Medicalodges Goddard

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 44 residents with three residents included in the sample. Based on observation, interview, and record review the facility failed to ensure an environment free of accident hazards on 01/14/25 when Certified Nurse Aide (CNA) M did not follow the standard of care and utilize another staff member assistance during the transfer of Resident (R) 1 from his wheelchair to his bed, using a Hoyer Lift (a mechanical device that helps people with limited mobility be transferred safely with minimal physical effort). Findings included: - The Quarterly Minimum Data Set (MDS) dated [DATE] revealed R1 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The Care Plan revision dated 12/31/24 revealed R1 required assistance from staff with all transfers. An observation on 01/14/25 at 12:35 PM revealed CNA M transferred R1 from his wheelchair to his bed using the Hoyer lift by herself. An interview on 01/14/25 at 12:35 PM with CNA M revealed if the resident 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 The facility reported a census of 43 with 3 residents selected for review. Based on observation, interview, and record review, the facility failed to implement infection control measurements by the failure to cleansing hands between glove changes during a wound dressing change on Resident (R) 2. Findings included: - The Physicians Order dated 08/29/24 revealed R2 had diagnosis that included chronic multifocal osteomyelitis of multiple sites (local or generalized infection of the bone and bone marrow), and pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence as results of pressure or pressure in combination with shear and/or friction). The Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief interview for Mental Status (BIMS) of 15, that indicated intact cognition. R2 had one stage three pressure ulcer injury over bony prominence upon admission. R2 used a pressure reducing device for chair and bed and was on a turning repositioning program. The 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 The facility reported a census of 38 residents. Based on observation, interview, and record review, the facility failed to store Controlled Medications (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence), permitting only authorized personnel to have access related to diversion of controlled medication for three residents. Resident (R)145 for unknown quantity of Lorazepam, 0.5 milligram(mg) tablets (anti-anxiety medication), R 146 for unknown quantity of Oxycodone 10/325 mg. tablets (a narcotic/pain medication), and R 147 for unknown quantity of Lorazepam. Additionally, the facility failed to provide a safe environment for all residents by the failure to ensure one of two medication carts, used to store resident's medications remained locked when not in direct line of vision of the licensed nurse passing medications from their carts. Findings included: - On [DATE] at 10:29…

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.

The facility reported a census of 38 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal [PBJ]), related to weekend staffing data is excessively low. Findings included: - Review of the Payroll Based Journal (PBJ) Staffing Data Report submitted revealed weekend staffing data excessively low as follows: 1. The first quarter of fiscal year (FY) 2023, (10/01/22 through 12/31/22). 2. The second quarter of FY 2023, (January 01,2023 through March 31/2023). 3. The third quarter of FY 2023, (04/01/2023 through 06/30/2023). 4. The fourth quarter of FY 2023 (July 01/2023 through September 30, 2023). Review of the nursing staff schedule, agency staff, and staff postings for direct care on the weekends identified above were inaccurate and did not…

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 The facility reported a census of 38 residents with 13 residents sampled. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff to follow infection control standards when delivering laundry to resident rooms and failure to follow the standard of practice when performing a partial bed bath to Resident (R) 195's perineum (the area of skin between the anus and the genitals). This deficient practice has the potential to lead to cross contamination between residents, and to place the residents receiving bed baths at increased risk of developing infections. Findings include: - On 02/20/24 at 12:46 PM, Laundry Staff I observed with an uncovered linen cart with clean linen being transported down the hallway, and Laundry Staff I delivered linens to several resident rooms while wearing the same gloves, no hand hygiene or glove change performed between contacts with resident rooms. On 02/20/24 at 12:50 PM, Laundry Staff I…

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.

The facility reported a census of 38 residents. Based on observation, interview, and record review the facility failed to ensure a safe sanitary environment for the residents and staff in the facility laundry. Findings included: - On 02/22/24 at 08:04 AM, the tour of the laundry with Maintenance Staff J and Laundry Staff I revealed the following concerns: 1. The linoleum floor with multiple raised, unsealed, and unsanitizable areas throughout the laundry area. 2. The ceiling with an approximate six-foot brown stain. 3. An approximate four-to-five-foot section of the sheetrock wall had missing and bubbling paint. The wall with the bubbling paint measured approximately a 4 by 5-foot section. 4. A unpainted, unsealed, irregular textured epoxy patch along the wall which was unsanitizable. 5. Approximately one to two feet of torn sheetrock behind the soiled linen barrels storage. 6. Multiple broken and missing floor tiles. On 02/22/24 at 08:24 AM, the tour of the laundry with Maintenance Staff J and Laundry Staff I confirmed and agreed with the above identified concerns . On 02/22/24 at…

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

The facility had a census of 38 residents. Based on observation, record review, and interview, the facility failed to maintain a clean, comfortable and homelike environment to the residents that resided in the facility. Findings included: - On 02/22/24 at 04:00 PM, initial walk through of the facility with Administrative Staff A, identified a broken fiberglass reinforced panel (FRP - a waterproof plasticized product that is often used on high-contact surfaces such as walls or doors to prevent damage to the structural integrity of the material underneath), with a jagged edge approximately 10-12 inches off the floor on the door to the shower room on 100 hall that was only utilized by the residents on the 100 hall. On 02/22/24 at 04:05 PM, Administrative Staff A stated that the shower room would be removed from service until the door had been repaired and notified the appropriate personnel to remove and replace the panel. On 02/26/24 at 07:30 AM, surveyor verified with Administrative Staff A that the door panel had been replaced and with visual inspection of the shower room door on 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 The facility reported a census of 38 residents with 13 residents sampled, that included five residents selected for review related to dignity. Based on interview, observation, and record review, the facility failed to protect the privacy and dignity of Residents (R)40 and R95. This deficient practice led to R40's and R95's respective urinary catheter (a tube inserted into the bladder to drain urine and into a collection bag) bags to be visible to visitors and other residents. This practice had the potential to lead to negative psychosocial effects related to dignity. Findings included: - R40's Electronic Health Record (EHR) revealed a diagnosis of benign prostatic hyperplasia (BPH, a non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections). The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 13, which indicated intact cognition. R40 had an indwelling urinary catheter (a tube…

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 The facility reported a census of 38 residents with 13 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for one sampled resident, Resident (R)195, related to the use of indwelling urinary catheter (a tube inserted into the bladder to drain urine into a collection bag). This placed the resident at risk for uncommunicated care needs. Findings include: - R195's Electronic Health Record (EHR) revealed diagnoses that included the following: urinary tract infection (UTI-an infection in any part of the urinary system), lack of coordination, overactive bladder, encounter following surgical amputation (surgical removal of a body part), osteomyelitis (local or generalized infection of the bone and bone marrow), need for assistance with personal care and generalized weakness. R195's admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact…

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 The facility identified a census of 38 residents, with 13 residents selected for review. Based on observation, record review and interview, the facility failed to develop a comprehensive person-centered care plan for Resident (R)39, regarding the need for isolation. Findings included: - Resident (R)39's signed physician orders, dated 02/16/24 revealed the diagnosis included respiratory syncytial virus (RSV is a contagious virus that causes infections of the respiratory tract). The admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required extensive assistance of two for daily care and was non-ambulatory. The resident received pain medication on an as needed basis for pain of 6/10 scale. The Quarterly MDS dated 12/22/23, revealed no significant changes in cognition or cares. R39's Care Plan dated 08/03/23 revealed the following: R39 required staff assistance with daily cares related to physical limitations. R39…

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 The facility reported a census of 38 residents. The sample included 13 residents. Based on observation, interview and record review, the facility failed to review and revise one resident's care plans, related to adequate monitoring and care of Resident (R)26's multiple skin areas/wounds. Findings included: - Review of Resident (R)26's undated Physician Orders, (POS) documentation included diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord) , anxiety disorder (mental or emotional reaction disorder characterized by apprehension, uncertainty and irrational fear) , chronic inflammation (a normal body's response to injury or infection) polyneuritis (inflammation of several peripheral nerves at the same time), and diabetes (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Annual Minimum Data Set, (MDS) dated [DATE], documentation included a Brief Interview for Mental Status, score (BIMS) of 14, indicating…

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 The facility reported a census of 38 residents. The sample included 13 residents with one resident sampled for skin condition, not related to pressure ulcer/injury. Based on observation, interview and record review, the facility failed to ensure adequate monitoring of one Resident (R)26's skin condition, to ensure resolution of multiple skin areas/wounds (20). Findings included: - Review of Resident (R)26's undated Physician Orders, (POS) documentation included diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord) , anxiety disorder (mental or emotional reaction disorder characterized by apprehension, uncertainty and irrational fear) , chronic inflammation (a normal body's response to injury or infection) polyneuritis (inflammation of several peripheral nerves at the same time), and diabetes (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Annual Minimum Data Set, (MDS) dated [DATE], 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 The facility reported a census of 38 residents with 13 residents sampled, that included two reviewed for urinary catheter (a tube inserted into the bladder to drain urine into a collection bag) care. Based on interview, observation, and record review, the facility failed to provide appropriate treatment and services of Resident (R)95 when resident was transported with the urinary collection bag above the level of his bladder. This deficient practice had the potential to negatively affect R95. Findings include: - Resident (R) 95's signed physician orders dated 02/09/24, revealed the diagnosis that included bladder neck obstruction (lack of ability to urinate and empty the bladder). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The resident required moderate assist with toileting and supervision with mobility. The resident had an indwelling urinary catheter (insertion of a catheter into the bladder to…

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.

The facility reported a census of 38 residents. Based on interview and record review, the facility failed to conduct annual performance reviews for one of the two Certified Nurse Aides that the facility had employed over a year. Findings included: - During review of employment records for the two Certified Nurse Aides (CNA), employed by the facility for over a year, the facility failed to complete one of the two CNA's annual performance review for Certified Nurse Aide (CNA) K, hired 09/29/2015. The most recent unsigned performance evaluation for CNA K, dated 08/31/2022 (six months past due). On 02/22/24 at 10:30 AM, Administrative Nurse B verified CNA K lacked an annual performance evaluation, which should have been completed within 12 months. She reported the facility lacked a policy regarding completion of annual performance evaluations for employees, but she was aware it was a regulatory requirement. The facility lacked a policy to address the completion of annual performance evaluations. The facility failed to conduct annual performance reviews for one of the two Certified Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 38 residents with 13 residents sampled, that included two reviewed for urinary catheter (a tube inserted into the bladder to drain urine into a collection bag) care. Based on interview, observation, and record review, the facility failed to provide appropriate treatment and services of Resident (R)195 from lack of documented catheter care. This deficient practice had the potential to negatively affect R195. Findings included: - R195's Electronic Health Record (EHR) revealed diagnoses that included the following: urinary tract infection (UTI-an infection in any part of the urinary system), lack of coordination, overactive bladder, encounter following surgical amputation (surgical removal of a body part), osteomyelitis (local or generalized infection of the bone and bone marrow), need for assistance with personal care and generalized weakness. R195's admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated…

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.

The facility reported a census of 38 residents. Based on interview and record review, the facility failed to ensure no less than 12 hours per year required in-service training to ensure the continuing competence of nurse aides for one of the two nurse aides employed for a year or more. Findings included: - During review of employment records for the two Certified Nurse Aides (CNA), employed by the facility for over a year, the facility failed to ensure no less than 12 hours per year required in-service training to ensure the continuing competence for Certified Nurse Aide (CNA) K, hired 09/29/2015. Review of her education profile revealed the CNA with 10.5 hours of continuing in-service training in the previous year. On 02/22/24 at 10:30 AM, Administrative Nurse B verified CNA K lacked the required 12 hours of continuing education to ensure competency. She reported the facility lacked a policy regarding the required 12 hours of in-service training annually for CNAs, but she was aware it was a regulatory requirement. The facility lacked a policy to address the required 12 hours of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 46 residents, with 12 sampled. Based on observation, interview, and record review, the facility failed to complete a comprehensive, accurate, standardized reproducible assessment within 14 calendar days after admission for Resident (R) 92. Findings include: - Review of Resident (R) 92's Electronic Health Record (EHR) dated 04/24/22 documented the following diagnosis: Methicillin-resistant Staphylococcus aureus (MRSA; a type of bacteria resistant to many antibiotics) of tracheostomy (opening though the neck into the trachea through which an indwelling tube may be inserted) stoma (surgically created opening of an internal organ on the surface of the body). The 04/29/22 admission Minimum Data Sheet (MDS) documented the assessment was in progress. R92 admitted to the facility on [DATE]. The assessment should have been completed by 05/04/22 or 14 days after admission. The Care Area Assessment (CAA) due on 05/04/22 had not been completed for R92. The 04/25/22 Care Plan documented R92…

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.

The facility census totaled 46 residents with 12 included in the sample. Based on observation, interview and record review the facility failed to revise the comprehensive care plan when Resident (R)20 readmitted to the facility to include oxygen use. Findings included: - R20's signed physician orders dated 05/02/22 revealed the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and peripheral vascular disease (abnormal condition affecting the blood vessels). The 03/10/22 Significant Change in Status Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The resident required extensive assistance of two staff for daily care. The resident had a urinary catheter. The resident readmitted with three venous and arterial ulcers…

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.

The facility had a census of 46 residents with 12 included in the sample. Based on observation, interview and record review the facility failed to provide bathing and grooming for three residents reviewed for bathing, as evidenced by lack of documentation on the bath record, long facial hair and dirty and long fingernails for Resident (R)25, R26, and R27. Findings include: - Resident (R) 25's signed physician orders dated 04/28/22 revealed the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD; progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 12/23/21 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status…

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.

The facility reported a census of 46 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to ensure they had a system in place to change oxygen tubing, nebulizer tubing and cleaning of respiratory equipment in a timely manner for Residents (R) 20 and R92. Findings included: - R20's 05/02/22 Signed Physician Orders documented the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and peripheral vascular disease (abnormal condition affecting the blood vessels). The 03/10/22 Significant Change in Status Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. R20 required extensive assistance of two staff for daily care. R20 received oxygen therapy (O2). 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.

The facility reported a census of 46 residents. Based on observation, interview, and record review the facility failed to ensure a safe sanitary environment to prevent infection for Resident (R) 92, by not storing his oxygen mask, nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) mask, and urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) drainage bag in a sanitary manner. Findings Included: - An observation on 05/09/22 at 04:54 PM R92 laid in bed on his back with the head of the bed elevated. R92's oxygen (O2) mask laid on the floor and still had O2 flowing through it. R92's urinary catheter drainage bag also laid on the floor under the bed. On 05/10/22 at 01:09 PM R92's O2 mask laid on the mattress next to him with no barrier noted between the mask and the mattress. On 05/11/22 at 09:33 AM R92's O2 mask hung over the back of his wheelchair, with no barrier noted. R92's nebulizer mask sat on the bedside table with no barrier under it and not in a protective covering. On 05/10/22 at 1:30 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.