation, interview, test tray review, record review, review of Resident Council Meeting Minutes, and facility policy review, it was determined the facility failed to serve food that was palatable for 7 of 7 residents (Residents' #10, #16, #17, #20, #24, #25, and #26) reviewed for food palatability. This failure created the potential to cause unmet nutritional needs for residents who consumed food prepared from the facility's kitchen. Findings include: The facility's policy titled, Food Preparation, dated 9/27/16, documented, food is stored and prepared by methods that conserve nutritive value, flavor, and appearance to the extent possible and food is prepared according to standardized, yield adjusted recipes by trained staff in order to produce a palatable and attractive meal. 1. On 8/20/24 Resident #25 was assessed to be cognitively intact. On 10/7/24 at 3:40 PM, Resident #25 stated the food served at the facility could be improved and specified the food served at meals did not always taste good and was not always seasoned. 2. Resident #20 was assessed on 10/1/24 to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of Resident Council Minutes, and facility policy review, it was determined the facility failed to offer and provide between-meal snacks to 4 of 4 residents (Residents' #5, #16, #20, and #25) reviewed for snacks and 3 additional residents (Residents' #29, #35, and #42) who participated in the Resident Council Interview. This failure had the potential to cause unmet nutritional needs for residents who resided in the facility. Findings include: The facility's policy titled, Food and Nutrition Services, revised 10/2017, documented nourishing snacks are available to the residents 24 hours a day and the resident may request snacks or snacks may be scheduled between meals to accommodate the resident's typical eating patterns. 1. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including diabetes and chronic obstructive pulmonary disease (COPD). On 9/17/24 Resident #5 was assessed to be cognitively intact. On 10/8/24 at 4:35 PM, Resident #5…

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 interview, and resident interview, it was determined the facility failed to ensure a therapeutic diet was served to 1 of 3 residents (Resident #29) who were prescribed renal diets. This failure placed Resident #29 at risk for complications related to her kidney disease. Findings include: The facility's undated policy titled Therapeutic Diets documented the Dietary Manager will establish and use a tray identification system to ensure each resident receives their diet as ordered. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses including diabetes, and end stage renal disease dependent on renal hemodialysis (a treatment using a machine to replicate kidney function, removing waste from the bloodstream). Resident #29's record documented a physician order, written on 6/12/24, for her to receive a CCHO/Renal (consistent carbohydrate/kidney healthy) diet. Resident #29's dietary meal slip directed the kitchen staff to serve her a Renal/CCHO diet and specified 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, policy review, and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 1 of 1 resident (Resident #42) reviewed for medication errors. This deficient practice created the potential for harm when the facility failed to administer Resident #42's blood pressure medication for four consecutive days Findings include: The facility's Medication Errors policy and procedure, release date January 2023, documented a medication error as any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional, resident, or consumer. Resident #42 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, high blood pressure, and schizophrenia. A nurse progress note, dated 5/18/24, documented Resident #42 continued to have elevated blood pressures and his physician prescribed Losartan 50 mg (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 observation, interview, record review, and facility policy review, it was determined the facility failed to honor known food preferences for 2 of 2 residents (Resident's #10 and #25) reviewed for food choices. This failure created the potential to cause nutritional needs to go unmet for residents who consumed food prepared from the facility's kitchen. Findings include: The facility's policy titled, Food and Nutrition Services, revised 10/2017, documented each resident is provided with a nourishing, palatable, well-balanced diet to meet their daily nutritional and special dietary needs, taking into consideration the preferences of each resident and reasonable efforts will be made to accommodate resident choices and preferences. 1. On 8/20/24 Resident #25 was assessed to be cognitively intact. On 10/7/24 at 3:40 PM, Resident #25 stated his food preferences were noted on his meal tray slip but the kitchen staff did not follow the slip when preparing his meals, so his preferences were not honored. On 10/9/24 at 8:20 AM, Resident #25 was observed in the main dining room waiting…

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 facility document review and staff interview, it was determined the facility failed to meet regulation requirements for the participation of Quality Assessment and Assurance (QAA) committee members in the Quality Assurance and Performance Improvement (QAPI) meetings. This failure had the potential to negatively affect all residents in the facility if quality deficiencies throughout the facility were not identified and responded to timely and appropriately. Findings include: On 10/19/23 at 5:39 PM, the Administrator stated the QAA team was comprised of the Medical Director, Pharmacy Consultant, the Interdisciplinary Team, and department managers. He added meetings were mandatory and to be held at least quarterly, and the facility chose to hold the meetings monthly. The Monthly QAPI Participation sign-in sheets from February 2023 to September 2023, did not include documentation the Medical Director and Pharmacy Consultant participated in the QAPI meeting in February, March, April, May, and June. The Administrator stated he was not able to provide documentation these…

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 policy review, review of grievance logs, and staff interview, it was determined the facility failed to ensure resident grievances were promptly addressed and the responses to the grievances documented. These deficient practices placed residents at risk of ongoing frustration and decreased sense of self-worth, as well as unmet care needs when their concerns were not promptly addressed by the facility. Findings include: The facility's Grievance policy and procedure, revised 3/2019, documented it was the facility's policy to support each resident's right to voice concerns/grievances. The facility should actively seek resolution to concerns and attempt to keep the individual who filed grievance updated on progress toward resolution. This policy further documented the Social Services Director should log all concerns/grievances received onto the facility grievance log, ensure completed with appropriate actions and follow-up, keep a running log of concerns voiced and their resolutions as well as a copy of the completed grievance forms. This policy was not followed. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, resident interview, and staff interview, it was determined the facility failed to ensure pre and post dialysis assessments were completed and accurate, an emergency kit was available at the bedside, and orders were followed for 3 of 6 residents (#25, #29, and #31) who received hemodialysis. This created the potential for adverse outcomes such as acute blood loss from the access site, infection of the access site, electrolyte imbalance, low blood pressure, and anemia. Findings include: 1. Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including hemodialysis (purifying the blood of a person whose kidneys are not working normally) for end stage kidney disease and Type 2 Diabetes. Resident #31 had an AV fistula to her left upper arm for dialysis. An AV fistula is a surgical connection between an artery and a vein for individuals who require permanent access to receive long-term hemodialysis. Resident #31's record…

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 review of staff time sheets, record review, resident interview, and staff interview, it was determined the facility failed to ensure residents received physical therapy services as ordered by their physician. This was true for 1 of 4 residents (Resident #55) reviewed for rehabilitative services. This failure created the potential for all residents in the facility who required physical therapy services to experience a decline in their physical functioning and ability to do ADLs when these services were not provided consistently. Findings include: 1. During a Resident Council meeting on 10/18/23, residents stated the facility had Occupational and Speech Therapy but not Physical Therapy. During the meeting, Resident #55 stated he was told by the DOR he had a list of goals he needed to meet in order to go home. He stated he and his family had not seen the list, even after the goals list was requested by him. Resident #34 stated he moved to the facility because they told him there was a Physical Therapist on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and resident, resident representative, and staff interview, it was determined the facility failed to ensure a resident or their representative participated in establishing the expected goals and outcomes of care. This was true for 1 of 4 residents (Resident #55) reviewed for care plans. This failure created the potential for harm if a resident experienced a decline in physical, mental, or psychosocial functioning due to lack of their input toward their goals. Findings include: The facility's Care Conference policy, last reviewed 2/2019, documented Review of the care plan with resident and/or resident representative shall be documented in EHR [Electronic Health Record]. The policy documented this included the existing care plan was reviewed with the resident or resident's representative at the care conference, and requests for change in regard to their existing care plan was documented. This policy was not followed. Resident #55 was admitted to the facility on [DATE], with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure chest straps were assessed as potential restraints. This was true for 1 of 1 resident (Resident #38) reviewed for restraints. This deficient practice had the potential for adverse outcomes if the chest strap was improperly used and if the resident experienced physical deterioration due to lack of movement. Findings include: The facility's Physical Restraints and Enablers/Devices policy, revised on 7/2023, stated the resident would be assessed for the least restrictive device and if appropriate a consent would be obtained prior to the application of the assistive device. The policy also documented the care plan would be evaluated quarterly and as needed and the resident would be evaluated on admission, re-admission, annually, and with significant change in condition. This policy was not followed. Resident #38 was admitted to the facility on [DATE], with multiple diagnoses including scoliosis (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 facility policy and record review, it was determined the facility failed to ensure information was provided to the receiving facility when a resident was transferred to another long-term care facility. This was true for 1 of 1 resident (Resident #40) reviewed for resident transfer. This deficient practice had the potential to result in adverse outcomes if Resident #40 was not treated in a timely manner due to lack of information provided upon transfer. Findings include: The facility's policy for Transfer or Discharge, dated 4/2020, stated, when the center transfers or discharges a resident .the center documents the transfer or discharge in the medical record and appropriate information is communicated to the receiving care institute or provider. As a minimum the following information is provided: a. Contact information of the practitioner responsible for the care if [sic] the resident. b. Resident representative information, including contact information. c. Advanced Directive information. d. Special…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 1 of 4 residents (Resident #9) whose care plans were reviewed. This placed Resident #9 at risk for adverse outcomes when his care plan was not revised to reflect current services. Findings include: Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including abnormalities of gait and mobility. A care plan, revised on 4/13/21, documented Resident #9 received physical therapy services. A quarterly MDS assessment, dated 7/23/23, documented Resident #9 required extensive assistance with transfers, bed mobility, and toileting. A physical therapy evaluation, signed on 8/10/23 at 8:25 AM, documented Resident #9 was authorized to have physical therapy 2 times a week for 29 days starting on 8/1/23 to 8/30/23. On 10/19/23 at 2:47 PM, the MDS coordinator stated Resident #9 was no longer on physical…

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 staff interview, it was determined the facility failed to ensure physician orders were followed prior to administering medication. This was true for 1 of 7 residents (Resident #254) whose medication records were reviewed. This failure created the potential to adversely affect residents whose care and services were not delivered according to their physician orders. Finding include: Resident #259 was admitted to the facility on [DATE], with multiple diagnoses including high blood pressure and chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow in the lungs). A physician order, dated 10/7/23, documented Resident #259 was to receive Atenolol (anti-hypertensive medication that can slow down the heart rate), 50 mg by mouth two times a day. The order stated to check the heart rate prior to administering the medication. The medication was to be held and the physician notified if the heart rate was less than 50 beats per minute.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to ensure restorative services were provided to increase range of motion and/or to prevent further decrease in range of motion. This was true for 1 of 3 residents (Resident #9) reviewed for restorative services. This failure placed Resident #9 at risk of decline in range of motion and function. Findings include: The facility's Restorative Nursing policy, revised on 2/2018, documented the following: Residents assessed with deficits in communication, mobility, range of motion, performance of ADLs, eating or toileting will receive necessary care and services to attain and maintain their highest practicable physical, mental and psychosocial well-being. This policy was not followed. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including abnormalities of gait and mobility. Resident #9's care plan, revised on 5/22/23, documented Resident #9 was receiving restorative services to maintain range…

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, policy review, record review, and resident and staff interview, it was determined the facility failed to ensure physician orders and indication for amount, method, and duration of oxygen usage were documented for 1 of 4 residents (Resident #29) reviewed for oxygen use. This deficient practice placed Resident #29 at risk of respiratory distress due to receiving too much or too little oxygen. Findings include: The facility's Respiratory Treatment policy, revised 6/22/22, documented residents received respiratory treatments and monitoring, per their physicians' orders, standards of practice and care plan. The amount, method and duration of oxygen usage and diagnosis were identified on the resident's treatment record per the physicians' orders and care plan. This policy was not followed. Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure and chronic kidney disease. On 10/17/23 at 10:23 AM, Resident #29 was asleep on her 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 record review and staff interview, it was determined the facility failed to ensure residents were free of significant medication errors. This was true for 1 of 7 residents (Resident #259) whose medications were reviewed. This failure created the potential for harm to Resident #259 when her medication was not administered as ordered by the physician. Findings include: Resident #259 was admitted to the facility on [DATE], with multiple diagnoses including hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow in the lungs). A physician order, dated 9/29/23, documented Resident #259 was to receive Benazepril (anti-hypertensive medication) HCL (hydrochloride), 20 mg by mouth every morning and at bedtime. Resident #259's MAR, dated 10/1/23 through 10/18/23, documented she did not receive Benazepril HCL in evening of 10/16/23 and in the morning of 10/17/23 and 10/18/23. On 10/18/23 at 12:01 PM, RN #1 stated she did…

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 resident and staff interview, the facility failed to ensure 1 of 1 resident (Resident #34) reviewed for the provision of dental services was provided with routine dental services. This failure created the potential for Resident #34 to experience physical discomfort and mental anguish when dental services were not provided. Findings include: Resident #34 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including motor and sensory neuropathy (damaged nerve cells throughout the body, causing nerve signals to slow or stop). A care plan, initiated on 12/27/21, documented Resident #34 had the potential for oral/dental health problems. Interventions included for staff to coordinate arrangements for dental care and transportation as needed. A physician order, dated 8/17/23, documented Resident #34 was to see a denturist for an upper denture. Resident #34's record did not include documentation of coordination of routine dental services for Resident #34.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents received a therapeutic diet following physician orders for 1 of 14 residents (Resident #13) whose dietary orders were reviewed. This placed residents at risk for adverse outcomes such as choking, aspiration of food and/or liquid, and worsening of diagnosed diseases and conditions. Findings include: Resident #13 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis (a disease that impacts the brain, spinal cord and optic nerves, which make up the central nervous system and controls everything we do). On 10/17/23 beginning at 12:30 PM, lunch service was observed in the facility's main dining room. RN #2 was observed assisting with passing out lunch trays to the residents in the dining room. RN #2 set a lunch tray down on the table in front of Resident #13. She removed the lid from the plate and the lunch included a grilled cheese sandwich cut in half and potato chips. RN…

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 staff interview, it was determined the facility failed to ensure hand hygiene was performed as needed by staff during meal service for 1 of 2 meals observed at the facility in the main dining room. This failure to perform hand hygiene had the potential to impact all residents who ate in the dining room and placed the residents at risk for cross contamination and infection. Findings include: The Centers for Disease Control and Prevention (CDC) website, accessed on 10/27/23, last reviewed 1/30/20, documented Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately before and after having touched a patient or the patient's immediate environment. This guidance was not followed. On 10/17/23 at 12:12 PM, CNA #1 was observed in the dining room offering and placing clothing protectors on residents, pouring and placing liquid drinks on the table in front of residents, and offering a drink through a straw for residents who required assistance. She was observed not performing hand hygiene…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, and staff interview, it was determined the facility failed to ensure infection control measures were consistently implemented and maintained to provide a safe and sanitary environment during medication administration. This was true for 1 of 2 residents (Resident #54) whose medication administration was observed. This failure created the potential for harm by exposing Resident #54 to the risk of infection. Findings include: The facility's Medication Administration Subcutaneous (below the skin) Insulin policy, dated 1/2023, directed staff to cleanse the injection site with an anti-microbial agent and allow it to dry then to inject the insulin slowly. This policy was not followed. Resident #54 was admitted to the facility on [DATE], with multiple diagnoses including diabetes. An admission MDS assessment, dated 7/18/23, documented Resident #54 received insulin injections. On 10/17/23 at 11:41 AM, LPN #2 was observed administering insulin by injection to Resident #54's lower…

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.