Hilltop Skilled Nsg & Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide safe and adequate assistance with showers to a dependant resident. This failure affected one of one resident (R39) reviewed for Activities of Daily Living on the sample list of 43. Findings Include: R39's Medical Diagnoses List dated October 2024 documents R39 is diagnosed with Lumbar Spondylopathies, Spinal Cord Injury of Lumbar Region, Neuromuscular Dysfunction of Bladder, Depression, Left and Right foot Drop, and Neurogenic Bowel. R39's Minimum Data Set, dated [DATE] documents R39 is cognitively intact. No documentation was entered for R39's showering needs. R39's Minimum Data Set, dated [DATE] documents R39 requires partial to moderate assistance with showering and lower body dressing. R39 requires substantial or maximum assistance for putting on or taking off footwear. R39 requires supervision or touching assistance for tub or shower transfers. R39's Care Plan dated 2/29/24 documents R39 has a self-care deficit and requires one person staff…

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 resident medical equipment was properly utilized for three (R8, R18, R42) residents out of three residents reviewed for safety in a sample list of 43 residents. Findings include: 1.) R8's undated Face Sheet documents medical diagnoses as Comminuted Fibula Fracture, Morbid Obesity, Diabetes Mellitus Type II, Chronic Respiratory Failure, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominate side, Obstructive Sleep Apnea, Pulmonary Hypertension, Legal Blindness and Dependence on Supplemental Oxygen. R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. R8's Hospital Discharge Record dated 10/11/24 documents R8 is to utilize 5 Liters of Oxygen per Nasal Cannula continuously. On 10/15/24 at 11:55 AM R8 was wearing her nasal cannula with her oxygen concentrator set at 5 Liters. R8's Oxygen concentrator was plugged into a pink extension cord laying on top of her bedside dresser. 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 interview and record review, the facility failed to obtain physician responses from pharmacist recommendations in a timely manner, and failed to develop their pharmacist policy to include timeframes for the steps in the monthly medication regimen reviews. This failure affects two residents (R16 and R44) out of five reviewed for unnecessary medications on the sample list of 43. Findings include: 1. R16's Census Detail dated 10/18/24 documents R16 was admitted to the facility 9/10/24. R16's Hospital Discharge Orders dated 9/10/24 document R16 had a physician ordered prescription for Semaglutide (Rybelsus) (Antidiabetic) 7 milligrams daily. R16's current Physician Order Sheet dated 10/17/24 documents R16's medication Rybelsus did not start until 9/24/24. R16's Consultant Pharmacist (V20) Recommendation dated 9/14/24 documents a notation R16 had a physician order for the medication Rybelsus on R16's hospital discharge record which was not present in the R16's electronic medical record. V20 documented to clarify this with the physician and update the electronic medical 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 observation, interview and record review the facility failed to honor one (R260) residents food preferences out of nine residents reviewed for meal service in a sample list of 43 residents. Findings include: R260's undated Face Sheet documents medical diagnoses as Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Orthostatic Hypotension, Dementia, Vitamin D Deficiency, Anemia and Chronic Kidney Disease Stage 3. This same Face Sheet documents R260 admitted to the facility on [DATE]. R260's Minimum Data Set (MDS) dated [DATE] documents R260 as moderately cognitively impaired. R260's Electronic Medical Record (EMR) does not include a food preferences interview. R260's Nutritional careplan was initiated 10/15/2024. R260's Careplan did not include a nutritional focus area, goal nor interventions prior to 10/15/24. R260's careplan intervention dated 10/8/24 documents R260 is of Hindu faith. On 10/15/24 at 12:45 PM R260 was served a Polish sausage, macaroni salad, spinach, chocolate chip cake with 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, interview and record review the facility failed to serve a resident meals consistent with a resident's allergies for one of nine residents (R6) reviewed for meal service in a sample list of 43 residents. Findings include: R6's undated Face Sheet documents medical diagnoses as Diabetes Mellitus Type II, Morbid Obesity, Gastroesophageal Reflux Disease (GERD), Spinal Stenosis, Dizziness and Giddiness, Mild Intellectual Abilities, Fusion of Spine, Major Depressive Disorder, Borderline Personality Disorder and Post Traumatic Stress Disorder (PTSD). This same Face Sheet documents R6's allergies as Bupropion, Regadenoson, Tetracycline, Valproic Acid, Buspar, Penicillin and Onion. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. R6's Physician Order Sheet (POS) dated October 2024 documents a physician diet order for Consistent Carbohydrate (CCHO) diet, regular texture and thin/regular consistency. R6's undated diet ticket documents R6 is allergic to onions. R6's Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document evaluations to determine cognitively impaired residents' capacity to consent to a known sexual relationship, failed to develop their policy on intimate resident behavior to include the criteria for initial evaluation and frequency with which a cognitively impaired resident's capacity to consent to an intimate relationship is to be evaluated, and to specify where and how the evaluations and determinations would be documented and maintained. This failure affects two (R1, R2) residents and has the potential to affect 22 additional cognitively impaired residents (R5 through R26) on the sample list of 26 reviewed for cognitive capacity. Findings include: The facility policy (undated) on Intimate Resident Behavior, Privacy, and Relationships, documents the facility may utilize, as appropriate, a mental health practitioner, psychiatrist, clinical social worker, or psychologist, or primary care physician to help in the evaluation and determination of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from sexual abuse by another resident. This failure affects two residents (R1, R2) reviewed for sexual abuse on the sample list of 26. Findings include: On 9/25/24 at 1:45 PM, V7 Licensed Practical Nurse, stated, I walked into R1's room and saw R1 with his privates (genitals) exposed and R2 was playing with R1's privates (genitals) with her hand. V7 then stated, I did not do anything about it because everyone tells me they are consensual. V7 concluded by stating, I think both R1 and R2 can form consent, they always sit at the table together and I hear them talking to each other asking if the other wants to come to their room. R2's Diagnoses List dated 9/25/24 documents R2's medical diagnoses includes Dementia. There were no facility assessments or referenced ability or inability for R2 to consent to sexual relationships documented in R2's medical record. R2's Minimum Data Set (MDS) dated [DATE] documents R2 scored a 2 out 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 interview and record review, the facility failed to develop residents care plans to include an intimate relationship and the need for privacy. This failure affects two residents (R1, R2) out of 5 reviewed for care plans on the sample list of 26. Findings include: On 9/25/24 at 1:45 PM, V7, Licensed Practical Nurse, stated, I walked into R1's room and saw R1 with his privates (genitals) exposed and R2 was playing with R1's privates (genitals) with her hand. V7 then stated, I did not do anything about it because everyone tells me they are consensual. V7 concluded by stating, I think both R1 and R2 can form consent, they always sit at the table together and I hear them talking to each other asking if the other wants to come to their room. On 9/25/24 at 1:25 PM, V5, CNA, stated, I have seen R1 and R2 hold hands, and R1 hug R2 around the neck. V5 further stated, Another resident reported to me seeing R1 in R2's room rubbing on R2's private area (genitals) with her hand. The facility policy (undated) on Intimate Resident Behavior, Privacy, and Relationships documents 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report an allegation of physical abuse to the Abuse Coordinator timely for two of seven residents (R1, R5) reviewed for abuse in the sample list of seven. Findings include: R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. The facility was not able to provide documentation that R5's allegation of physical abuse between R1 and R5 was ever reported to the Abuse Coordinator and/or the State Agency. On 7/18/24 at 11:45 AM R5 stated A couple of months ago (R1) and I were roommates and we (R1, R5) got into a fist fight. (V8) Certified Nurse Aide (CNA) worked last night and I told her about that. (V8) said she didn't have any control over who my roommate is and I would just have to deal with it. On 7/18/24 at 2:30 PM R1 stated My old roommate (R5) and I didn't get along. We (R1, R5) beat each other up one time. I don't remember when. I never liked him (R5) anyway. I let (R5) have it. On 7/18/24 at 12:15 PM V8 Certified Nurse Aide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide denture care assistance for two (R1 and R3) of three residents reviewed for activities of daily living from a total sample list of seven residents reviewed. Findings include: The undated facility policy documents that denture care is to be provided before breakfast and at bedtime. The resident is to be encouraged and assisted as needed. As denture care is provided, examination of the resident's mouth and gums for paleness, mouth sores, bleeding or areas of discoloration should be done. Encourage the resident to perform as much of the procedure as possible. 1.) R1's admission assessment dated [DATE] documents that R1 admitted to the facility with upper and lower dentures. R1's updated care plan does not document denture care. On 2/26/24 at 8:50AM, V4 Certified Nursing Assistant (CNA) stated that morning cares consist of washing (the residents) up, making sure they have their call lights, brushing their teeth, cleaning their dentures,…

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 maintain a safe, sanitary, and comfortable environment by failing to prevent ongoing water leakage through the roof and mold-like growth in the shower rooms and on ceiling tiles. This failure has the potential to affect all 62 residents residing in the facility. Findings Include: On [DATE] at 9:35 AM there was black mold-like substance on the East Hall shower room ceiling vent grate. There was also black and orange mold-like substance on the shower stalls wall and floor. The caulk was peeling off and the black mold like substance was growing underneath. On [DATE] at 9:40 AM one 2'x2' ceiling tile in front of room [ROOM NUMBER] and 106 was missing and the tile next to that spot appeared to have been saturate with water at one point, was bulging downward towards the floor and was discolored and brown. On [DATE] at 9:46 AM two 2'x2' ceiling tiles in front of room [ROOM NUMBER] and 108 were missing and four ceiling tiles around that spot had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide individualized fall interventions and provide safe access for communication/response to resident's requests for care. This failure affects one resident (R5) of five residents reviewed for fall interventions in the sample of five. Findings include: The facility's Fall Prevention Program/Protocol dated Revised 2/1/23, documents based on previous evaluations and current data, staff will identify interventions related to resident's specific risks to prevent resident from falling; new admissions will be reviewed for fall history and interventions put in place prior to admission to the facility; and rounds will be completed at least daily to ensure fall intervention remain in place. R5's Nursing Progress Notes dated 11/15/23 at 7:20 PM, documents R5 arrived to the facility by ambulance from the hospital, oriented to self only, resident up walking in halls, gait unsteady. This same progress note documents significant physical therapist…

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 prepare and distribute food under sanitary conditions. This failure has the potential to affect all 61 residents residing in the facility. Findings include: On 10/31/23 at 10:57 AM, V23 [NAME] pureed a pork loin. V23 was wearing a ball cap. V23's hair stuck out of the edges of the ball cap. V23 had a full beard and and was not wearing a face covering over his beard. On 10/31/23 at 12:11 PM, V23 was serving lunch and was not wearing a face covering or a ball cap. On 11/01/23 at 1:28 PM, V22 Dietary Manager stated that V23 should have had his beard covered when cooking and serving food on 10/31/23. The facility's Long Term Care Application for Medicare and Medicaid form dated 11/1/23 signed by V1 Administration documents there are 61 residents residing in the facility.

Based on interview and record review the facility failed to develop, implement and maintain an ongoing quality assurance performance improvement program over the past 12 months. This failure has the potential to affect all 61 residents of the facility. Findings include: The Long-Term Care Facility Application For Medicare and Medicaid dated 11/1/23 and signed by V1 Administrator documents 61 residents reside in the facility. The facility provided Quality Assurance Policy dated 7/20/22 documents that the Quality Assurance Performance Improvement (QAPI) Committee oversees implementation of the QAPI plan, which is the written component of describing the specifics of the QAPI program, how the facility will conduct its QAPI functions and the activities of the QAPI committee. On 11/1/23 at 11:35AM, V1 stated that she was not aware of any performance improvement projects that had been developed by the quality committee over the past year. Nor was any performance project implemented with the front line staff and evaluated by the quality committee. No tracking and trending of performance…

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 hold quarterly quality improvement meetings over the past 12 months. This failure has the potential to affect all 61 residents of the facility. Findings include: The Long-Term Care Facility Application For Medicare and Medicaid dated 11/1/23 and signed by V1 Administrator documents 61 residents reside in the facility. The facility provided Quality Assurance Policy dated 7/20/22 documents that the administrator is responsible for insuring that the facility's quality program complies with federal, state and local regulatory requirements. On 11/1/23 at 11:54AM, V1 Administrator stated that no quality information could be provided prior to August of 2023, including meeting minutes. On 11/1/23 at 12:00PM, V10 Chief Operating Officer confirmed that no quality information could be located prior to August 2023.

A. Based on record review and interview the facility failed to initiate a water management program. This failure has the potential to affect all 61 residents residing at the facility. B. Based on observation, interview and record review the facility failed to prevent potential cross contamination during incontinence care for one of two residents (R50) reviewed for incontinence care in the sample list of 34. Findings Include: a.) The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 11/1/23 documents 61 residents reside in facility. The facility's policy Legionella Water Management Program last revised July 2017 (not reviewed annually) states Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. The water management team will consist of at least the following personnel: Infection preventionist, the Administrator, the Medical Director, the Director of Maintenance, the Director of Environmental Services. The purpose of the water management program is to identify areas in the water system where…

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 assess the need for Psychotropic medications for five of five residents (R52, R9, R50, R18, R24) reviewed for unnecessary medications in the sample list of 34. Findings include: The facility's undated Psychotropic Medication Protocol documents, Purpose: To provide guidance to facility staff in the implementation, monitoring and gradual dose reductions of psychotropic medications. Initiate GDR (Gradual Dose Reduction) monitoring flow sheet. Within 30 days of Initiation Discuss at weekly risk meeting, potential GDR evaluation (Complete assessment and update GDR monitoring flow sheet), AIMS (Abnormal Involuntary Movement Scale) (if antipsychotic). Quarterly Initiate potential GDR (complete assessment and update GDR monitoring flow sheet). 1.) R52's Order Summary Report dated 10/31/23 documents diagnoses including Generalized Anxiety Disorder, Bipolar Disorder, Vascular Dementia, Adjustment Disorder with Depressed Mood, Suicidal Ideation, Auditory Hallucinations, Mild Cognitive Impairment and Major Depressive Disorder. R52'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 record review and interview the facility failed to offer/administer Pneumococcal vaccines for four residents (R23, R29, R8, R49) of five residents reviewed for Vaccines in a sample list of 34. Findings include: The facility's Infection Control policy revised 5/21/22 states Each resident will be offered the influenza, pneumonia, and SARs-Co-V2 (COVID) vaccines as directed per CDC (Centers for Disease Control) guidelines, unless medically contraindicated. This shall be documented. 1. R23's Minimum Data Set (MDS) dated [DATE] documents R23 was not offered and did not receive the pneumococcal vaccine. There is no consent or refusal of the pneumococcal vaccine included on R23's electronic medical record. The immunization tracking included in R23's medical records does not document R23 received pneumococcal vaccine(s) according to current guidelines. 2. R29's Minimum Data Set (MDS) dated [DATE] documents R29 was not offered and did not receive the pneumococcal vaccine. There is no consent or refusal of the…

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

Based on record review and interview the facility failed to offer/administer Sars-Co-V2 (COVID) vaccines for four residents (R23, R29, R8, R49) of five residents reviewed for vaccines in a sample list of 34. Findings include: The facility's Infection Control policy revised 5/21/22 states Each resident will be offered the influenza, pneumonia, and COVID vaccines as directed per CDC (Center for Disease Control) guidelines, unless medically contraindicated. This shall be documented. COVID-19 Vaccines for Long-term Care Residents Updated Sept. 25, 2023 documents: CDC recommends everyone aged 5 years and older, including people who live and work in Long-term Care (LTC) settings, get 1 updated COVID-19 vaccine. People who are moderately or severely immunocompromised can get additional updated COVID-19 vaccines. Learn more about additional doses. People who live in LTC settings must give consent, or agree to getting a COVID-19 vaccine. 1. There is no consent or refusal of the current COVID booster included on R23's electronic medical record. The immunization tracking included in R23's…

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

Based on observation, interview, and record review the facility failed to ensure a call light was in reach for one resident (R213) of 16 residents reviewed for call lights in a sample list of 34. Findings Include: R213's Order Summary Report printed 11/1/23 at 3:10PM documents R213 was admitted to the facility 10/21/23 with diagnoses of Extensive Heart and Lung Disease and chronic Kidney Disease for Hospice care. On 10/30/23 at 3:20 PM R213 was resting in her bed. R213 stated I can't get to my call light. I'm thirsty, I want some ice, and I need straightened out in bed and I can't reach my call light. R213's call light was observed on the floor between the left side of the bed and the wall. No staff were observed in the room or the hall outside R213's room. On 10/31/23 at 3:15 PM R213 was resting in her bed. R213's call light was observed lying on the floor between the left side of the bed and the wall. V27, Certified Nurse's Aide (CNA) entered the room. V27 stated The call light fell off. All residents should have a call light in reach at all times. On 10/31/23 at 11:00AM V2,…

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 interview and record review the facility failed to notify the resident's representative of a change in condition for one resident (R20) of 16 residents reviewed for condition change in a sample list of 34 residents. Findings include: R20's Care Plan revised 10/11/23 includes the following diagnoses: Type II diabetes Mellitus, Heart Disease, Anxiety, Dementia, Psychotic Disturbance, Mood Disorder, and Chronic Kidney Disease. R20's Minimum Data Set, dated [DATE] documents R20 is severely cognitively impaired. R20's Face Sheet reviewed 10/30/23 documents V28 is R20's resident representative and Power of Attorney. On 10/30/23 at 12:37 PM V28 stated (R20) had diarrhea and black stool in July and the facility did not notify me. It turned out to be C-Diff (Clotridoides difficile) and they didn't let me know that either. R20's Progress note dated 7/4/23 at 11:15PM documents (R20) has large black foul smell stool. (R20) lethargic with temperature of 100.4, blood pressure 106/50,16 respirations, and 110 pulse.…

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 notify the resident's representative of a transfer to the hospital for one resident (R20) of 16 residents reviewed for condition change in a sample list of 34 residents. Findings include: R20's Care Plan revised 10/11/23 includes the following diagnoses: Type II diabetes Mellitus, Heart Disease, Anxiety, Dementia, Psychotic Disturbance, Mood Disorder, and Chronic Kidney Disease. R20's MDS (Minimum Data Set) dated 9/27/23 documents R20 is severely cognitively impaired. R20's Face Sheet reviewed 10/30/23 documents V28 is R20's resident representative and Power of Attorney. On 10/30/23 at 12:37 PM V28 stated (R20) had diarrhea and black stool in July and the facility did not notify me. It turned out to be C-Diff (Clostridium difficile) and they didn't let me know that either. I didn't even know they sent (R20) to the Emergency Room. R20's Progress note dated 7/5/23 at 12:00AM documents (R20) has another large black foul loose stool. Temperature 100.5, blood pressure 107/48, pulse 109, respirations 15. (R20) lethargic. Sending…

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 interview and record review, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) level I screening was completed for two (R24 and R37)of two residents reviewed for PASARR level I screenings with serious mental illnesses and prescribed anti-psychotic medication from a total sample list of 34 residents reviewed. Findings Include: 1. R24's level I PASARR dated 7/1/19, documents that a level II PASARR is not required due to R24 not having a SMI (Severe Mental Illness) diagnosis upon admission to the facility on 7/2/19. R24's diagnosis sheet dated 11/20/20 documents a new diagnosis of Psychosis. R24's diagnosis sheet dated 1/5/23 documents a new diagnosis of Schizoaffecive disorder. R24's October 2023 physician order sheet documents Olanzapine 2.5 milligrams (mg) daily for schizoaffective disorder, Lorazepam 0.5mg for anxiety twice daily and Zoloft 25mg daily for depression. On 11/1/23 V19 Director of Operations said that another PASARR level one screening had not been…

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 interview and record review the facility failed to update a care plan with resident's significant weight loss for two of 16 residents (R11, R20) reviewed for care plans in the sample list of 34. Findings include: The facility's Care Plan policy with a revision date of 1/11/23 documents, Purpose: To provide guidance to the facility in developing, implementing and communicating the individualized plan of care of residents. Policy: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 1.) R11's Order Summary Report dated 11/1/23 documents diagnoses including Hemiplegia following a CVA (Cerebrovascular Accident), Dysphagia Oral Phase, Unspecified Protein-Calorie Malnutrition and Vitamin B12 Deficiency Anemia. R11's Weight Summary dated 11/1/23 documents R11's weight on 7/12/23 as 142.5 pounds, 8/14/23 as 134.0 pounds, 9/11/23 as 125.0 pounds and 10/16/23 as 120.0 pounds. That is a significant weight loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assist with/provide ADL (Activities of Daily Living) care for two of three residents (R11, R50) reviewed for ADLs in the sample list of 34. Findings include: The facility's ADL Support policy with a revised date of 5/2/23 documents, Residents will be provided with care, treatment, and service as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). 1.) R11's Order Summary Report dated 11/1/23 documents diagnoses including Hemiplegia…

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 provide pressure ulcer treatments and relieve pressure while up in the wheelchair for one (R18) of four residents reviewed for pressure ulcers on the sample list of 34. Findings include: On 10/31/23 at 2:00 PM, R18 had a dime sized pressure ulcer to the left upper thigh. R18's wound assessment and plan dated 10/18/23 documents R18's wound to the left upper thigh as a pressure injury measuring 0.5 centimeters by 1.1 centimeters by 0.1 centimeters. On 10/30/23 from 12:12 PM to 12:29 PM, R18 was sitting in the dining room. R18 complained multiple times that he was sliding down in the wheelchair. R18 was noted to be sitting on a pressure relief cushion. A mechanical lift sling was positioned under R18's buttocks and on top of the pressure relief cushion. The sling was noted to be bunched in places. V6 Certified Nurse's Assistant assisted R18 with re-positioning in the wheelchair. On 11/01/23 at 2:51 PM, V6 stated she helped R18 with repositioning in the dining room on 10/30/23. V6 stated the mechanical lift sling…

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 perform complete incontinence care for one of two residents (R50) reviewed for incontinence care in the sample list of 34. Findings include: The facility's Incontinence Care Policy with a revised date of 5/16/22 documents, All incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/or odor. Incontinence care will be provided as required. Wash all soiled skin areas and dry very well, especially between skin folds; changing gloves and performing hand hygiene as required to prevent cross-contamination. R50's Order Summary Report dated 10/30/23 documents diagnoses including Neurocognitive Disorder With Lewy Bodies and Unspecified Osteoarthritis. R50's MDS dated [DATE] documents R50 has severe cognitive impairment and requires extensive assistance of one staff for ADLs. On 10/31/23 at 12:05 PM, V6 and V7 Certified Nursing Assistants completed incontinence care for R50. V6 washed R50'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 implement nutritional interventions for a resident with significant weight loss for one of four residents (R11) reviewed for weight loss in the sample list of 34. Findings include: The facility's Weight Assessment and Intervention policy with a reviewed date of 11/2/21 documents, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Interventions for undesirable weight loss shall be based on careful consideration of the following: choices, preferences, nutrition and hydration needs, functional factors, environmental factors, chewing and swallowing abnormalities, medications, supplemental feeding and end of life decisions. R11's Order Summary Report dated 11/1/23 documents diagnoses including Dysphagia Oral Phase, Unspecified Protein-Calorie Malnutrition, Gastro-Esophageal Reflux Disease, Hypokalemia and Vitamin B12 Deficiency Anemia. R11's Weight Summary dated 11/1/23…

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 provide oxygen therapy as ordered and failed to change oxygen tubing weekly for one (R17) of one residents reviewed for oxygen therapy from a total sample list of 34 residents. Findings include: The facility Oxygen Administration policy dated 3/17/22 documents that it is the responsibility of the charge nurse to ensure that residents who have an order for oxygen are receiving it properly. Additionally, the tubing will be changed and dated weekly. R17's undated diagnosis sheet documents Acute and Chronic Respiratory Failure, Chronic Pulmonary Edema and Chronic Obstructive Pulmonary Disease. R17's October physician order sheet documents oxygen to be administered at 2-4 liters per nasal cannula to maintain oxygen above 90 percent. On 10/30/23 at 11:58AM, R17 was wearing oxygen while working a puzzle. R17's portable tank was empty and the nasal cannula tubing was dated 10/23/23, confirmed by V2 Director of Nursing. On 11/1/23 at 11:30 AM, R17's oxygen was running at three liters per nasal cannula with the tubing…

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 assess the risk for entrapment for the use of a bed rail for one of one resident (R18) reviewed for bed rails on the sample list of 34. Findings include: On 10/31/23 at 9:12 AM, R18 was lying in bed. The bed was positioned along the wall. A half bed rail was elevated on R18's right hand side of the bed. R18's medical record did not contain documentation that R18 was assessed for the risk of entrapment for the use of the bed rail. On 11/01/23 at 10:35 AM, V1 Administrator stated there is not an assessment for the use of R18's bed rail.

Based on observation, interview and record review the facility failed to securely store a schedule four medication and failed to dispose of undated insulin for three (R4, R47 and R213) of three residents reviewed for medication storage from a total sample list of 34 residents. Findings include: The facility Medication Storage policy dated 7/11/21 documents that all drugs will be stored in a safe, secure and orderly manner in accordance with state and federal regulations. Additionally, schedule 2-4 controlled medications will be stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medication. The facility provided insulin drug manufacturer instructions document that multidose, Lantus and Humalog Insulin vials must be disposed 28 days after opened. The facility provided insulin drug manufacturer instructions document that a multidose, Levemir Insulin vial must be disposed 42 days after opened. On 10/30/23 at 3:51PM, V5 Registered Nurse (RN) confirmed that R4's open Lantus Insulin, nor open Humalog…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide appropriate and sufficient services to prevent urinary tract infection (UTI) for a resident with an indwelling urinary catheter. The facility also failed to obtain an acceptable urine specimen from a resident with an indwelling urinary catheter from 9/26/23 to 10/11/23(2 weeks) resulting in a delay of treatment. These failures affects one resident (R4) of three residents reviewed for catheter care in a sample list of seven residents. Findings include: R4's Undated Face Sheet documents R4 admitted to facility on 8/25/23 with medical diagnoses of Infection and Inflammatory Reaction due to indwelling Urethral Catheter, Urinary Tract Infection, Dementia, Weakness, Spinal Stenosis and Urine Retention. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as moderately cognitively impaired. This same MDS documents R4 requires extensive assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene. R4'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 maintain infection control practices for one (R4) resident on contact isolation precautions for Extended Spectrum Beta-Lactamase (ESBL) in urine out of three residents reviewed for catheters in a sample list of seven residents. Findings include: R4's Undated Face Sheet documents R4 admitted to facility on 8/25/23 with medical diagnoses of Infection and Inflammatory Reaction due to indwelling Urethral Catheter, Urinary Tract Infection, Dementia, Weakness, Spinal Stenosis and Urine Retention. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as moderately cognitively impaired. This same MDS documents R4 requires extensive assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene. R4's current Careplan documents R4 as a high risk for a Urinary Tract Infection (UTI). This same careplan does not include an intervention to maintain contact isolation precautions. R4's Urine Culture and Sensitivity Results…

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 employ a qualified director of food and nutrition services. This failure has the potential to affect all 60 residents residing in facility. Findings include: The Facility Midnight Daily Census Report dated 9/26/23 documents 60 residents reside in facility. On 9/28/23 and 9/29/23 there was no Dietary Manager observed onsite. On 9/26/23 at 10:15 AM V9 Certified Dietary Manager (CDM) stated I split my time between this facility and another facility. I am not here at this facility full time. I believe we are supposed to have a full time person in this role. I have (V6) who is a dietary manager in training but he is not certified and is not trained yet. We (facility) are working towards that. On 9/27/23 at 2:00 PM V18 Regional Dietary Manager stated (V9) is a Certified Dietary Manager who does oversee two facilities. (V9) is not at this facility Full-Time but that is our goal.

Based on observation, interview and record review the facility failed to properly label and store refrigerated food products, failed to properly store thawed meat to prevent meat juice from dripping on other foods, failed to ensure cleanliness of food serving area and sanitation of food preparation equipment and failed to ensure the dishwasher was operating as designed to sanitize dishes to prevent potential food borne illness to residents. This failure has the potential to affect all 60 residents residing in facility. Findings include: The facility Midnight Daily Census dated 9/26/23 documents 60 residents reside in facility. 1.) On 9/26/23 at 9:25 AM Observed V5 Dietary Aide test the dishwashing machine using a test strip. The test strip turned a light purple color indicating 25 parts per million (ppm). On 9/26/23 at 9:27 AM V5 Dietary Aide stated That dishwasher is gross. It really needs de-limed. Look at all the buildup (pointing to lime build-up) on the inside of the metal area where the water runs over and back to the dishes. That is nasty The (test) strip should be at least…

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 serve foods that were palatable to four (R1, R4, R7, R9) residents out of four residents reviewed for Dietary Services in a sample list of eleven residents. Findings include: Resident Council Minutes dated 8/24/23 document a new concern of serving times. These same council minutes document the department response as Serving times are set for the building. We (staff) will get meals served on time as close as possible to times that are set. 1.) R1's Minimum Data Set (MDS) dated [DATE] documents R10 as cognitively intact. On 9/27/23 at 12:35 PM R1 stated I just hope the food is hot today. Most of the time it is lukewarm at best. 2.) R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. On 9/26/23 at 12:11 PM Observed V7 Dietary Aide place a quarter pan of barbecued pulled pork on serving line. Observed V7 Dietary Aide obtain temperature of pulled pork which was 119 degrees Fahrenheit. Observed V3 [NAME] plate this same…

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 serve foods timely based on resident preference to four (R1, R4, R7, R9) residents out of four residents reviewed for Dietary Services in a sample list of eleven residents. Findings include: Resident Council Minutes dated 8/24/23 document a new concern of serving times. These same council minutes document the department response as Serving times are set for the building. We (staff) will get meals served on time as close as possible to times that are set. 1.) R1's Minimum Data Set (MDS) dated [DATE] documents R10 as cognitively intact. On 9/27/23 at 12:35 PM R1 stated I am sure they (staff) are doing the best they can but it gets tiring to have to wait so long for our meals. My butt gets sore from sitting so long. 2.) R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. On 9/26/23 at 12:40 PM Observed V14 Certified Nurse Aide (CNA) serve lunch tray with pulled pork sandwich to R4 in room. On 9/27/23 at 12:37 PM R4…

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

Based on interview and record review, the facility failed to ensure the Infection Preventionist had completed mandatory training in Infection Control and Prevention per the Centers of Disease Control (CDC). This failure has the potential to affect all 53 residents residing in facility. Findings include: The Facility Census and Condition Report dated 12/6/22 documents 53 residents reside in facility. On 12/8/22 at 2:30 PM, V2 (Director of Nursing/DON) stated, I am the Infection Preventionist for the facility. I have completed all of the modules but unable to provide documentation of the completion of the course. On 12/9/22 at 1:00 PM, V1 (Administrator) stated, I am an Infection Preventionist but do not have my certificate at facility and unable to provide the necessary documentation. V1 (Administrator) confirmed facility is unable to provide documentation of Infection Prevention completion for any other staff members.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report potential verbal abuse to the Administrator. This failure affects one of two residents (R31) reviewed for abuse on the sample list of 27. Findings include: R31's Progress Note dated December 2022 documents R31 is diagnosed with Bipolar Disorder, Anxiety Disorder, Major Depressive Disorder, and Factitious Disorder Imposed on Self. R31's Minimum Data Set, dated [DATE] documents R31 is cognitively intact. R31's Care Plan dated 10/7/21 documents R31 has a potential for abuse related to her low self-esteem, anxiety, and attention seeking behavior. Staff are to monitor, document, and report any signs or symptoms of R31 posing a danger to herself or others. R31 also displays negative verbalizations towards staff and other residents and can be disruptive, insensitive, and disrespectful. R31's Progress Note dated 5/12/22 documents V11 (Activities Staff) (no longer a facility employee) witnessed R31 screaming and cursing at three other residents that were…

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

Based on interview and record review, the facility failed to ensure required personnel attended the required quarterly Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 53 residents in the facility. Findings include: The undated Quality Assurance Performance Improvement Program documents the facility QAA Committee consists of the Director of Nurses, the Medical Director, the Administrator, at least two other members of the facility staff, and the Infection Control staff member. On 12/8/2022, V1 (Administrator) provided five QAA Meeting Verification Sheets (3/3/2022, 4/27/22, 5/25/22, 6/29/22, and 9/28/2022) for the previous year's QAA meetings. The March, April, May, and September 2022 QAA Meeting Verification Sheet sheets do not document the facility Director of Nursing was present at the meetings. On 12/8/22 at 3:30 PM, V1 (Administrator) confirmed all required members of the QAA committee including the Director of Nurses should be present at all quarterly QAA meetings. The facility Resident Census and Conditions of Residents…

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 follow hand hygiene practices to prevent potential cross contamination during urinary catheter care for one (R45) resident out of one resident reviewed for catheter care in a sample list of 27 residents. Findings include: The undated facility policy titled 'Handwashing/Hand Hygiene' documents the following: This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub (ABHR) containing at least 62% alcohol; or, alternatively, soap (Antimicrobial or non-Antimicrobial) and water for the following situations: before and after direct contact with residents, before and after handling an invasive device (urinary catheter) and before moving from a contaminated body site to a clean body site during resident care. R45's undated Face Sheet…

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.