Complete Care at Corsica Hills LLC

Based on record review and interviews, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete documentation. This was found evident in 2 (Resident #1 and #7) out of 33 residents reviewed during the survey. The findings include:1) On 1/7/26 at 7:12 AM, the surveyor conducted an interview with Resident #1. During the interview the Resident stated that on occasion scheduled showers have not been given. On 1/7/26 at 11:31 AM, the surveyor requested shower documentation for Resident #1 from December of 2025 and January 2026. Next the surveyor reviewed the documentation. The surveyor noted that on Resident #1's scheduled shower days of 12/4/25, 12/8/25 and 12/11/25 the documentation was left blank. On 1/8/26 at 10:15 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the NHA stated that she had reached out to the 2 staff responsible for giving showers to Resident #1 on the days that there was no documentation. She stated the on 12/4/25…

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

Based on observation and interview, it was determined that the facility failed to maintain a sanitary environment in resident shared areas and the laundry room. This was evident in 2 (C, D) out of 4 shower rooms and the laundry room observed during the recertification survey.The findings include:On 01/07/2026 at 9:30 AM, the surveyors observed soiled linen on shower room D's floor. GNA #9 entered the shower room and picked up the linen from the floor saying I came in to make sure the shower was clean. GNA #9 stated that they did not know why there was soiled linen on the floor because the facility expects staff to place soiled linen in the hamper. The surveyors also observed a brown substance on the floor of a shower stall next to a brown-stained commode chair.On 01/07/2026 at 9:45 AM, Unit Manager #10 observed the findings in the shower stall and stated she would have the area cleaned.The Nursing Home Administration (NHA), Maintenance Regional Director, and Maintenance Supervisor acknowledged the concerns on 01/07/2026 at 11:37 AM. On 01/12/2026 at 11:26 AM, the surveyors observed…

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, review of the facility documentation, and review of the facility policy, the facility failed to ensure policies and procedures were implemented to address the facility's Quality Assessment and Performance Improvement (QAPI) plan and program, in which data was gathered, analyzed, developed, implemented, and re-evaluated to address adverse events related to potential deficient practice of abuse. This had the potential to affect all 105 residents residing in the facility at the time of the survey. Findings include: Review of the facility's policy titled, [Facility Name] Quality Assurance and Performance Improvement (QAPI), dated 2020, indicated .To provide continuous evaluation of [Name of facility] systems with the objectives of keeping systems functioning satisfactorily, preventing points of accountability for ensuring quality of care and quality of life . A request was made for any Performance Improvement Plan (PIP) regarding the prevention of abuse from 01/01/22 to 07/11/24. The facility provided documents from 09/19/22, which indicated the facility had an…

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, record review, and facility policy review, the facility failed to ensure that grievances were promptly resolved and ensure all written grievance decisions included the date of the grievance, a summary of the resident's grievance, a summary of the findings, a statement as to whether the grievance was confirmed or not confirmed, corrective action taken as a result of the grievance, and the date the decision was issued. Specifically, the facility failed to ensure grievances voiced by residents during resident council were documented, investigated, resolved, and followed up on by the facility of 105 residents. This failure had the potential to cause further grievances to be unresolved for residents throughout the facility. Findings include: Review of the facility's policy titled, Resident Council Meetings, dated 04/25/23 and provided by the facility, revealed The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decision to the Council. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) Review of R303's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, revealed R303 was admitted to the facility on [DATE] with a diagnosis of a rib fracture and adjustment disorder with anxiety. Review of R303's admission MDS with an ARD of 06/24/24 located in the EMR under the MDS tab, revealed R303 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Per the MDS, the resident did not exhibit any behavior during the assessment period. During an interview on 07/08/24 at 11:50 PM, R303 stated sometimes at night she was told by staff to go to the bathroom in her brief. She stated it felt awful and she did not like doing it. She stated sometimes she also had a bowel movement in her brief which felt very uncomfortable. She stated she would wiggle in the chair. She stated last night she was told this by a GNA who provided care. R303 stated she reported this to GNA148 this morning. During an interview on 07/11/24 at…

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

Based on interviews, record review, and review of facility policy, the facility failed to revise the care plan to include recommendations from the dental consult on 05/11/24 for one of 21 sample residents (Resident (R) 73) reviewed for care plan revision. This failure caused staff to be unaware of recommendations from the dentist or possible tooth pain for R73. Findings include: Review of the facility's policy titled, Care Planning - Comprehensive Person-Centered, dated 10/19, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan will: . Describe services that would otherwise be provided . but are not provided due to the resident exercising his or her rights, including the right to refuse treatment . Review of R73's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 07/27/22 with medical diagnoses that included…

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 it was determined that the facility failed to have a process in place to ensure the resident's safety directly following an allegation of abuse and to conduct a thorough investigation of the allegation. Evident for 3 (#913, #921 and #928) and Evident for 4 (#905, #911, #919 and #924) of 26 residents reviewed for abuse allegations during a recertification and complaint survey. The findings include: 1) A review of the facility's investigation file for the self-reported incident #MD00203605 on 7/10/24 at 7:15 PM revealed witness statements written by Geriatric Nursing Assistant (GNA) #130 and GNA #23 that read they had witnessed Registered Nurse #152 cursing and hitting Resident #921 on 3/14/24 at approximately 6:00 AM. However, the abuse was not reported to the Director of Nursing (DON) until 7:23 AM that morning. Therefore, RN #152 continued to have access to vulnerable residents for 1 hour and 23 minutes after she abused Resident #921. An interview with the DON on 7/11/24 at 1:11 PM revealed she was aware of the delayed reporting and offered 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 it was determined that the facility staff failed to allow a resident the right to have a dignified existence by failing to be listening to the Resident during his/her care (Resident #911). This was evident for 1 of 73 residents reviewed during a complaint and recertification survey. The findings include: A review of the facility reported incident #MD00187781 on 7/10/24 at 10:30 AM revealed Resident #911 had reported an allegation of abuse on 1/14/23, because the GNA #148 turned me, and I yelled out in pain and asked her to stop and the GNA #148 continued working. An interview by the Director of Nursing on 1/14/23 revealed that Resident #911 felt that the GNA was not listening to me I instructed her how I like my care done and she would not listen. On 1/14/23 The roommate, Resident #929 called the manager to report that GNA #148 was mistreating my roommate, and he/she was not listening to him/her during his/her care. Resident #911 was no longer at the facility for an interview. On 7/10/24 at 12:30 PM, an interview with roommate Resident #929…

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 staff interview it was determined that the facility failed to ensure that residents and/or resident representatives were afforded the right to file a grievance and receive a response regarding the action taken by the facility (Resident #906). This was evident for 1 of 3 residents reviewed during a recertification and complaint survey. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A review of the complaint #MD00186681 on 7/8/24 at 10:15 AM revealed that there were care concerns regarding Resident #908. The concerns included but were not limited to a nurse dispensing medications to four people at one time, staffing on the memory care unit was not consistent, the resident not being changed, wearing dirty clothing, and having body odor. An interview with the complainant on 7/8/24 at 10:31 AM revealed that the complainant had…

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

Based on medical record review and interview with facility staff, it was determined that the facility failed to review and implement a care plan when there were noted changes in condition requiring further facility services and follow-up (Resident #905). This was evident for 1 of 73 residents reviewed during a complaint and recertification survey. A care plan is a comprehensive and personalized document that outlines the specific needs, goals, and preferences of a patient. Care plans also address the specific services needed to attain and maintain a resident's highest practicable well-being through focus, goals and interventions. The findings include: Review of the electronic health record for Resident # 905 on 7/11/24 at 2:00 PM failed to reveal updated care plans related to 2 allegations of abuse occurring on 11/6/22 and on 11/9/22 respectively involving Resident #905. Resident #905's care plans in place were noted to address depression and cognitive decline, however, nothing related to having been exposed to 2 incidents of abuse 4 days apart. This concern was reviewed with the…

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

Based on record review and interview it was determined that facility staff failed to provide activities of daily living (ADLs: bathing, personal hygiene, toileting, getting in and out of bed) for a resident who was dependent on them for care (Resident #906). This was evident for 1 (MD00186681) of 11 complaints reviewed during a recertification and complaint survey. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. A medical record review for Resident #906 on 7/12/24 at 8:32 AM revealed the attending physicians' progress note for a visit on 11/29/22 that read the resident had Alzheimer's dementia with anxiety. Review of an MDS (minimum data set) with an assessment reference date of 12/9/24 which…

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, medical record review and interview it was determined that the facility failed to 1) complete an admission nursing assessment thoroughly and therefore implement the correct interventions for a resident with known dementia history (Resident #917) This was evident for 1 of 1 resident reviewed for elopement and 2) ensure that residents residing on their dementia care unit had activities to help them achieve their highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (#906) of 4 residents reviewed for dementia care. The findings include: 1) Review of the medical record for Resident # 917 on 7/9/24 at 12:08 PM revealed admission to the facility the end of November 2023, post hospitalization for change in vital signs, dementia and Alzheimer's behaviors including a recent hip fracture with continued falls. Review at this time of a facility incident report completed on 12/10/23 revealed that Resident #917 was able to exit the facility out a side door of the rehabilitation unit alone. According to the facility report a geriatric…

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 reviews of administrative records and staff interview, it was determined that the nursing administrative staff failed to 1) conduct a yearly performance review on the entire geriatric nursing assistant staff for the year of 2018, and 2) ensure that all geriatric nursing assistant (GNA) staff completed a minimum of 12 hours of education per year. The findings include: 1) In an interview with the Director of Nursing (DON) on 05/23/19 at 11:34 AM, the facility DON stated that none of the geriatric nursing assistant staff received a performance evaluation for 2018. 2) On 05/24/19, a review of 6 random geriatric nursing assistant (GNA) staff members, educational records for 2018, revealed that 2/5 GNA's (staff member #14 and #15) failed to complete at a minimum of 12 hours of education for the year of 2018.

Based on observation and interviews of facility staff, it was determined that food service employees failed to ensure that sanitary and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents. The findings include: On 5/20/19 at 9:35 AM an initial tour of the facility's food storage, kitchen and dining room was conducted with the Foodservice Manager in Training (Staff #13) and the following observations were made: 1. The kitchen hand washing sink adjacent to the fume hood and 3 compartment sink was not operational. 2. The hand washing sink in the dishwasher room had no paper towels and the nozzle from a water hose was laying in the sink. 3. The dishwashing machine was soiled with a thick, visible layer of dust, food crumbs and debris. The exhaust fan for the dish room was caked with dust and is placed directly overtop the conveyor where the clean dishes exit the machine to be collected and dried. Dust was observed on walls and shelving above the dish line. 4. Unused plastic bins, scattered…

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 dining observation and interview, it was determined the facility staff failed to provide residents with the most dignified existence with dining. This was evident for 2 (Resident #49 and #4) of 12 residents observed for dignity during an annual recertification survey. The findings include: 1A) The facility staff failed to provide Resident #49 with the most dignified existence with dining. Surveyor observation of breakfast on 5/21/19 at 9:40 AM revealed the resident in the dining room on the long-term care unit revealed Resident #49 being fed by facility staff #18; however, the facility staff was standing to feed Resident #49. Sitting is the most dignified way to feed a resident. 1B) The facility staff failed to provide Resident #49 with the most dignified existence with dining. Surveyor observation of breakfast on 5/24/19 at 9:35 AM revealed Residents #81 and #49 positioned at the same table in a small dining room on the long-term unit. It was noted at that time, Resident #81 was eating and the food tray for Resident #49 was on the table and not being addressed. It 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.

Based on observation and interview, the facility staff failed to ensure that call bells were within reach for Resident (#47 and #68). This was evident for 2 of 53 residents selected for review during the annual recertification survey. The findings include: 1) A call bell is a bedside button tethered to the wall in the resident's room, which directs signals to the nursing station; a call light usually indicates that the patient has a need or perceived need requiring attention from the nurse or geriatric nursing assistant on duty. There is a call light for each resident in the room, for each bed. Surveyor observation of Resident #47 on 5/23/19 at 11:00 AM and 12:10 PM revealed the resident out of bed in the wheelchair. The resident was placed in the middle of the room between the 2 beds in the room. Further observation revealed the facility staff failed to provide Resident #47 with the call light within reach. It was noted the call light delegated for Resident #47 could not be detected and the other call light- delegated for the other resident was noted to be in the middle of the bed…

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 medical record review and interview it was determined the facility staff failed to provide showers to Resident (#71). This was evident for 1 of 2 resident reviewed for choices during the annual survey process and 1 of 53 residents selected for review. The findings include: Medical record review for Resident #71 revealed the resident was to have showers on Monday and Thursday 7-3 shift. Interview with Resident #71 on 5/20/19 at 2:00 PM revealed the resident stating that he/she did not receive showers. Record review revealed the facility staff failed to document showers for the resident on 5/9/19 and 5/20/19. Interview with the Director of Nursing on 5/23/19 at 10:00 AM confirmed the facility staff failed to provide showers to Resident #71 as ordered.

Based on medical record review and interview, it was determined the facility staff failed to 1) notify the physician of a finger stick above 400 as ordered by the physician for Resident (#47), 2) notify the physician of a delay in obtaining a stat x-ray for Resident (#71) and 3) notify a resident's physician and the facility nutritionist when a resident was identified with a significant weight loss for Resident #26. This was evident for 3 of 53 residents selected for review during the annual survey process. The findings include: 1) The facility staff failed to notify the physician of a finger stick above 400 as ordered. Medical record review for Resident #47 revealed on 11/30/18 the physician ordered: FS, notify physician if results are above 400 or below 70. Finger stick (FS) is a procedure in which a finger is pricked with a lancet to obtain a small quantity of capillary blood for testing of blood sugar. Blood sugar testing requires the use of a small electronic device called a glucometer. The meter reads the amount of sugar in a small sample of blood, usually from your fingertip,…

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 reviews of a medical record, it was determined that the facility failed to accurately evaluate and revise a resident nutritional care plan. This was evident for 1 (Resident #26) of 11 residents reviewed for nutrition during an annual recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. A review of Resident #26's medical record on 05/20/19 revealed a nutritional care plan for weight loss that was initiated on 06/29/16 which revealed a 07/06/16 staff intervention to: weight per policy and alert dietician and physician to any significant loss or gain. Further review of Resident #26's medical record revealed the flowing weights: 04/03/19 - 144.8 02/07/19 - 153.0 10/19/18 - 163.2 Resident #26 suffered a 11.2 % (18.4 pounds) significant weight loss from 10/19/18 thru 04/03/19. On 04/10/19, Resident #26's physician assessed Resident #26 and placed Resident #26 on palliative care. The nursing staff have not revised Resident #26'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 record review, observation and interview, it was determined the facility staff failed to provide care to promote the highest well-being for Residents (#47 and #71). This was evident for 1 of 2 residents selected for review of skin conditions and 2 of 53 residents selected for review during the annual survey process for quality of care. The findings include: 1. The facility staff failed to provide cushioning to side rails for Resident #47. Medical record review for Resident #47 revealed on 3/1/19 the physician ordered: cushion side rails. Further record review revealed the following nurses' note on 5/18/19 at 7:09 PM: resident noted with: right wrist lateral (side) and medial (middle) side-purple in color, right elbow bruised, base of thumb old purple bruise and left upper arm- large purple bruise. On 3/1/19 the physician ordered: Geri sleeves 3/1/19 always except for morning care the and the physician re-ordered the Geri sleeves on 5/21/19. Geri-Sleeves protect the upper extremities from abrasions, bruises, snags and tears throughout the day. They also help provide relief…

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, observation and interview, it was determined the facility staff failed to provide an environment free from potential accidents for Residents (#5 and #47). This was evident for 2 of 53 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to maintain an environment free from potential accidents for Resident #5. Medical record review for Resident #5 revealed the following nurses' note: on 4/12/19 at 10:30 PM the facility staff documented: nurse found a stock pile of 5 Diazepam (Valium) and 1 Amlodipine (Norvasc) hidden in resident's drawer. This nurse crushes and watches resident swallow medications. Interview with the Director of Nursing on 5/23/19 at 11:00 AM revealed the facility staff failed to notify the staff of finding the medications at the bedside and failed to determine what the facility staff nurse did with the medications. It was determined at this time; the facility staff examined the resident's room and did not detect any medications at the bedside. Interview with the Director of 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.

Based on medical record review and interview, it was determined the facility staff failed to document the heart rate and blood pressure for Resident #35 when the physician ordered parameters. This was evident for 1 of 6 residents selected for un-necessary medication review and 1 of 53 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #35 revealed on 4/24/19 the physician ordered: Metoprolol 50 milligrams by mouth 2 times a day for blood pressure, hold for systolic blood pressure (top number) less than 110 or heart rate less than 55. Metoprolol is used alone or in combination with other medications to treat high blood pressure. Metoprolol is in a class of medications called beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure. Review of the Medication Administration Record revealed the facility staff documented the administration of the Metoprolol from 5/1/19 to 5/7/19 at 9:00 AM and 9:00 PM; however, failed to document the blood pressure or…

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 during tour of the facility's dumpster area, it was determined the facility staff failed to dispose of garbage and refuse properly. This deficient practice has the potential to affect all residents. The findings include: An observation of the facility's dumpster/trash disposal area was conducted on 5/23/19 at 9:30 AM. Two plastic bags filled with uneaten food were observed on the ground beside the dumpster's. Plastic forks, sugar packets and straws were also observed on the ground. An uncovered trash can was observed on the back patio area outside the kitchen exit used to remove trash. The uncovered trash can contained old plastic wrap, Styrofoam drink cups, and a discarded bag of chips. Ants and flies were observed on and in the trash can. The findings were reviewed with the Foodservice Manager In-Training (Staff #13) upon returning to the kitchen.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation during a tour of E wing, it was determined that the facility failed to ensure hand rails were secured firmly to the wall. This deficient practice has the potential to affect all residents within the unit. The findings include: On 5/24/2019 at 10:30 AM a tour of the facility's E wing was conducted. During this tour the handrails in the hallway outside the linen room, nourishment room, dining room and room [ROOM NUMBER] were observed to be loose and not securely affixed to the walls. The Administrator and DON were made aware of the findings during the exit conference on 5/24/19.