Arc at Sangamon Valley

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide medication on admission on 1 of 3 (R2) residents investigated for quality of care in a sample of 20.R2's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE].R2's EMR dated 4/18/25 documents a diagnosis of aftercare following joint replacement surgery and presence of right artificial hip joint.R2's EMR dated 4/18/25 documents a diagnoses of unspecified asthma and chronic obstructive pulmonary disease with acute exacerbation (COPD).R2's Care Plan dated 5/18/25 documents The resident is at risk for pain r/t Osteoarthritis and RTHAR2's Care Plan dated 5/18/25 documents The resident has altered respiratory status/difficulty breathing r/t COPD.R2's Physician Order dated 4/18/25 documents Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen); Give 1 tablet by mouth every 6 hours as needed for Pain.R2's Physician Order dated 4/18/25 documents Apixaban Oral Tablet 5 MG…

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 notify a resident's responsible party of a resident injury for 1 of 4 residents (R3) reviewed for notification in the sample of 6.Findings Include:R3's medical diagnosis sheet, print date of 7/23/25, documented R3 has diagnoses including unspecified severe dementia with agitation, dysphagia, osteoporosis, crest syndrome, anemia, and congestive heart failure. R3's MDS (Minimum Data Set), dated 6/23/25, documented R3 is severely cognitively impaired and is dependent on staff for ADLS (activities of daily living). R3's progress note, dated 7/10/25 at 11:57 PM, documented CNA (Certified Nurse Assistant) made writer aware that resident had smashed her finger in the door. 4th digit of right hand observed to have the door indention print, redness and what look like a bruise forming. POA/MD (Power of Attorney/Medical Doctor) updated. On 7/22/25 at 10:27 AM V4, private caretaker for R3, stated last week on 7/11/25 during one of her visits to see R3 as she was washing R3's hands she noticed her right hand was bruised, swollen, 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 interview, observation, and record review, the facility failed to properly supervise 2 of 3 residents (R2, R3) reviewed for incidents and accidents in the sample of 6. This failure resulted in a resident (R2) to fall in an office rest room that was left unlocked after the office staff left for the day and R2 was not found for approximately 2.5 hours after staff noticed him missing. The facility also failed to complete an incident report per its policy after R3 sustained an injury when she got her hand stuck in a door and did not add an intervention to R3's care plan until 12 days after R3's incident. Findings Include:R3's medical diagnosis sheet, print date of 7/23/25, documented R3 has diagnoses including unspecified severe dementia with agitation, dysphagia, osteoporosis, crest syndrome, anemia, and congestive heart failure.R3's MDS (Minimum Data Set), dated 6/23/25, documented R3 is severely cognitively impaired and is dependent on staff for ADLS (activities of daily living).R3's progress note, dated 7/10/25 at 11:57 PM, documented CNA (Certified Nurse Assistant) made…

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 wheelchairs were clean for 1 of 5 residents (R2), reviewed for safe/clean/comfortable/homelike environment in the sample of 5.Findings include:On 7/1/25 at 9:00 AM, R2 was observed in her wheelchair, in the dining room. The wheelchair had dried debris on the edges of the seat, wheels, and frame.On 7/1/25 at 12:45 PM, R2 stated the facility staff is to clean her wheelchair once a month, but she isn't sure if they do it.R2's Minimum Data Set, dated [DATE], documents R2 has a BIMS (Brief Interview of Mental Status) score of 14, indicating R2 is cognitively intact.On 7/1/25 at 4:00 PM, V1, Administrator, stated he will make sure R2's wheelchair is cleaned. The Cleaning & Sanitizing - Wheelchairs and Other Medical Equipment, dated 11/20/12, documents the following: Medical equipment/devices will be cleaned and sanitized weekly or more often if needed, when used by the same resident.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place in 1 of 4 residents (R3), reviewed for falls in the sample of 5.Findings Include: R3's Face Sheet, undated, documents R3 has the following diagnoses: Dementia, History of Falling, and Chronic Kidney Disease.R3's Minimum Data Set, dated [DATE], documents R3 has moderate cognitive impairment, utilizes a wheelchair for mobility, and is dependent upon staff for chair/bed transfers. R3's Care Plan, dated 10/5/23, documents R3 is at risk for falls with the following interventions: Tilt Broda (reclining wheelchair) back in a reclining position when she is up and is not eating, keep furniture in locked position, and placement of a reminder sign to lock the Broda chair brakes when resident is sitting at the table due to resident pushing herself away from the table and is unbalanced and will lean forward causing unbalanced trunk movements.On 7/1/25 at 1:10 PM, R3's reclining wheelchair was observed 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 provide enough nursing staff to adequately meet the needs for 4 of 4 (R2, R4, R7, and R11) residents reviewed for staffing in the sample of 16. These failures have the potential to affect all residents residing at the facility. Findings Include: 1.R2's diagnosis sheet, print date of 5/12/25, documented R2 has diagnoses including acute hematogenous osteomyelitis of left ankle and foot, type 2 diabetes mellitus, chronic kidney disease, hypertension, and heart disease. R2's MDS (Minimum Data Set), dated 4/18/25, documented R2 is cognitively intact and requires partial to moderate assistance with transfers to and from wheelchair. R2's care plan, undated, documented R2 has an ADL (activities of daily living) self-care performance deficit related to generalized weakness and requires assistance with all ADLS including bathing and toileting. On 5/7/25 at 9:15 AM V6, (husband of R2), step out of R2's room with a full bag of soiled laundry in 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 interview and record review, the facility failed to develop a baseline care plan within the first 48 hours of admission to the facility and failed to provide the baseline care plan to the resident within 48 hours of admission for 1 of 4 residents (R11) reviewed for baseline care plans in the sample of 16. Findings Include: R11's clinical census sheet, print date of 5/13/25, documented R11 was admitted to the facility on [DATE]. R11's medical diagnosis form, print date of 5/12/25, documented R11 has diagnoses including laceration of esophagus, history of anaphylaxis, gastrostomy status, hypertension, depression, anxiety, and anemia. R11's [NAME] Data Set/MDS, dated [DATE], documented R11 is cognitively intact and dependent on staff for all ADLS (activities of daily living). On 5/12/25 at 12:56 PM R11 stated no facility staff have discussed her care plan with her, she has not received a copy of it, and she has not been invited to a care plan meeting. R11's progress note, dated 4/25/25, documented baseline…

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 residents who require assistance receive a shower or bath for 3 of 4 residents (R2, R11, R14) reviewed for Activities of Daily Living assistance in the sample of 16. This failure has the potential to affect all 126 residents residing at the facility. Findings Include: 1.R2's diagnosis sheet, print date of 5/12/25, documented R2 has diagnoses including acute hematogenous osteomyelitis of left ankle and foot, type 2 diabetes mellitus, chronic kidney disease, hypertension, and heart disease. R2's MDS (Minimum Data Set), dated 4/18/25, documented R2 is cognitively intact and requires partial to moderate assistance with transfers to and from wheelchair. R2's care plan, undated, documented R2 has an ADL (activities of daily living) self-care performance deficit related to generalized weakness and requires assistance with all ADLS including bathing and toileting. On 5/13/25 at 10:12 AM R2 stated she has not been receiving showers on 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 interview, and record review, the facility failed to provide consecutive 8-hour Registered Nurse (RN) coverage in the facility. This has the potential to affect all 122 residents residing in the facility. Finding includes: The Facility Schedule for March of 2025 documents no consecutive 8-hour RN coverage in 24 hours for the following dates: 3/7, 3/14, 3/21, and 3/31/25. On 4/3/2025 at 12:50 PM V1, Administrator, stated that they are actively hiring staff. V1 stated that they have recently hired 31 staff. V1 stated that they are giving bonuses for nurses and increased wages. V1 stated that she is performing open interviews and accommodating schedules. On 4/1/2025 the facility provided a list, dated 4/1/2025 at 10:04 AM, documents that census is 122.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to report an injury of unknown origin to the administrator for 1 of 3 residents (R2) reviewed for reporting allegations of abuse in the sample of 29. Findings include: R2's Face Sheet, print date of 4/1/25, documented R2 has diagnoses including stage 4 pressure ulcer of sacral region, methicillin susceptible staphylococcus aureus infection, metabolic encephalopathy, unspecified dementia, stable burst fracture of T11-T12 vertebra, hyperlipidemia, hypertension, atrial fibrillation, hypoosmolality, and hyponatremia. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is severely cognitively impaired and is dependent on staff for all ADLS (Activities of Daily Living). On 4/1/25 at 9:13 AM V15, R2's granddaughter, stated R2 developed a skin tear to her left upper arm and left hand during her two weeks stay at the facility. On 4/1/25 at 10:13 AM V16, daughter/POA (Power of Attorney), stated R2 developed a skin tear on her left upper arm around…

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 investigate an injury of unknown origin for 1 of 3 residents (R2) reviewed for abuse investigation in the sample of 29. Findings Include: R2's face sheet, print date of 4/1/25, documented R2 has diagnoses including unspecified dementia. R2's Minimum Data Set, MDS, dated [DATE], documented R2 is severely cognitively impaired and is dependent on staff for all ADLS (Activities of Daily Living). On 4/1/25 at 9:13 AM V15, R2's granddaughter, stated R2 developed a skin tear to her left upper arm and left hand during her two weeks stay at the facility. On 4/1/25 at 10:13 AM V16, daughter/POA (Power of Attorney), stated R2 developed a skin tear on her left upper arm around the middle of last week. V16 stated the skin tear was uncovered for a couple of days and then over the weekend it had a dressing over it. V16 stated R2 told her a CNA (Certified Nurse Assistant) was rough with her during her shower resulting in the skin tear. V16 stated this is…

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 complete incident investigations, root cause analysis of skin tears, and failed to implement interventions as documented on resident care plans to reduce the risk of further skin tears and/or falls for 3 of 3 residents (R2, R10, R13) reviewed for supervision to prevent accidents in the sample of 29. Findings Include: 1.R2's face sheet, print date of 4/1/25, documented R2 has diagnoses including stage 4 pressure ulcer of sacral region, methicillin susceptible staphylococcus aureus infection, metabolic encephalopathy, unspecified dementia, stable burst fracture of T11-T12 vertebra, hyperlipidemia, hypertension, atrial fibrillation, hypoosmolality, and hyponatremia. R2's MDS (Minimum Data Set), dated 4/2/25, documented R2 is severely cognitively impaired and is dependent on staff for all ADLS (Activities of Daily Living). On 4/1/25 at 9:13 AM V15, R2's granddaughter, stated R2 developed a skin tear to her left upper arm and left hand during…

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 sufficient nursing staff to provide nursing and related services to meet the residents' needs for 3 of 29 residents (R9, R16, R17) reviewed for staffing. Findings include: 1. On 4/1/2025 1:50 PM V12, Certified Nurse's Assistant (CNA), stated that that food is late a lot. V12 stated that the residents complain about the food being cold. V12 stated that the food is cold. V12 stated that they are frequently warming up food using the microwave on the hall. V12 stated that they have staffing problems. V12 stated that they work together and get everything done but it takes longer to get it done. It takes longer to pass trays when there are 2 staff and 1 is caring for someone and the other is passing the trays or care. It may take longer to get to a resident than it would if there were more staff. R16's Minimum Data Set (MDS) dated [DATE], documents that R16 is moderately cognitively impaired. On 4/1/2025 the facility provided a document…

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 residents with food that was served a palatable temperature for 3 of 5 residents (R16, R17, and R18) reviewed for food palatability in the sample of 29. Findings include: 1.R16's Minimum Data Set (MDS) dated [DATE], documents that R16 is moderately cognitively impaired. On 4/1/2025 the facility provided a document that indicated R16 was interview able. R16's Progress Note, dated 3/31/2025 at 3:19 PM, documents Skilled Charting Narrative: Mental Status: Resident is alert. Oriented to: Oriented to Person, place, time, and situation. Short-term memory impairment. On 4/1/2025 at approximately 2:30 PM R16 resided on the 500-hall and received a hall tray. R16 stated that her food was not hot. R16 stated that it was lukewarm. R16 stated that it was not ice cold, but it surely was not hot. R16 stated that she has not had hot food at the facility. R16 stated that the food was very late and that she did not get her food until after 1:00 PM…

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 a resident's skin upon admission, failed to document weekly skin assessments, and failed to notify the physician for treatment orders when a pressure ulcer was documented for 1 of 4 residents (R1) in a sample of 10. Findings include: R1's Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including a stage 2 pressure ulcer. R1's CNA (Certified Nurse Aide) Skin Attention Form, dated 4/1/2025 documents his buttocks was circled and staff documented S2 (stage 2) bilateral buttocks. The form was signed by V2, Director of Nursing (DON.) R1's Physician's Order Sheet (POS) dated 4/1/2025 documents weekly skin assessments. No pressure ulcer treatment was on the POS at that time. R1's Progress Note, dated 4/1/2025 at 3:49 PM, no documentation of admission skin assessment. Staff documented, see admission assessment. R1's History and Physical Progress Note, dated 4/2/2025 at 3:26 PM, documents skin: warm 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 interview and record review the facility failed to report and initiate investigation to determine cause of hematoma and skin tear for 1 of 3 residents (R2) reviewed for injury of unknown origin in the sample of 5. Findings include: R2's facesheet dated 3/3/2025 documents in part a diagnosis of Type 2 Diabetes Mellitus with Diabetic neuropathy, unspecified diastolic (congestive) heart failure, chronic kidney disease stage 4, and paroxysmal atrial fibrillation. R2' minimum Data Set (MDS) dated [DATE] documents A Brief Interview of mental status (BIMS) of 7 which indicates severe cognitive impairment. R2's MDS documents that R2 requires substantial /maximal assistance for sit to stand, chair-bed to chair transfer, toilet transfer, rolling left and right. R2's care plan dated 1/22/2025 documents R2 needs assistance with Activities of Daily Living (ADL'S). R2's care plan documents the following interventions; toileting- dependent on staff with gait belt, transfers sit to stand lift Assist x2. R2's care plan…

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 sufficient staff were available to provide needed care in a timely manner and supervision. This failure has the potential to effect all 109 residents residing in the facility. Findings include: 1. On 1/29/25 at 1:35 PM, R2 stated that R1 was crying a couple of weeks ago because she was so upset about how long it was taking for staff to come in and help her. On 1/29/25 at 1:45 PM, R1 stated that she believes the facility is short staffed because you have to wait for help. R1 stated that it can take over an hour to get help. R1 stated about 2 weeks ago, I was crying because no one would come and answer my light and I needed to go to the bathroom. That night I waited for 2 hours. R1's Face Sheet, print date of 2/4/25, documents R1 was admitted on [DATE] with diagnoses of a history of a Heart Attack and Chronic Obstructive Pulmonary Disease. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 is cognitively intact and is dependent on 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 educate residents on safety protocol and supervising dining for 6 of 7 residents (R2, R7, R8, R9, R10, R11) reviewed for accidents and supervision in the sample of 28. Finding include; 1. On 1/29/25 at 8:15 AM, V3, Registered Nurse (RN), stated R2 went to (Department Store) a couple of weeks ago. She called a cab, put her coat on, got her purse, and when the cab came she went out and left. We went and got her. On 1/29/25 at 9:30 AM, V2, Director of Nurses (DON), stated R2 is cognitively intact, she called a cab, got her coat and purse, and went to (Department Store). During a shift change rounds, the aide was told by R2's roommate (R1) that R2 had went to (Department Store). I was notified that she was not in the building, I looked at the camera and it showed her getting into a cab at 1:55 PM. I called the cab company and they told me they picked R2 up and took her to (Department Store). They told me they were familiar with her and 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 interview and record review, the facility failed to answer call lights timely for 3 of 9 (R1, R13, R17) residents reviewed for dignity in the sample of 28. Findings include: 1. On 1/29/25 at 1:35 PM, R2 stated that R1 was crying a couple of weeks ago because she was so upset about how long it was taking for staff to come in and help her. On 1/29/25 at 1:45 PM, R1 stated that she believes the facility is short staffed because you have to wait for help. R1 stated that it can take over an hour to get help. R1 stated about 2 weeks ago, I was crying because no one would come and answer my light and I needed to go to the bathroom. That night I waited for 2 hours. R1's Face Sheet, print date of 2/4/25, documents R1 was admitted on [DATE] with diagnoses of a history of a Heart Attack and Chronic Obstructive Pulmonary Disease. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 is cognitively intact and is dependent on staff for toilet and sit to stand transfers and is occasionally incontinent of urine…

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, observation, and record review, the facility failed to serve food, dispose of outdated food, label and date food items to prevent food borne illness. This has the potential to affect all 116 residents residing in the facility. Findings include: On 9/23/24 at 9:30 AM, V5, Dietary Manager stated food is only good for 3 or 4 days after preparing it, all food should be labeled and dated, properly sealed and employees should not have drinks in the refrigerators. On 9/23/24 at 9:30 AM, the kitchen was entered. In the stand-up refrigerators, a large pan of spaghetti and meat sauce, a small bowl of spaghetti and meat sauce, ½ cheese sandwich, large pan of cooked chicken breast, multiple small bags of carrots and purple cabbage that is shredded, 2 pies, large stainless container of shredded lettuce, large stainless container of shredded cheese, and stainless-steel container of red sauce. All of which are not dated or labeled. A large container of cooked hamburger patties dated 9/15/24, small container of tuna salad dated 9/16/24, large container of chicken breast dated…

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, observations, and record reviews the facility failed to provide assistance with personal hygiene and feeding for 5 out of 32 residents, (R43, R46, R60, R7, R8), reviewed for assistance with activities of daily living (ADL) in a sample of 51. Findings include: 1. R43's Minimum Data Set (MDS), dated [DATE], documents she is moderately cognitively impaired and requires supervision or touching assistance while eating. This MDS also documents she requires a mechanically altered diet involving the change in texture of food or liquids to pureed food or thickened liquids. R43's care plan, dated 8/20/2024, documents she has a behavior problem of throwing feces in room, throwing food, plates on floor, related to dementia. Interventions put in place for staff to follow involve monitoring/documenting/reporting targeted behaviors and to attempt interventions as well as analyze key times, places, circumstances, triggers, what de-escalates the behavior and to document. On 9/23/2024 at 12:02 PM, R43 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to wear appropriate Personal Protective Equipment, perform hand hygiene between glove changes, and perform hand hygiene between resident contact to prevent cross contamination for 8 of 32 residents (R13, R25, R43, R45, R67, R86, R100, R106) reviewed for infection control in the sample of 51. Findings include: 1. On 9/24/24 at 12:15 PM, V20 Certified Nurse Aide (CNA) is assisting R100 with transfer and changing his clothes. V20 is wearing gloves only. V20 stated that she was going to switch R100's large urinary bag to his leg bag. V20 retrieved the leg bag and emptied a small amount of urine that was left in the bag previously. V20 then placed the leg bag into another bag. The urinary bags were never switched. V20 then removed her gloves and donned new gloves with no hand hygiene. V20 then removed R100's shirt and put a new shirt on him. R100's room door has signage indicating that he is on Enhanced Barrier Precautions and all Personal…

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 provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF/ABN) form CMS 1055 to residents prior to discharge from Medicare Part A services for 2 of 3 residents (R106, and R315) reviewed for Medicare Part A services in the sample of 51. Findings include: 1. R106's facesheet dated 9/26/2024 documents R106 was admitted to the facility on [DATE]. R106s' face sheet documents a diagnosis in part of unspecified fracture of T9-T10 vertebra, chronic kidney disease, syncope, collapse and repeated falls. Review of record documents R106 Medicare Part A Services stated 6/24/2024 and terminated on 8/5/2024 with benefit days remaining. The SNF/ABN form CMS 1055 was not provided to R106 by the facility. 2. R315's face sheet dated 9/26/2024 document R315 was admitted to the facility on [DATE] with diagnosis of bilateral primary osteoarthtritis of hip, radiculopathy lumbar region, repeated falls and spinal stenosis. Review of R315's record documents R315 Medicare…

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 incontinent care, for 2 of 5 (R6, R45) residents, reviewed for incontinence, in a sample of 51. Findings include: 1. On 09/25/2024 at 10:15 AM, V23, Certified Nurse Assistant (CNA), cleansed R6's left buttock down to inner thigh, and cleansed front to back peri rectal and rectal area using wet cleansing wipes. V23 did not dry the cleansed areas. R6 was then rolled onto her back, and V23 cleansed her abdominal fold, bilateral groins and labia with the wet cleansing wipes. These areas were not dried nor was R6's left hip, buttock or back of left thigh cleansed. V23 then put a clean incontinent brief on R6 and then pulled her pants back up. R6's Physician's order sheet, dated 9/2024, documented a diagnoses of personal history of urinary tract infections, dementia and anxiety. R6's Minimum Data Set (MDS), dated [DATE], documented that she was always incontinent of her bowels and her bladder, that her cognition was severely…

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 address Pharmacy Recommendations in a timely manner for 1 of 5 residents (R87) reviewed for medication review in the sample of 5. Findings include: R87's admission Record, print date of 9/24/24, documents that R87 was admitted on [DATE] and has diagnoses of Parkinson's Disease, Depression, Dementia, and Anxiety. R87's Pharmacy Recommendation, dated 6/27/24, documents, (R87) has been receiving clonazepam 0.25 mg once daily for anxiety since 1/20/24. Dose reduction attempts should be made for anxiolytic medications at least twice in the first year and then yearly to ensure drug effectiveness with minimal side effects. This Pharmacy Recommendation was reviewed and signed by V31, Medical Director on 9/25/24. R87's Pharmacy Recommendation, dated 7/12/24, documents, (R87) has been receiving Quetiapine 12.5 mg in the afternoon and 50 mg at bedtime for Major Depression since dose was increased 1/2024. Dose reduction attempts should be made for antipsychotics…

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, observations, and record reviews the facility failed to review a urine culture and obtain a wound culture for 1 out of 6 residents, (R67), reviewed for antibiotic stewardship in a sample of 51. Findings include: R67 was admitted to the facility on [DATE] with diagnosis of, in part, urinary tract infection (UTI), chronic kidney disease, stage 3, bladder-neck obstruction, diabetes mellitus type 2, benign prostatic hyperplasia with lower urinary tract symptoms and presence of urogenital implants. R67's Minimum Data Set (MDS), dated [DATE], documents he is severely cognitively impaired and completely dependent on staff to provide assistance with toileting and personal hygiene. R67's care plan, dated 7/15/2024, documents he has a diagnosis of BPH and for staff to monitor for signs and symptoms of urinary retention: no urination for 8 hours - if he can barely urinate or feels like bladder if full for an hour or more, having urgency when he feels like emptying, frequent urination, a stream of urine…

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 call light within reach for 1 of 7 residents (R4) reviewed for call lights in the sample of 8. Findings Include: On 8/13/2024 at 9:22 AM, R4 in bed. R4's call light was lying on the floor at the head of the bed out of R4's reach. On 8/13/2024 at 1:29 PM, R4's call light remains on the floor out of reach. R4's Care plan dated 6/30/2023 documents R4 attempts to self transfer with intervention to remind R4 to call for assist when needs help. On 8/14/2024 at 2:11 PM, V3, Executive Director stated call light should be within reach of residents. The facility policy Call Light System dated, revised December 20, 2011 documents it is the policy of the facility to provide a means of communication to meet the needs of each resident. The policy documents staff will: assure the call light is within easy reach of the resident.

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 verbal abuse for 1 of 3 residents (R4) reviewed for abuse in the sample of 8. Findings include: V9, Licensed Practical Nurse (LPN) written statement dated 8/14/2024 documents on 8/2/2024 that V9 was notified by assigned Certified Nursing Assistants (CNA) that resident often makes verbal statement to her roommate telling her to shut the f* up. V9's statement documents if resident begins crying or yelling at staff providing care. CNAs state resident has also made verbal statements that she would hit roommate on head. V9's statement documents she informed CNAs to report these concerns as abuse. V9's statement documents social services was notified at that time for requested room change. V1, Administrator written statement dated 8/2/2024 at 2:30 PM documents Administrator was notified by SSA (social service aide) that R3 and roommate were cussing at each other in their room. V1's statement documents that V1 interviewed R3…

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 abuse policy for 1 of 3 residents (R4) reviewed for abuse in the sample of 8. Findings include: R4's Minimum Data Set (MDS) dated [DATE] documents that R4 has severe cognitive impairment. R4's MDS documents that R4 is dependent on staff for personal hygiene, lower body dressing, sit to stand, toilet transfers and requires substantial to maximal assistance with oral hygiene, toileting, bathing upper body dressing. R4's face sheet dated 8/14/2024 documents in part that R4 has a diagnosis of unspecified dementia, moderate with other behavioral disturbances. R3's care plan dated 5/16/2023 documents R3 has potential to be verbally abusive/aggressive (yelling/screaming, abusive language) related to ineffective coping skills, anxiety disorder, depression. R3's care plan documents R3 will demonstrate effective coping skills and will verbalize understanding of need to control verbally abusive behavior through the review date. R3's care plan documents…

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 abuse policy for 1 of 3 residents (R4) reviewed for abuse in the sample of 8. Findings include: R4's Minimum Data Set (MDS) dated [DATE] documents R4 has severe cognitive impairment. R4's MDS documents that R4 is dependent on staff for personal hygiene, lower body dressing, sit to stand, toilet transfers and requires substantial to maximal assistance with oral hygiene, toileting, bathing upper body dressing. R4's face sheet dated 8/14/2024 documents in part that R4 has a diagnosis of unspecified dementia, moderate with other behavioral disturbances. R3's care plan dated 5/16/2023 documents R3 has potential to be verbally abusive/aggressive (yelling/screaming, abusive language) related to ineffective coping skills, anxiety disorder, depression. R3's care plan documents R3 will demonstrate effective coping skills and will verbalize understanding of need to control verbally abusive behavior through the review date. R3's care plan…

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 investigate an allegation of abuse for 1 of 3 residents (R4) reviewed for abuse in the sample of 8. Findings include: R4's Minimum Data Set (MDS) dated [DATE] documents that R4 has severe cognitive impairment. R4's MDS documents that R4 is dependent on staff for personal hygiene, lower body dressing, sit to stand, toilet transfers and requires substantial to maximal assistance with oral hygiene, toileting, bathing upper body dressing. R4's face sheet dated 8/14/2024 documents in part that R4 has a diagnosis of unspecified dementia, moderate with other behavioral disturbances. R3's care plan dated 5/16/2023 documents R3 has potential to be verbally abusive/aggressive (yelling/screaming, abusive language) related to ineffective coping skills, anxiety disorder, depression. R3's care plan documents R3 will demonstrate effective coping skills and will verbalize understanding of need to control verbally abusive behavior through the review date. R3's care plan…

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 resident is free from misappropriation of their property for 1 of 4 residents (R6) reviewed for misappropriation of property in the sample of 6. Findings include: On 7/9/24 at 9:16 AM V6, Licensed Practical Nurse (LPN) administered R1's morning medications to her. When V6 opened R1's Lidocaine patch she dropped the patch on the floor and discarded it after picking it up off the floor. V6 then went back to the medication cart to retrieve another Lidocaine patch and writer requested to see the package V6 got the patch from to check the dose, physician order and name on the package. V6 stated, I just used (R1's) last patch; that was the one I dropped on the floor. I just borrowed one from (R6). I will replace it when R6's patches come in because I will still be here tonight when pharmacy delivers them because I work 16 hour shifts on Tuesdays. I borrowed it from (R6) because it is not (R1's) fault that I dropped her patch on the floor. V6 stated she doesn't always borrow one resident's medication 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 Based on observation, interview and record review, the facility failed to follow Nursing Standards of Practice while performing medication administration for 3 of 3 residents (R1, R3 and R4) reviewed for medications in the sample of 6. Findings include: On 7/9/24 at 9:05 AM a Medication Pass Observation was done with V6 Licensed Practical Nurse (LPN) on 100 hall. V6 stated, I already signed out all my medications but I still have some residents to give their medications. My computer doesn't always work good and I work two 16 hour shifts, on Mondays and Tuesdays, and every other weekend, so I know everyone's medications. I have not let administration know about the computer not working sometimes, I just deal with it. If a resident refuses one of their meds, I just go back and strike it out. V6 did not use the computer on her medication cart to check the e-mar while passing medications. On 7/9/24 at 9:07 AM V6 administered medications to R1. She read the names of the medications off the prepackaged pouch of…

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

Based on observation, interview and record review, the Facility failed to ensure the current staffing record was posted. This failure has the potential to affect all 117 residents residing in the Facility. Findings include: On 5/20/2024 at 9:25 AM, there was a posting titled, Report of Nursing Staff directly responsible for resident care dated 4/26/2024 as well as a disclaimer dated 3/29/2024 documenting the Facility does not meet the federal staffing guidelines. On 5/21/2024 at 9:30 AM, the Report of Nursing Staff directly responsible for resident care was not posted. On 5/21/2024 at 12:44 PM, V1, Administrator stated she was aware the Report of Nursing Staff directly responsible for resident care was not posted and she sent an email to make sure it is kept current, because that is the regulation. V1 also stated, Hopefully it is posted today. On 5/29/2024 at 2:33 PM, V1 stated the census of the facility was 117 on both 5/20/2024 and 5/21/2024. The Facility's Staffing and Staffing Notification Policy dated 9/1/2009 documents, It is the policy of (Facility) that communities provide…

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's Rights and dignity were honored regarding timely assistance in order to prevent incontinence as well as ensure residents were not left in soiled linens for 4 of 5 residents (R2, R6, R9, R10) reviewed for dignity, in the sample of 12. Findings include: 1. R10's Minimum Data Set, dated [DATE] documents R1 is cognitively intact, requires substantial/Maximal assistance with toileting needs and is frequently incontinent of bowel and bladder. R10's Care Plan dated 7/26/2024 documents R10 is incontinent of bladder, but does not address bowel incontinence. On 5/21/2024 at 9:35 AM, R10 stated, I don't get my call light answered to go to the bathroom. I've been trying to go to the bathroom and I've been waiting 20 minutes, maybe longer. I put my call light on at 9 (AM) according to my watch. They wonder why I dirty my clothes. I've seen at least 10 people walk by. It's ridiculous. I feel like I've dirtied my clothes. I hope not. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the Facility failed to ensure there were enough staff available to meet the needs of residents safety for transfers and call light response time for 5 of 5 residents (R2, R6, R8, R10, R11) reviewed for Lack of Staff, in the sample of 12. Findings include: 1. R10's Minimum Data Set, dated [DATE] documents R1 is cognitively intact, requires substantial/Maximal assistance with toileting needs and is frequently incontinent of bowel and bladder. R10's Care Plan dated 7/26/2024 documents R10 is incontienent of bladder, but does not address bowel incontinenece. On 5/21/2024 at 9:35 AM, R10 stated, I don't get my call light answered to go to the bathroom. I've been trying to go to the bathroom and I've been waiting 20 minutes, maybe longer. I put my call light on at 9 (AM) according to my watch. They wonder why I dirty my clothes. I've seen at least 10 people walk by. It's rediculous. I feel like I've dirtied my clothes. I hope not. At this time two Certified Nursing…

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 mechanical lift policy to ensure the safety of residents for 2 of 4 residents (R2,R6) reviewed for Resident Injuries, in the sample of 12. Findings include: 1. R2's Face Sheet dated 5/28/2024 documents R2 has a diagnosis of Multiple Sclerosis (MS). R2's MDS dated [DATE] documents R2 is cognitively intact. R2' Care Plan dated 2/27/2024 documents R2 uses a mechanical lift (sit to stand) and requires an assist of 2 for all transfers. R2's Care Plan dated 9/3/21 documents R2 has a history of legs giving out during transfers. On 5/21/2024 at 10:20 AM, R2 stated, My left side is paralyzed. I use the sit to stand. The nurse says there is supposed to be two but they don't have the staff for two. There's never two, only one. I fell one time, a couple weeks ago while using it (sit to stand lift). I got a bruise on my arm. The Facility's Incident/Accident Log documents R2 had a fall on 5/1/2024. R2's Fall Detail Report documents R2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide complete incontinent care for 2 of 3 residents (R1, R3) reviewed for bowel and bladder incontinence, in the sample of 6. Findings include: 1. R1's admission Profile, print date of 4/2/24, documented that R1 was admitted on [DATE] with diagnoses of a right broken ankle and weakness. R1's Minimum Data Set, (MDS), dated [DATE], documented that R1 was cognitively intact, required substantial / maximum assistance for all mobility and toileting, was always incontinent of urine and occasionally incontinent of bowel. On 4/2/24 at 9:58 AM, V3, Certified Nurses Aide, (CNA), transferred R1 from her wheelchair to bed. R1's incontinent brief was removed. It was soiled with urine. R1 took one pre-moistened periwash cloth and wiped once down the labia. R1 was then rolled over to her left side, with one cloth, V3 wiped the buttocks in circles, did not cleanse entire buttocks, and then took one cloth and wiped the rectal area up and down. 2. R3'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 interviews and record review the facility failed to provide sufficient nursing staffing of Certified Nursing Assistants (CNA) for 30 residents on skilled unit. This failure has the potential to affect all 30 residents on this unit. Findings include: On 3/2/2024 at 9:30 am, R3 stated that on 2/24/2024 he was not able to get up to his chair for supper due to there only being one CNA on duty and it takes two CNA's to get him out of bed. R3 continued to state that he also turned his call light on and it took a long time for staff to answer it and come change his linens because they were soiled. On 3/2/2024 at 11:30 am, V2, Director of Nursing, (DON), stated that on 2/24/2024, on the second shift, their skilled unit had only one CNA for the unit for 30 residents. V2 continued to state that he worked as CNA on the unit from 4pm-8pm on 2/24/2024. V2 stated that he does not clock in or out when he works the floor. On 3/2/2024 at 12:30 pm, V1, Administrator, stated that the skilled unit had 30 residents with only one CNA on the date of 2/24/2024. She continued to state that herself…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to report injury of unknown origin for one of three residents (R2) reviewed for abuse notification in the sample of 9. Findings include: On 3/2/2024 at 11:00 AM, R2 was observed sitting up in wheelchair with bilateral eyes and cheeks dark purple in color extending up forehead into hair line. R2 has cervical (C) collar in place. R2's Face Sheet, dated 3/5/2024, documents admission date of 5/30/2023 and diagnoses of Dementia, Hypertension, GERD and hearing loss. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is severely cognitively impaired and that R2 is dependent on staff for mobility, toileting, transfers, sitting and requires maximum assistance of staff for bed mobility. R2's Progress Notes, dated 2/24/2024 at 8:00 AM, written by V4, Registered Nurse (RN), documented that R2 has a bruised eye on left eye and partial bruising on right eye. There was no documentation in this Progress Note as to how R2 sustained these injuries. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews the facility failed to have fall interventions in place for one of three (R2) residents reviewed for accidents, in a sample of 9. Findings include: On 3/2/2024 at 11:00 am, R2 was up in his wheelchair in his room. R2 was noted to have bilateral bruising to both eyes and entire forehead bruising noted. R2 was observed with cervical (C) collar in place. The following fall interventions were not in place; his wheelchair did not have anti roll backs on it, there were no nonskid strips noted in front of toilet, no alarm on bathroom door and no antiskid mat in his room. On 3/5/2024 at 3:00 pm, R2 was lying in bed and the following fall interventions were not in place; his wheelchair did not have anti roll backs on it, there were no nonskid strips in front of his toilet, there were no alarm on bathroom door, no antiskid mat on floor next to bed and his wheelchair was not removed from his sight while he was resting in bed. R2's care plan and [NAME], dated 12/1/2023,…

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 interviews the facility failed to investigate allegation of abuse for 1 of 5 residents (R3) reviewed for abuse investigation in the sample of 6. Findings include: R3's admission Record Face Sheet, print date of 12/5/23, documented R3 had diagnoses of include hypertensive, infection, and inflammatory reaction due to internal left knee prostheses, subsequent encounter, occlusion and stenosis of right middle cerebral artery, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R3's Progress Note dated 8/17/2023 at 9:37pm documents Backnote @ (at) 0530 Heard (R3) screaming 'Help'. When writer arrived in (R3's) bathroom, (R3) was observed on his knees in front of w/c (wheelchair). Resident stated that he pushed me down. (V5, Certified Nurse's Aide, CNA) present with R3 in bathroom. R3 was lowered to floor per (V5). Resident assisted up into w/c with (full body mechanical) lift and assist of 2 without difficulty. ROM (Range of Motion) WNL (within normal limits) to all extremities. No…

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 assess R3 and determine a root cause related to a fall and implement interventions based upon this assessment/investigation for one of four residents (R3) reviewed for supervision to prevent accidents in the sample of 6. Findings include: R3's, admission Record, undated, documents R3's diagnoses as hypertensive, infection, and inflammatory reaction due to internal left knee prosthesis, subsequent encounter. R3's Progress Note, dated 8/17/2023 at 9:37 PM documents Backnote @ (at) 0530 Heard (R3) screaming Help. When writer arrived in (R3's) bathroom, R3 was observed on his knees in front of w/c (wheelchair). Resident stated that he pushed me down. (V5, Certified Nurse's Aide, CNA) present with (R3) in bathroom. (R3) was lowered to floor per (V5). Resident assisted up into w/c with (full-body mechanical) lift and assist of 2 without difficulty. ROM (Range of Motion) WNL (Within Normal Limits) to all extremities. No shortening/rotation. Denies hitting head. Abrasions noted to bilateral knees. Cleansed with wound cleanser 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 interview and record review the facility failed to determine if a resident had an advance directive in place upon admission or wanted to formulate an advanced directive for 1 of 5 residents (R1) reviewed for advanced directives in the sample of 5. Findings include: R1's Face Sheet, undated, documents R1 has the following diagnoses: Type 2 Diabetes, Hypertension, Hyperlipidemia, Bipolar Disorder, Epilepsy, Difficulty in Walking and Weakness. R1's Electronic Medical Record (EMR) was reviewed and failed to document an advanced directive/code status for R1. On [DATE] at 2:00 PM, R1 stated his son and wife signed him in a couple of days ago. R1 stated he already has a signed DNR (Do Not Resuscitate) in place and has had for many years. There was not an advanced directive or POLST (Physician Orders for Life Sustaining Treatment) form in the POLST book at the nurse's station for R1. On [DATE] at 2:05 PM, V5, Licensed Practical Nurse, stated R2's POLST is not in the binder, so it must not be completed yet, V5…

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, observation and record review, the facility failed to provide ADL (Activities of Daily Living) care to 3 of 5 residents (R1, R4 and R5) reviewed for ADL care in the sample of 5. Findings include: 1. On 11/9/23 at 1:30 PM, R5 was observed in her room with a slight urine odor. R5 stated the hospice aid came in this morning around 11:00 AM to give her a bath before lunch. R5 stated when she puts her call light on, sometimes it's an hour, 2 hours, sometimes 4-6 hours before anyone comes in. R5 stated she likes to get up in the morning and on bingo days, she stays up until about 3:00 PM and sometimes it 7:00 PM, 8:00 PM or sometimes 10:00 PM at shift change before anyone comes in, checks on her or puts her to bed. R5 stated there's been days when she's been up over 12 hours. R5 stated this happened just within the last week or two and it was reported and V1, Administrator was supposed to come and talk with her but hasn't yet. R5 stated she is a light sleeper and can sense when someone is in 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 provide complete incontinent care for 1 of 3 residents (R2) reviewed for incontinent care in the sample of 12. Findings include: On 11/2/23 at 10:03 AM, R2 pressed her call light, stating she was ready to get changed. At 10:07 AM V12, Certified Nursing Assistant, (CNA), answered the call light and asked R2 what she needed and R2 stated, I'm ready to be changed. V12 told her she would let V17, R2's CNA know and left the room. At 10:19 AM V17 entered the room wearing disposable gloves. V17 informed R2 she had been assisting another resident in the bathroom and apologized for it taking a few minutes for her to get to her. R2 stated, she had last been changed around 6:00 AM by night shift. V17 stated, she is agency and stated R2 walks her through it with incontinent care. V17 put a clean diaper under R2's wet diaper then pulled the wet diaper out from under her, causing R2's wet skin to lay against the clean adult diaper. V17 rolled R2 onto…

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, observation and record review, the facility failed to provide hygiene after meals and oral care for 5 of 5 residents (R2, R3, R4, R5, R11) reviewed for assistance with Activities of Daily Living in the sample of 13. Findings include: 1. R4's admission Record, print date of 10/3/23, documents that R4 was admitted on [DATE] and has diagnoses of Dementia and Chronic Obstructive Pulmonary Disease. R4's Minimum Data Set, (MDS), dated [DATE], documents that R4 is cognitively intact, requires supervision for eating, extensive assistance of 2 staff members for incontinence, extensive assistance of 1 staff member for hygiene and is always incontinent of bladder. On 10/3/23 at 1:55 PM, R4 is sitting in his room in his wheelchair. R4 has dried pureed carrots all around his mouth and chin. He has dried food debris between his legs on the wheelchair seat. V10 Certified Nurse Aide, (CNA), entered the room to lay him down. On 10/3/23 at 2:10 PM, R4 is lying in bed. R4's mouth and chin still have dried…

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, observation and record review, the call light was not accessible for 2 of 9 residents (R1, R7) reviewed for call lights in the sample of 13. Findings include: 1. R1's admission Profile, print date of 10/18/23, documents, that R1 was admitted on [DATE], with diagnosis of Hemiplegia and Hemiparesis following a stroke and has C-Diff. R1's Minimum Data Set, (MDS), dated [DATE], documents, that R1 is cognitively intact, requires extensive assistance of 1 staff member for bed mobility, transfers, locomotion with a wheelchair, dressing, toileting, and personal hygiene. On 10/17/23 at 1:55 PM, R1 is sitting in the middle of her room in her wheelchair. R1's bed is pulled a foot away from the wall. The call light has been clipped to the quilt close the edge which is nearest the wall. R1 is unable to reach her call light if she needed it to call for help. R1's room is located at the end of the hall, which is the farthest one from the Nurses Station. On 10/17/23 at 1:55 PM, R1 stated, that she does use…

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

Based on interview and record review, the facility failed to report an allegation of abuse to the Administrator immediately for 1 of 13 residents (R10), reviewed for abuse in the sample of 13. Finding include: On 10/17/23 at 1:21 PM, V22, Certified Occupational Therapy Assistant, (COTA), stated, Last week on 10/10/23 (V4, Physical Therapist), asked me if I would talk to R10. I went in a little before 5:00 PM to talk with R10 which was upset. She wanted to contact a Manager about the night before, and how she was put to bed. She said that staff had gotten 3 people and a sit to stand and put her to bed. She told them, she didn't want to go to bed at 6:00 PM and they made her anyway. She said when they put her to bed, they flung her leg into bed. There was also, a shower issue, she wanted a shower, because she was going to the Doctor the next day and she didn't get one until 1:00 AM. She said that the sit to stand hurt her shoulder, so she didn't like them using it. She was assessed for the sit to stand machine and was appropriate for her. She seemed more emotionally upset than…

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 do a complete and thorough investigation, into an allegation of abuse for 1 of 13 residents (R10) reviewed for abuse. Findings include: On 10/17/23 the facility was entered at 8:00 AM. V1, Administrator, stated, The Executive Director made me aware that Therapy had notified her of the residents' comments, so I went in to speak with her. (R10) did complain that she was put to bed at 6 PM, but her main complaint was about the way the staff had transferred her with the sit to stand machine and that it had hurt her. She (R10) had complaints of hip and arm pain, from the beginning of her stay. I had gone in and talked to her and at that time she was just saying that she was not happy with the way the staff were transferring her and she was having pain. We sent her out to the Hospital. I sent in an initial report to the state. Once at the Hospital, she told them a different problem, that she never mentioned to us (V1). The only way I (V1) found out about it was that we were reading the notes from the Hospital and there 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 observation, interview, and record review, the facility failed to provide meals at palatable temperatures for one of five residents (R10) reviewed for palatable food in the sample of 15. Findings include: 1. On 9/13/23 at 12:16 PM the noon meal trays came to the 2nd floor for delivery. At 12:17 PM the first tray was removed from the cart. During the observation it was noted that the aides pulled the tray from inside the cart and placed it on top. V7, Certified Nurse's Aide, CNA, and V21, CNA, then removed the insulated bottom and top plate coverings and carried the plates uncovered to each resident's room on the hall. On 9/13/23, at 12:31 PM, the last resident was served, and the test tray was tested with a digital thermometer. The parmesan chicken and carrots both tasted lukewarm. The breadstick was cool to touch. The parmesan chicken had a temperature of 116.9 degrees Fahrenheit (F), the carrots had a temperature of 120.6 degrees F, and the Bread had a temperature of 110.4 degrees F. On 9/13/2023 at 12:35 PM, V7 stated that there are times when they don't have staff 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 interview, observation and record review, the facility failed to provide assistance for 6 of 11 residents (R6, R10, R11, R12, R14, R27) reviewed for Activities of Daily Living in the sample of 27. Findings include: 1. R14's Face Sheet, print date of 8/28/23, documents, that R14 was admitted on [DATE] with diagnoses of Dementia and Severe Protein Calorie Malnutrition. R14's Minimum Data Set, (MDS), dated [DATE], documents, that R14 is severely cognitively impaired, requires limited assist of one staff member for: walking in the corridor, dressing, toileting, personal hygiene, requires supervision with set up help from one staff member for eating and that R14 was frequently incontinent of bowel and bladder. R14's Care Plan, dated 6/9/23, documents, The Resident needs assistance with ADL's, (Activities of Daily Living). (R14) needs set up assistance with meals and encouragement to eat. On 7/31/23 at 12:40 PM, R14 was in the 400-hall living room sitting at the dining table. R14 is sitting with her chair…

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, observation and record review, the facility failed to provide a clean environment for 2 of 23 residents (R8, R27) reviewed for environment in the sample of 27. Findings include: 1. R27's admission Record, print date of 8/23/23, documents, that R27 was admitted on [DATE] with diagnosis of Dementia. On 8/1/23 at 8:11 AM, R27 is sitting up in wheelchair, and smells of urine and R27's room smells of urine. On 8/1/23 at 8:11 AM, R27 stated, that she takes herself to the bathroom and does not need help from anyone. On 8/13/23 at 11:25 PM, R27 is sitting up in wheelchair, R27 smells of urine and again R27's room smells of urine. 2. R8's Face Sheet, print date of 8/28/23, documents, that R8 was admitted on [DATE] and has diagnoses of Alzheimer's, Dementia, Retention of Urine and Encounter for Palliative Care. On 8/1/23 at 8:11 AM, R8's room smells of urine. On 8/13/23 at 11:25 PM, R27's room smells of urine. On 8/17/23 at 2:25 PM, V13, Licensed Practical Nurse, stated, (R8's) and (R27's) room does…

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, observation and record review, the facility failed to notice and act upon a change of condition for 1 of 3 residents (R14) reviewed for change of condition in the sample of 27. Findings include: R14's Face Sheet, print date of 8/28/23, documents, that R14 was admitted on [DATE] and has diagnoses of Dementia and Severe Protein Calorie Malnutrition. R14's Minimum Data Set, dated [DATE], documents, that R14 is severely cognitively impaired, requires limited assist of one staff member for: walking in the corridor, dressing, toileting, personal hygiene, requires supervision with set up help from one staff member for eating and that R14 was frequently incontinent of bowel and bladder. On 8/17/23 at 1:00 PM, R14 is lying on the couch in the 400-hall living room asleep. R14 has two white towels on the arm of the couch which R14's head is on. There are approximately 3 to 4 white towels on the floor at the base of the couch on the floor. The towels are observed to have large amounts of brown substance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to complete treatments to 1 of 3 (R6) residents reviewed for pressure ulcers in the sample of 27. R6's face sheet dated 8/21/2023 documents, an admission date of 7/13/2023 with diagnosis of Respiratory failure with hypoxia, pneumonia, bipolar disorder, cerebral infarct and pressure ulcer sacral region. Minimum Data Set, (MDS), dated [DATE] documents, R6 is moderately cognitively impaired and requires extensive assist for activities of daily living. On 8/16/2023 at 1:10pm R6 states, that her dressing on her bottom does not get changed twice a day. On 8/17/2023 at 9:25 am, R6 states, that her dressing to her left buttock was changed on dayshift, yesterday but was not changed on second shift last night. R6 states, that the dressing was only changed once, yesterday but it is supposed to be changed twice a day. On 8/17/2023 at 9:25 am, observed dressing change to left buttocks. V9, (Registered Nurse), pulled incontinent brief down that contained…

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 and interview, the Facility failed to ensure refrigerated food was stored, labeled, and dated in a sanitary environment to prevent the risk of food borne illness. This has the potential to affect all 10 residents living in 500 Hall (R46, R389, R386, R222, R120, R104, R388, R385, R36, R390). Findings include: On 06/20/2023 at 3:10 PM, in the Resident Refrigerator in the 500 Hall Medication Storage Room, there was a package of hot dogs that was opened, but not labeled or dated. There was a package of cheese that was opened, but not labeled or dated. There was a jar of grape jelly that was opened, but not labeled or dated. There was a jar of strawberry jelly that was opened, not labeled or dated. There was a container of pickle relish that was opened, but not labeled or dated. There was a bottle of mustard that was opened, but not labeled or dated. There was a bottle of ranch dressing that was opened, but not labeled or dated. There was a box of carry out pizza that was not labeled or dated.…

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 incontinent care, catheter care and appropriate hand hygiene during care for 4 of 5 residents (R13, R16, R35, R40) reviewed for incontinent care/catheter care in the sample 45. Findings include: 1. R13's Care Plan, dated 1/4/21, documents (R13) has frequent bladder incontinence. R13's Care Plan documents Incontinence care with each incontinence episode. On 5/24/2022 at 2:40 PM V24, Certified Nurse's Aide (CNA), and V25, CNA, assisted R13 with toileting. V24 and V25 assisted R13 onto the commode. V24 then pulled down R13's pants. V25 removed R13's urine soiled incontinent insert and indicated it was wet. At 2:55 PM, V24 assisted R13 into standing position. R13 had a bowel movement. V25 then cleansed R13's buttocks, then with the same soiled gloves V25 obtained a clean undergarment and applied it to R13. V25 did not cleanse R13's inner and outer labia or thighs. 2. R16's Care Plan, revision date 3/23/2020, documents that R16…

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.