Brooking Park

Based on observation, interview, and record review, the facility failed to ensure one resident was served meals in a timely manner when staff served meals outside the timeframes designated by the facility (Resident #1). The sample was seven. The census was 63 with 28 in certified beds. Review of the facility's mealtimes showed: -Breakfast is served at 7:30 A.M. through 9:00 A.M.; -Lunch is served at 11:30 A.M. through 1:00 P.M.; -Dinner is served at 4:30 P.M. through 6:30 P.M. -Review on 3/19/25 at 10:05 A.M., of the meal service logbook, showed the space for each day to record the start and stop time for each meal service. There were multiple days staff failed to document any times in the designated dates and/or times for each meal services The dates and times the staff did document showed they documented the start and end of each meal on each day mirrored the facility's mealtimes showing that Breakfast was started at 7:30 A.M. and ended at 9:00 A.M., lunch was started at 11:30 A.M. and ended at 1:00 P.M., dinner started at 4:30 P.M. and ended at 6:30 P.M. Review of Resident #1'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain an effective grievance process for residents and family members to voice grievances and to promptly resolve grievances for one resident (Resident #1). The facility failed to follow-up on concerns expressed at Resident Council meetings. In addition, the facility failed to identify a Grievance Official responsible for overseeing grievances in their policy. The failure has the potential to affect all residents. The census was 52 with 25 in certified beds. Review of the facility's grievance policy, dated 2017, showed: -Preface: It is the policy of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal; Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furbished, the behavior of the staff and of other residents, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents were served meals in a timely manner, which included two sampled residents (Resident #1 and Resident #2). The sample was eight. The census was 52 with 25 in certified beds. 1. Review of the facility's menus labeled Bistro 307 showed: -Breakfast is served at 7:30 A.M. through 9:00 A.M.; -Lunch is served at 11:30 A.M. through 1:00 P.M.; -Dinner is served at 4:30 P.M. through 6:30 P.M. 2. Review of Resident #1 's admission Minimum Data Set (MDS, a federally mandated assessment instrument competed by facility staff), dated 11/5/24, showed: -Severe cognitive impairment; -Requires moderate assistance from staff with eating; -Dependent on staff assistance going from lying to sitting position, -Diagnose included: Diabetes, urinary tract infection in the last 30 days, Alzheimer's disease, and Parkinson's disease (a neurological disease that causes tremors and shaking of the body). Review of the resident's care plan, in use at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs, bathing, dressing and toileting) received the necessary services to maintain adequate personal hygiene when staff did not provide showers to two residents (Resident #1 and Resident #2). The sample was eight. The census was 52 with 25 residents in certified beds. Review of the facility's Bathing policy, review date February 2019, showed; Policy: To cleanse the skin on micro-organisms (small bacteria) thus preventing infections and preserving the integrity of the skin; To provide comfort and relaxation, stimulate circulation, encourage passive and active range of motion (ROM) and improve self-esteem through appearance; Bath days and the type of bath to be given will be assigned by the Charge Nurse. 1. Review of Resident #1's admission Minimum Data Set (MDS, a federally mandated assessment instrument competed by facility staff), dated 11/5/24, showed: -Severe…

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 staff failed to ensure one resident (Resident #1) who developed a newly acquired pressure ulcer (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) had weekly skin assessments completed, according to the resident's care plan. Facility staff also failed to notify the physician of the new pressure wound and obtain new treatment orders in a timely manner. In addition, the facility staff failed to complete weekly skin assessments, according to facility policy, on one resident (Resident #2) who had a history of pressure ulcers. The sample was eight. The census was 52 with 25 residents in certified beds. Review of the facility's Prevention and Treatment of Skin Breakdown and Other Skin Conditions policy, dated 2017, showed: Policy: -It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcer/injuries; 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.

Based on observation, interview and record review, the facility failed to follow their policy and the resident's care plan and ensure two staff members assisted residents who required a sit-to-stand mechanical lift for transfers (Resident #2). The sample size was eight. The census was 52 with 25 residents in certified beds. Review of the facility's Sara lift (a type of sit-to-stand mechanical lift) policy, dated September, 2017, showed: Purpose: To provide a safe transfer for all residents who are unable to be transferred by staff due to a physical condition; Procedure: Two nursing persons must be used for a Sara lift transfer; Note: Nursing staff not using two nursing personnel for a Sara lift transfer will begin counseling process for failure to follow facility policy and procedures for safe transfer. Review of Resident #2's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 10/4/24, showed: -Severe cognitive impairment; -Dependent on staff for toileting, showering, bathing, and bed to chair transfers; -Always…

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

Based on observation, interview and record review, the facility failed to provide one resident (Resident #1) with proper urinary catheter (tube that drains the urine from the bladder) care by failing to have catheter supplies readily available to ensure the resident's catheter was changed, and failed to obtain a urine specimen, according to physician orders, in a timely manner. The staff failed to place the resident's urinary catheter below the resident's bladder during a transfer, which put the resident at greater risk for infection. The sample was eight. The census was 52 with 25 in certified beds. Review of the facility's catheter policy, review date February 2019, showed: -Catheter Care should be given every shift and as needed; -Never lift bag above bladder level (source of infection); -Change drain bag and tubing every 30 days; -Change indwelling Foley catheter as indicated based on assessment or per physician order. 1. Review of Resident #1's admission Minimum Data Set (MDS, a federally mandated assessment instrument competed by facility staff), dated 11/5/24, showed: -Severe…

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 acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multi drug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for one resident with a urinary catheter (a tube that drains the bladder) for one resident (Resident #1). The facility failed to ensure staff used acceptable infection control practices with one resident when providing perineal care (peri-care, cleansing of the genitals) (Resident #1). In addition, the facility staff failed to use acceptable infection control practices when administering medications for one resident (Resident #2). The sample was eight. The census was 52 with 25 residents in certified beds.…

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, record review, and facility document and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure: 1. open food items were labeled with a description of the food item and an open or expiration date; 2. food items were not stored beyond their use-by-dates and moldy onions were discarded; 3. dishware was allowed to airdry prior to use for meal service; 4. prepared foods were stored in a manner to prevent potential cross-contamination; and 5. the food preparation area and dietary equipment were maintained in a clean and sanitary manner, and the ceiling did not drip water onto the steam table used for meal service hot holding when it rained. Findings included: 1. An undated facility policy titled, Labeling and Dating revealed, Prepared or Opened Food -All prepared or opened foods will be wrapped or covered and labeled with the following 1. The date…

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, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 3 (Resident #17, #21, and #22) of 3 residents reviewed for EBP and failed to ensure respiratory equipment was stored in a manner to decrease risk of infection for 3 (Resident #22, #228, and #230) of 3 residents reviewed for respiratory care. The facility also failed to follow their infection control policy when staff failed to complete a two step and the annual one step of the employee tuberculosis (TB, a potentially serious infectious bacterial disease that mainly affects the lungs) screening tests in a timely manner for a total of seven employees. The census was 100 with 69 in certified beds. Findings included: A facility policy titled, Enhanced Barrier Precautions Policy, dated 04/2024, indicated, It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure baseline care plans were completed within 48 hours of admission for 5 (Residents #178, #228, #230, #22, and #21) of 13 sampled residents. Findings included: An undated facility policy titled, Care Plan Implementation, revealed, Policy: For [NAME] Park to provide quality care and services to each resident with a consistent standard of care a baseline care plan should be completed on each resident upon admission with a comprehensive care plan to be created on or before day 21 of their stay. The policy further indicated, Procedure: 1. At the time of admission, a Baseline Care Plan will be created in [the facility's electronic medical record system] with the completion of the Clinical admission Evaluation. The admission nurse will ensure the baseline care plan reflects the resident's condition and needs. 2. The unit manager will review and audit the admission to ensure the Baseline Care Plan is in place and make any…

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, record review, and interview, the facility failed to ensure a licensed practical nurse (LPN) verified the identity of the intended resident prior to obtaining a fingerstick blood sugar, which resulted in testing of the wrong resident. This affected 1 (Resident #17) of 2 residents observed during a finger stick blood sugar checks. Findings included: During an interview on 07/17/2024 at 3:30 PM, the Quality Control (QC) and Wound Care Specialist stated staff were expected to follow physician's orders, but the facility did not have a specific policy that addressed it, because following orders was a standard of practice. An admission Record revealed the facility admitted Resident #17 on 06/18/2024. According to the admission Record, the resident had a medical history that included a diagnosis of quadriplegia. The admission Record did not reflect a diagnosis of diabetes or hypoglycemia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/25/2024, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15, 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, interview, record review, facility document review, and facility policy review, the facility failed to ensure a physician's order for the use of oxygen was in place for 1 (Resident #228) of 3 residents reviewed for respiratory care. Findings included: A facility policy titled, Oxygen Administration, dated 02/2019, revealed, NOTE: You must have a physician's order to apply oxygen. Oxygen may be administered in an emergency until a physician's order can be obtained. An admission Record revealed the facility admitted Resident #228 on 07/10/2024. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen. Resident #228's Order Summary Report, listing active orders as of 07/16/2024, revealed no orders for the use of oxygen. On 07/15/2024 at 10:38 AM, Resident #228 was observed sitting in a recliner chair in their room. The resident was wearing a nasal cannula with an oxygen concentrator set at four liters per minute. On 07/16/2024 at 8:25 AM,…

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, record review, and facility policy review, the facility failed to ensure medication was stored appropriately on the medication cart so that staff could administer the medication as ordered for 1 (Resident #8) of 13 sampled residents. The facility further failed to ensure ordered medication was available in the facility for administration for 1 (Resident #232) of 13 sampled residents. Findings included: A facility policy titled, Medication Administration - General Guidelines, with an effective date of 07/2021, revealed, The facility has a sufficient staff and a medication distribution system to ensure safe administration of medication without unnecessary interruptions. 1. An admission Record indicated the facility admitted Resident #8 on 04/12/2024. According to the admission Record, the resident had a medical history that included a diagnosis of hereditary spastic paraplegia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/03/2024, revealed Resident #8 had 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, record review, and facility policy review, the facility failed to ensure medications were securely stored for 2 (Resident #228 and Resident #21) of 13 in-house sampled residents observed with medications at their bedside. Findings included: A facility policy titled Storage of Medications, dated 07/2021, revealed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 1. An admission Record revealed the facility admitted Resident #228 on 07/10/2024. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, unspecified dementia, weakness, and dependence on supplemental oxygen. Resident #228's electronic medical record revealed their admission Minimum Data Set (MDS), 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.

Based on interview, record review, and facility policy review, the facility failed to ensure the medical record for 1 (Resident #12) of 5 sampled residents reviewed for unnecessary medications accurately reflected the administration of medications. Specifically, staff interviews revealed oxycodone (a narcotic pain medication) that was removed from the facility's emergency medication supply was administered to Resident #12. However, Resident #12's administration record revealed no documentation indicating the medication was administered. Findings included: A facility policy titled, Medication Administration- General Guidelines, effective 07/2021, revealed section D. Documentation (including electronic) specified, 5) When PRN [as needed] medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site. b. Complaints or symptoms for which the medication was given. c. Results achieved from giving the dose and the time results were noted. d. Signature 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, interview and record review, the facility failed to document and notify one resident's physician of a large area of redness on a resident's buttock which was discovered during a skin assessment (Resident #4). The sample size was 7. The census was 98 with 25 residents in certified beds. Review of the facility's Body Audit Policy and Procedure, undated, showed: -Policy: To be completed weekly for all residents to identify any new alterations in skin integrity; -Procedure: On designated day each resident is to have an assessment of their skin, obtain AMS Weekly Licensed Nurse Body Audit in the electronic medical record (EMR); -Provide privacy to resident; -The Nursing Assistant is to contact the Licensed Nurse for the skin inspection and pain assessment when the resident has been prepared for the skin inspection; -The Licensed Nurse is to explain the procedure of the skin inspection to the resident; -The Licensed Nurse completes a head-to-toe inspection of the skin with notation of any new alterations in skin condition on the Body Audit form. The Licensed Nurse is…

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

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to label, date and cover food, and discard expired food. The facility also failed to ensure a cup was removed from the flour and sugar bins and appropriately stored and failed to ensure kitchen equipment was kept clean during two of three days of observation. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The sample size was 12. The census total was 51 with 23 in certified beds. 1. Observation on 2/21/23 at 9:40 A.M. and on 2/22/23 at 3:21 P.M., of the kitchen, showed the following: -Dry storage room: -A bag of mostaccioli noodles wrapped in plastic and without a date; -Three premium packages of popcorn with an expiration date 12/5/22; -A bottle of cranberry juice with an expiration date 11/27/22; -A jar of mustard with an expiration date 1/23/23. -Freezer: -A box of croissants, opened and exposed to air; -A box of tortilla shells, opened and…

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

Based on interview and record review, the facility failed to ensure 6 of 10 sampled staff hired within the past 12 months received their two-step tuberculin skin test. The census was 51 with 23 residents in certified beds. Review of the facility's Tuberculosis (TB) Exposure Control Plan policy, undated, showed: -Policy: It is the policy of this facility to institute an active TB Control Plan that includes identification of risk (to be included in the facility assessment information), early detection of latent TB infection, screening for infectious TB disease, follow-up where necessary, appropriate transfer and isolation of infectious TB, and treatment of persons with non-infectious TB; -All aspects of this facility's TB Control Plan will be contained in this document or is referred to by this document; -The Infection Preventionist, or designee, is responsible for developing, implementing and monitoring the TB Control Program in collaboration with the Administrator, Medical Director, and Director of Nursing (DON)/designee; -Healthcare workers will have a pre-placement and annual…

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 perform a self-administration of medication assessment and obtain physician orders for one resident who was observed with medications left at his/her bedside (Resident #119). The sample size was 12. The census was 51 with 23 in certified beds. Review of the facility's Self Administration of Medication Policy, undated, showed: -Purpose: To allow for safe administration of medications by the resident in accordance to regulatory standards; -Policy statement: Self-control of prescription medication, a resident may be allowed only if approved in writing by the resident's physician and in accordance with facility standards; All medications shall be safely stored at proper temperature and shall be kept in a secured location behind at least one locked door or cabinet; -Procedure: -Assessment: -The resident's ability to self-administer his/her medications will be assessed by licensed nurse using the Medication Self Administration Evaluation form; -If assessment indicates that the resident is capable of safely…

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 two residents (Resident #172 and Resident #16) had admission orders for their indwelling catheters (a sterile tube inserted into the bladder to drain urine). The sample was 12. The census was 51 with 23 in certified beds. Review of the facility's nursing services department policy and procedure, dated April/2020, showed: -Policy: admission orders will be transcribed in the medical record with accuracy; -Procedure: Upon admission, hospital orders will be accurately transcribed into the electronic medical record; Orders transcribed will include: Catheter orders for Foley (a sterile tube inserted to drain the bladder to drain urine) including size and balloon (a bulb at the end of the catheter that prevents the catheter from being dislodged) volume. 1. Review of Resident #172's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/18/23, showed: -admission date, 2/11/23;…

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 discard opened food items and maintain the cleanliness of the walk in freezer, walk in refrigerator, an oven, the stove top grill and the floor of the kitchen during three of four days of observation. This deficient practice affected all residents who ate at the facility. The census was 61 with 17 residents in certified beds. Observation on 7/9/19 at 8:33 A.M., of the main kitchen, showed: -One opened bag of what appeared to be frozen carrots, not labeled or dated, in the walk in freezer; -One opened bag of frozen biscuits, that had not been sealed after opening, inside of a box inside the walk in freezer; -Approximately four pepperoni slices were scattered on the floor of the walk in freezer; -One empty Styrofoam cup was in the corner of the walk in freezer floor; -Lettuce and white spectacles were on several areas of the floor of one of two walk in refrigerators; -Overall floor of the walk in refrigerator was sticky; -The Vulcan four door oven, showed a heavy build-up of grime and grease on the outside of the four doors;…

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.