Pacific Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to inform the resident and/or resident's representative, in writing, of the facility's bed hold policy at the time of transfer for four residents (Resident #9, #13, #21, and #49) out of 14 sampled residents. The facility's census was 54. 1. Review of the facility's Bed Hold Policy Guidelines, undated, showed the facility will notify all residents, and/or their representative of the bed hold policy guidelines. This notification shall be given: upon admission to the facility, at the time of the transfer to the hospital or leave, and at the time of non-covered therapeutic leave. 2. Review of Resident #9's medical record showed the resident transferred to the emergency room (ER) on 07/01/24 and readmitted to the facility on [DATE]. Review of the medical record did not contain documentation staff notified the resident or resident representative in writing of the bed hold policy prior to transfer/discharge. 3. Review of Resident # 13's medical record showed…

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, facility staff failed to develop and implement a comprehensive person-centered care plan for seven residents (Resident #16, #21, #25, #32, #33, #49, #50) out of 14 samples residents. The facility census was 54. 1. Review of the facility's policy titled MDS and Care Planning Guidelines dated [DATE] shows it is the policy of this facility is to use the most current Centers for Medicare & Medicaid Services (CMS) Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Manual, any published interim RAI manual errata documents, and applicable federal guidelines as the authoritative guide for completion of MDS, CAAs and resident care planning. 2. Review of Resident # 16's Quarterly MDS, a federally mandated assessment tool, dated [DATE], showed staff assessed resident as: -Significantly cognitively impaired; -Received hospice. Review of the resident's hospice documentation, dated [DATE], that showed the resident discharged from hospice services. Review of the care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to provide activities of daily living (ADLs) for eight residents (Resident #9 #21, #23, #26, #27, #33, #40 and #210) out of fourteen sampled residents when staff did not provide showers. The facility's census was 54. 1. Review of the facility's policy titled, Daily Care Needs, undated, showed before beginning care, check the resident's care plan. 2. Review of Resident # 9's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/20/24, showed staff assessed the resident as severely cognitively impaired, and dependent on staff for hygiene and bathing. Review of the resident's care plan, dated 06/22/24, showed: -Cognitive loss and memory issues; -Received Hospice care; -Dependent on staff for bed mobility, transfers, dressing, toileting, and hygiene; -Dependent on staff for bathing/showers. Review of the master shower list showed the resident not on the list. 3. Review of Resident # 21's admission MDS, dated [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review facility staff failed to complete bed rail assessments and obtain consent for the use of bed rails for three (Resident #21, #33, and #49) of 14 sampled residents. The facility census was 54. 1. Review of the facility's policy titled Bed Rails, undated showed staff were directed to: -Complete bed rail observation; -Obtain consent for the bed rails; -Provide education to the resident/legal representative on the benefits and risk of bed rail use; -Develop a care plan for bed rail use; -Staff will conduct regular inspections of all bedframes, mattresses, and bed rails to identify areas of possible entrapment. Review of the United States Food and Drug Administration (FDA) document entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated March 10, 2006, showed 413 people died as a result of entrapment events in the United States. Further review showed those among the most vulnerable for these entrapment type events are elderly…

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, facility staff failed to ensure four nurse aides ((NA) NA R, NA K, NA Q, and NA S) out of six sampled NA's, completed the nurse aid training program within four months of their employment in the facility. The facility census was 54. 1. Review of the facility's policy's showed the facility did not provide a policy for the completion of the nurse aide training program. Review of the Facility Assessment Tool, dated July 2024, showed staff documented all NA's must be certified within 120 days. 2. Review of NA R's personnel file showed a hire date of 10/10/23. The file did not contain documentation NA R completed the nurse aide training program. Review of NA K's personnel file showed a hire date of 10/24/23. The file did not contain documentation NA R completed the nurse aide training program. Review of NA Q's personnel file showed a hire date of 12/12/23. The file did not contain documentation NA R completed the nurse aide training program. Review of NA S's personnel file showed a hire date of 01/02/04. The file did not contain documentation NA R…

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, facility staff failed to reconcile narcotics at the change of shift when the medication cart changed from one staff member to another. The facility census was 54. 1. Review of the facility's policy titled Narcotic Count, undated, showed one Registered Nurse (RN), Licensed Practical Nurse (LPN), or Certified Medication Technician (CMT) going off duty and one RN, LPN, CMT coming on duty must count and justify accuracy of narcotics supply for each resident at the change of shift. Narcotic records are to be retained for at least one year. After the supply is counted and justified, the nurse/CMT records the date and his/her signature verifying the count is correct. 2. Review of the facility's staffing report showed: -Day shift charge nurse worked 7:00 A.M. to 7:00 P.M.; -Night shift charge nurse worked 7:00 P.M. to 7:00 A.M.; -Day shift CMT worked 6:00 A.M. to 2:00 P.M.; -Evening shift CMT worked 2:00 P.M. to 10:00 P.M.; -Did not contain a night shift CMT from 10:00 P.M. to 6:00 A.M. 3. Review of the facility's unlabeled on-coming 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 observation, interview and record review, facility staff failed to help prevent the development and transmission of infections when staff failed to perform hand hygiene in a manner to reduce the spread of infection for for three residents (Resident #14, #24, and #35) out of 14 sampled residents. The facility census was 54. Review of the Centers for Disease control and Prevention CDC Hand Hygiene in Healthcare Settings guidelines, last reviewed 01/10/20, showed the guidance directs healthcare personnel to follow the following recommendations: -Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indication: -Immediately before touching a patient; -Before performing an aseptic task (e.g. placing an indwelling device) or handling medical devices; -Before moving from work on a soiled body site to a clean body site on the same patient; -After touching a patient or the patient's immediate environment; -After contact with blood, body fluids, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review facility staff failed to conduct regular inspections of bed rails as a part of regular maintenance program for four residents (Resident #21, #25, #33, and #49) of 14 residents' sampled to identify areas of possible entrapment. The facility census was 54. 1. Review of the facility's policy titled Bed Rails, undated, showed staff will conduct regular inspections of all bedframes, mattresses, and bed rails to identify areas of possible entrapment. Review of the United States Food and Drug Administration (FDA) document entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated March 10, 2006, showed 413 people died as a result of entrapment events in the United States. Further review showed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice…

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 staff failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed ensure outdoor waste containers remained covered when not in actual use. The facility census was 54. 1. Review of 2022 United States Food and Drug Administration Food Code, subsection 5-501.113 (Covering Receptacles), showed receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered with tight-fitting lids or doors if kept outside the food establishment. Observation on 07/23/24 at 12:45 P.M., showed the outside dumpster, which contained waste, uncovered and it did not contain lids or doors to cover the waste. Observation also showed paper and food waste scattered on the ground around the dumpster and a plastic bag of waste on the ground near the right facing side of the dumpster. Observation on 07/24/24 at 8:17 A.M., showed the outside dumpster, which contained waste, uncovered and it did not contain lids or doors to cover the waste. Observation…

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, facility staff failed to prevent the misappropriation of funds for one resident (Resident #1) out of four sampled residents, when Housekeeper A stole the Resident #1's wallet and used his/her debit card without the resident's consent consent. The facility census was 54. 1. Review of the facility's Abuse, Neglect, Exploitation or Mistreatment Policy and Procedure, undated, showed it is the right of residents to be free from abuse, neglect, exploitation or mistreatment, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility is committed to protecting residents from mistreatment, neglect, abuse and exploitation by anyone including but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individuals. Misappropriation is defined as the deliberate misplacement, exploitation or wrongful, temporary or permanent, use of a resident ' s belongings or money without 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, facility staff failed to ensure the wireless call light system was fully operational twenty-four hours per day, seven days a week when direct care staff failed to carry and utilize the wireless nurse call pagers at all times. This failure had the potential to affect 56 residents who resided in the facility. The facility census was 56 residents. 1. Review of the facility's Call Light, answering policy, undated, showed some residents may not be able to use their call light. Be sure to check these residents frequently and answer the resident's call as soon as possible. The policy did not contain direction on when to obtain pagers, what to do if the pager did not work, and how to utilize the pager. Review of the facility's approved excemption, dated August 2023, showed the operator will ensure all direct care staff carry and utilize the wireless nurse call pagers at all times and resident care and services are not adversely affected in any way by the exemption. 2. Review of the facility's Call Light report, from 4/18/24 at 12:00 A.M.…

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, facility staff failed to revise a comprehensive person-centered care plan for four (Resident #2, #13, #14, and #18) out of six sampled residents who had a fall. The facility census was 56. 1. Review of the facility's Care Plan Comprehensive policy, undated, showed: -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -The interdisciplinary team (IDT) is responsible for the periodic review and updating of care plans when a significant change has occurred or when changes occur that impact the resident's care. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/11/24 showed staff assessed the resident as: -Cognitively impaired; -History of falls one month prior to admission; -Two or more non-injury falls since prior assessment; -History of falls. Review of the nurse notes, dated 04/08/24 at 03:24 P.M., showed the resident found on the…

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

Based on observation, interview, and record review, facility staff failed to ensure one resdident (Resident #3) of three sampled dependent residents received the necessary services to remain clean and dry, when staff failed to provide timely toileting assistance and incontinence care. The facility census was 56. 1. Review of the facility's Perineal Care policy, undated, showed: -The purpose is to cleanse the perinium and prevent infection and odor; -Use a wet lightly soaped washed cloth to wash from front to back; -Rinse and pat dry; -The policy did not contain direction on when/how often to provide perineal care. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/11/24 showed staff assessed the resident as: -Cognitively impaired; -Did not have behaviors or rejection of care; -Functional impairment on one side; -Required partial to moderate toilet assistance; -Required substantial to maximal assistance for toilet transfers; -Frequently incontinent of bladder and occasionally incontinent of bowel; -Diagnosis of hemiplegia…

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, facility staff failed to provide safe transfers with a mechanical lift for one resident (Residents #3) of two sampled residents in a manner to prevent accidents. The facility census was 56. 1. Review of the facility's Hydraulic Lift policy, undated, showed to follow manufacturer's instructions when using any type of hydraulic lift: . Review of the hydraulic lift manual, dated September 2023, showed: -Residents should be able to bear some weight, have upper body strength and able to follow simple commands; -For safety of resident, securely fasten the safety strap around the residents torso, secure the buckle and pull the strap to tighten; -Position the resident's arms on the outside of the harness and have them place their hands on the paddle handles; -If a caregiver deems it necessary to keep a resident's shins or feet on the footplate, secure the shin straps around the resident's legs; -As the resident is being raised, simultaneously tighten the safety strap buckled around their torso. 2. Review of Resident #3s Quarterly Minimum…

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, interviews, and record review, the facility staff failed to ensure the ice bin drained through an air gap and to properly store open food to prevent cross contamination and outdated usage. This had the potential to affect all facility residents. The census was 57. 1. Review of the facility's Monthly Preventative Maintenance Checklist, undated, showed staff are instructed to inspect the ice machine to ensure there is at least a two inch air gap above the floor drain. Observation on 2/8/23 at 1:57 P.M., showed the ice machine, located in the kitchen storage room off the utility hallway, contained two drains which did not drain through an air gap. Further observation showed a clear plastic tube connected the ice storage bin drain to the floor drain, and the inside of the plastic tubing contained an accumulation of a black substance. During an interview on 2/8/23 at 1:59 P.M., the maintenance director said he checks the ice machine monthly, and he uses the facility's Monthly Preventative Checklist as the policy. The maintenance director said the ice machine has two…

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, facility staff failed to maintain the dignity of three residents (Residents #14, #16, and #30), when staff failed to cover two residents' (Resident #14 and Resident #30) catheter (a tube inserted into the bladder) drainage bags, and failed to notify Resident #16 prior to elevating the back of a reclining chair. The facility census was 57. Review of the facility's Resident Rights document, undated, showed residents have the right to be treated with consideration, respect and dignity. Review showed it did not indicate or provide direction on how to maintain or provide resident dignity. 1. Review of Resident #14's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/28/22, showed staff assessed the resident as: -Severe Cognitive Impairment; -Required limited assistance from one staff member for transfers; -Had an indwelling catheter; -Diagnoses of Anxiety Disorder, Stroke, and Dementia. Review of the resident's care plan, revised…

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, facility staff failed to provide a comfortable and homelike environment, when staff failed to ensure resident rooms were clean, and maintained. Further, facility staff failed to ensure a comfortable water temperature in resident rooms. The facility census was 57. Review of the policies provided by the facility showed they did not contain a policy for environmental concerns. 1. Observation on 2/7/23 at 3:04 P.M., showed Resident #8's room had gouges in the wall, toilet paper and black marks on the floor, and the paper towel dispenser did not work. Observation on 2/9/23 at 3:27 P.M. showed Resident #8's room had gouges in the wall, black marks on the floor, and the paper towel dispenser did not work. During an interview on 2/9/23 at 3:27 P.M., Resident #8 said the paper towel dispenser doesn't work, and hasn't worked for a while. He/She said he/she has to use toilet paper to dry his/her hands, and it bothers him/her. The resident said he/she has told staff it does not work. 2. Observation on 2/7/23 at 3:38 P.M., showed room A8 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for five sampled residents (Residents #14, #33, #38, #46 and #57). The facility census was 57. Review of the facility's Care Plan, Comprehensive Policy, undated, showed: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The comprehensive care plan will be based on thorough assessments that includes, but is not limited to, the Minimum Data Set (MDS) a federally mandated assessment completed by facility staff; -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -Interdisciplinary care plan team (IDT) is responsible for the periodic review and updating of care plans when a significant change in a resident's condition has occurred. 1. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed ensure four dependent residents (Resident #31, #33, #38 and #57) received the necessary services to maintain good grooming and personal hygiene when staff failed to maintain the residents' facial hair and nails. The facility census was 57. Review of the facility's Nails, Care of (Fingers and Toes) policy, undated, showed the purpose is to provide cleanliness, comfort, and prevent the spread of disease. Review showed it did not contain direction for staff on when to provide nail care. Review of the facility's Shaving the Resident policy, undated, showed the purpose is to remove facial hair and improve the resident's appearance and morale. Review showed it did not contain direction for staff on when to provide facial shaving. 1. Review of Resident #31's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/2/23, showed staff assessed the resident as: -Moderately impaired cognition; -Required extensive assistance…

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, facility staff failed to provide safe transfers with a mechanical lift for two residents (Residents #16 and #38) and failed to propel two residents (Resident #14 and #57) in wheelchairs in a manner to prevent accidents. The facility census was 57. 1. Review of the EZ Way Smart Lift safety guide, undated, showed: -Patient falls from lifts may cause injuries, including head trauma, fractures and death; -Move lift base legs near or around the resident's device; -Base legs are usually more stable in the full open position; -Clear a path for the lift; -Ensure there is space for lift to pivot and move freely to receiving area; -Do no leave the resident unattended while in the lift; -Never keep resident suspended in sling for more than a few minutes. Review of the facility's Wheelchair policy, undated, showed: -Do not remove footrests unless resident uses feet on floor to enable mobility; -Lower footrests and place resident's feet on footrests if used; -Assist resident to the area of the facility desired; -Encourage and instruct resident…

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

Based on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment when staff failed to use hand hygiene during resident care and change gloves during care for four residents (Resident #31, #14, #16, and #57) during perineal care for two residents (Resident #16 and #38) and wound care for one resident (Resident #30). Additionally, facility staff failed to decrease the risk of infection for one resident (Resident #37) when staff failed to ensure sanitary conditions for catheter tubing, failed to sanitize or clean a mechanical lift (mechanical device used to lift and transfer residents) after use for one resident (Resident #36), and failed to sanitize or clean a pulse oximeter (device used to measure oxygen levels) between two residents (Resident #48 and #5). The facility census was 57. 1. Review of the facility's Standard and Transmission Based Precautions policy, undated, showed the following: -Standard precautions presume all blood, body fluids, secretions…

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, facility staff failed to provide appropriate treatment and services to prevent further decrease in range of motion (ROM- movement of a joint), for one resident (Resident #30), who had a contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the left wrist. The facility census was 57. 1. Review of the facility's Range of Motion (ROM) Policy, undated, showed: -ROM is used to improve or maintain joint mobility and muscle strength; -Assistive devices may be used; -When resident's activity level or joint function is at risk of or decreased, ROM should be started as soon as possible; -Joints may begin to stiffen within 24 hours of disuse. Review of Resident #30's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/21/22, showed staff assessed the resident as: -Cognitively Intact; -Required limited assistance from one staff member for eating; -Required extensive assistance from one staff member for dressing 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.