Coventry House Inn

Based on observation, interview, and record review, the facility failed to: 1. Clean non-food contact surfaces; 2. Label and date cooked potentially hazardous food products with a prepared and discard date; 3. Repair or replace a water-damaged temperature gauge on the dish machine; 4. Ensure dish machine was at proper temperature prior to use; 5. Ensure food products reached safe internal temperature prior to service; and 6. Ensure prepared food was properly cooled. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness for all residents who consume food from the kitchen. Findings include: An initial kitchen/food service tour was conducted on 12/3/24 beginning at 9:15 AM with Food Service Director (FSD) M. The following observations/interviews/record reviews were completed: At 9:24 AM in the walk-in cooler it was noted that the floor had a build-up of dirt and debris under the food racks and in the corners. There was a pan of roast beef that was not labeled or dated. FSD M confirmed that the floor needed to be cleaned 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 food products were served at a palatable temperature for 2 of 12 sampled residents (Resident #22 and #133) reviewed for food palatability, and 5 of 6 residents from the confidential resident meeting, resulting in dissatisfaction with meals, and the potential for decreased food acceptance and nutritional decline. Findings include: Resident #22 Review of an admission Record revealed Resident #22 was a male. Review of a Minimum Data Set (MDS) assessment for Resident #22, with a reference date of 9/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #22 was cognitively intact. In an interview on 12/3/24 at 11:16 AM, Resident #22 reported concerns with food served at the facility. Resident #22 reported despite going to the dining room for some meals, his food was not consistently hot enough (not served at a palatable temperature). Resident #133 Review of an admission Record revealed Resident #133 was a female. Review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration for 1 resident (Resident #84) of 7 residents reviewed for medication administration, resulting in medication being administered without a physician order, and the potential for less than therapeutic effects of medications, and the worsening of medical conditions. Findings include: Resident #84 Review of an admission Record revealed Resident #84 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes mellitus (a disorder in which the amount of sugar in the blood is elevated) . In an interview on 12/3/24 at 11:32 AM, Resident #84 reported that she had been managing her blood sugar using insulin for 70 years, and that the facility didn't seem to understand how to manage her Type 1 diabetes. Review of Resident #84's Physician Orders revealed, Insulin (helps to regulate blood sugar levels) Lispro (1 Unit Dial) 100 UNIT/ML…

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 residents received coordination of care in accordance with physician orders and professional standards for skin conditions in 1 resident (Resident #13) of 1 resident reviewed for skin conditions, resulting in burning pain, the potential for an exacerbation of stasis dermatitis and an increased risk for infection due to compromised (weakened) skin integrity. Findings include: Resident #13 Review of Resident #13's Skin Integrity Care Plan revealed, .BLE (bilateral lower extremity) redness from stasis dermatitis (a skin condition caused by poor blood circulation in the lower legs) .Interventions: Monitor for signs and symptoms of infection (swelling, redness, increased pain, firmness, drainage) . There were no interventions specific to dry skin, and/or the lower legs. During an observation on 12/03/24 at 10:17 AM in the hallway, Resident #13 was walking with Occupational Therapist (OT) T. Resident #13's lower legs were observed with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00146244. Based on interview, and record review, the facility failed to maintain professional standards of care for 1 resident (Resident #83) of 1 resident reveiwed for accidents and hazards, from a total sample of 12 residents, resulting in the potential for unidentified internal bleeding when Resident #83, who was taking an antiplatelet medication (which decreases blood clotting ability) was not sent to the hospital after sustaining head trauma following a fall. Findings include: Resident #83 Review of Resident #83's Care Plan revealed, .Focus: .receiving an antiplatelet medication r/t (related to) CAD (coronary artery disease: common type of heart disease) . Review of Resident #83's Fall Report dated 8/3/24 revealed, .guest was seen laying on the floor in the hallway .Neuro's (neurological checks) initiated due to being unwitnessed. Resident taken to hospital? NO . Review of Resident #83's Fall Report dated 8/4/24 revealed, .Resident was on the floor next to the bed in…

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 the physician reviewed and responded to the registered pharmacist's monthly medication regimen review recommendations for 1 (Resident #2) of 5 residents reviewed for medications, resulting in the registered pharmacist's recommendations not being addressed in a timely fashion and the potential for negative medication side effects as a result of unaddressed recommendations. Findings include: Resident #2 Review of an admission Record revealed Resident #2 was a female, with pertinent diagnoses which included: generalized anxiety disorder. Review of a Pharmacist Clinical Record Review dated 11/7/24 for Resident #2 revealed, .5. Recommendations I would make the following recommendations: Medication regimen reviewed see report .(also referred to as Prescriber Recommendations). On 12/4/24 at 1:40 PM, Nursing Home Administrator (NHA) A was requested, electronically, to provide this surveyor with a copy of Resident #2's 11/7/24 Pharmacist Medication Review Report. In an interview on 12/5/24 at 11:03 AM, NHA A reported she had…

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

Based on interview and record review, the facility failed to discontinue psychotropic medications (drugs that alter brain chemistry and can affect mood and behavior) prescribed on an as needed (PRN) basis after 14 days and/or document rationale to extend PRN psychotropic medication use in 2 of 5 residents (Resident #2 and #134) reviewed for unnecessary medications, resulting in the potential for unnecessary medication use with the increased potential for adverse side effects. Findings include: Resident #2 Review of an admission Record revealed Resident #2 was a female, with pertinent diagnoses which included: generalized anxiety disorder. On 12/4/24 at 2:40 PM, a review of Resident #2's current physician's Order Summary revealed a Physician's Order for hydrOXYzine HCl Oral Tablet (Hydroxyzine HCl) Give 10 mg by mouth every 6 hours as needed for Anxiety Pharmacy Active 11/6/2024 It should be noted that there was no stop date identified for this PRN psychotropic medication. Review of a pharmacist clinical record review report for Resident #2 dated 11/7/24 and titled Prescriber…

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

Based on observation, interview, and record review the facility failed to follow the standards of infection control for hand hygiene and glucometer (handheld machine used to check blood sugar level) cleaning for 3 residents (Resident #84, #8, and #85) of 3 residents receiving blood sugar assessments, resulting in the potential for cross contamination and the spread of disease to a vulnerable population. Findings include: During an observation on 12/05/24 at 12:06 PM in the hall at the medication cart, Registered Nurse (RN) J was preparing to perform a blood sugar check for Resident #84. RN J donned gloves, entered Resident #84's room, poked Resident #84's left right finger to obtain a blood specimen, and then picked up the glucometer with a test strip in it, and touched it to the drop of blood on the resident's fingertip. RN J sat the glucometer on the resident's table, wiped the blood from the resident's finger, removed his gloves, then picked up the glucometer and exited the resident's room. RN J did not perform hand hygiene after removing his gloves, returned to 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 interview, and record review, the facility failed to employ an Activity Director who possessed the required qualifications for the position, resulting in the potential for unmet met psychosocial needs, feelings of boredom and a lack of person-centered activities. This citation has the potential to impact all 27 residents within the facility. Findings include: In an interview on 11/1/23 at 3:22pm, Activities Director (AD) R revealed resident involvement in group and individual activity attendance was currently not being tracked in a manner that would allow for her to ensure residents were being provided with activities of interest and attending activities consistently each week. AD R reported the current system of activity attendance documentation also would not result in timely awareness of a resident's decline in involvement. AD R reported prior to working as the Activities Director, she worked as an Admissions Coordinator at the facility. When queried about her training, AD R revealed she did not possess any of the qualifications required to oversee the activities…

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

Based on observation and interview, the facility failed to: 1. properly date and discard food items, 2. securely store packaged food product after opening, 3. clean food and non-food contact surfaces, 4. properly store clean cooking utensils and pans to prevent bacterial harborage and contamination. Findings include: On 10/30/23 beginning at 9:33 AM, an initial tour of the kitchen/food service was conducted with Dietary Manager (DM) Q. The following observations/interviews occurred during this initial tour: At 9:33 AM in the dry storage area, noted the following: an opened, bulk-sized container of baking soda labeled with an opened date of 12/2/22 and a discard date of 5/2/23; an opened, bulk-sized bag of puffed rice cereal labeled with an opened date of 4/19/23 and a use by date of 8/19/23; 2 opened bottles of food coloring labeled with a delivery date of 12/17/18 but no label for opened or discard dates; 4 unopened cans of evaporated milk with a best by date of July, 2023; an opened, 8 ounce container of baking powder that was not labeled with opened or discard dates; and opened…

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 use it's resources to effectively administer the facility to attain and maintain the highest practicable physical, mental, and psychosocial well-being for all 27 residents that resided at the facility. This deficient practice resulted in a staff member holding a position without the required qualifications, and a potential for unmet psychosocial needs. Findings include: Review of a Facility Assessment Tool dated 6/19/23, a section 3 titled Facility Resources Needed to Provide Competent Support and Care for our Resident Population revealed the staffing plan included an Activities/Life Enrichment Director. Section 3.4 Staffing training/education and competencies revealed: Those with professional certification are authenticated before hire. In an interview on 11/1/23 at 3:22pm, Activities Director (AD) R revealed she did not possess any of the qualifications required to oversee the activities program. AD R reported she and the Nursing Home Administrator had been looking into the specialized training she needed…

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

Based on observation, interview and record review the facility failed to follow their policy and ensure the storage of medications and biologicals were in locked medication carts for 2 of 2 medication carts reviewed for medication storage, resulting in the potential for diversion and/or misappropriation of medications. Findings include: In an observation on 10/31/23 at 10:18 AM., Licensed Practical Nurse (LPN) M was preparing medications for a resident on the unit. LPN M finished the preparation of the medications. LPN M then walked away from the medication cart, and left the cart unlocked, and did not return to the medication cart. In an observation/interview on 10/31/23 at 10:28 AM., Registered Nurse (RN) H walked up to the medication cart and noticed it was unlocked. RN H quickly locked the medication cart. RN H reported she was unsure which nurse left the medication cart unlocked, but that she (RN H) and (LPN M) were both using the medication cart to pass their medications to their assigned residents. RN H reported the medication carts should always be locked when not in use,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has 2 Deficient Practice Statements (DPS) A & B. DPS A Based on observation, interview, and record review, the facility failed to have an active plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection for all the 27 residents in the facility. Findings include: Review of Overview of Water Management Programs, Center for Disease Control (CDC) 3/25/21, revealed Water management programs .minimize the growth and transmission of Legionella and other waterborne pathogens .Developing and maintaining a water management program is a .process that requires continuous review. Review of a water analysis report provided by the facility revealed the facility's water had not been tested for legionella since 5/12/22. Review of a Water Management Plan policy dated 2018 revealed 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 interview and record review, the facility failed to educate all residents regarding the benefits and potential side effects of 23-valent pneumococcal polysacaride (PPSV 23) vaccination and offer PPSV23 vaccination to those residents who were eligible, therefore increasing the risk of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. Findings include: Review of a facility policy titled Pneumococcal Vaccination dated 6/22 revealed under a category labeled General a statement: The most effective way to treat pneumococcal disease to prevent it though immunization. Under Guidelines the policy stated: Nursing will assess the pneumococcal vaccination status of reach resident upon admission .it is reasonable to expect administration or documentation of pneumococcal vaccine by the first quarterly assessment or patient discharge, whichever comes first. Nurse will provide education regarding pneumococcal vaccination, and administer the vaccine when indicates, unless refused .…

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 treat residents with dignity and respect and failed to provide an environment that promoted and enhanced resident quality of life for 1 of 3 residents (Resident #128), reviewed for dignity, resulting in the potential for feelings of frustration, depression, and loss of self-worth and an overall deterioration of psychological well-being. Findings include: Review of an admission Record revealed Resident #128 was a female, with pertinent diagnoses which included: essential (primary) hypertension (high blood pressure) and chronic obstructive pulmonary disease. During an observation/interview of the lunch meal service on 10/31/23 at 12:30 PM in the main dining room, Resident #128 motioned this surveyor over to where she was seated at the dining table. Resident #128 was seated at a table with 6 other residents who had finished eating their meals. Resident #128 had a bowl of salad and a cup of juice in front of her and no other food. Resident #128 reported that she had been the first one to arrive in the dining room…

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 assess and ensure the right to safe self-administration of medication in 1 of 3 residents (Resident #9) reviewed for medication administration, resulting in the potential for unsafe self-administration of medication, medication errors, and medications not being stored in a secure manner. Findings include: Review of an admission Record revealed Resident #9 was a female, with pertinent diagnoses which included: type 2 diabetes mellitus without complications (a condition where the body is not able to properly use sugar from the blood), syndrome of inappropriate secretion of antidiuretic hormone (high levels of a hormone causing the body to retain water) and hypo-osmolality and hyponatremia (retention of water and low levels of sodium). During an observation/interview on 10/31/23 at 9:06 AM, Resident #9 was observed in her room seated up in her bed eating her breakfast. There was a medication cup that contained 3 tablets on Resident #9's bedside table next to her meal tray. When queried about the tablets in the…

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

Based on observation, interview, and record review the facility failed to ensure a resident's privacy during wound care for 1 resident (Resident #226) of 3 residents reviewed for wound care of a total sample of 12, resulting in the potential for embarrassment, humiliation, frustration and anger. Findings include: Review of an admission Record for Resident #226 dated 10/21/23 revealed the resident was admitted to the facility with the following pertinent diagnoses: major depressive disorder (mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy), and abscess of liver (swollen area within body tissue, containing an accumulation of pus). Review of a Minimum Data Set (MDS) assessment for Resident #226 dated 10/27/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated the resident was cognitively intact. Section D of the MDS revealed Resident #226 expressed feeling down, depressed, or hopeless 2-6 days during the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a baseline care plan for 1 resident (Resident #124) reviewed for care plans, resulting in the potential for inappropriate care and decreased quality of life. Findings include: Review of an admission Record revealed Resident #124, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Dementia. Review of a Minimum Data Set (MDS) assessment for Resident #124, with a reference date of 10/22/23 revealed a Brief Interview for Mental Status (BIMS) indicated Resident #124 was cognitively impaired. Review of Resident #124's Care Plan revealed: (Resident #124) has Oxygen Therapy r/t (related to) Ineffective gas exchange .Created on: 10/30/2023 by: .Minimum Data Assessment-Registered Nurse (MDS-RN) G . INTERVENTIONS: Administer oxygen per physicians orders Date Initiated: 10/30/2023 Created on: 10/30/2023 Created by: Minimum Data Assessment-Registered Nurse (MDS-RN) G . During an interview on 11/01/23 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 interview and record review, the facility failed to develop and implement a comprehensive care plan in 1 of 12 residents (Resident #8) reviewed for comprehensive care plans, resulting in Resident #8's diuretic therapy not being care planned and the potential for unrecognized medication side effects and a lack of resident-centered interventions. Findings include: Review of an admission Record revealed Resident #8 was a female, with pertinent diagnoses which included: atherosclerotic heart disease of native coronary artery without angina pectoris and essential (primary) hypertension (high blood pressure). Review of Resident #8's current Order Summary revealed Torsemide Tablet 10 MG (milligrams) Give 2 tablet by mouth one time a day for CHF (congestive heart failure)/Fluid overload Pharmacy Active 7/12/2022. Review of Resident #8's current Care Plan revealed no care planned focus, goals, or interventions related to Resident #8's prescribed diuretic medication. In an interview on 11/1/23 at 9:32 AM, Minimum Data Set Registered Nurse (MDSRN) G reported she was responsible for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a medication error rate less than 5% (error rate was 16% - 4 errors in 25 opportunities) in 2 (Resident #226, and Resident #9) of 7 residents reviewed for medication administration, resulting in the potential for reduced medication effectiveness and increased risk of infections, adverse reaction/side effects, medication errors, and medications not being stored in a secure manner. Findings include: Resident #226 Review of an admission Record revealed Resident #226, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: asthma, chronic obstructive pulmonary disease (COPD). Review of a Minimum Data Set (MDS) assessment for Resident #226, with a reference date of 10/27/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #226 was cognitively intact. Review of Resident #226's Physicians Orders dated 10/22/23 revealed: Spiriva Respimat-Inhalation…

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 effectively clean and maintain the resident privacy curtains, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: In an observation on 10/31/23 at 12:23 PM., noted both privacy curtains in room A-83 were heavily soiled in various areas of the curtains. Noted stains, dark colored spots that appeared to be dried blood, and an overall soiled appearance. In an observation on 10/31/23 at 12:31 PM., noted in room A-75 both privacy curtains and the toilet riser were heavily soiled with dark stains, dried blood and dried feces. In an observation on 10/31/23 at 12:34 PM., noted in room A-79 both privacy curtains were heavily soiled. The privacy curtain for bed-2 was noted to have dried dark red blood stains in various areas of the curtain. In an observation on 10/31/23 at 12:37 PM., noted in room A-82 both privacy curtains were heavily soiled with dark stains in various areas. In an observation on 10/31/23 at 12:45 PM., noted in room A-81…

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.