Parc Joliet

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure food was prepared, stored, and served under sanitary conditions. This failure applies to 144 residents who are served food from the kitchen. Findings include:On September 25, 2025, at 3:59 PM, V1 (Administrator) stated out of 147 residents in the facility, there are 144 residents receiving food from the kitchen.On September 23, 2025, at 10:39 AM, Upon entering the kitchen V15 (Cook) was standing at the food prep table handling food prep items then donned gloves without performing hand hygiene.On September 23, 2025 at 10:41 AM In the kitchen, V16 (Dietary Aide)collected and rinsed soiled dishes, placed them in a dish rack and into the low temp dishwasher, then collected clean dishes from the dishwasher without performing hand hygiene; after pulling a rack of clean dishes from the dishwasher V16 grabbed a towel from the top of a box of latex gloves sitting in a part of the dish washing machine, wiped the water out of multiple bowls…

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 that residents shower room was free of black substances and failed to ensure that a resident's toilet was in good repair.This applies 16 of 16 residents (R24, R47, R58, R85, R92, R101, R103, R104, R105, R138, R140, R144, R149, R150, R156, and R164) reviewed for homelike environment in the sample of 29. Findings include:1. On September 22, 2025 at 10:20 AM, R58 was in her room alert and oriented and stated that the exhaust fan in the shower down the hall from her doesn't work, and she saw sparks come from it a month ago. R58 stated that there is also mold in the same shower all along the edge of shower. On September 23, 2025 R58 stated she told a Certified Nursing Assistant (CNA) about the mold and the shower but she doesn't know their name. R58 stated the sparks had been there 4-5 months. R58 stated, because the fan hasn't been fixed yet, R58 tells all the staff not to turn on the fan when they help her with a shower. On September 22, 2025 at 10:50 AM, in the shower room down R58's hall, there is 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 assist residents identified as needing assistance with personal hygiene and bed bath or shower.This applies to 6 of 7 residents (R6, R38, R49, R50, R52 and R137) reviewed for ADL (activities of daily living), in the sample of 29.The findings include:1.According to the Electronic Medical Records (EMR), R137 has multiple diagnoses including cerebrovascular disease (Stroke) with right side paralysis affecting dominant side, abnormality of gait and mobility, Alzheimer's disease and dementia. The (MDS) Minimum Data Set, dated [DATE], showed R137 had severe cognitive impairment and required assistance for personal hygiene, and dressing. R137's Care Plan for (ADL) Activities of Daily Living self-care deficit initiated on March 24, 2025, showed R137 requires moderate to maximum assistance with dressing and grooming tasks. On September 22, 2025, at 11:07 AM R137 was sitting in the dining room in her wheelchair. R137's shirt had crumbs of food, and…

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 that residents who smoke and require supervision for smoking were monitored closely during smoking period. In addition, facility also failed to ensure that residents are not keeping their own cigarette lighters. This applies to 6 of 8 residents (R26, R71, R75, R110, R151, R164) reviewed for smoking in the sample of 29. The findings include:On September 23, 2025, at 3:35 PM, V23 (Activity Aide) was in the dining/dayroom near the door of the back patio handing cigarettes to residents during smoke time. V23 was the only staff supervising the smoking period. Glass windows/walls with horizontal window blinds separated the dayroom from the back patio area. However, V23 was only intermittently looking outside through the glass window to monitor the residents who were smoking. R110 was observed in the back patio smoking and carrying a lighter. R110 lit up another cigarette with this lighter and then put the cigarette lighter in her pocket when she finished smoking and walked back inside the facility without…

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 follow standard infection control practices with regards to hand hygiene during range of motion assessments and administration of insulin. In addition, the facility failed to wear complete PPE (Personal Protective Equipment) during provision of wound treatment and administration of intravenous (IV) medication for residents who are under Enhance Barrier Precaution (EBP). This applies to 5 of 6 residents (R9, R29, R50, R135, R163) reviewed for infection control in the sample of 29. The findings include: 1.According to the face sheet, R163 has multiple diagnoses including, cellulitis of right lower limb, local infection of skin and subcutaneous tissue, quadriplegia and history of other venous thrombosis and embolism. R163's POS (Physician Order Sheet) dated September 22, 2025, showed an active order for a (PICC) Peripherally Inserted Central Line Catheter to (RUE) Right Upper Extremity. On September 23, 2025, at 9:02 AM, V22 (Registered Nurse) was preparing R163's (IV) intravenously medication, Ceftriaxone…

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 prevent a demented male resident from kissing a demented female resident. This applies to 1 of 1 resident (R148) reviewed for abuse in the sample of 29.Findings include: R148's admission record showed her to be a [AGE] year-old female with diagnoses that included unspecified severe dementia with mood disturbances, depression, anxiety and congestive heart failure. R148's Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) dated July 22, 2025 showed her to be severely cognitively impaired with a BIMS score of zero. R148's care plan showed the following: R148 is disoriented to person, place and time related to dementia diagnosis. R73's admission record showed him to be [AGE] years old with diagnoses that include dementia, bipolar, traumatic brain injury, paranoid schizophrenia. R73'BIMS score of 1, showed him to be severely cognitively impaired. R73 criminal background checks showed he had a history of aggravated domestic…

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 updated PASRR (Preadmission Screening and Record Review) referrals were completed when new psychiatric diagnoses were identified after admission.This applies to for 3 of 3 residents (R10, R35, R61) reviewed for PASRR compliance in the sample of 29.The findings include: 1.R61 was admitted on [DATE]. The PASRR Level I, dated October 30, 2023, indicated: No Level II Required - No SMI/ID/RC (Severe Mental Illness/Intellectual Disability/Related Condition.) The rationale stated: There is no evidence of a PASRR condition. If changes occur or new information refutes these findings, a new screen must be submitted.Review of medical diagnosis showed diagnoses of bipolar disorder, Schizophrenia, and Depression were created on November 03, 2025. No updated PASRR referral was completed.The resident's care plan dated March 18, 2025, showed, Resident is an adult living with chronic mental illness. Resident has been screened through the outside screening…

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 thoroughly cleanse a resident's skin prior to application of skin treatment and failed to ensure that psychotropic medication was administered as ordered. This applies to 2 of 2 residents (R52, R121) reviewed for quality of care in the sample of 29. The findings include:1. On September 23, 2025, at 9:36 AM, V4 (Wound Care Nurse) assessed R52's skin while V6 was providing incontinence care. There was multiple striation of redness all over on R52's backside and buttocks. There was a yellow stain noted on the fitted sheet right by R52's upper back. V6 said that the stain came from the fluids that was secreting from R52's skin. There were also clumps of dead skin scattered all over R52's backside and buttocks. V4 said that R52 has history of fungal rash on his back that's why he is receiving Nystatin ointment. V4 applied the Nystatin ointment without ensuring that R52's back was cleansed. On September 23, 2025, at 10:06 AM, V4 and V5 (Both…

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 assess and provide orthotic devices and services to residents, to prevent further reduction in mobility and ROM (range of motion).This applies to 2 of 6 residents (R12 and R123) reviewed for limited ROM, in the sample of 29.The findings include:1. R12 had multiple diagnoses including, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cerebral infraction due to thrombosis of left middle cerebral artery and severe morbid obesity due to excess calories, based on the face sheet.R12's annual MDS (Minimum Data Set) dated July 29, 2025 showed that the resident was cognitively intact. The same MDS showed that R12 had functional limitation in ROM to one side of both upper and lower extremities.On September 22, 2025 at 11:20 AM, R12 was in bed, alert and oriented. R12 had right arm and hand weakness. R12 was having a hard time to move her right arm and hand without the help of the left hand. R12 stated that she…

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

Based on observations, interviews and record review, the facility failed to ensure that continuous oxygen therapy was consistently provided and monitored as ordered.This applies to 1 of 2 residents (R35) reviewed for respiratory care in the sample of 29.The findings include: R35's medical diagnosis list created on January 17, 2024, shows multiple diagnosis including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and shortness of breath.The Physician's Order Sheet includes an order dated January 17, 2024, to administer oxygen at 3 liters per minute via nasal cannula continuously every shift to maintain SpO (Oxygen Saturation) greater than 90% related to COPD. Additional orders included oxygen saturation monitoring and oxygen equipment maintenance.On September 22, 2025, at 10:27 AM, R35 was observed sitting on the edge of the bed watching television with oxygen in place at 3 liters per minute via nasal cannula. When asked about portable oxygen use, R35 stated they did not have a portable tank and that they were supposed to remain on oxygen all the time…

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 administer medications as ordered during medication administration observation. There were 25 medication administration opportunities with 2 errors resulting to 8% percent medication error rate.This applies to 2 of 4 residents (R147 and R163) reviewed for medication administration in a sample of 29.The findings include:1.According to the face sheet, R147 has multiple diagnoses including, bilateral secondary cataract, presence of intraocular lense, chronic obstructive pulmonary disease, and heart disease.R147's POS (Physician Order Sheet) dated September 20, 2025, showed an active order for FML Litquifilm Opthalmic Suspension 0.1% (Fluorometholone), instill 1 drop in both eyes one time a day for episcleritis (an inflammation in the eyes).On September 23, 2025, at 9:25 AM, V22 (Registered Nurse) administered the eye drops, FML Litquifilm Opthalmic Suspension 0.1% (Fluorometholone) to R147 in each eye. The eye drops instructions on the medication label showed, shake well before each use. V22 failed to shake 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 observation and interview the facility failed to ensure that couches inside resident rooms were clean and sanitary and in accordance with what a resident would expect in a clean homelike environment. This applies to 3 of 3 residents (R2, R5 and R6) reviewed for housekeeping issues in the sample of 11. The findings include:On September 12, 2025 at 1:59 PM, the couch inside R2's room had multiple dark stains on the seat cushion area. V2 (Director of Nursing) who was present stated that R2's couch had dark stains and that the said couch needed to be cleaned.On September 12, 2025 at 2:33 PM, the couch inside R6's room had multiple white stains on the seat cushion area. V2 who was present stated that R6's couch needed to be cleaned because of the white stains.On September 12, 2025 at 2:40 PM, the couch inside R5's room had multiple dark stains on the seat cushion area and on the arm rest. V2 who was present stated R5's couch had multiple dark stains and added that R5's couch needed to be cleaned.

Based on observation, interview, and record review, the facility failed to ensure mechanical lift devices are maintained in safe, operating condition, are routinely inspected, and removed from service when repairs are needed. This applies to 30 of 30 residents (R4-R33) reviewed for mechanical lift transfers in the sample of 33. The findings include:The facility provided a list of all residents residing in the facility who require the use of a mechanical lift device for transfers between surfaces. The undated list shows R4-R33 require the use of a full-body mechanical lift for transfers between surfaces. On August 25, 2025, at 9:50 AM, V2 (DON-Director of Nursing), and V1 (Administrator) said there was an incident at the facility on July 28, 2025 involving R4 and a mechanical lift. V2 said, The wheel on the [mechanical lift] buckled. It fell enough for [R4] to hit her shoulder on the wall and break a bone. On August 25, 2025 at 1:36 PM, V7 (CNA-Certified Nursing Assistant) said, I was getting [R4] up for dialysis on July 28, 2025. Another CNA was with me. We used the [mechanical…

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 protect a resident's right to be free from physical abuse by another resident. This applies to 1 of 3 residents (R3) reviewed for resident-to-resident assault in the sample of 33. The findings include:On August 21, 2025 at 1:05 PM, R3 was lying in bed in his room. R3's right eyelid was closed/drooping, and some redness was noted on his cheek below his right eye. R3 said, I was punched in the eye by another resident. I don't know why he hit me. I went to the hospital. It doesn't hurt anymore. The EMR (Electronic Medical Record) shows R3 was admitted to the facility on [DATE] with multiple diagnoses including, cerebral infarction, hemiplegia and hemiparesis of the left side following cerebral infarction, asthma, abnormal gait and mobility, dysphagia, chronic kidney disease, delusional disorders, anxiety disorder, major depressive disorder, and anemia. R3's MDS (Minimum Data Set) dated May 15, 2025 shows R3 has severe cognitive impairment,…

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 an accurate medical record regarding a resident's incident during a mechanical lift transfer. This applies to 1 of 3 residents (R4) reviewed for falls in the sample of 33. The findings include:On August 25, 2025, at 10:25 AM, R4 was sitting in the chair with an ice pack over her right shoulder area. R4 said, The other day I was up in the sling of the mechanical lift. The staff were transferring me to the dialysis chair from my bed when the entire [mechanical lift] tipped over with me in it. I slammed into the wall in my room hard, then the chair, and then the floor. My whole body ended up on the floor, still attached to the [mechanical lift]. I had very bad pain in my right shoulder. The [mechanical lift] machine also fell on one of the staff and she was pinned under the lift and my whole body. I went to the hospital, and they said I broke my arm by my shoulder. The facility's incident report dated July 28, 2025 shows, Floor nurse…

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 protect residents' right to be free from abuse. This applies to 2 of 3 residents (R4, R5) reviewed for abuse in the sample of 14. The findings include: The facility's 2/12/2025 final Facility Incident Investigation Report for R4 and R5 showed .it was determined that on 2/5/25, [R4] was sitting outside .he saw [R5] come outside, and he called him a mooch. [R5] overheard [R4] and in reaction, he went towards the latter. As [R5] approached, he swung at [R4] and missed, lost his balance, and his momentum caused both residents to land on the ground [R5] had a scrape on his left forearm .[R4] had scratches on the right side of his face . The Report showed that both residents are alert and oriented and are responsible for themselves. On 2/25/25 at 10:40 AM, R4 in his room. R4 had just returned from an appointment and his gait and steps were a little bouncy and unsteady. R4 stated R5 always asked for cigarettes and money and R5 still owed him three dollars. R4 stated that on 2/12/2025 before their altercation, 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 observation, interview and record review, the facility failed to prepare and dress a resident appropriately for an outside appointment. This applies to 1 of 3 residents (R1) reviewed for accommodation of resident needs. The findings include: The facility's Clinical Communications-Facility Bulletin Board section of the Electronic Medical Record system showed R1 had an apponitment on 12/18/2024, and the notification included .10 AM pick up by [ambulance] going by AMB 9 AM pick up. On 12/24/24 at 7:30, AM V10 (R1's Guardian) stated that R1 was not properly dressed for the appointment. V10 stated R1 was dirty and only had a gown on, and was covered only with a sheet and no blanket. V10 also stated R1 was 40 minutes late to the appointment. On 12/24/24 at 8:45 AM, R1 was in a low bed with bolsters bilaterally and a floor mat was in place. R1 had contractures on both hands and he wore a hospital gown. R1 was unable to be interviewed due to his nonverbal status. R1's 10/3/24 Minimum Data Set (MDS) showed he is dependent on staff for his activities of daily living. On 12/24/24 at…

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 implement fall interventions for 2 residents (R3, R5) who are at risk for falls in a sample of 5. The findings include: 1. R3's electronic health records showed she has a history of falls, including on 10/5/24. R3's 9/6/24 care plan shows she is at risk for falls with interventions in place including provide resident a reacher for safety reaching items, and fall update of 5/25/24 showed apply the specialized mat to wheelchair for safety. R3's 10/21/24 MDS (Minimum Data Set) showed R3's decision making is impaired. On 10/30/24 at 3:15 pm, R3 was observed in the dining room, and she did not have her reacher with her. The staff, V4 and V5 (Certified Nurses Assistants), brought R3 to her room. V4 and V5 stood R3 up and showed R3 did not have a specialized seating mat on the seat of her wheelchair. V5 said she has worked with R3 a lot including last Monday (2 days prior), and has never seen R3 with a (specialized seating) mat on her wheelchair seat. On 10/30/24 at 3:40 pm, V8 (Activities Director) said she 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.

Based on observation, interview, and record review, the facility failed to properly label/date/seal/store items, remove expired items, and clean and address standing water by drain to avoid flies in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671), dated 9/3/24, documents the total census was 153 residents. On 9/5/24 at 11:31 AM, V22 (Social Services) verified the facility has 3 strict NPO (Nothing By Mouth) residents; all other residents eat from the facility kitchen. On 9/3/24, starting at 10:34 AM, the facility kitchen was toured in the presence of V16 (Dietary Manager) and the following was found: In the refrigerator: 1. 24 fresh whole eggs with no date. 2. A medium sized silver bin of unlabeled and undated ground meat. V16 said he thought it was ground turkey. In the dry storage: 3. Standing water by drain in the floor located next to the door/entrance to the dry…

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 call light access to residents, a functioning and useable bariatric shower bed, and a proper-sized incontinent brief for residents. This applies to 4 of 4 residents (R7, R35, R39, and R78) reviewed for reasonable accommodation of needs in a sample of 35. The Findings Includes: 1. R7 is a [AGE] year-old male with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. R7 was admitted with diagnoses including falls, anxiety, depression, alcohol abuse, restlessness, and agitation. On 9/3/24 at 12:17 PM, R7 was in his bed sitting at the bedside and tried to put the call light on. The call light string was not connected to the call system to trigger the call. R7's call light string was observed tied to his roommate's (R78) call light string. 2. R78 is a [AGE] year-old male with severe cognitive impairment as per the MDS dated [DATE]. R78 was admitted with diagnoses including dementia, Alzheimer's disease, need for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. R20's 7/19/24 MDS (Minimum Data Set) showed her cognition is intact, and her MDS section GG showed she needs assistance for personal hygiene. R20's 8/8/23 care plan showed a self-care deficit (ADLs/Mobility) (assistance in daily living) related to diagnoses including type 2 Diabetes, insomnia, anemia, osteoarthritis, and hypertension with interventions including supervision or touching assistance with ADL tasks. On 09/03/24 at 11:26 AM, R20 was observed with long jagged fingernails. R20 said it has been months since she has had them cut and she would like for the staff to cut them. On 09/05/24 at 10:38 AM, V1 (Administrator) said R20's nails should not have been long and jagged. V1 said the nails should be trimmed and clean for safety, dignity, and for infection control. Based on observation, interview, and record review, the facility failed to provide incontinence care and grooming assistance to dependent residents. This applies to 6 of 8 residents (R20, R34, R39, R87, R92 and R128) reviewed for incontinence…

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 timely foot care to meet the needs of all residents. This applies to 4 resident (R46, R35, R20, and R13) reviewed for podiatry services in a sample of 35 residents. The findings include: 1. R46's Face sheet shows she was admitted to the facility on [DATE], with primary diagnosis of quadriplegia. R46's MDS (Minimum Data Set), dated 7/1/24, shows her cognition is intact, she has impairments to both upper and lower extremities, and she requires maximal assistance for personal hygiene. R46's Care Plan, initiated on 10/11/2023, shows she has self-care deficit due to quadriplegia. Interventions include provide max assistance with grooming tasks. R46's last and only podiatry note was reviewed from visit date of 2/27/24. Podiatrist wrote R46 presented with thick, discolored, dystrophic nails. Podiatrist trimmed R46's nails and wrote for follow up visit in 9 weeks. A 9 week follow up visit would have occurred on or around 4/30/24, but…

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 interviews and record reviews, the facility failed to inform, provide written information, and formulate Advanced Directives upon admission for 1 resident (R116) in a sample of 35. The findings include: R116 is a [AGE] year old male admitted to the facility on [DATE], with diagnoses including malignant neoplasm of the larynx, spinal stenosis, dysphagia oral pharyngeal phase, suicidal ideations, anemia, and major depressive disorder. On 09/04/24 at 11:02 AM, R116 had no POLST (Physicians Orders for Life Sustaining Treatment) or Advanced Directives in his electronic health record, and the facility's Advanced Directives book showed no records for R116. R116's face sheet showed R116 was a full code, and R116's 7/22/24's Physician's order showed full code. On 09/05/24 at 08:55 AM, R116 denied ever being asked from the facility what his wishes were for life sustaining treatments in case of an emergency. R116 also denied ever signing any Advanced Directives forms. R116 said he did not want to have any life…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to apply splints to prevent contractures. This applies to 2 of 2 residents (R95 and R85) reviewed for contractures in a sample of 35. The findings include: 1. R85's electronic health record showed she is a [AGE] year old female with diagnoses including Alzheimer's disease, type 2 diabetes, seizures, and hereditary and idiopathic neuropathy. R85's 8/15/24 MDS (Minimum Data Set) section GG showed R85 is dependent in all care. R85's 5/14/24 care plan showed resident would benefit from participation in the following restorative programs: splint right palm protector, (8/20/24-waiting for left palm protector) due to impaired cognition, and impaired communication with interventions including assistance with left palm protector, apply every morning daily. On 09/03/24 at 11:27 AM, R85 was observed in bed asleep, with both her left and right hands contracted and no devices on her hands. On 09/05/24 at 09:14 AM, R85 was observed in her bed again, 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, interview, and record review, the facility failed to utilize safety interventions and maintain an environment free of trip hazards. This applies to 2 of 5 residents (R14 and R135) reviewed for accidents and hazards in a sample of 35. Findings include: 1. R135 admitted to the facility on [DATE], with diagnoses that includes intervertebral disc displacement, hyperlipidemia, alcohol abuse, hypertension, insomnia, adult failure to thrive, history of transient ischemic attack, and cerebral infarction without residual deficits. R135's MDS (Minimum Data Set), dated 6/30/24, indicates he is cognitively intact and uses a walker for mobility. R135's MDS indicates he requires supervision or touching assistance from staff while walking. The care plan, dated 7/15/24, stated R135 is at risk for falls interventions include to anticipate and meet the individual needs of the resident. On 9/03/24 at 10:58 AM, a blower fan was in the middle of the hallway, with the electrical cord stretching past two resident…

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 humidification with oxygen therapy to avoid nasal dryness. This applies to 1 of 1 resident (R59) reviewed for respiratory therapy in a sample of 35. The Findings Includes: R59 is a [AGE] year-old female, with very mild cognitive impairment, as per the Minimum Data Set (MDS), dated [DATE]. R59 was admitted with an admitting diagnosis, including asthma, congestive heart failure, sleep apnea, and dyspnea. On 09/03/24 at 02:22 PM, R59 was in her bed, with oxygen therapy with a nasal cannula (NC) at 2.5 liters per minute (L/M) without any humidification. On 9/5/24 at 9:45 AM, R59 was observed again in her bed, with NC at 2.5 L/M. R59 stated her nares are dry. On 09/05/24 at 11:30 AM, V3 (Director of Nursing / DON) stated, Our policy is to administer oxygen with humidification. We have couple of people refused to have humidification. I will check to see if (R59) was refusing the humidification. On 09/05/24 at 12:56 PM, R59 stated, They…

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 label, date, discard expired food/beverages, and complete daily temperature logs for resident's personal refrigerators. This applies to 2 of 2 residents (R2 and R51) in the sample of 35. The findings include: 1. R2's Face Sheet showed diagnoses of asthma, chronic pain due to trauma, dysphagia, schizophrenia, major depressive disorder, anxiety, epilepsy, hypertension, heart failure, and hemiplegia/hemiparesis. R2's MDS (MDS/Minimum Data Set), dated 07/19/24, showed R2 was cognitively intact. The same MDS showed R2 had an impairment on one side of her upper extremities, and an impairment on side of her lower extremities. On 09/03/24 at 11:10 AM, R2 had a personal refrigerator in her room. The refrigerator contained two cartons of chocolate milk, with an expiration date of 06/08/24 and 07/28/24. The refrigerator had one carton of white milk, with expiration date 06/08/24. R2 had two bowls of shredded cheese in the refrigerator without a date and label. R2 said the staff comes and checks the temperature of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its Enhance Barrier Precautions (EBP) Guidelines by staff not wearing gowns during wound care to EBP resident,s and not having a trash can inside the resident room and near the exit for discarding PPE after removal. The facility also failed to maintain effective hand hygiene during resident care. This applies to 2 of 4 residents (R95 and R124) reviewed for infection control practices in a sample of 35. The findings include: 1. R124 is a [AGE] year-old male with severe cognitive impairment as per the Minimum Data Set (MDS), dated [DATE]. R124 was admitted with an admitting diagnosis, including cerebral infarction, dysphagia, and gastrostomy tube (GT) feeding. On 9/4/24 at 9:58 AM, R124's entry door was observed with an EBP sign to wear gloves, gown, and mask to provide high-contact resident care activities. On 9/4/24 at 10:00 AM, V5 (Wound Care Nurse) and V8 (Certified Nursing Assistant / CNA) provided wound care to R124's sacral…

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 implement their abuse policy and notify the State Agency of an allegation of theft. This applies to 1 of 8 residents (R1) reviewed for misappropriation of property. The findings include: R1 is a [AGE] year-old female admitted on [DATE] with moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. R1 was interviewed on 4/12/2024 at 10:45AM, and stated she reported to V8 (Registered Nurse/RN)a few weeks ago, that she lost $80.00 from her wallet. According to R1, V8 was the supervisor that day. On 4/12/24 at 11:25 AM, V8 stated \he charted the incident that R1 was missing her $80.00, and reported it to V13 (Social Service). On 4/12/24 at 12:55 PM, V13 stated V8 didn't notify her R1 was missing $80.00 from her wallet. V13 added when she checked with V8, he (V8) said he notified the Assistant Administrator (V2). On 4/12/24 at 3:30 PM, V2 stated V8 never notified her. On 4/12/24 at 3:30 PM, V1 (Administrator) stated, (V8( should have…

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 reord review, the facility failed to provide access to a call light for one resident. This applies to 1 of 25 residents (R1) reviewed for call light access in the sample of 25. The findings include: The Face Sheet for R1 shows R1 has a diagnosis of hemiplegia and hemiparesis following a cerebrovascular accident (CVA or stroke) affecting the left non-dominant side. R1 has incomplete use of the right side, as well. The most recent MDS (minimum data set) for R1, dated 4/4/23, shows R1 requires substantial/maximal assistance to roll side to side in the bed substantial/maximal assistance for eating and is dependent for dressing and for all transfers. On 10/23/23 at 11:26 AM, the call light cord for R1 was on the floor, out of reach of R1. At this time, R1 was in bed and stated she did not know where her call light was located. On 10/24/23 at 9:14 AM, R1 was in bed. The call light cord was clipped to the left side of R1's gown. R1 attempted to reach the cord, but could not. On 10/24/23 at 9:16 AM, V14 (LPN - Licensed Practical Nurse) stated the call…

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 residents identified as needing assistance with personal hygiene. This applies to 3 of 4 residents (R55, R59 and R173) reviewed for ADLs (activities of daily living) in the sample of 25. The findings include: 1. R173 had multiple diagnoses including unspecified injury at unspecified level of cervical cord and carpal tunnel syndrome, based on the face sheet. R173's progress notes, dated 10/17/23 created by the Social Service, showed the resident was cognitively intact. R173's point of care documentation showed from 10/20 through 10/24/23, the resident required moderate to maximum assistance from the staff to perform grooming task. On 10/23/23 at 10:48 AM, R173 was in bed, alert, oriented, and verbally responsive. R173 had bilateral wrist/hand splints in place. R173's fingernails were long, jagged and with black substances underneath. R173 stated, Oh yes, it definitely needs cut and cleaning. Whatever you can do for me, I will…

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 doctor's order to schedule for a resident a doctor's office visit for an out-patient procedure. This affected 1 of 1 resident (R100) reviewed for quality of care in the sample of 25. The findings include: Review of R100's face sheet documents a [AGE] year old male admitted to the facility on [DATE], with diagnoses that include Injury at C4 level of Cervical Spinal Cord, Neuromuscular Dysfunction of Bladder, Abnormalities of Gait, Type 2 Diabetes Mellitus, and Benign Prostatic Hyperplasia with lower Urinary Tract Symptoms. On 10/23/23 at 10:52 AM, R100 stated he does not know why he still has an indwelling urinary catheter. R100's Physician order, dated 3/16/23, showed the following: Please schedule [a] follow up appointment with Urology for out-patient cystoscopy. On 10/24/23 at 4:30 PM, V5 (Activities Director) stated the last appointment R100 had was a neurology appointment in January of 2023. V5 stated there are no other…

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 that one resident's toenails that were extremely overgrown were cut by the podiatrist. This applies to 1 of 1 resident (R67) reviewed for foot care in the sample of 25. The findings include: Review of R67's face sheet documents a [AGE] year old female admitted to the facility on [DATE] with diagnoses including Dementia, need for assistance with personal care, Type 2 Diabetes Mellitus, Seizures, Cerebral infarction without residual deficits. On 10/23/23 at 11:00 AM, R67 was noted to be in bed with bare uncovered feet. R67's toe nails were noted to be long and needing to be cut. R67 stated she needs her toenails cut. On 10/25/23 at 09:06 AM, V10 (Registered Nurse/RN) stated the podiatrist comes to the facility and cuts the toenails of residents. V10 stated there is a list of residents who need to see the podiatrist. According to the podiatrist list, R67 was last placed on the list to be seen on 2/14/2023. R67 was not on the current…

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 perineal and indwelling urinary catheter care and services in a manner that would prevent potential infection and maintain hygiene. The facility also failed to ensure that the urinary catheter tubing and urinary privacy bag containing the drainage bag were not touching the floor. This applies to 1 of 3 residents (R82) reviewed for perineal and urinary catheter care in the sample of 25. The findings include: R82 had multiple diagnoses including malignant neoplasm of stomach, type 2 diabetes mellitus, and need for assistance with personal hygiene, based on the face sheet. R82's urine analysis result collected on 8/9/23 showed that the resident had history of Klebsiella pneumoniae ESBL (Extended Spectrum Beta-Lactamase). R82's quarterly MDS (Minimum Data Set), dated 10/1/23, showed the resident was cognitively intact. The MDS showed R82 required substantial/maximum assistance from the staff with regards to toileting hygiene. The same MDS showed R82 had an indwelling urinary catheter and was frequently…

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 follow physician's order with regards to use of the oxygen humidity bottles and administration of continuous oxygen. The facility also failed to label the oxygen tubing per policy and procedure. This applies to 3 of 3 residents (R31, R32 and R43) reviewed for oxygen therapy in the sample of 25. The findings include: 1. R43 had multiple diagnoses including type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, ischemic cardiomyopathy and hypoxia, based on the face sheet. On 10/24/23 at 8:29 AM, R43 was in bed alert, oriented, and verbally responsive. R43 had ongoing continuous oxygen via nasal cannula at 4.5 liters per minute using an oxygen concentrator. There was no oxygen humidity bottle being used. R43 stated the inside of his nose and mouth were dry. R43 also stated his oxygen tubing was not changed by the staff for almost a month. R43's oxygen tubing had a label dated 9/25/23. R43's order summary report showed an order, dated 9/29/3 for…

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

Based on observation, interview, and record review, the facility failed to refill prescribed pain medications for a resident. This applies to 1 of 25 residents (R88) reviewed for medication availability in the sample of 25. The findings include: R88's diagnoses on face sheet included other acute osteomyelitis, other site, pneumonia, unspecified organism, major depressive disorder, recurrent, unspecified, gastro-esophageal reflux disease without esophagitis, chronic viral hepatitis C, and type 2 diabetes mellitus with diabetic neuropathy, unspecified. R88's quarterly MDS (Minimum Data Set), dated 9/8/23, showed R88 was cognitively intact. R88's Physician Order Sheet included orders for the following pain medications: Lyrica Capsule 25 MG (Pregabalin), Give 1 capsule by mouth two times a day for Nerve pain (start date 5/11/23), reordered 10/20/23. Percocet Oral Tablet 10-325 MG (Oxycodone with Acetaminophen), Give 1 tablet by mouth every 6 hours as needed for Pain (start date 5/2/23) Ibuprofen Tablet 800 MG Give 1 tablet by mouth every 8 hours as needed for Pain (start date 6/14/23).…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and assist one resident in obtaining routine oral care annually. The facility also failed to follow up to ensure one resident was seen by visiting dentist. This applies to 2 of 25 residents (R69, R72) reviewed for dental care in the sample of 25. The findings include: 1) Review of R69's face sheet documents a [AGE] year old male admitted to the facility on [DATE], with diagnoses including Cerebral Infraction affecting left non-Dominant side, Dysphagia following cerebral infarction, Dysarthria following cerebral infarction, and need for assistance with personal Care. R69's Minimum Data Set (MDS) Assessment, dated 9/25/23, documents R69 requires extensive assistance for personal hygiene. On 10/23/23 at 10:32, R69 was lying in bed. R69's teeth are extremely brown, crooked, and possibly broken. R69 stated he has issues with swallowing. 10/24/23 at 12:47 PM, R69 stated he doesn't know the last time he brushed his teeth, and…

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 thickened fluids to residents that have been identified having swallowing problems. This applies to 3 of 10 residents (R11, R69 and R72) reviewed for thickened liquids in the sample of 25. The findings include: 1. R11's face sheet included diagnoses of pneumonia, unspecified organism, dysphagia, oropharyngeal phase, gastro-esophageal reflux disease without esophagitis, rheumatoid arthritis, chronic obstructive pulmonary disease with (acute) exacerbation, and antiphospholipid syndrome. R11's quarterly MDS (minimum data set), dated 10/13/23, showed R11 was cognitively intact. R11's Physician Order Sheet included R11 is on General diet, Regular texture, Nectar Thick liquids consistency for cough ( order start date 9/6/23). On 10/25/23 at 9:08 AM, R11 was in her room eating her breakfast. R11 received thickened liquids with her breakfast tray. R11 was noted to have a disposable cup of clear water that was about 1/3 full. R11 stated 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, interviews, and record review, the facility failed to maintain transmission based precautions for residents in isolation with infections, failed to perform hand hygiene, failed to use personal protective equipment, and failed to maintain sanitary conditions during patient care. This applies to 2 of 2 residents (R77 and R82) reviewed for infection control in the sample of 25. The findings include: 1. According to the facility medical record, R77 was on contact isolation due to surgical wounds infected with an antibiotic-resistant bacterium (Carbapenem-Resistant Enterobacterales - CRE) and had been since admission to the facility 6/23/23. The isolation condition was indicated by a printed sign on the door to the room and by a cart next to the door containing PPE (personal protective equipment). The sign showed disposable gloves and disposable gown should be worn by any person entering the room. On 10/23/23 at 12:42 PM, V20 (CNA - Certified Nursing Assistant) entered the room carrying the lunch tray, without first donning PPE of any kind. R77 asked V20 to fill his…

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.