Waters Of Lebanon, The

Based on observation, record review, and interview, the facility failed to ensure a resident had a self-adminstration asessment for a medication (Ventolin) stored at bedside for 1 of 12 residents (Resident 34) reviewed for medications at bedside. Findings include: On 9/10/24 at 10:12 a.m., an inhaler of Ventolin (a bronchodilator) used to treat chronic obstructive pulmonary disease (COPD) was observed on Resident 34's bedside table. Resident 34 was not observed in her room. The medication was left unattended. On 9/10/24 11:28 a.m., a record review was completed for Resident 34. She had the following diagnoses which included but not limited to COPD, heart failure, dementia, and anxiety disorder. She had an order for Ventolin HFA inhalation aerosol solution 108 (90 base) mcg/act (micrograms/actuation) (albuterol sulfate) take two puffs inhale orally every four hours as needed for shortness of breath (SOB). Residnet 34's record lacked a medication self-administration assessment. On 9/10/24 at 11:00 a.m., during an interview with the Director of Nursing, she indicated the medication…

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 and interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded for 5 of 12 residents reviewed for resident assessments (Residents 6, 34, 13, 43 and 29). Findings include: 1. On 9/10/24 at 11:16 a.m., a record review was completed for Resident 6. She had the following diagnoses which included, but were not limited to, End Stage Renal Disease (ESRD- disease and degeneration of the kidneys), type 2 diabetes (an inability for the body to produce/process blood sugar), and muscle weakness. She had a physician's order, dated 1/27/24, which indicated she may attend dialysis on Monday, Wednesday, and Friday at a specific center. She had a comprehensive care plan, dated 1/26/24, which indicated she had a diagnosis of ESRD and required dialysis treatment. A Minimum Data Set (MDS) assessment, dated 8/23/24, indicated Resident 6 had not recieved dialysis treatments. 2. On 9/10/24 at 11:35 a.m., a record review was completed for Resident 34. She had the following diagnoses which included, but were not limited to, heart…

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 who was at risk for developing pressure ulcers, received a pressure reducing device for her wheelchair for 1 of 2 residents reviewed for pressure ulcers (Resident 29). Findings include: On 9/9/24 at 10:10 a.m., Resident 29 was observed. She was seated in a wheelchair (WC) with her overbed table in front of her. She rested her head in her hand with her eyes closed. No Pressure reducing cushion was observed on her WC seat at that time. On 9/9/24 at 12:33 p.m., Resident 29 was observed. She remained seated in her WC, no pressure reducing cushion was observed, as lunch trays were delivered. On 9/9/24 at 1:23 p.m., Resident 29 was observed. She remained seated in her WC and no pressure reducing cushion was observed in place. On 9/10/24 at 11:00 a.m., Resident 29's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of disease which affect lung tissue and capacity making…

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 assess on a quarterly basis to determine any improvement, decline or remained the same level with mobility and Range of Motion (ROM) for 2 of 3 residents reviewed (Resident 1 and 36). Findings include: 1. On 9/10/24 at 2:04 p.m., a record review was completed for Resident 1. He had the following diagnoses which included but not limited to type 2 diabetes, difficulty walking, heart failure, and history of falling. Resident 1 had undated care plans that indicated he required assistance with his ADLs related to a history of falls, weakness, and decreased mobility. He had an undated care plan that indicated he required a restorative program for Active Range of Motion (AROM) to restore or maintain his functional range of motion (the amount of movement a joint or body part can make, usually measured in degrees). Interventions included to evaluate and revise the program as needed and to notify nursing of decline or improvement for further evaluation, possible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident received oxygen as ordered for 1 of 1 resident reviewed for Oxygen services (Resident 29). Findings include: On [DATE] at 10:10 a.m., Resident 29 was observed. She was seated in a wheelchair (WC) with her overbed table in front of her. She rested her head in her hand with her eyes closed. An oxygen (O2) concentrator was observed against the wall with tubing in a clear plastic bag. The Nasal Canula (NC) was not in place, and the concentrator was not turned on. On [DATE] at 12:33 p.m., Resident 29 was observed. She remained seated in her WC with her eyes closed. Her O2-concentrator remained off and no O2 was applied to Resident 29. On [DATE] at 1:23 p.m., Resident 29 was observed. She remained seated in her WC with her eyes closed. Her O2 was not in place, and the concentrator remained off. On [DATE] at 10:56 a.m., Resident 29 was observed in bed with her eyes closed. Her O2 was not in place, and the concentrator remained…

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 label tuberculosis testing serum appropriately for 1 of 2 medications rooms reviewed (100 hall). Findings include: On 9/9/24 at 10:38 a.m., a vial of tuberculin serum was observed undated and in the specimen refrigerator. LPN 21 removed the serum from the refrigerator. The freezer was approximately 2 inches deep with ice buildup in this refrigerator. On 9/10/24 at 10:40 a.m., during an interview with the Director of Nursing (DON), she indicated the serum should have been dated when it was opened. A policy titled, Tuberculosis Testing (Mantoux Test), dated March 2023, was provided by the Director of Nursing on 9/10/24 at 11:52 a.m. It indicated, .After a physician's order is secured, acquire the dose necessary from the vial located in the medication refrigerator. If opening a new vial, it must be initiated and dated, as it is only good for 30 days after opening the vial . 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on observation, interview, and record review the facility failed to ensure effective handwashing of staff delivering lunch trays for 2 of 4 residents observed for receiving lunch trays (Residents 42 and 43). Findings include: On 9/9/24 11:56 a.m., the Social Services Director (SSD) was observed removing Resident 42's lunch tray from the mobile kitchen cart and not using hand hygiene before entering and after leaving his room. A sign on his door indicated to stop because the resident required EBP. The sign indicated, .Everyone must: Clean their hands, including before entering and when leaving the room Then, without using hand hygiene, she returned to the mobile kitchen cart and removed and provided lunch for Resident 43. During an interview, on 9/9/24 at 11:59 a.m., the SSD indicated that she thought she had gelled her hands before entering and after leaving Resident 42 and Resident 43's room. During an interview, 9/9/24 at 12:00 p.m., the Assistant Director of Nursing (ADON) indicated the SSD should have used hand sanitizer before entering and leaving Resident 42 and 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 interview and record review, the facility failed to ensure a resident's right for his medical record to be kept private and confidential when it was not discussed without the resident's permission for 1 of 3 residents reviewed for resident's rights (Resident H). Findings include: During an interview on 3/7/2024 at 10:06 a.m., Resident H's family indicated they had received clinical information from the Business Office Manager (BOM), regarding Resident H's medical condition, treatment, and services on several occasions, which included a private meeting outside of the facility property. Information provided by the BOM to Resident H's family included but was not limited to the following details: a. The facility had not provided Resident H with wound care and there were no Wound Care notes. b. The facility had not provided Resident H Physical Therapy (PT), as ordered, and there were no PT notes. c. The BOM filed reports/grievances with the Executive Director (ED) in regard to her opinion of a lack of care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure compliance with Indiana Department of Environmental Management's (IDEM) requirement to submit documentation of a fully certified Water Distribution Manager to comply with the Safe Drinking Water Act. Further, the facility failed to ensure a Plan of Correction was submitted after an onsite inspected which resulted in deficient practice on [DATE]. These deficient practices had the potential to effect 43 of 43 residents who resided in the facility. Findings include: During an interview on [DATE] at 12:14 p.m., the Section Chief for the IDEM Drinking Water Field Inspection, (SC), indicated, IDEM did not have documentation to satisfy the requirement of a designated water safety operator. Additionally, an onsite inspection had been conducted on [DATE], and the facility failed to submit a formal Plan of Correction for the cited deficiencies at that time. On [DATE], a second letter of noncompliance was submitted which requested these requirements to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to ensure medications were stored properly in 2 of 2 medication carts, and 2 of 2 treatment carts reviewed for medication storage (100 hallway, and 200 hallway). Findings include: During a random observation of the 100 hallway medication cart with Registered Nurse (RN) 9, on 7/10/23 at 10:09 a.m., the following was observed to be unbagged, not stored separately, or treatments in the medication cart among oral medications, a. Top right drawer was observed to be a catch-all of items to include, but were not limited to, a bottle of Johnson's baby shampoo without a resident label, 3 prefilled syringes of 0.9% sodium chloride injection with no resident label, an opened bottle of COVID -19 Ag reagent, 2 pill crushers soiled with unidentified white powder, AA batteries, [NAME] hand lotion, and 2 cigarette lighters. b. Bottom drawer had an opened tube of Biofreeze (topical analgesic) belonging to Resident 40, a glucagon pen (emergency injection to treat sever low…

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 all kitchen foods were covered, hand washing was correctly completed in the kitchen and dining room (Resident 7 and 10), and failed to clean to fryer in a timely manner for 2 of 2 days of observations. These deficient practices had the potential to effect 43 of 43 residents who received food from the kitchen. Findings include: 1. On 7/10/23 at 10:45 a.m., 2 large, pre-cooked turkey breasts were observed, uncovered, sitting on the stainless steel counter top. The Dietary Manager (DM) indicated the internal temperature of the turkey breasts were 83.4 degrees F. She indicated the danger zone for food sitting-out was 70 degrees F. The DM indicated she took them out of the refrigerator at 8:30 a.m. and set them on top of the oven. The oven was on and set at 350 degrees Fahrenheit (F). At 9:00 a.m., she set them on the kitchen counter and went to morning meeting. On 7/10/23 at 11:00 a.m., the DM indicated that was not how the kitchen usually handled food. She indicated it was after breakfast, and she 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 and record review, the facility failed to ensure a resident's choice of code status was documented consistently in the medical record and the physician and staff were aware of the resident's choice for 1 of 2 residents reviewed for code status (Resident 196). Findings include: During a record review for Resident 196, on [DATE] at 11:16 a.m., the resident record lacked documentation for code status preferences available in a publicly accessible area. Resident 196's record was reviewed on [DATE] at 1:18 p.m. Resident 196 was admitted on [DATE] with diagnoses to include, but were not limited to, pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), and clostridium difficile [c-diff] (inflammation of the colon caused by bacteria that disrupt normal bacteria in the colon, often from antibiotic use, highly contagious, can cause severe damage to the colon, and even be fatal). Discharge Instructions from a local hospital, dated [DATE], indicated no documentation…

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 an unusual occurrence that directly affected the wellbeing and health of a resident (Resident 32) was reported to the State Department of Health. This deficient practice had the potential to effect 1 of 3 residents reviewed for accident. Findings include: On [DATE] at 11:24 a.m., Resident 32 was observed in her room. She was seated in a regular wheelchair (WC). She had poor posture and was hunched forward, unable to lift her head all the way. She indicated, on [DATE], she was in the main dining room when she all of the sudden didn't feel right and she started to choke. She did not remember anything else because she lost consciousness and was told later, staff had to perform cardiopulmonary resuscitation (CPR). During an interview on [DATE] at 9:22 a.m., Resident 32's husband indicated he had been notified of Resident 32's choking incident. Apparently, she had choked on a piece of chicken during lunch. No one was sure if her choking…

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.

A. Based on record review and interview, the facility failed to ensure a resident received a complete neurological assessment after an unwitnessed fall for 1of 3 residents reviewed for accidents (Resident 30). B. Based on record review and interview the facility failed to ensure a resident with a history of seizures had follow up assessments and physician notification after having seizure activity for 1 of 2 residents reviewed for quality care with catheter use (Resident 45). Findings include: A. On 7/14/23 at 11:14 a.m., Resident 30's medical record was reviewed. She had diagnoses which included, but were not limited to, unspecified psychosis (a mental disorder characterized by disconnection from reality), COPD (chronic obstructive pulmonary disease) (a group of lung disorders that block airflow and make it difficult to breathe), essential hypertension (high blood pressure), osteoarthritis (the breakdown of joint cartilage and the underlying bone), insomnia (inability to sleep), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia…

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 necessary treatments and services to promote the healing of a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident 196). Findings include: On 7/11/23 at 10:44 a.m., Resident 196 was observed to be lying flat on her back in bed with the covers up to her chin. The resident was alert, talkative, and indicated her plan was to discharge to home when she was steadier and could ambulate independently again. On 7/13/23 at 9:30 a.m., Resident 196 was observed lying flat on her back in bed with the covers up to her chin. The resident's bottom with Licensed Practical Nurse (LPN) 14, resident indicated she had a sore that staff treated every day. During an observation the resident's entire buttocks was pink, dry, and had flaky skin. The coccyx/sacral area and surrounding tissue was open to air, no medication was observed. Two open areas approximately 1 centimeter (cm) circular, pink in color with white slough (dead…

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

Based on interview and record review, the facility failed to ensure, a resident (Resident 45) with a history of electrolyte imbalance, seizures and urinary tract infections (UTIs) received ordered labs in a timely manner for a urinalysis, reported and reviewed labs in a timely manner for 1 of 2 resident reviewed for catheter use. Findings include: On 7/11/23 at 2:16 p.m., Resident 45's closed medical record was reviewed. She admitted to the facility with diagnoses which included, but were not limited to, deficiencies of B-group vitamins, Vitamin D deficiency, epilepsy, and neoplasm (cancer) of the bladder. A Physician's note dated 11/7/22 at 1:58 p.m., indicated Resident 45 was being seen for a regularly scheduled, annual assessment as well as complaints for a possible UTI. patient has concern for urinary urgency and possible getting UTI patient is getting frequent UTIs due to straight cath . [straight catheter, also called an intermittent catheter, is a soft, thin tube inserted into the bladder through the urethra used to empty urine from the body] will check UA [urinalysis] 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 a resident who was at risk for nutritional decline received thorough monitoring and interventions to prevent avoidable weight loss for 1 of 2 residents reviewed for nutrition (Resident 30). Findings include: During an observation and interview on 7/10/23 at 12:45 p.m., Resident 30 indicated she did not receive her weekly house shake that was ordered for Mondays. She indicated she would get it the next day. During an interview on 7/12/23 at 1:15 p.m., Resident 30 she indicated she received her house shake for the week. She indicated it had been added because she had weight loss. On 7/14/23 at 11:14 a.m., Resident 30's medical record was reviewed. She had diagnoses which included, but were not limited to, unspecified psychosis (a mental disorder characterized by disconnection from reality), COPD (chronic obstructive pulmonary disease) (a group of lung disorders that block airflow and make it difficult to breathe), essential hypertension (high blood pressure), osteoarthritis (the breakdown of joint…

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 pain relief and failed to update his pain management care plan to include leg pain for 1 of 1 residents reviewed for pain management (Resident 8). Findings include: On 7/11/23 at 1:46 p.m., Resident 19's record was reviewed. He was initially admitted on [DATE]. His diagnoses included, but were not limited to, chronic pain disorder, low back pain, peripheral vascular disease (PVD), and rhabdomyolysis (break down of muscle tissue resulting in kidney damage). A care plan, dated 6/13/23, indicated Resident 8 was taking anticonvulsants medication related to low back pain. The intervention indicated to carry out the medication management regimen as prescribed. A care plan, dated 6/25/23, indicated Resident 8 had pain related to a previous humerus (upper arm bone) fracture. An intervention indicated to give medication as ordered. A care plan, dated 6/26/23, indicated Resident 8 had compression hose for his left leg related to varicose…

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 reviews and interviews the facility failed to properly reconcile and account for medications that were sent home with a resident who discharged from the facility for 1 of 2 residents reviewed for discharge (Resident 44). Findings include: A comprehensive record review was completed on 7/11/23 at 11:23 a.m. Resident 44 had the following diagnoses, but not limited to ASHD (arteriosclerotic heart disease, a thickening and hardening of the walls of the coronary arteries), essential hypertension (high blood pressure), chronic pain syndrome, fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness and insomnia), restless leg syndrome (uncomfortable sensations in the legs and the urge to move them in order to relieved the sensations, typically occurring in the evening or at night and often interfere with sleep), and diabetes mellitus, type 2 (elevated blood sugars). Resident 44 discharged from the facility on 5/20/23. A progress note, dated 5/20/23 at 12:50 a.m., indicated that Resident's daughter wanted to 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 record review, the facility failed to prevent a significant medication error related to administering a potassium extended release tablet dissolved in water with an indication of do not crush (Resident 16) for 1 of 29 residents observed for medication administration, and failed to hold a hypertensive medication Coreg per manufactures guidelines related to a low blood pressure reading (Resident 15) 1 of 29 residents observed for medication administration Findings include: 1. During a random observation of medication administration to Resident 16 on 7/13/23 at 7:30 a.m., Licensed Practical Nurse (LPN) 14 was observed to place a potassium chloride ER (extended release) tablet in a plastic medication cup with water and spend over 15 minutes smashing the tablet with a spoon until totally dissolved. The medication was then administered to the resident. LPN 14 indicated the resident received the medication twice daily and would not take it whole. She knew she was not supposed to crush the medication so she would dissolve it in water every day. 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 ensure a resident, (Resident 32) received a pneumococcal vaccination upon her admission and written consent for 1 of 5 residents reviewed for vaccination status. Findings include: On [DATE] at 11:24 a.m., Resident 32 was observed in her room. She was seated in a regular wheelchair (WC). She had poor posture and was hunched forward, unable to lift her head all the way. She was alert, oriented and pleasant. When asked if she had any concerns, she indicated, she wanted to get off her all-liquid diet. When asked why she was on a full liquid diet, Resident 32 indicated, on [DATE] she was in the main dining room when she all of the sudden didn't feel right and she started to choke. She did not remember anything else because she lost consciousness and was told later, staff had to perform cardiopulmonary resuscitation (CPR). Resident 32 indicated she had a type of neuropathy that affected more than just her extremities and her esophagus 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.